Health care practice and delivery

Health Care

The Black Plague killed an estimated forty percent of the population of Europe between 1347 and 1427; with some cities and villages experiencing seventy or eighty percent mortality (Herlihy 2, 43). Out of its ashes rose a new understanding of medical science, the European renaissance, as well as a powerful respect for disease. Over five hundred years later Western scientists, armed with post World War II technology, seemed prepared to rid the world of any disease that could threaten humanity. Yet, despite the new weaponry on the side of humans and the heightened optimism of the time, new plagues seemed ready to meet the challenge -- medical science was the real underdog. During the twentieth century western medicine has gone through several phases, all as responses to immediate medical needs and pervading public worries of the time.

The analogy between the Black Plague of the Middle Ages and AIDS of today is an interesting one. Both have uncertain origins. In fact, "the rapid dissemination of AIDS, unlike that of typhus, cholera, or tuberculosis later in the nineteenth century, cannot be pinned on social conditions that may have arisen from urbanization, industrialization, or inequalities in class structure. The origins of AIDS, as with the plague of 1348, remain more mysterious." (Herlihy 5). Additionally, both were looked upon by many members of the populous as signs from God; pestilences sent to punish the wicked and cleanse the earth of sin. Also, a significant portion of people refused to trust the modes of transmission experts believed were connected to each of these diseases, and consequently, either took unnecessary measures to prevent infection or no measures at all. Clearly, despite the somewhat warranted confidence many people have in current medical science, the problems that threatened medicine six hundred years ago still remain undefeated today.

For Western physicians, the 1950's and 1960's were a time of tremendous optimism. Nearly every week the medical establishment declared another "miracle breakthrough" in humanities war with infectious disease." (Garrett 30). And of course, there was no obvious reason why these physicians, and the populous, should not be hopeful for the future. After all, a war had just been won on the shoulders of science -- namely, physics -- and was accompanied by a host of practical advancements that improved living standards and provided products that made individual's lives easier.

This attitude towards medical science certainly had a substantial amount of supporting evidence. "Antibiotics, first discovered in the early 1940's, were growing in number and potency." (Garrett 30). Diseases like Staphylococcus, and tuberculosis were almost completely destroyed by these early developments. Smallpox, the most devastating killer of all time, became extremely rare and was eventually defeated in America and Europe. But perhaps the strongest testament to mankind's success over the microbes was the defeat of polio. "Dr. Jonas Salk's in 1955 mass experimental polio vaccination campaign was so successful that cases of the disease in Western Europe and North America plummeted from 76,000 in 1955 to less than 1,000 in1967." (Garrett 30). However, any good evolutionary biologist could have told you that these successes were short-lived. Humanity was merely eradicating the diseases that had existed for hundreds of years, and therefore, had not needed to undergo serious evolution -- they were successful without it. In the subsequent years, with scientists bombarding new bacterial strains with antibodies, they were effectually tempering these new diseases to evolve more rapidly.

Yet, even in the age of optimism there were signs that perhaps medicine was not up to the task on a worldwide scale. Outbreaks of yellow fever began to occur in Europe and the United States, and were greeted with the same confidence as the aforementioned diseases. Eventually, the cause of the disease was tied to a specific breed of mosquito in the tropics. Although many experts believed that yellow fever could be nearly eradicated by spaying of the fields and jungles in these areas, it was deemed too expensive of an endeavor (Garrett 70). Consequently, yellow fever was allowed to ravage the underdeveloped countries in South America and Africa because it was not cost-effective for the wealthier nations to stop it. This illustrates a significant ideological hole in the American health care system -- it is driven by profit. Consequently, many of the poor in the United States to not receive the care they need, and many portions of the world are almost completely ignored.

In the post World War II era the majority of the Western medicine practiced in third world nations was in the form of missionary work. Mostly young medical students with big hearts and little money were the ones who found themselves thrust into some of the most demanding situations on earth, and were on the front lines of the most frightening diseases. Aside from this small minority of medical workers, most American medicine was practiced with an almost isolationist attitude. Since the real market for medicine was at home, diseases were treated on a need basis rather than on a preventative one. This is because a true preventative stance to the most threatening diseases would require treating individuals and nations that cannot make the venture profitable.

Consequently, "The great Ebola drama went almost unnoticed in the United States in 1976, even in the hallways of the Centers for Disease Control. The nation was preoccupied. And Africa was, in the American consciousness, far away." (Garrett 153). The relative ignorance of the general public and most physicians to threats like Ebola came about largely because of this isolationist attitude, and also contributed to the rate at which medical scientists fell behind the evolution of harmful bacteria and viruses. The general lack of concern for everything not immediately affecting America caused other aspects of medicine to be addressed more readily than potential plagues hidden in the far reaches of the world.

Critics of the American health care system have said, "The medical system may not be doing too well at fighting disease, but as any broker will testify, it's one of the healthiest businesses around." (Lindorff 1). This aspect of our current medical system was also born in the post World War II era. "The histories of the individual companies are widely different, but the for-profit hospital chains large and small are all the product of a sudden change in the political-economic environment of the mid-1960's -- the creation of a government insurance system for the elderly and the poor." (Lindorff 33). Despite the good intentions of the founders of Medicare and Medicaid, it created an environment whereby medical establishments could generate profits, at the expense of the federal government, by providing care for these people.

By generating more profits the medical industry was able to accomplish one thing: much more money could be put into research. As a consequence, thousands of medical discoveries and "breakthroughs" have pepped the past half-century. This has resulted in the American form of healthcare being able to provide the highest level of care in the world to those who can afford it. Unfortunately, "The American system of health care financing reduces the quality of care for at least one group of people: those without insurance." (White 55). Clearly, this would not be a problem if the uninsured did not require as much medical care as those who possess insurance. but, "The uninsured are twice as likely to be hospitalized for conditions that are treatable through appropriate ambulatory care and are more likely than the insured both to delay needed care and to say they did without care that they felt they needed." (White 55). These are the troubling observations regarding the poor and uninsured at home.

Abroad there are even less incentives for medical establishments to treat patients, even if their ailments are as severe as smallpox or malaria -- diseases that have been almost completely destroyed in America, but still account for significant proportions of worldwide deaths. Not surprisingly, social issues are influencing the distribution of medical services domestically and worldwide.

In New York City, 1,017 were born with congenital syphilis in 1988, up from only 16 in 1982.... Newark had a 35% rise in the number of new tuberculosis cases from 1988 to 1989, and the pediatric clinic at Newark's University Hospital reported a fourfold increase from1987 through 1990." (Eckholm 28). Diseases that were completely preventable began to reemerge in the poorest sections of the nation's inner-cities towards the end of the 1980's. Social factors are likely to have played a large role in this problem -- by the late 1980's the class divide between the upper and lower classes in America, and indeed, in the world was growing exponentially.

Running parallel to the problem of lack of proper medical care in American inner cities is the same problem in the underdeveloped nations of the world. Ebola continued to devastate communities in central Africa in the late 1970's and early1980's, and the medical facilities there, rather than stemming the spread of the disease actually added potency its destructive effects. The "poorly run hospitals operating under conditions of extreme deprivation were the amplifiers of microbial invasions. What might have otherwise been individual illness, limited to one or two cases of Ebola, was magnified in a hospital setting in which unsterile equipment and needles were used repeatedly on numerous patients." (Garrett 220).

Even with the significant accomplishment of learning to genetically engineer biologic material, the means did not exist to apply this new knowledge where it was needed most. Economic, social, governmental, and geographic barriers prevented this advancement from having the impact it could have. As a result, the microorganisms continued to outpace the medical scientists.

It is important to understand that, largely, what has determined the direction of the American medical industry during the post war -- for profit -- era has been the market for new drugs and treatments. It has already been established that this market is relatively unconcerned with those who cannot afford service: uninsured Americans and poor foreigners. Therefore, it should be expected that the services that were in the highest demand during the dawn of such potential plagues as Ebola and AIDS were things that were completely unrelated to these treacherous threats. In accordance with this theory, it should be noted that some of the most expensive research and products came out of the search for new methods to treat cancer -- a disease that was and is prevalent among the elderly and insured. Magnetic Resonance Imaging and CAT scans were in development at this time. Although their immense medical value cannot be denied, it still provides an illustration of the priorities set by the American medical system.

Tied in with the idea of demand is the idea of public awareness. News coverage of the beginnings of Ebola and AIDS was relatively unclear as to what the threat was while these diseases were first being discovered. These far-off diseases "boiled down to the same set of troubling perceptions for the American public, and, to a lesser extent, the Canadian, Mexican, Australian, New Zealand, and European publics: something new and very scary was coming; nobody was sure what it was, but the experts were certain that it was dangerous; the federal government seemed quite distressed about the matters, but the experts and authorities didn't seem to agree as to what, if anything, should be done to protect the public; and it was all costing taxpayers a pretty penny." (Garrett 153-154). In the midst of such ambiguous interpretations of impending doom, which seemed to appear in the news weekly, the natural response of a public thousands of miles away is to ignore it. With a lack of general concern from the American public the medical industry had little incentive to invest potentially millions or billions of dollars into stopping another African disease.

By 1982 AIDS, a serious epidemic threat, reached America. In that year the Centers for Disease Control closed their report on the disease by saying, "Of the 788 definite AIDS cases among adults reported thus far to CDC, 42 (5.3%) belong to no known risk group (i.e., they are not known to be homosexually active men, intravenous drug abusers, Haitians, or hemophiliacs).... This report and continuing reports of AIDS among persons with hemophilia a raise serious questions about the possible transmission for AIDS through blood and blood products." (Garrett 309). Suddenly AIDS had become a clear and present danger to the United States and since the modes by which it was transferred were unclear, it provided fuel to the fire of those who looked to blame the homosexual community.

Consequently, the need for the American medical community to act had finally come -- the public was finally sufficiently scared to demand that action be taken. Unfortunately, too much time had been wasted. Attacking the disease from a biomedical standpoint was fairly ineffectual. The best advice that the medical community could give was for individuals to alter their lifestyles appropriately with latex contraceptives and monogamy. Regardless of the gross failure of the American medical practices, still millions of dollars have been invested to develop drugs and treatments that slow the onset of AIDS and prolong the life of infected individuals. So in this sense, the industry has responded; and although they have yet to yield a cure, they have still found a way in the face of existing demands to generate a profit out of their shortcomings.

The already desperate state of the poor in the United States with the new threat of HIV and AIDS threatened to overrun the medical facilities in place to support them. "Any disease that hit the poor urban Americans disproportionately would tax the public hospital system. But AIDS, which was particularly costly and labor intensive to treat, threatened to be the straw that broke the already weakened back of the system." (Garrett 506). Combating this potential epidemic meant treating those who could not afford it, and the system was forced to find some sort of answer.

One problem was, "A significant percentage of the nation's HIV-positive population was also homeless, living on the streets of American cities." (Garrett 507). As aforementioned, the poor and uninsured often receive sub-standard medical treatment or sometimes no treatment at all. Homeless men infected with HIV or AIDS, additionally, may not be able to afford proper contraception. Consequently, they spread the disease to others -- particularly, prostitutes -- who have more unprotected contact with different individuals. These facts created a state of unbelievable risk for individuals living in the most economically deprived areas of the United States. To quantify these risks, "Harlem Hospital chief of surgery Dr. Harold Freeman calculated that men growing up in Bangladesh had a better chance of surviving into their sixty-fifth birthday than did African-American men in Harlem, the Bronx, or Brooklyn." (Garrett 508).