Friday, December 25, 2015

Is Healthcare a Human Right?

What do we mean when we say that healthcare is a human right?

The simplest case is that we mean what the United Nations means in the Universal Declaration of Human Rights:asdf

Article 25 
Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

Critics claim that "just because the UN says it doesn't make it so."

Fair enough.

For me, the reason to support the concept of healthcare as a human right requires a simple thought experiment, "What kind of society do I want to live in?"

More specifically, "How do I want my society to respond to the sick?"

It's perhaps easiest to begin by describing how I certainly don't want my society to respond. I hope it's a comfortable assumption that I speak for most Americans when I say that allowing the sick to suffer and die, unaided in the street, is abhorrent. Although there are philosophical treatises underlying this position, I think we can save some time and simply agree that callous indifference to the suffering and vulnerable is unacceptable in 2015.

The real question is not whether or not our society is responsible for the sick and vulnerable, but how responsible is it?

Put another way; it's one thing to say that indifference is unacceptable. It's another thing to compel the citizenry to act on behalf of the vulnerable.

Fortunately, we already do act, and not out of any compulsion to do so. Anywhere in this country, bystanders routinely call 911 when they witness extremis, summoning the couriers of the emergency medical system to whisk them off to an emergency room replete with all the modern tools of resuscitation. Emergency rooms treat all comers, regardless of their background, their social status, or their ability to pay This is not a small thing, and for those who can sense a righteous tone that may be building in the paragraphs to come, let me say clearly that many wonderful people execute complex care coordination to provide this essential safety net.*

Emergency services are wonderful, but health requires much more than intervening at the point of desperation. How far should our society go?

For me, a simple answer is a comparison of our education system. Any child, regardless of the neighborhood they live in, their poverty, or even their beliefs about education, gets to go to school. It is an expectation. Their is a transport system established for those who don't have access. There are support services to help parents navigate the system. There is free lunch for those who need it. The US has provided every child with a right to an education.

I think we should do the same for health. There should be an expectation that anyone who is ill, regardless of where they live or how impoverished they are, can see a doctor. If they can't get themselves there transportation should be provided. There should be services to aid navigation. Beyond acute illness, patients should have access to preventive care and social supports.

Almost every other developed nation, and even some that are underdeveloped, has this. The US does not. Unlike other nations, one's access to healthcare depends on their proximity to a clinic (community health centers are closing), on the availability of basic services in that clinic (mental health is notably lacking in primary care), on patients' ability to navigate a complex system (talk to anyone trying to understand their medicare coverage), and last but certainly not least, on the ability to pay for both insurance and out-of-pocket fees.

Simply put, healthcare is not a right for the poor and marginalized in the US.

Any discussion of rights necessarily includes a discussion of responsibility. Rights are meaningless without responsibility. The right to life is the responsibility not to kill. More than that, it is the responsibility to set up mechanisms to prevent others from killing through laws and a police force. The right to education is a responsibility not only to not interfere with another's education, but to support students with teachers and infrastructure.

We all pay taxes to support the criminal justice system and the education system. In fact, if we don't, we can be put in jail. Society compels us to pay through threat of force.

When we hand out rights, we also hand out coercion, which paradoxically amounts to taking away rights. The right to life takes away my right not to be taxed for law and order. The right to education takes away my right not to pay school taxes.

Handing out rights is more than a dreamy exercise in imprinting our vision of the world in a high-minded list. It is also handing out obligation and responsibility, collected under threat of jail time. I can understand those who are resistant to the idea of a self-selected group of idealists sitting down at a convention and deciding which obligations the rest of us have.

So, when I say I want our society to treat healthcare like we treat education, I need to make the case to those who do not want to be saddled with the responsibilities of making this a reality.

Interestingly, those skeptics often spend a good deal of time extolling the virtues of this nation, its ideals, its strengths, and its standing as a moral force in the world. They trace this virtue back to the founding fathers and the provision of rights as set forth in the Constitution. This society has become what it is, still the envy of much of the world, because of its provision of rights. Human rights serve human dignity, and human dignity is the well-spring of human flourishing.

Look what happens when we provide our citizens with education?

We can only gain by doubling down on our commitment to health.

Thursday, December 17, 2015

How I woke up to the Issue: #Blacklivesmatter

I just finished reading The New Jim Crow, by Michelle Alexander, and all I can do is wonder if there is a bigger problem, a bigger injustice, a bigger moral failing than the simple fact that Black Americans are incarcerated far more frequently for drug crimes than whites.

I verified the numbers myself. In 2013, a total of 88,500 whites were sentenced for drug-related charges compared to 117,300 blacks, according to the Bureau of Justice Statistics.1 Even though there are six times more whites in the general population, and rates of drug use are equal among whites and blacks, blacks are arrested and sentenced to prison MORE OFTEN than whites.

Like any statistic, there's more to this than simple numbers, and counterarguments and caveats are important. However, given the scale of this injustice, the burden of proof falls on those who would deny that this system is racist.

The simple conclusion is that the US drug policy discriminates according to race. If drug incarceration rates among blacks and whites were equal in 2013, then roughly 102,900 black Americans would have been spared prison.

That's 102,900 extra people behind bars, a year. That's 102,900 excess people taken away from their families, from the workplace, from their communities. That's 102,900 excess families laboring under the stigma of criminality. That's lost votes. That's lost public housing. That's lost dignity.

That's a humanitarian crisis. 

The criminal justice system is a foundational piece of our society, and it is systematically rounding up minorities and locking them in cages. How can black communities, already relegated to inner city ghettos and stigmatized by a white society, possibly reach any kind of parity in quality of life when their own government is so disproportionately heavy handed.

The book ticks off one head-shaking statistic after another, but Alexander's comparison to society's response to drunk driving is particularly compelling. In the 1980's, when drunk driving fatalities outnumbered drug related fatalities, a grassroots movement preceded a government intervention. For the population of largely white men, the focus on reforming drivers and keeping them in society resulted in a 50% reduction in drunk driving fatalities. Imagine if there was a War on Drunk Driving, stigmatizing white men and herding them into prisons by the millions while drunk driving went on unabated? 

Alexander is compelling when she traces the systematized oppression of blacks as a means to capture white voting constituencies, from the end of slavery to Jim Crow to the war on drugs and mass incarceration. 

She calls for what Martin Luther King called for, a human rights movement. 

I'm outraged, but I'm also embarrassed. How could I be an educated 36 year old physician and just now realize that I'm a tax-paying accomplice to a humanitarian crisis? We are hiding the truth from ourselves, we are deceiving ourselves. We are comforting ourselves that, since a black man is president, we are finally absolved from our legacy of oppression. 

I believe, as Alexander does, that like myself, most Americans genuinely abhor the thought of racism and would never characterize themselves as such.

If that's the case, then we have to get off our butts and do something about this. 

For a detailed look at strategy for effective engagement with this topic, please consider taking the time to read this strategy piece by the Open Philanthropy Project.

1- Appendix Table 4 page 30