A Selection of Essays on Healthcare

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Letting Go: What should medicine do when it can’t save your life? by Atul Gawande in The New Yorker (2 Aug. 2010). Gawande’s usual excellent writing about “a modern tragedy” weaves information about end-of-life politics, costs and choices with a few personal stories, one of a young woman with late-stage breast cancer, another of a 72-year old woman with multiple medical issues (congestive heart failure and pulmonary fibrosis), and a third about a 42-year-old man with metastatic pancreatic cancer. Read it before you need to.

“Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop.” …

“Besides, how do you attend to the thoughts and concerns of the dying when medicine has made it almost impossible to be sure who the dying even are? Is someone with terminal cancer, dementia, incurable congestive heart failure dying, exactly?”

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What Broke My Father’s Heart by Katy Butler in the New York Times (18 June 2010). Another end-of-life tragedy, as doctors’ aggressive treatments and patients’ lack of information about the pros and cons of procedures and treatments ensures that a man who’s had a stroke, suffers dementia and whose body is collapsing “like an ancient, shored-up house” lives on against his wishes.

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The Truth About Recovering from a Brain Injury by Tim Lusher in the Guardian (22 June 2010). A story of his ongoing recovery from “an abscess on the cerebellum, which controls movement, balance and coordination,” and others’ stories of head injury recovery. The main truth is that is takes a lot of time to recover — and the exhaustion during recovery and relearning can be immense.

“Having a catastrophic illness (the term gives me a slight thrill) is an interesting experience if it doesn’t see you off, albeit one you wouldn’t wish for. You learn a lot: about yourself, about your friends, family and colleagues, what matters and doesn’t. But mainly you learn about the grind of illness and recovery.”

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17 Years Later, Stage 4 Survivor Is Savoring a Life Well Lived by Katherine Russell Rich in the New York Times (26 April 26 2010). This essay is about living with serious cancer long-term. Rich has had breast cancer for 22 years — and Stage 4 breast cancer for 17 years.

“[W]hen the cancer returned, it came on so fast, spread so quickly, that I was given a year or two to live. Within months, the disease turned vicious. It started breaking bones from within, and was coming close to severing my spinal cord.

“Nothing was working, till a doctor tried a hormone treatment no one used much anymore, and the cancer turned and retreated, snarling. It remains sluggish but active.”

About 2% of people with Stage 4 breast cancer live for 20, 30 or more years, and no one knows why, though they tend to “have disease that has spread to the bone (as opposed to lung or liver, say) and feeds on estrogen.”  But neither of those is true for some women who live for decades after a Stage 4 diagnosis.

“When I was told I had a year or two, I didn’t want anything one might expect: no blow-out trip to the Galápagos, no perfect meal at Alain Ducasse, no defiant red Maserati. All I wanted was ordinary life back, for ordinary life, it became utterly clear, is more valuable than anything else.

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How American Health Care Killed My Father in The Atlantic by David Goldhill (Sept. 2009). It’s a year old but oh-so-relevant. Though the title suggests a personal story (and there is one told), the article is actually quite intelligently political and offers the best prescription for the U.S. healthcare crisis that I’ve seen:

The problem, as Goldhill states it:

“Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasize treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality.”

His solution: treat health insurance as insurance:

1.Replace the “current web of employer- and government-based insurance with a single program of catastrophic insurance open to all Americans … with fixed premiums based solely on age.” Catastrophic = costs $50K or more, or covers a “chronic condition with expected annual costs above some lower threshold.”

2. Pay for regular (non-catastrophic) healthcare from income and savings, through a health savings account.

3. For major expenses that are not catastrophic, we’d pay for these as we pay for “most expensive purchases that confer long-term benefits: with credit. Americans should be able to borrow against their future contributions to their HSA to cover major health needs.”

He calculates (with stated assumptions) that a 22-year-old man will pay — in conjunction with his employer — at least $1.77 million for his healthcare in his lifetime, and that’s assuming healthcare costs are tamed; if not, it could be more like $4 million. How else could we use this money to promote health and treat medical conditions?

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