April 8, 2020

Albert Lamorisse’s Le Ballon Rouge

I apologize for no long post last night. I’ve tried to be disciplined and keep these up every other evening but last night I felt like a balloon after all the air has been let out of it and I crawled into bed by 9 and slept through until the alarm went off at 7 this morning. I feel fine. I think my brain just needed some off time from the toxic stew of life stresses that we’re all marinating in at the moment. At least the new work patterns are becoming slightly predictable and I’ve been able to stay on top of the crises in three different systems: UAB Geriatrics Clinic, Birmingham VA Home Based Primary Care and Comfort Care Hospice. One day, one patient, one problem at a time – although my phone continues to ding regularly with incoming texts from whichever two sites I’m not currently at.

An anecdote from my very distant past involving a balloon. I must have been three or four at the time. My parents gave me a red balloon, fairly strong and sturdy and rubberized that had a cat face on it. I don’t remember where we got it or why and it had no magical properties, unlike the one in the fabulous French short film by Albert Lamorisse. I was playing with it in the alley behind my house when my friend Jay came out of his house across the way and told me it would be great fun to pop it. Jay was a couple years older than I was so I looked up to him as an experienced man of five or six and said sure, that should be fun. He couldn’t find a rock that would puncture it but finally found a stick and convinced me to poke a hole in the balloon. If it had exploded with a satisfying bang, I might have enjoyed the noise – all boys love blowing things up but instead it slowly leaked air and involuted and started to shrink away. My three year old brain hadn’t considered the possibility that my toy might do that and become less usable and fun. I took my wounded balloon inside to my mother who, to her credit, didn’t laugh at me but rather took it as a chance to teach me a lesson in actions have consequences and some decisions, once made, cannot be undone. I kept what remained of that balloon in my room for quite a while as a reminder to be careful with what I chose – and as a reminder to not always follow someone based on seniority. (I’ve taken that last lesson very much too heart and had major problems arise from it at times, but I think I’m happier bucking the system when I know I’m right rather than going along to get along.) It was probably also my introduction to the second law of thermodynamics although I didn’t figure that out until years later.

The number of Facebook friend requests I’m getting and my blog readership are going up astronomically since I’ve started into what I’m calling my plague diaries. Quite frankly, I’d much rather still be doing travel diaries but one writes about what one knows and journaling comes out of the mundane and minutia of everyday life and all of our everyday lives have become about Covid 19 whether we want them to be or not. I did a podcast recording a couple of weeks ago (https://audioboom.com/posts/7547581-season-3-episode-6-one-doctor-s-life-in-the-time-of-coronavirus) where we talk a bit about this blog. Yes, the title is a nod to Douglas Adams. It’s been years since I’ve read his books, but his wonky sense of humor has always appealed to me and it’s very similar to my own. If you doubt me, read the movie columns. Of course, when Mr. Adams was my age, he’d been dead for nearly a decade so he accomplished a lot more with his writings than I have with my own.

In my last long post, I explored – briefly – why the US has health insurance tied to employment while such a system happened nowhere else in the industrialized world. Tonight I want to say a few words about another aspect of the US health care system that’s unique and which causes us a significant amount of trouble. I’m not passing judgment on why this is or the ethics or social trends behind it, I’m just going to lay it out there.

The vast majority of world health systems, especially those of the developed world, are morbidity driven health systems. The aim of the systems is to keep their populations well. They understand that health is much cheaper for a system than disease and resources are deployed to try to keep the majority of the population as healthy as possible. Healthy adults come from healthy children come from healthy infants come from healthy parents so they put enormous resources into making sure all of their population has access to care, that primary care is funded and available, that there is adequate prenatal and child care, that pediatric care will not stress a family unit, and preventive services that will keep people from falling into ill health by catching disease early are easy to come by. What’s the result? Their populations have higher life expectancies than we do, their systems cost much less (usually 9-11% of GDP while ours is something over 17% of GDP), and no one in their populations worries about medical bills and the possibility of bankruptcy from a health condition is so alien as to be unfathomable.

On the contrast, the US health care system is a mortality based system. We worry about why people die and do everything we can to prevent that occurrence. A death is considered a failure of the system to provide adequate care in some way (and our legal system is always looking to find someone at fault). We view life as linear with death as an endpoint and, if our health system is applied properly, we should never actually reach that spot. There are some generational differences in these ideas but it is most clearly seen in the early Boomers, those now in their early 70s who still view themselves as being forever young. There’s a line from a film which paraphrased is something like ‘How can I be old? I was at Woodstock!’

This cultural need to prevent death leads us to pour huge resources into individuals who are obviously in a dying process. For most people, death is a process – a very quick process for some (almost instantaneous in some cases) and a very slow process for others. Most health professionals know when someone is in that process but we are taught from early in our training how not to take away hope and the ethics of doing everything in our power to preserve life if that is the wish of a patient and family. But, deep inside, we often recognize when the continued treatments are doing no good. The specialty of palliative care which has arisen over the last few decades is capitalizing on this mismatch and showing that there is another way of not being aggressive with treatments during the dying process and they have shown scientifically that, in a lot of cases, people actually live longer with just having their symptoms treated rather than trying to cure the incurable underlying disease process.

Other systems look at us somewhat amused, ‘Those crazy Americans – they see death rates ticking up from cardiac disease and put everyone on aspirin, everyone on a statin, train more cardiologists. And then the cancer rates start to go up so more cancer centers, new chemo regimens, new biologic tumor annihilators. And now it’s an increase in dementia so more work on new drugs to prevent it (so far unsuccessful). Don’t they realize that the numbers always add up to 100% and all you can do is move people from one category to another?’ The problem is, we really don’t when it comes to how our health system actually operates. I am fond of reminding Medicare insurance executives of the fact that everybody dies in meetings when they’re touting how wonderful their product is at keeping people alive. It has not endeared me to them but I don’t mind.

This issue of morbidity vs mortality is going to play out during the current pandemic. I don’t know how yet but it will be interesting to keep comparing the response in other countries to what we have here. I remain afraid that we’re still in early days with this thing, no matter how tired we all may be of our disrupted lives.

Stay well.

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