Guest Post: "A health care catastrophe"

Good health is 20 percent medical care, and 80 percent the social determinants of health.

      Jonathan Gell, M.D.

After four decades practicing medicine, Jonathan Gell concluded that the health of any one individual is a reflection on the whole society. It is a cultural issue. An economic issue. An infrastructure issue. It is public health in the broadest sense. As a physician in a hospital, he realized he was at the back end of a person's health outcome. He was the "last responder." And he told me that Donald Trump's approach to U.S. health care is a catastrophe.

Jonathan Gell shares his biography and thoughts on the politics of healthcare in his guest post.

Guest Post by Jonathan Gell                   

“You don’t miss your water ‘till the well runs dry”
         William Bell, 1961. Covered by the Byrds on Sweetheart of the Rodeo, 1968

Trump is a Health Catastrophe 

I spent 40-plus years in Southern Oregon's Rogue Valley as a healthcare professional. After 10 years in private practice in the 1980’s, I moved to an administrative position as medical director of both Providence Hospital and Asante, the two hospitals in Medford. Later, I worked in the hospital caring for sick adults, and later still in skilled-nursing homes. I learned where health comes from. About 20 percent of the health of a population derives from health care, that is the doctors and nurses and others working in clinics and hospitals. The other 80 percent comes from effective public health and the social determinants of health (SDH). SDH can be either positive or negative. Examples are:.

Peace or war
Food or famine and drought
Clean air and water or pollution and unsanitary water
Living wage or poverty
Education or poor educational access
Social order and tolerance or social chaos with intolerance
Access to effective healthcare or quackery

If I had to summarize my role in health care in two words, it would be “last responder." All homage to the first responders on the front lines: EMT’s, emergency room doctors and nurses, and even primary care providers assessing patient issues in their offices. But that was not my role; I saw patients when the assessments and treatments had not helped. 

 

Before embarking on a new treatment plan, which might well be onerous, it was incumbent on me ethically to explain the rationale for the plan, detail the risks and cover alternative approaches that could be taken, including no further treatment and comfort care only. It was also my responsibility to check that the patient understood this information and to give them the opportunity to ask questions or seek the advice of others.

Trump and his appointee Robert F. Kennedy Jr. are embarking on a new plan for the health of our nation. They are arranging cuts to programs that help states address infectious disease, mental health, addiction and childhood vaccination. We are seeing plans for massive cuts in the Centers for Disease Control and Prevention, the Food and Drug Administration, the National Institutes of Health, and the National Science Foundation. Trump’s attorneys from the U.S. Department of Justice have sent veiled-threat letters to multiple esteemed medical journals including NEJM (New England Journal of Medicine) and Chest, implying that the journals are partisan. Cuts to programs to curtail AIDS in Africa will likely kill millions, with the threat of resurgence here. Texas is already seeing rising mortality rates in pregnant women. Cuts to education, housing, food assistance and the other SDH are forthcoming.

RFK Jr.'s Make America Healthy Again urges improvement in American health with concerns about rates of chronic illness without acknowledging the reduction in mortality rates in cancer and heart disease over recent decades resulting from research and new treatments. If he had highlighted the continuing role of tobacco and alcohol, I would applaud. I have no problem with efforts to improve pesticide safety and making better food choices -- though this is hardly new information. Project 2025 notes excess influence of Big Pharma on the FDA; I have no disagreements there, but then they proceeded to cut the staff that oversees drug safety. Project 2025 was also highly critical of the CDC's having recommended closure of houses of worship during the pandemic. Project 2025 felt the CDC had no business deciding that saving lives trumped saving souls.

Has Trump explained the rationale of his plan for America’s health? Has he or RFK listed alternatives or possible negative results or side effects of their prescription for America? Are they answering questions coherently, focusing on known science? No. Trump feels his election was informed consent. 

Eisenhower warned about the military-industrial complex. There is a medical-industrial complex that needs much work. There are alternative approaches to how we are handling health care in the U.S.  But destroying public health, undermining the social determinants of health, cutting access to health care, and calling global warming fraudulent will create a catastrophic cascade of avoidable events. Rural hospitals and clinics are already stressed, and access to health care is one of those social determinants of health. They won’t survive cuts to Medicaid. The local veterans hospital provides essential services to the Rogue Valley, and cuts are expected there. Oregon Health Science University in Portland is currently losing about $8 million a month, and it is anticipating a $70 million cut in federal research funding. Will there even be a CDC to track and post the upcoming calamities?

 

Being healthy isn't what a physician does to you. It is what the society you live in does to you and for you, and what you do to yourself. During my medical training in the seventies, I was counseling a smoker with lung disease to quit. He retorted that there were more old smokers than old doctors. Doing the math, I realized that was numerically true (170 docs for 100,000 people versus 40-plus percent of adults who were smokers). I didn’t see him again, but likely his lungs did him in  Lung deterioration does stabilize in those who quit smoking. RFK reminds me of that old smoker, except he is deciding on your family and community’s future health.

We will sure miss the water.

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