One of the wrong questions you will hear raised in the upcoming health care debate is this one: Aren’t the poor outcomes in health care in the United States all the fault of the bad health choices Americans make? Stated baldly: “It’s not our fault, it’s those irresponsible citizens who account for the bad health care outcomes.” As it happens at the Mailman School of Public Health at Columbia University researchers Peter A. Muennig and Sherry A. Glied, asked just this question. They compared the health care systems of 13 first world nations, including the United States, Australia, Austria, Belgium, Britain, Canada, France, Germany, Italy, Japan, the Netherlands, Sweden and Switzerland.

Their study, which covers the years 1975 to 2005, is particularly important, not only because it is recent and well designed, but because in addition to health care expenditures in each country, it focuses on 15-year survival for people at 45 years and for those at 65 years. As they say in their report published in the November Health Affairs journal:

Many advocates of U.S. health reform point to the nation’s relatively low life expectancy rankings as evidence that the health care system is performing poorly. Others say that poor U.S. health outcomes are largely due not to health care but to high rates of smoking, obesity, traffic fatalities and homicides. We used cross-national data on the 15-year survival of men and women over three decades to examine the validity of these arguments. We found that the risk profiles of Americans generally improved relative to those for citizens of many other nations, but Americans’ relative 15-year survival has nevertheless been declining. For example, by 2005, fifteen-year survival rates for 45-year-old U.S. white women were lower than in 12 comparison countries with populations of at least 7 million and per capita gross domestic product (GDP) of at least 60 percent of U.S. per capita GDP in 1975. The findings undercut critics who might argue that the U.S. health care system is not in need of major changes.

Nicholas Bakalar, writing about the 30 years of the study in the The New York Times said:

In 1975 the United States was close to the average in health care costs, and last in 15-year survival for 45-year-old men. By 2005 its costs had more than tripled, far surpassing increases elsewhere, but the survival number was still last — a little over 90 percent, compared with more than 94 percent for Swedes, Swiss and Australians. For women, it was 94 percent in the United States, versus 97 percent in Switzerland, Australia and Japan.
The numbers for 65-year-olds in 2005 were similar: About 58 percent of American men could be expected to survive 15 years, compared with more than 65 percent of Australians, Japanese and Swiss. While more than 80 percent of 65-year-old women in France, Switzerland and Japan would survive 15 years, only about 70 percent of American women could be expected to live that long.

One of the most cynical aspects of the Illness Profit System, is that it hides its rapacity, behind the smiling humanitarian face of the health professionals who administer the treatments. Thousands of hours of advertising, showing us friendly doctors and nurses being competent and compassionate, re-enforces the natural deference we show to those who care for us when we are weak or ill. The system understands and exploits this just as it does the health professionals in its employ, exploiting their calling to the service of healing even as the system is constantly trying to corrupt them.

It starts with the broad population of physicians tempted with conferences at great resorts and spas, that qualify for continuing education — read presenting information on pharmaceuticals, that just happen to be made by the sponsors.

A second level of the process addresses a more select population. This concerns the fees paid to prominent physicians for speaking at conferences. Tom Detzel writing on the investigative siteProPublica presents a survey of seven companies using data taken from the companies own websites — information in some cases compelled by litigation to be released. In 2009-2010, just seven of the big pharmaceutical companies paid 17,700 presenters a total of $281.9 million to promote their products. These physician presentations were instrumental in a “combined prescription drug sales amounting to 36 percent of the $300 billion U.S. market in 2009.”

But it is in the third, most exclusive, tier of corruption that real damage is done. Science depends on properly executed studies accurately reported in an unbiased way. It is the fundamental code of all experimental research. In medicine it may literally be a matter of life or death. And it is exactly at this vulnerable fulcrum that the Illness Profit System seeks to corrupt physicians and medical researchers.

The Project on Government Oversight, is an independent nonprofit that “investigates and exposes corruption and other misconduct to achieve a more effective, accountable, open and ethical federal government.”

Once, years ago, walking across Louis Kahn’s magnificent campus designed for the Salk Institute, Jonas Salk answered my question about how he had seen so clearly what others had not seen. He said, “The answers are not the hard part. It is the questions. Asking the right question. That’s hard.”

We are about to enter yet again into the great debate over American health care, and the discussion once again will be mostly couched in financial terms. I want to suggest money is the wrong question, and it leads us to the wrong debate. Here’s what I think we should be asking: Is the health of the American people an essential part of our national security and prosperity? Is America better equipped to deal with the challenges of the 21st century when it has a healthy population more capable of working at its full potential? If the answer is “Yes,” then the next question to ask is: Why is our health care system so very bad — 37th in the world according to the World Health Organization? To answer that, we need to accept this reality and to start fixing it by telling the truth to ourselves about money.

The Center for Defense Information estimates the cost of the Iraq and Afghanistan wars will total over $1 trillion by the end of fiscal year 2010. We have almost nothing to show for these wars, and the sacrifices made by young men and women motivated by honor, duty and a call to serve. Yet we have made these wars such a priority that in the midst of the worst economic downturn in two generations we continue to fund them at a cost of tens of millions each day. It’s not about the money.

We have a defense budget that is larger than the defense budgets of every other nation in the worldcombined – $683 billion, going to $743 billion in 2015. It’s not about the money.

The sense of spiritual consciousness, connecting to something greater than oneself, is one of the most intoxicating realms a human can enter. Across the millennia, such experiences have shaped the lives of individuals and, upon occasion, whole cultures. The question for science is not to deny them, but to seek to understand the processes by which they occur and the domain into which they lead us. Central to these true stories is a special state of mindfulness, what the psychologist Charles Tart described in his classic 1972 Science paper as a state of consciousness.

Although these experiences, when they happen spontaneously, are often one-time events, almost every human culture on earth has developed practices, usually in a spiritual or religious context, for attaining this state. Similarly, all the martial arts have this component of mindful discipline, a practice of focusing intentioned awareness. Collectively, we have come to call these practices meditation.

Of all the things that you can do to know yourself, nothing will serve you as well as developing the practice of meditation. Although meditation is often associated with Asian cultures, it is not Christian, Jewish, Buddhist, Muslim, Satanic or any faith at all. It can be done in the name of any of these faiths, or without faith in a religion — as distinct from a spiritual sense. Meditation is a single term defining many practices.

The most important political and intellectual reality in America today can be seen in a 2006 CBS News poll, which found that a large segment of Americans “do not believe that humans evolved.” This sentiment is usually discussed in religious terms. I suggest it should be seen as a political statement.

The Gallup Organization addressed the same issue, but also included the age of the Earth, and conducted a series of polls of American adults in 1982, 1991, 1993, 1997, 1999, 2001, and 2004. In each survey the wording of the questions was kept the same, so that the polls would be equivalents, and multi-year analyses could be carried out. Here is the data from the poll taken in November 1991. The only significant difference between this and the 2004 poll is that in 1982, 44 percent held the Creationist view and in 2004 this number was 45 per cent.

It was Benjamin Franklin’s view that where justice was absent, civil society was impossible. He and the other Founders agreed on the essential importance of justice in a democracy. I feel the same way, and you probably do as well. If you do you will probably be as appalled as I was when I read the World of Justice Project report: Rule of Law Index 2010.

I will not deny that it has left me shaken.

To understand why I think this report is such a big deal, perhaps it will help to say who funded it: The Bill and Melinda Gates Foundation, The Neukom Family Foundation, the GE Foundation, The Ewing Marion Kauffman Foundation, and Lexis Nexis. I list them to make the point that this is the pinnacle of non-partisan philanthropy, not some political think tank with an agenda. We can trust the data.

The project, involving 900 researchers from 35 countries, who have polled 35,000 individuals, in addition to searching each nation’s records, presents itself in a way that Benjamin Franklin would have understood and endorsed.

No founder had as detailed a plan, or worked more diligently to create the kind of country he had in mind than Benjamin Franklin. Two things he knew were important were healthcare and having enough to eat. He was a founder of the first hospital on these shores, and worked tirelessly to create opportunities so that more and more poor people could move up into the middle class, thus assuring hunger would not be an American issue. As we prepare to vote it is worth considering where we are on Franklin’s goals on the eve of the election.

Physical Health

In 1950, before the inception of the present illness profit industry, the United States, compared with the world’s other leading industrial nations was fifth with respect to female life expectancy at birth, surpassed only by Sweden, Norway, Australia, and the Netherlands.

In 2010 the United States position concerning female life expectancy had fallen to forty-sixth. And when both men and women were combined it fell to forty-ninth. Americans live 5.7 fewer years of “perfect health” — a measure adjusted for time spent ill — than the Japanese.

Benjamin Franklin saw America as a democratic society: middle class, largely urban, technologically sophisticated, family centered, joyful, and upwardly mobile. The America we try to present to the world was largely Franklin’s vision. But recently we have been oriented more towards Ayn Rand than Benjamin Franklin. And we have been that way long enough that on the basis of data and not ideology we can evaluate how these anti-Franklinian policies have performed. What has been their success at nuturing and perpetuating the vital democratic middle class that has been America’s greatest strength — as important as its military prowess? There are many factors one might use to make this evaluation. Here are seven chosen across a broad spectrum of American society:

Tax Cuts:

Just as they did in 2000, the Republicans are running on an economic platform centered on tax cuts, and proposing that the Bush cuts be made permanent for the richest Americans. The 2008 income tax data are now in, so we can assess what their economic theory is worth, and how it fulfilled its promise that tax cuts would produce widespread prosperity by looking at all the years of the George W. Bush presidency.

EXCERPT:

In the spring of 1789, Benjamin Franklin was in his eighth decade and he knew he did not have long to live. Tormented by gout, eczema, kidney stones, boils and a host of other afflictions, he said, “little remains of me but a skeleton covered with a skin.” As he lay in bed or, on good days, when it was warm, sat under the large mulberry tree in his back garden at 318 Market Street in Philadelphia, he conceived of a way to reach out beyond the grave to promote civic virtue. “I have considered that among artisans, good apprentices are most likely to make good citizens, and, having myself been bred to a manual art, printing…I wish to be useful even after my Death, if possible, in forming and advancing other young men that they may be serviceable to their Country,” he wrote.

Franklin had drafted a will dated July 17, 1788, making generous disposition for family and others, including even his son William, who he thought had betrayed both him and America by remaining loyal to the British crown. Now he amended the will with a codicil, executed on June 3, 1789, which was a final expression of his belief that culture was formed on the development of personal character. In one of the grandest expressions of benevolence in American history, Franklin combined his goal of promoting civic virtue and his fascination with the power of compounding interest to make even small sums of money grow by creating two carefully structured philanthropic trusts designed to last exactly 200 years. He made separate bequests of 1,000 pounds—the equivalent of roughly $100,000 in 2008 dollars—to the cities of Boston and Philadelphia and instructed that the money be used to make small loans, at 5 percent interest per annum, to married men under 25 who had completed apprenticeships and wanted to start their own businesses.

Publication History:  American History, February 2009

Do you sense the schism occurring in the United States? Not the red and blue of politics, although that comes into it. Something deeper, a shift that is producing two very different reactions. Can you feel the ground moving? The zeitgeist of one population is grounded in fear, resentment, anger, and a sense of loss. It is theologically conservative, politically rigid, and exclusionist. The other population holds a sober realization that great change is coming, but also the sense that it offers at least the putative opportunity to create a more stable life-affirming culture. It is theologically and politically accommodating, and inclusionist.

We all have a vested interest in this schism and the struggle it has produced, not only because through our choices we are its source, but because we will live with the consequences of the decisions made over the next few years. What is particularly concerning is the obsession amongst the population driven by fear with willful ignorance. Yet it cannot be denied that this is an essential attribute of its world view. Only by denying a fact-based world can this perspective be maintained. Most of human history can be seen as a striving for deeper understanding. Science is the highest manifestation of this impulse, perhaps because it is the most objective manifestation. Yet now in the 21st century, we see its antipode emerge—a deep denial of science and the fact-based view of the world. Science, from this perspective, is just another political position, competing in the marketplace of ideas as a political theory.