Thinking Unconstrained

Examining the world with a critical eye. Topics span a wide range including but not limited to, observations, insights, problems, solutions, proposals, and hypothetical scenarios.
Emergency services are an integral part of the functioning of any safe and well governed society. Emergencies are supposed to be rare occurrences, but when they do occur, those services thankfully ensure that they're taken care of professionally and without any strings attached. An ideal society then runs its emergency services through public entities for the benefit of all the people within their jurisdictions. When there's a fire, the fire department comes to the rescue. When there's a crime, the police department comes to the rescue. When there's a medical emergency... Well... Stop and remember the following steps as you agonize tremendously before deciding if this is indeed an emergency:

1. Deliberate on whether it's better to call an ambulance or have a friend drive you to the hospital, since an ambulance ride will cost you an arm and a leg - hopefully not in a literal sense.
2. Decide if you want to walk through the doors of emergency care or wait until morning for regular/urgent care, since going to the emergency room will cost you a stupendous amount.
3. Try to remember which hospital is best for the type of insurance you have and how the coverage plan impacts it. Is the clinic/hospital in-network? Will the insurance even cover this emergency condition I have? Should I call the insurance before going to the hospital to make sure? How much am I going to pay if I have to stay at the hospital over night?

If this is the modus operandi of modern healthcare, then I think it's no understatement to say that the medical emergency service of today falls far short from the ideal. It simply cannot be called an emergency service if the citizen needs to make a decision between receiving life saving care and that of emptying her bank account. After paying a third of her taxation into healthcare, one would expect that receiving a decent care from her public contribution is only fair and decent. Alas you're a fool to expect such a treatment. Your life is only as good as your bank account. The roulette of death chose your unlucky behind on this fateful evening, and you must pay either "Mr. Black robe" or "Mr. White robe" if you want to live another day.

So the question is, why is this tolerated and why can't it be fixed? The obvious broad stroke answer to the question is that it's broken for some, but it works conveniently well for others. Otherwise it wouldn't continue to be so. Who does it work well for? The doctors, nurses, medical staff? The insurances, pharmaceuticals, medical companies and labs? Or maybe the lawyers, governments and NGOs? Or is it that this is what the system naturally devolved into as a continuing trend brought about by other non-obvious forces? The answers are likely many. The yarn complicated to untangle. But surely healthcare was not always so, and this modern incarnation is not an acceptable service by any measure. Let us then follow the serpent intertwined around the rod of Asclepius and get to the root of this inhumane situation. Let us see if the snake is rotting from the head down or the rot is stemming from the bottom of the stick.
Healthcare is expensive. Ergo emergency healthcare is expensive. People go to emergency healthcare because they don't receive good healthcare. People can't afford to get good healthcare because it's expensive. A catch twenty two situation, a circular logic, and a death spiral to be sure. So the pertinent question is, why is it so expensive in the first place? Perhaps framing the question in this way is the wrong approach to solving the problem, as the most obvious and moot answer to it is that "they" all need/want money for a variety of reasons. A better way to look at the problem may be to ask what is the ideal situation for both the patient and the doctor so as to minimize the middlemen, and hence keep only the minimal cost. That way, we can see why certain entities need to be paid and why some things are more expensive than they actually should be.

An ideal patient from a cost standpoint (and one's own health viewpoint) is one that has no problems; Someone who does not need to see a doctor unless there's a medical condition needing attention. A healthy patient requires no treatment. Preventing a healthy patient from turning into an unhealthy one, who would then be susceptible to all manner of medical conditions, is an important part of keeping the medical cost low. The steps to achieving this are seemingly simple but seldom followed; Eat healthy, keep stress low, and get enough exercise. Such a person would only need to go to the doctor for checkups and tests, and would need treatment only when certain conditions arise. An unhealthy patient on the other hand would need more regular visits and treatments, which overall amounts to larger medical bills. Now, let's have a look at the viewpoint of an ideal doctor.

The doctor's foremost primary interest is in the patient's health and well-being. As such, when a healthy patient comes in and does not require any treatment, he is delighted but he is also reservedly thorough to ensure that there aren't any hidden conditions that may cause problems later on. Such a doctor is referred to as a general practitioner or a primary care physician, and he is the one in charge of preventative care and of making referrals to specialists. Since this type of doctor needs to understand many different types of diseases and needs to directly interact with more patients than specialists, he provides a much needed first line of defense against illnesses and acts as a buffer for the medical community in general.

A well-functioning and healthy society then ensures that the people are healthy in the first place. Those that need minor medical attention should be easily taken care of without requiring additional complexities. For those that require serious medical interventions, they should be addressed by specialists and other secondary/tertiary care physicians. This is the ideal setup, a heavily simplified point of view, without involving other extraneous components. We should start from this baseline to identify the wrong things that deviate from this ideal. I think there are several obvious problems even at this basic level.
You mean like the fact that 42% of American adults are now obese and that an additional 31% are overweight? Therefore 73% are at high risk from all sorts of diseases, not just to cardiovascular and insulin resistance but to others such as various respiratory conditions? Why, that's ludicrous! These people are "healthy", and they can't possibly be bogging down the health system with their easily preventable conditions... These numbers are from 2018 but who knows what the actual numbers are in 2021, given that many people have been living a bunkered existence subsisting on snack foods and takeouts for almost a couple of years. Let us then conservatively assume that the overweight population is now at 80%. That is, 80% of adults are now in need of additional care from medical facilities, not to mention the additional cost that needs to come from somewhere to cover the medical bills. In other words, they are ill, and have a high chance of running into complications from all sorts of diseases that may otherwise be benign to normal weight individuals.

But it's not only the adults that are at risk. Obesity rate among children is at 20%, again using 2018 numbers. Due to the fact that many children have been stuck indoors and have been eating the same diet as their parents at least for the last 18 months, let us conservatively say that this number is actually at 25% in 2021. One in four children are thus sick, and have compromised health. Therefore can one state with a straight face that preventative care is working? Or to fine-hone the point, can one who is impartial to the medical establishment observe the evidence and acknowledge that preventative care is creating a healthy and fit population? Can one claim that an obese 4 year old is the epitome of a strong and vibrant child full of vigor and vitality? No, there isn't a single person in the medical field worth their salt who would say such a thing.

To be fair though, one must also understandably ask, how can a primary care physician dictate the diet and the lifestyle of his patient? Authoritative medical intervention is unethical and fundamentally goes against the sanctity of bodily autonomy. If a patient insists on not following a prescribed treatment, the doctor cannot force the person to do it. If 80% of his patients insist on eating playdough putty masquerading as "food", and desire to live as a sofa-spud, then the doctor can only refer them to "specialists" in a last ditch effort of winning against the certain time bomb ticking away on the electrocardiogram. In this sense, primary care is working. But it's not working well enough. The medical establishment as a whole suffers from this first grave misstep of defense. "Prevention is better than cure", says the old proverb. To cure the ills of the medical establishment, it must then first prevent it from becoming ill in the first place.
Losing weight is not easy, especially for those who have lived with pounds load of it throughout their lives. A big person looks in the mirror every single day and knows that her body is not as it should be, even though she may try to convince herself that being heavy is beautiful or that it is now socially acceptable since everyone around her is as well. But she's wrong and she knows it. This is a disease, and frankly put, overweight people are gravely ill. The level of fat accumulation is bizarrely high, as if they were poisoned at the cellular and glandular level. They have constructed their bodies with low quality food stuffs and reversing that damage may not be a viable option. Any effort made to fundamentally shift the scales may be temporary and may require other stricter measures than for someone who gained the extra weight later on in life.

Not only that, the decision to no longer be a big person is as a radical thought as deciding to change one's identity. You'd have better luck convincing an alcoholic to stop boozing or a smoker to quit than to turn a life-long heavy sugar fiend to eating a moderate diet. It's as much a psychological battle as it is physical. And that battle is much more difficult to win, especially given that we have very little understanding of ourselves and our psychological constructs. But we've defeated other deadly addictions before - Western society managed to mostly "kick the habit" of tobacco use in the past couple of decades. And that certainly gives us hope that "kicking the habit" of eating bad foods is also an achievable goal. We can draw some common parallels between these two addictions to help us along. Perhaps that might give us a better understanding of the picture.

Tobacco use in the west is a tradition of almost 400 years and that means it has a lot of emotional and cultural weight behind it. We recall memories of hazy, congested, eye-watering, dim-lit rooms baptizing our bodies with its distinctly odorous perfume. Overflowing ash trays impaled with cigarette buttends were the norm, as if we were ritualistically stabbing the voodoo dolls of ourselves as a form of cruel mortification. The smoke stained cathedral roof of the car interior, and those hideous yellow-black-rot teeth of our loving relative's heartwarming smile; Our future selves reflected in those pearly golds. But even with all these apparent negative aspects, smoking made us feel like movie stars. We were rebels against ourselves and the establishment. We felt empowered. And we kept telling ourselves that how it made us feel and how it changed our perceptions were what mattered to us. Even when our health deteriorated to such a degree that it couldn't be ignored any more. When the pain got bad enough, we grudgingly made our way to the doctor's office. We sat in that clinical chair and intently listened to the physician as he told us with a concerned expression that he would make a referral to a specialist about that persistent blood in the cough. His face was visibly distraught. The hand was fidgeting. It moved into the coat pocket of his pristine white coat, and out came a packet of "most doctors smoke this than any other cigarette". We watched him slide one tube out of its factory perfect case and let it go through its familiar torching ritual. That click of the flint, the spark in the leaf, and the long smooth drag was enough to trigger the automated Pavlov response. We promptly joined him as we took out our own favorite brand and lit up. Then we coughed up blood on the floor of the doctor's office as he understandingly patted us on the back. We looked up at the good doctor, and gave him an apologetic smile. We were all thinking the same thing - "Those cigarettes sure are smooth though, right"?
Mobilize the lawyers, they're threatening our bottom line! These people are insinuating that the "brand that doctors prefer" is the cause for people getting lung cancer! Shut them up and shut them down! Your honor, we object to this heinously false accusation. There is absolutely no link between lung cancer and smoking. Ask this panel of medical experts (*psst*, Jimmy! We really need to better hide their affiliations to us) who can testify to the absolutely unquestionable truth of the health benefits that moderate tobacco smoking have on the American public. It's a travesty of justice that such misinformation and outright lies be allowed to be told unchecked to our fellow citizens. It's our duty to protect their health by any means necessary, and that means accusations such as these and other similar attacks against the tobacco industry at large must be considered illegal and downright immoral. These people are criminals, your honor. Their lies will cost the American people of our vitality and dare I say, our god-given freedom to live a life of liberty and pursuit of happiness... *Cough*! *Hack*! *Cough"!

That was Jimmy Sr. back in the day. He made a good living and passed away due to lung cancer at a ripe old age of 62 years. His law firm, "Hooke, Lien, & Sinker LLC" grew to become a juggernaut in "their law" world, and after his passing, he was succeeded by his progeny, Jimmy Jr. The well respected and prestigious law firm now handles many different corporate clients spanning a wide range of industries, delivering unmatched excellence and professionalism in all dealings both complex and confidential. We had a chance to meet with Jimmy Jr. this week for an exclusive and rare interview. When asked about the legacy of Jimmy Sr. and the irony of his death brought about by lung cancer, now affirmatively acknowledged to have been caused by his notorious chain smoking, he replied that "daddy bravely did what was expected of him, and I'm proud of what he accomplished for his clients". We cannot argue with him there. The man was certainly a man of integrity. So much so that he died for his clients. This is dedication, and this is what "Hooke, Lien, & Sinker LLC" is all about. Its lawyers will happily stand by you till death do you part, as long as the price is right! Jimmy Jr. lives happily with his wife and their 3 children in the pristine and immaculate town of Silverspoon, USA.

The story of Jimmy is only one aspect of the law, and attests to the tremendous power it can posses when used in the hands of organizations with deep pockets. But the law is also a powerful protector of the rights of the little people. Take a look at the legal protections that healthcare employees enjoy. Whenever a patient comes in to the doctor's office, he must sign a tome of paperwork, to ensure that there is absolutely no way that the patient can ever win a malpractice case. The initials, signatures, and scribbles absolve the medical staff from any mishaps or complications that may arise during the visit. Nobody ever reads these in detail, nor do they understand what they mean. However we must all sign if we want to receive care. But does this mean that the patient gets the highest quality care he deserves from the legally-fortified and ironclad army of Hippocrates? Well...

We'd like to think so. But there is doubt whether one can receive the best healthcare by tying the hands of the medical staff from properly doing their jobs. Why is it that a doctor should be afraid to practice his profession properly according to his years of training and accredited qualifications? He often needs to follow the clinic's protocols for reasons other than what is best for the patient. There's an obvious conflict of interest here, and naturally an inevitable erosion of trust between the patient and the medical field overall. The legal bindings bind the hands of both the healthcare staff and the patient. The laws do not work in their best interest, but rather for the fictional limited liability persons. Everyone else appears to be liable. Real people are "resources" and numbers on spreadsheets, plotted against risks and graphed in probability distributions. It appears we're just a statistic on a bell curve, and the individual is only an identifier.
Statistically speaking then, if 80% of the people are diabetic and/or have cardiovascular problems, there should be a separate fund just for "regular" treatments such as insulin shots and heart medications. These can be directly prescribable at the pharmacies with their own medical staff. They can also provide the necessary controls to ensure a safe distribution. The fund itself would be paid for by public pools at a drastically reduced/subsidized rate, bypassing extraneous components such as health insurances and co-pays (although they can still contribute. But they should not be necessary). One would also ramp up local production of these types of medications for the public good, rather than relying on global logistics, which can be sensitive to supply problems and other issues such as contamination and quality control. Taking these steps would provide a sorely needed stop-gap measure until a more permanent solution can be implemented to fix the obesity problem. Hopefully they would be enough to significantly ease the load of the medical establishment in a generation or two.

The production and distribution of these types of medications in this way is not a controversial idea. The common annual influenza vaccine works in a similar manner. Therefore there's no compelling reason why diabetic and heart medications cannot be deployed in much the same way. The added benefit of this type of approach is that fixing the obesity problem will likely make those vaccinations moot for the majority of the population, as they would have a stronger immune system and hence better able to fight against common seasonal respiratory illnesses. For these populations (aside from the elderly and other immune-compromised segments), taking the vaccines would only provide a marginal benefit, if at all. That is, unless an unusually potent strain with a high mortality rate posing a significant danger to healthy individuals were to find its way into the general population.

If such a situation were to occur, one would hope that there would exist a suitable protocol to effectively contain and resolve the pathogenic threat in a professional and disciplined manner, as one would have for military entanglements. If such foresight is lacking, then one would hope that the military would be used to bolster the medical facilities and implement effective marshal law containment before the problem has a chance to become widespread. They would convert non-medical facilities to temporary wards, call on anyone with medical training to assist, ramp up industrial production of life-saving medical apparatus and medicines, distribute hazmat suits to critical personnel in highly contaminated areas, etc. If such efforts are not effectively exercised or done in half measure, the disease would be so widespread that there would be no choice but to accept its presence in the general population. At that point, one would hope that it would either mutate to a benign variant or an effective treatment to starve it of potential hosts would become available. In the meanwhile, any and all treatments to reliably control the symptoms and increase the chance of defeating the disease would be embraced unanimously by both the medical community and the public at large. If such treatments were not available, one would expect mass graves and pandemonium in cities would be the result of such failure. The officials would get an F- on their public health and effective governance exams, and there would be vehement calls for resignation en masse. That is, if they were to survive such a devastating disease of epic proportion in the first place.