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Getting health care right

Our Nation's Health Care System: A Conversation With Abigail Neely

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It's now common to refer to health plan members and patients alike as “health care consumers,” and to talk about the trend toward consumerism in U.S. health care. But what does that really mean — and is this mindset a good one to embrace?

That was the topic explored by four experts with diverse backgrounds in “What Is Health Care Consumerism?”, the last of the 2015 Vital Signs Health Care Forum Series events.

Co-sponsored by the Pittsburgh Post-Gazette and Highmark Inc., the Health Care Forum Series included four free events where a panel of experts and the general public discussed critical topics shaping the present and future of the U.S. health care system. To extend these conversations, several panelists and Highmark Health experts also generously took time to share additional insights on the Highmark blog.

Abigail Neely

Abigail Neely is an assistant professor of geography at Dartmouth College who studies relationships between the material world and how people understand that world through institutions, culture and experience. She has done extensive research in rural South Africa focusing on who and what changes health, and how an understanding of both material and symbolic influences could change how we think about health programs.

Don Bertschman (DB): You study the physical and cultural impacts on health — which is not the first thing most people expect of a geographer. What background and motivations led you into your field?

Abigail Neely (AN): Geography is a broad discipline. There are physical geographers who in other instances might have been ecologists or geologists. Human geography ranges from economic and sociological study of populations, to philosophers who create social theory, to my work, which I sometimes describe as a cross between history and cultural anthropology. And then we also have cartography and geographic information systems (GIS) — the people who collect and analyze spatial data and who make maps. What ties these together tends to be a commitment to broad questions that are intellectually exciting and important practically, an interest in using a mix of research methods, and an interest in the relationships between people and their environment.

After I finished a master's in geography, I went to work for the Environment Unit of the United Nations Development Program in Namibia. What Namibia has accomplished in terms of conservation is impressive. You have many groups working together: the United Nations Development Program, the government, NGOs and communal conservancies. I knew that I wanted to eventually get a PhD, and I initially had the idea of studying plant transfers and human migration. But in Namibia, I would go to meetings of all these groups doing remarkable work, and at the end of every meeting it would be clear that the biggest challenge we faced in Namibia — this was 2005 — was HIV/AIDS. Half of the staff at any given time was sick, dying or caring for somebody with HIV/AIDS.

It was an unbelievable realization that this place which had done remarkably well in all ways when it came to nature conservation — and for the most part in terms of caring for people and addressing the social justice and environmental concerns that I hold dear — was being undermined not by funding, but by this disease. We had world-leading scientists almost in tears at these meetings trying to figure out what to do.

When I left to do my PhD, I wasn't sure that doing research on anything that wasn't related to HIV/AIDS mattered because of what I had experienced. As a result of that, and my interest in thinking historically and geographically, I chose to do research about the relationship between health and environment, and in particular I wanted to study environmental conditions that we don’t always think of as environmental. The type of question that had come to me through my experience in Namibia was what could we do about, and what did it mean to look at, HIV/AIDS as an environmental disease? That's how I ended up moving in the direction of my current work.

DB: In the Health Care Forum you participated in, the panelists all had at least some reservation about the word “consumer.” What do you see as the drawbacks to a “consumer” framework when it comes to health care?

AN: I have three major reservations with the notion of “consumers.” First, we think of consumers as individuals. So, in the context of health care, now we're thinking of individuals who access health care to improve or maintain their own health. There's a way in which that's fine. But it also hides how health is tied to the communities in which individuals live, as well as the larger society and broader forces that they may or may not have control over. Talking about a “health care consumer” individualizes our understanding of why someone is well or ill — and then all the solutions that come from that mindset also become individualized.

Second, consumption in this country is tied, in both discourse and reality, to our economy. If consumption levels rise, the economy is assumed to be doing better. But we also see consumption as a problem. Overconsumption is linked to debt, which we think of as bad. With this framework, health care “consumption” becomes either a luxury or irresponsible; those who consume too much are irresponsible and those who can consume a lot are in the market for luxury goods. When a good is a luxury, it's OK for only certain people to have access to it. That mindset cuts off the possibility that health care is a basic right that could be something everybody has access to.

Third, on our panel, David Meyers brought up the idea that the consumption model implies that we're consuming or competing for finite resources. That doesn't make sense with health and health care. Why is health a finite resource? Why can't we build and grow?

Think about discussions around the Affordable Care Act, and health plans getting labeled “Cadillac plans,” for example. When we think in terms of consumption, money is always driving the equation. If you have money, you have access to health care, if you have more money, you have access to more health care. If health care is a right, however, questions around money either fall out or need to be framed and approached quite differently.

DB: The consumerist framework also tends to shift responsibility to the individual. Health becomes about personal behaviors; controlling costs focuses on increasing out-of-pocket responsibility so individuals pay attention to their health spending. During the forum, you mentioned “social medicine” — how does that differ from a consumerist approach?

AN: One way we understand health is through a biomedical framework. If I'm ill, treatment will involve biological medicine to manage or get rid of the pathogen in my body. Social medicine includes the biomedical approach, but it also says it's not simply that pathogens make individuals sick; certain people get more sick, or get sick more often, because of social circumstances, such as where they live, income, education, race, gender and age. Social medicine takes into account these social determinants of health, as well as the biological determinants.

That framework makes the practice of medicine quite different. I do research in Pholela, a rural area of South Africa. Between 1940 and 1962, the government implemented an experimental social medicine program at the Pholela Community Health Center. That brand of social medicine came to be called community-oriented primary care (COPC). The vision developed in Pholela was that the majority of care should not be provided by doctors or nurses, but by health educators who spoke Zulu and for the most part lived in this place — and further, that it should be done in the homes of the residents in addition the health center.

This played out through educational visits to talk about hygiene or nutrition, for example, or provide information on communicable diseases like syphilis or tuberculosis. But the health educators would also do things like encourage people to build vegetable gardens — and, in fact, helped community members build gardens and brought seeds and tools. They also had a state-of-the-art medical facility staffed by doctors and nurses, so the attention to what could be done at home was coupled with top-of-the-line clinical care in the health center.

This model relied on local relationships, but it was fully funded first by the South African government, and then also by the Rockefeller Foundation, which meant that people accessed this health care for free. There was never an assumption that these people, some of the poorest people in South Africa, should pay for it — this health care program recognized that people had a right to health care.

This program — and eventually there were more than 40 more health centers like this set up in South Africa during this period — has been called one of the most successful health interventions in the history of the world. Infant mortality rates dropped by more than 67 percent; crude mortality rates dropped by more than 40 percent; acute malnutrition all but disappeared. And much of its success was linked to its focus on the social determinants of health and to the relationships the health center established in the communities in which it worked.

DB: Can something like this be done on a larger, national scale, or does it necessarily have to stay at this community level?

AN: The short answer is probably a little bit of both. Let's think about the larger scale first. In 1948, apartheid began in South Africa. The doctors who started this community center found their work more and more difficult. Many of them eventually left South Africa, sometimes under duress and protest, but doing so, they brought this model all over the world. Jack Geiger, a famous social medicine doctor in the U.S., had trained at Pholela, and he later ended up talking to Sargent Shriver as Lyndon Johnson's Great Society program was being conceived. Under the Great Society program, the U.S. implemented a huge network of community health centers basically modeled on Pholela. Those centers now help over 14 million underserved people in the U.S., but they do so through the community model.

So there's a way these kinds of things can roll out on a large scale, but they have to be specific to a community, with a commitment to the people of each community.

DB: If I understand what I've read about the book you're working on, you're emphasizing that we can't overlook the impact on health of cultural and political practices that we might think of as separate from health. In Pholela that includes witchcraft; in the U.S., would we also look at the impact of marketing and political ideology?

AN: One major lesson that comes out of my work is that thinking about the impact of something like witchcraft on health in Pholela helps us recognize that health might be more complicated than the way we understand it through thinking just about our biological bodies and social systems.

In the U.S., one example of thinking about health in terms of politics is the obesity epidemic. How do we know what we know about obesity?

There's a fabulous book called “Weighing In” by Julie Guthman that examines everything from how obesity has been constructed literally as “an epidemic” to shortcomings in how body mass indexes that define normal, overweight and obese are calculated; to how we define "normal" at a particular moment in the past, and when it's not linked to health outcomes; and much more.

Guthman also looks at how thinking of obesity as a problem is linked to what are now termed “lifestyle diseases.” Think of that phrase — “lifestyle” is something you choose, right? So we're framing type 2 diabetes and hypertension and other conditions as lifestyle diseases, focusing on individual choices, when we don't know all the causal mechanisms for these diseases in either specific cases or even generally.

Now, people of color, poor people and women disproportionately fall into the categories of overweight and obese — and we should think about why that is. Where do these people live? Can they walk around their neighborhood? What kind of commute do they have? What kind of food do they have access to? How much money do they make, and what can they afford to buy? In other words, what conditions shape their livelihoods?

Guthman also talks about “healthism,” which is the notion that a normative body, as in the body we should all have or should want to have, is a healthy body, and you need to get there through things like diet and particular kinds of exercise, most of which cost money. Generally speaking, this means that the so-called solutions to the so-called problems of obesity are not geared to the people who are likely to fall into the obese category — the people who can't afford healthy food or gym memberships, and live in neighborhoods that aren't set up for people who want to exercise. Rather, they are geared to people who tend to be barely over the line into the overweight category, who have extra money to spend, and who will spend it on this industry's products and services if they believe their weight is a problem.

Like others, she also links all of this to how the U.S. farm bill heavily subsidizes things like corn, but not vegetables. So corn-based products become cheaper, which means people buy more of them. But here's the punchline of her book: The problem is that our nation needs cheap food; and we need cheap food because wages are low. In other words, many people eat cheap, corn-based food — and need to eat it — because they don't make enough money to buy vegetables.

The myth of obesity — and the very survival of the diet industry — rests on the notion that if people just made healthier choices, they wouldn't be obese, and that individuals make money according to how hard they work. The logic is that if people worked harder, they would make more money, and then they would buy better food — so everything comes back to personal choice. The fact of the matter is that many obese people are not truly able to "choose" what they eat.

DB: You captured that quite well at the forum when you said, “We all make health choices, but we don't all make those choices under conditions of our own choosing.”

AN: Right, and so work like Guthman's helps us think about how the health of a large part of the population is embedded in the wage structure of this country, which is quite uneven.

It's intuitive at a certain level that our mental and physical health is connected, and that our social lives and relationships matter to our health. People get that. But Guthman is showing how the broader political economy — our intertwined political and economic systems — also shape health at the societal level. Adding that perspective changes how we think about health problems, and what the most effective solutions would be.

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