Designing our health

Ashby Wolfe MD, MPP, MPH

Ashby Wolfe is a resident physician in the Department of Family and Community Medicine at the UC Davis Medical Center in Sacramento. She holds an MD as well as masters degrees in public policy and public health. She blogs at and is a guest blogger for on issues of family medicine and community health. Her opinions are her own and do not necessarily represent the views of UC Davis or

As our Congressional representatives and Senators continue to negotiate and compromise in order to draft a universal piece of health reform legislation, I am reminded of a statement paraphrasing Virchow:

“Medicine, if it is to improve the health of the public, must attend at one and the same time to its biologic and its social underpinnings. It is paradoxic that at the very moment when the scientific progress of medicine has reached unprecedented heights, our neglect of the social roots cripples our effectiveness.” (Eisenberg 1984)

These words could not have rung more true than in a recent visit with one of my new patients. For purposes of the example, let us call him Mr. Smith. He is a 40-something gentleman, a 2 pack-a-day smoker, who has never needed to visit a doctor in his adult life until two weeks ago when he could not catch his breath and was running a high fever. Mr. Smith was seen in the emergency room, treated, and told to “follow up with his regular doctor” for further management of his severe obstructive lung disease – likely a consequence of his 30 year smoking history. Fortunately, he had health insurance and the fact that he didn’t have a regular doctor was not lost on him.

So he ambled into my office for the first time last week for a check-up. At first glance Mr. Smith was slightly out of breath but an otherwise healthy-looking gentleman, with an athletic physique. As I talked with him, it became clear that he was struggling at his construction job primarily because he could not catch his breath; and his single inhaler was not relieving his symptoms. He told me that he didn’t want to quit his job because he would lose his health insurance, but that he was worried that he would get fired if he could not do his duties as a result of his current state of health. He also informed me that he was running out of his medication, but could not afford the $30 co-pay at the pharmacy to pick up his remaining refill. “Doc,” he said, “I have to put food on the table and pay the rent, you know.”

This is a situation many of us have heard before – either spoken by a politician stumping for votes, or by community members advocating for a better system of care. It is a different feeling entirely when you in a position having a direct effect on another person’s health. As I talked with Mr. Smith, I felt that his future held one of two outcomes that I could predict with cold certainty: (1) that he begin to use a (cheap, generic, available) medication which I wanted to prescribe that day, even if that meant sacrificing some other purchase this month, and would therefore receive the treatment he needed; or (2) that he not obtain his medications which would undoubtedly result in another expensive trip to the emergency room.

Some of you may be thinking “I bet those cigarettes cost money – couldn’t he choose between medicine and cigarettes instead?” The answer, of course, is yes. But does the visit end there? Could I say that to this patient and believe – really believe – that would be enough? That I would have done everything I could for my patient? Yes, it is true that his lung condition is likely due to cigarettes. Yes, he probably could afford the medication if he quit smoking. And yes, I do believe that my patient has a responsibility to himself to make that decision to quit…and I want to help him quit as part of his overall health care plan. But quitting smoking takes time, discipline and – let’s face it – hard work. So what to do in the meantime while he works on quitting completely?

The above example is just one of many stories health professionals collect on a daily basis – and it demonstrates just how interconnected our well-being is to all aspects of our society including the health system. In reviewing the national health reform bills with the above story in mind, it occurred to me that our current health system is perfectly designed – to result in the current health outcomes that we see every day:

(1) most health insurance is linked to employee status; so if one gets sick or loses a job, it becomes very difficult and expensive get care, see a regular doctor, or obtain basic health services

(2) as a society we value advances in medical technology that provide quick relief or immediate treatment, so our care is often expensive and less sustainable than cheaper, long-term alternatives

(3) our environment and lifestyles often do not promote our making healthy choices

So, what do we do about it? Do we lose hope in the current process? Do we shrug and say “well, health reform would have been nice, but you can’t win ’em all”? The reality is that we must make difficult decisions about how we will use available resources to improve our health. This is the very essence of why national health reform is so important and essential to our welfare. Is it really the best use of our time, energy and money if some of us can afford all kinds of extra health care, and others of us must choose between an office visit with a $40 co-pay and dinner? The fact is that despite what special interests in Washington DC will tell you, most people in our country support health reform once they are made aware of the specifics contained in the legislation (Kaiser Family Foundation 2010). For those of us who have been in a room with someone like Mr. Smith, that fact alone makes all the difference in our hope for a system designed to improve our health.

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