08 March 2009

The American Way of Illness

Though President Obama has refused to seek to make health care in the United States universally available — a bone of contention in his campaign against Hillary Clinton last year — he has vowed to bring it closer to universality. As one whose health insurance (American) is flimsy at best, I like the idea of affordable, available health care. I’m baffled by those Americans who treat health as a kind of commodity, upon which prices can be put, and which should be bought and sold like pork bellies in a free market. I’ve never quite understood why a doctor who charges more is automatically accepted as better qualified, or why a drug that costs more is more effective. “This is a capitalist country,” my cousin told me tartly, when I asked why she opposed a health-care reform measure under discussion a few years ago. She’s not alone in her revulsion at the thought of “socialized medicine,” and there are powerful lobbyists working hard to reinforce the notion that any change in the system will be exactly that, and that “socialized medicine” is not merely a bad thing but the worst construct devised by the mind of man.

Mr. Obama has his work cut out for him, and I daresay it’s his awareness of this mindset that restrains his ambitions to change the health-care system in America. His opening bid is more modest than the one Candidate Hillary proposed, because he knows he’ll be negotiating with some very tough characters. They smashed Mrs. Clinton’s plans, 15 years ago, with the result that nothing was changed, and Americans continue to pay more for less care, and the care we do get is less effective: our infant-mortality rate, for example, compares with that of Second- and Third-World countries. And there are plenty of insurance and pharmaceutical executives, plenty of doctors’ associations, and whole armies of lobbyists eager to keep things this way, and to spend heavily to persuade Congress to agree with them.

Yet these aren’t the biggest opponents that the President and any reformer must face down. The two real culprits are older, more deeply entrenched, and impossible to dissuade: the Pilgrim and the Cowboy. Both in what they believed and in what we believe about them, the Pilgrim and the Cowboy are powerful influences on American thought about health care — though I’m not sure we realize that.

You’re in good hands with the Almighty:
A different kind of insurance policy?

Since the days of our Pilgrim Fathers, Americans have believed that illness is a sign of personal weakness, even one of God’s disfavor. Why on earth would we as a nation pick up the tab for the medical care of a sinner? Never mind that this attitude is analogous to believing that illness is caused by Evil Spirits: it’s our attitude, and we’re slow to relinquish it. Look at an overweight person and try telling yourself that he isn’t responsible for his fat, try convincing yourself that obesity isn’t a symptom of lack of restraint, try not to mock him when he says, “It’s a glandular condition.” Just try it. You can’t do it, can you? The Pilgrim within you won’t permit it. And so you blame the patient for his illness.

(This attitude was rampant during the early years of the AIDS crisis, of course. If the patient had possessed sufficient rectitude to refrain from drug abuse or ungodly homosexual activity, he wouldn’t be in this jam, would he? And so we let thousands die.)

He cast a long shadow.

What the Cowboy actually believed is almost irrelevant: because of Hollywood movies about him, we believe that he rode tall in the saddle, even when he was sick or wounded. He was so manly that he wouldn’t reveal his pain. And so Americans associate illness not merely with moral weakness, but with physical weakness. We feel contempt for the patient. A kind of Social Darwinism sets in: “survival of the weakest” is not a winning slogan.

I have no idea how to change these attitudes, but I recognize their existence — something that few people I speak with ever do. Living in a country where preventive care is the norm, I see that it’s also more efficient: curing an illness is more expensive than preventing one. Americans don’t seem to grasp that concept. The French actually talk to their doctors — and to their pharmacists. Americans go to the pharmacy and buy over-the-counter remedies in secrecy and perhaps shame: we mustn’t let anyone know we were weak enough to catch a cold, so we buy Contac and scurry to the checkout quickly, before anyone sees us. The French engage in long discussions with the pharmacist (“Is this remedy better than that one?” “This is how you use this, and remember to be careful if you’ve got condition X, Y, or Z”); in many cases, customers arrive at the pharmacy with a prescription for a specific remedy, because they’ve already been to the doctor, whom they paid the flat rate of 21 Euros for an office visit, because they’re insured, because everybody’s insured. I had a hard time believing the amount of personal attention the French get at every step of their health care, while Americans are left pretty much to their own devices. From conversations, I gather the French are far happier with their health care than Americans are with theirs.

Pharmacien français: à votre écoute

Americans may be a long time understanding that “socialized medicine” doesn’t have to mean Orwellian bureaucracy or Sovietic privations, that while no system is perfect, there are degrees of awfulness: the French system seems pretty good, the American pretty awful.

But then, the French didn’t have Pilgrims or Cowboys to contend with. In order to heal ourselves — and our system — Americans will have to start by healing those guys.


Anonymous said...

I believe you're onto something here! Taking place 'twixt the fundies and John Wayne, rational discussion is going to be tough.

Anonymous said...

Americans are given a certain number of sick days by their employers every year, and are fully expected to use them. Nothing secretive about that. How do we compare to other countries in this regard?

We also witness massive public campaigns every year to raise funds/awareness about breast cancer and various other illnesses. You might think such campaigns would be unpopular and would take a less public approach if the stigma attached to sickness is so pervasive and reaches the level of the Pilgrims' attitudes about witches.


William V. Madison said...

Yeah, Americans take a sick day when they get the flu: they stay home in bed. People in other countries seek medical attention. See the difference?

Americans are subjected to those public-service announcements precisely because a stigma is attached to illness. We wouldn't need them if we had a more enlightened attitude toward health care, or if we already had the information in the first place -- which we could do if we received more medical attention and preventive care. You have in a sense helped to prove my point. Thanks!

Anonymous said...

I don't think I have proved your point. If Americans truly felt contempt for those who get sick, would these public campaigns for the ill have any chance at all of drawing sympathy and support (not to mention massive donations), and would anyone bother to pursue them?

Why did you move to France, anyway? I'm curious.


William V. Madison said...

Who says those campaigns do work? Do you see any cures? Do you see improved care? Granted, some of the money seems to have made certain treatments more effective, in some cases. But you're really talking about advertising, and I'm talking about why we need the advertising in the first place.

(Maybe the Man in the Grey Flannel Suit should join the Pilgrim and the Cowboy as the villains of this piece?)

Go to the pharmacy in America, then go to the pharmacy in France, and you'll see what I mean about shame. (I thought I'd described those opposing circumstances pretty well, but I guess I failed.)

As for contempt, that may not apply in every case, I agree. But how many people hear a man cough in the middle of an opera and think, "Oh, the poor dear"? No, instead we think, "That jerk, why couldn't he stay home?" We resent the sick person who spoils our good time, and he can do that merely by his presence, by reminding us that sickness exists. We blame him for that. I saw it too many times in the 1980s, when a guy with AIDS would walk into a bar.

Even by asking "What have I done to deserve this?" when we get sick, we may suggest a moral element or agency in our illness -- which is a reflection of our lingering Puritanism.

As for the reasons for my move to France, it's one of my favorite topics, but I must beg off -- I'm under the biggest deadline pressure of my life right now. There are several entries on this blog that address the topic, though, and a very good hint on the right of this page, just below my picture.

I do very much appreciate your giving this essay so much serious thought.

Anonymous said...

I don't want to keep after you when you're on a deadline, but I asked my last question for a reason. When I first encounted this blog, I got the impression that you moved to France because you were fed up with a country that would re-elect George W. Bush. We all know the litany of criticisms of Bush. But it seems odd that someone who objects to chauvinism in foreign affairs, the mistreatment of minorities and foreign detainees, the condonement of torture, and a nationalistic, insular attitude, would register his objection by moving to France. I could scarcely think of a country that has done more to bully and humiliate smaller and weaker countries, put its own self-interest first even to the point of detonating nuclear weapons near populated islands, resort to torture as a means of extracting information, and degrade and disparage foreign cultures both diplomatically and in domestic policy, than France. I'm sure you know that the term "chauvinism" derives from one Chauvin, a soldier in Napoleon's army, who liked to boast about France's superiority and right to push around inferior peoples. It's an atittude we see all around us today -- and the enemies in France's many imperialistic wars most emphatically have NOT enjoyed even the nominal constitutional protections of the Gitmo detainees. So maybe you could enlighten us about your peculiar choice.


William V. Madison said...

I'm immensely sorry that I haven't had you at my side on the several occasions I've found myself in bar fights (not of the fisticuff variety) in this country. As I listen to the French berate my native country for its colonialism and imperialism, I've often remarked how ignorant the French are of their own track record in this field. You'd make an excellent wingman. Let me know the next time you're in town, and I'll buy you a beer.

That said, I'm unaware of any nation that has a monopoly on virtue, and because I'm not French, there's a soothing detachment that comes from living here. For the disinterested (or in my case, only partially interested) observer, following French politics is sometimes like attending a comic opera. And learning this country's history, whether the French study it or not, has proved an excellent means of understanding key chapters of America's past and present. Some of the parallels between Napoléon III and Bush II are downright spooky.

Certainly I was fed up with Bush and his policies, and disillusioned by an electorate that -- knowing already what it was setting itself up for -- returned him to office in 2004. But even at the time, I didn't want to go too far in making Bush responsible for my decision to leave the country. He was seizing enough power already, without my handing him more.

So long as we're identifying influential archetypes in American thought, let us point to the Expatriate Artist, who leaves the New World and roams the Old in search of inspiration and cheap wine. In his way, he's as potent a figure as the Pilgrim or the Cowboy. Henry James, F. Scott Fitzgerald, Edith Wharton -- even John Malkovich, for mercy's sake. Why wouldn't I want to join that club?

Moreover, I speak the language and I knew somebody with a spare room. Other, more civilized countries (if there are any) don't offer such advantages, and moving there would have been a hassle.

Anonymous said...

Well be careful about bringing up John Malkovich, because he's a reminder that there are highly intelligent conservatives . . . something I think you might be reluctant to admit.


William V. Madison said...

Au contraire, Monsieur! I not only admit the existence of highly intelligent conservatives, I delight in them. The cousin referred to in paragraph 1 is one such, and I adore her; indeed, I'd be a highly stupid liberal if I didn't.

Acknowledgment of thoughtful minds does not require me to agree with them, however.