How can we best improve people's health, both in the United States and in developing nations? Nobel laureate economist Robert Fogel wrote a book in 2004 called The Escape From Hunger and Premature Death, 1700-2100. Europe, America, and the Third World. The book was a fascinating (if somewhat technical) review of the era when the Western world made a dramatic transition from high death rates and birth rates to low death rates and low birth rates; an era demographers refer to as the Demographic Transition.
At the book's conclusion, Fogel offers his opinions about what we should do to improve health care based on what we have learned from historical experience. I'm going to break his comments into two parts. The first part deals with the situation in the US. Tomorrow I'll present his views about developing nations. All emphases are mine:
The best way to improve the health system of the poor is to identify their most urgent needs and design an effective way of ministering to those specific needs. This goal will not be met merely by equalizing the annual number of visits to doctors (since the rich often waste medical services) or the annual expenditures on drugs (since the rich often overmedicate). Focusing on specific needs of the poor may not save money, but it will ensure that whatever is spent is properly targeted.
In this spirit, the number one priority ought to be an expansion of prenatal and postnatal care targeted particularly at young, single mothers. This priority is suggested by the new evidence that proper nutrition, including supplements of such key nutrients as folate and iron, can reduce perinatal deaths and birth defects, including damage to the central nervous system. It is also necessary to counsel pregnant women on the dangers to the fetus of smoking and alcohol consumption, and on the benefits of proper diets, regular and early examinations, and exposing the fetus to a stimulating environment (music and conversation). A focus on young, single mothers makes sense not only because they are among the most needy, but also because there is now pervasive evidence that insults in utero that reduce birth weight and length, as well as inadequate weight gains in infancy, greatly increase health risks throughout the life cycle.
A second priority is improved health education and mentoring to enable poorly educated people, both young and old, to identify their health problems, to follow instructions for health cares, to use medication properly, and to become involved in social networks conducive to good health. It is not enough to wait for such individuals to seek out available services. Outreach programs need to be developed to identify the needy individuals. Hence, support should be extended to organizations already experienced in outreach, such as Girls Clubs of America and community churches, so that they can include health screening and counseling among their services. Systems for monitoring the effectiveness of such community organizations also need to be established.
Another priority is reintroduction into public schools, particularly those in poor neighborhoods, from nursery school through the 12th grade, of periodic health screening programs, using nurses and physicians on a contract basis. Personnel should also be employed to ensure that parents understand the nature of their children’s problems and to direct the parents to public health facilities that can provide appropriate services.
A fourth initiative is the establishment of public health clinics in underserved poor neighborhoods that can supplement the emergency rooms of regular hospitals, which are a frequent source of routine health care services for the poor and near poor. Convenient access is a key issue, since even individuals with insurance, such as those on Medicaid, fail to take advantage of available facilities because they are inconvenient. Time is a cost to the poor as well as the rich, and a lack of convenient facilities may cause individuals to accept higher health risks than they would otherwise choose. The mission of community clinics should include health education in addition to treatment. Community clinics need to be regularly monitored to ensure effectiveness. Church basements and public schools after normal teaching hours can be good locations for community clinics both because they help to stretch available funds and because they provide familiar settings.
Readers may be surprised that I have not emphasized the extension of health insurance policies to the 15 percent of the population not currently insured. The flap over insurance has more to do with taxation than with health care services. Keep in mind that the poor are already entitled to health care under Medicaid and that the near poor often receive free health care through county or city hospitals and emergency rooms. What they do not do is pay taxes for those services. Most proposals for extending health insurance involve taxing their wages for services they already receive. Such insurance may relieve the pressure on the public purse, but it will not guarantee better health care. I believe that health screening in schools and community clinics has a better chance to success than unexercised theoretical entitlements. (104-106)
Tomorrow I'll present his views about developing nations. What do you think about these ideas for the USA?
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