When Bill Clinton signed the welfare overhaul in 1996, he and his supporters promised that its problems could be fixed later. One problem at the top of the list was the bill's savaging of the food stamp program, including sharp financial cuts and the removal of legal immigrants from its rolls. It wasn't fixed.
Six years and lots of empty plates later, there's a chance to make a considerable improvement--if the senators who see the need to fix it hold out. The 2002 farm bill, with a price tag of $75 billion, has passed both houses and is now in conference committee. The Senate version adds $8.9 billion to the nutrition budget, mostly for food stamps, and requalifies most legal immigrants, including all children and also the disabled--which would add an estimated 400,000 people. In determining general eligibility, it also takes a more realistic view of what poor people have to spend for shelter and to keep a car running. The House adds only a bit more than a third of that and, in the spirit of both the House leadership and the 1996 welfare bill, doesn't fix much.
The Senate pays for its nutrition increases by limiting the farm subsidies that can be paid to individual and corporate farmers. The House--and some senators--would rather keep the money flowing in the same old streams. "The problem is that the House doesn't like the payment limits," says Andy Fisher, spokesman for Senator Richard Lugar of Indiana. "You would think that members would be ashamed to take that position, but they're not."
It's one of the quirks of Washington that the major federal nutrition programs are part of the farm bill, written by legislators generally more interested in peanut price supports than peanut butter sandwiches. This year the bill was complicated by the large number of vulnerable Democratic senators from farm states--including Tim Johnson of South Dakota, Jean Carnahan of Missouri, Tom Harkin of Iowa and Paul Wellstone of Minnesota--and Democratic nervousness about the effect of subsidy limits on their chances this fall. But, insists Wellstone, "There's no reason why we can't get it right on both family farms and nutrition."
The issue comes up as the need for food help is surging, spiked by the unemployment jump of the past year--especially in areas like Florida and Las Vegas, where the drop in airline traffic belted low-wage (and heavily immigrant) tourism workers. America's Second Harvest, the national alliance of food banks, issued a call to action in February to raise 365 million pounds of food. "When legal immigrants lost eligibility," says Doug O'Brien of Second Harvest, "it just shifted responsibility from the federal government to food banks." With the small difference that it's a lot harder for food banks to pay for it.
In January the Bush Administration--driven by the realities of hunger in Texas and by GOP interest in the Hispanic vote--came out for sharply relaxing the legal immigrant exclusion, giving the idea momentum. The National Governors Association, seeing hunger from closer up than Congress does, backs the Senate bill.
But in early March the Senate plan was hurt by the discovery that its bill would cost $6 billion more than expected and more than the budget allowed. Still, the senators on the conference committee include longtime nutrition advocates like Lugar and Patrick Leahy, and a high-ranking Senate staff member insists that the Senate side has so far refused--even after the revelation of its faulty accounting--to put nutrition cuts on the table. "I'm very hopeful," says Representative Eva Clayton, the first black woman to represent North Carolina and described by O'Brien as a "heroine" on hunger issues. "The House has not been very strong or aggressive on the issue of nutrition. We really need a little more pressure on us."
Senators--and all those who think it's a good idea to feed more hungry Americans--should turn up the heat on the nutrition conference committee.
It's the largest profession in healthcare. It's the largest female profession in America. But despite its tremendous importance and impact, most people know very little about contemporary nursing. Public ignorance of the present-day profession, however, pales in comparison with ignorance of nursing's history. How many of us know that the development of nursing as the first secular profession for respectable women was a major feminist achievement? Or that Florence Nightingale was not, in fact, the "founder" of modern nursing? Or that nurses played a key role in developing the American hospital system, as nursing historian Sioban Nelson has documented in her recent book Say Little, Do Much? How many of us know about the role of nursing in the development of public health and care of the chronically ill and poor? Most important, how many of us recognize that society's persistent devaluation of nursing--reflected today in the prejudices of many newly liberated female physicians, health policy experts and journalists--is a legacy of longstanding, socially enforced subordination to medicine?
Katrin Schultheiss, an assistant professor of history and women's studies at the University of Illinois, Chicago, is one of a handful of non-nurses who understand what the profession has to teach us about the complex process of female emancipation, as well as about the development of modern healthcare systems. She recounts the tortuous history of how the "professionalization" of nursing in France coincided with anticlericalism and the secularization of the field. Although her story focuses on the forty-year period from 1880 to 1922 and takes place in one country, the gender dilemmas Schultheiss explores have hampered nurses' ability to care for patients in healthcare systems around the globe, including in the United States.
Her tale begins with the advent of France's Third Republic and follows political reformers who attacked clerical authority as they tried to modernize the healthcare system. Until that time, nursing outside the home was typically provided by convent-trained nuns. Modern hospital reformers recognized that nursing required more nurses with more systematic education, but therein lay the problem. Since knowledge is power, the acquisition of knowledge was inevitably a challenge to authority.
Physicians, as men, did not welcome women on their terrain. As members of a developing profession--one that did not then command the prestige it enjoys today--doctors were also adamant about defending their field "from irregular or illegal practitioners."
Even doctors who recognized the need for a more educated nursing work force and who wanted to laicize the care of the sick would not countenance the education of nurses if, in the process, nurses attained the kind of knowledge and stature that would allow them to demand greater authority and autonomy in both the workplace and society. So even lay nursing had to be constructed in altruistic terms that stressed not nurses' knowledge but their virtue. As Schultheiss writes, "As long as nursing was clearly understood to be a custodial, maternal, or charitable occupation, and as long as nurses were regarded as the social, economic, and educational peers of the patients, rather than the doctors, there would be no ambiguity about who held medical authority within the hospital."
In Paris, nursing nuns, while obedient and devoted, presented a problem to medical reformers. "The very existence of an autonomous community of women called into question the hierarchy of power within municipal institutions," Schultheiss notes. Happily, secular authorities found lay nurses, as one reformer commented, to be "infinitely more subordinate than the religious nurses and more scrupulous in the strict execution of doctors' orders."
While anticlerical reformers touted the benefit of lay nurses, the French public was attached to the nuns who had provided what out-of-home nursing care had existed since the seventeenth century, and even before. Of course, Schultheiss points out, even support for religious nurses was cast in gendered terms. Proponents of the nuns insisted that nursing should be left to a special group of religious women because it would corrupt lay women for their real work--which was mothering. "A woman is either a bad mother or a bad nurse," was their motto. To convince the public to support secularization, reformers had to "feminize nursing--to turn nursing into a general feminine virtue that all women could possess."
Schultheiss's story also introduces us to a peculiar hybrid form of religious nurse--the "hospitalières" of the Hospices Civils of Lyons. These women were secular nuns, congregationist sisters "who undertook a lifelong commitment to serve the sick and poor under harsh physical conditions and with virtually no monetary compensation, but who remained under the direct authority of the secular administration." According to Schultheiss, laicizers supported them because they were easily controllable and because their sense of devotion was easily manipulated by civil administrators who didn't want to pay the real cost of nursing care.
In this section of the book, class also enters the story: If civil administrators were to get nursing care for little or nothing, women's educational standards--and thus their salaries--had to be low. Whether they were secularizers or not, reformers recognized that more highly educated women of a better class would eventually demand more pay, and more say.
Finally, Schultheiss takes us to Bordeaux, where we meet Anna Hamilton, a reformer and devotee of Florence Nightingale. With connections to the international nursing reform movement, Hamilton wanted to open a nursing school that would produce a "new nurse," recruited from the so-called better classes. This new nurse, she insisted, would deliver better patient care than nursing nuns. Hamilton's critique of the nuns, Schultheiss explains, was not based on anticlericalism. Rather, Hamilton argued that the nuns had "distanced themselves from direct patient care" while creating obstacles to the creation of "a single medical hierarchy grounded on universal principles of hygiene and scientific health care."
Hamilton was able to gain support for her project from Paul-Louis Lande, a physician who became mayor of Bordeaux, because she firmly linked the "professionalization and feminization of nursing." Doctors in Bordeaux, Schultheiss writes, recognized "the need for improving the training of hospital nurses, but rejected all aspects of reform that expanded the nurses' autonomy or authority beyond the narrowest limits."
Hamilton accepted these limits, asserting that "it is extremely ridiculous for a nurse who possesses neither the knowledge nor the rights nor the sex of the doctor to try to imitate his way of interacting with the patient and to try to use his language." Thus, in France, as in England and the United States, the nurse-doctor game began with the acceptance of the notion that nurses could not--or should not--possess medical knowledge and that they therefore could not--and should not--use medical language.
Schultheiss ends her story after the First World War. The war produced such a huge need for nurses that the debate over the virtues of lay versus religious nurses effectively ended. When more than 100,000 nurses culled from every social class enlisted to serve "la Patrie," this "demonstrated that women's special aptitudes could be attached fruitfully to the state." However, even during this period and afterward, nursing was valued not for its knowledge but for its virtue. It had become, the author concludes, "a twentieth-century version of republican motherhood."
French nursing carries that legacy to this day. Last year, when I was strolling down the Boulevard St. Germaine in Paris, a book displayed in the window of a children's bookstore caught my eye. It was called Je Sais Qui Me Soigne ("I Know Who Takes Care of Me") and is part of a series on citizenship and the professions. Nurses make a brief appearance in the book--as doctors' servants who have, as the text reads, "just enough schooling to follow doctors' orders."
For nurses struggling to put their education to use for patients, rather than for physicians, the ability to escape, at least temporarily, medical domination has always made home care attractive. Which brings us to Karen Buhler-Wilkerson's part of the story. In No Place Like Home, Buhler-Wilkerson, a professor of community health and director of the Center for the Study of the History of Nursing at the University of Pennsylvania School of Nursing, traces the development of home care from the opening of the first US home-care agency--the Ladies Benevolent Society, founded in 1813 in Charleston, South Carolina--through the present.
In Charleston, as elsewhere, respectable society ladies started home-care agencies because they felt "obligated to improve the conditions of and provide for the comfort of the poor," who were, in turn, "expected to manifest their gratitude to the rich," who established these agencies. But they did not deliver the care. Nurses did.
No Place Like Home does a great service to these ordinary nurses who are often dismissed as know-nothings by some nursing elites today. Buhler-Wilkerson details the complexity of caring for victims of tuberculosis or managing patients during typhoid epidemics. She also documents the persistence of the issues with which home-care agencies still struggle today: how to navigate doctor-nurse relationships; how to choose appropriate patients for home-care services; how to deal with gender, race and class prejudice; and how to secure long-term services for the chronically ill.
From the early days of home care, doctors were concerned about nurses invading their territory. In Boston, for example, doctors "confided to lady managers that 'the constant danger with trained nurses is that they shall usurp the doctors' position and prescribe for patients.'"
At the turn of the twentieth century, with the founding of the Henry Street Settlement on the Lower East Side of Manhattan, Lillian Wald and her colleagues developed public health nursing--"to improve standards of living" of the poor. One of the great innovations of the Henry Street Settlement was the establishment of a "First Aid Room." This was a kind of community clinic where immigrants could gain easy access to nursing care for routine health problems. Doctors, however, soon complained that "nurses were carrying ointments and even giving pills outside the strict control of physicians." Even outspoken nurses like Wald's colleague, socialist Lavinia Dock, feared a confrontation with powerful physicians. By 1911 questionable cases were no longer treated in the First Aid Room. "Later publications," Buhler-Wilkerson writes, assured the public that "the real Henry Street Settlement nurse will make the doctor feel that she is exerting every effort to have his treatment, not hers, intelligently followed."
An equally fascinating subject tackled by Buhler-Wilkerson is the impact of racial prejudice on nurse-patient and nurse-doctor relationships. In both the North and the South, lady managers as well as nurses fretted about whether it was appropriate for white nurses to care for black patients or black nurses for white patients. When insurers, notably Metropolitan Life, entered the field at the turn of the last century, managers considered the same imponderables. Race invariably trumped the needs of care and even of doctor domination of the nurse-physician relationship. For example, Buhler-Wilkerson tells us that the respectable ladies of Richmond, Virginia, who ran home care in that city, decided it was "'eminently' satisfactory for white nurses to care for black patients on the 'same footing' as white patients--but drew the line at white nurses 'taking orders from colored physicians.'"
The advent of health insurance also had a critical impact on the home-care agencies. Wald convinced Metropolitan Life to cover home-care services in 1909. Met Life wanted to reduce the high mortality rate of black life insurance subscribers--thus delaying payments on their life insurance policies. Home-care nursing's preventive approach initially seemed to make good business sense. By the 1950s, public health nursing and medical advances had paid off: Fewer people were dying of infectious diseases, and more acute illnesses were treated in the hospital. This meant that the bulk of home-care patients were chronically ill. To reward public health nursing for its success, Met Life curtailed its home-care program. "Providing care for those who failed to recover quickly was, from an insurance perspective, a poor investment," Buhler-Wilkerson states bluntly.
Since the fate of nursing is tied to the fate of the patients nurses serve, the situation has not improved much, as first Medicare and Medicaid and now managed care have "rediscovered" home care. Indeed, today the promise of the home as a place where nurses and their patients can escape the negative consequences of medical paternalism and give or receive higher-quality care has remained largely unfulfilled.
In Devices & Desires, Margarete Sandelowski uses a different lens--the world of medical technology--to explore the issue of gender and nursing. This brilliant book shows just how much the "charitable, devotional and altruistic" image of the nurse conceals. From the discovery of the thermometer to the development of intensive heart and fetal monitoring, Sandelowski documents doctors' dependence on nurses for their reputation for scientific and technical mastery. As Sandelowski shows, nurses have been critical in administering medical technology, monitoring the information it provides and interpreting that information to physicians, not to mention "educating patients about new devices, getting patients to accept and comply with their use, and alleviating patients' fears about them."
An eye-opening segment describes the use of the first thermometer, rather than the hand, as a diagnostic tool in the mid-nineteenth century. In it, we learn that the thermometer we take for granted today was originally an unwieldy, dangerous instrument that had to be carefully manipulated so as not to injure the patient. Because diagnosis and treatment involved taking the patient's temperature numerous times a day, busy physicians assigned the task to nurses. This involved, however, far more than simply recording data. The nurse, Sandelowski writes, "had to know what caused various temperatures to occur and the nursing measures that would lower or raise temperature to normal levels."
While physicians were the ones to insert the first unwieldy and equally dangerous intravenous devices, nurses were the ones to make sure the patient's arm remained immobile and that the patient could tolerate the discomfort of IV therapy. Nurses are the ones who developed the intensive-care unit--to provide intensive nursing care--and who track and interpret data from fetal monitors. As the primary users of much medical machinery, nurses are often more knowledgeable about equipment than doctors. Indeed, "the benefits of machine monitoring could not be fully harnessed without nurses who understood and could act immediately on the information monitors generated." While the public does not recognize this fact, the author tells us that medical equipment manufacturers certainly do. This is why nurses continually work with physicians and manufacturers to create design improvements and to insure that "expensive machinery [is] fully utilized."
What is amazing about this story is how little nurses have benefited from their technological mastery. Sandelowski shrewdly diagnoses a classic Catch-22. While it is true that nurses' status is somewhat enhanced by their technical proficiency, the recognition they receive does not match their actual accomplishments. That's because physicians quickly label the technical activities nurses engage in as "simple enough" for a nurse to perform.
No matter how much nurses participate in the diagnostic process, of course, physicians have maintained a legal and linguistic stranglehold on "medical" diagnosis. Even as "physicians were increasingly expecting them to perform de facto acts of diagnosis," Sandelowski writes, "nurses were in the bizarre position of having to be mindful of symptoms without speaking their mind about them."
Nurses were supposed to be able to distinguish between normal and abnormal conditions and to look for reasons for any abnormal findings. But nurses were never to use the words "normal" or "abnormal" in reporting or recording patient conditions, and they were to refrain from offering their opinions on etiology or diagnosis.... Nurses were to say (report and record) only what they saw, unlike physicians, who maintained the right to say what they knew.
This has produced the peculiar phenomenon--even today--of the nurse who recognizes that a cancer patient has diarrhea or a mentally ill patient is hallucinating, but who is not allowed to use the actual medical word because that would suggest that she, or he, is making a "medical diagnosis."
As she describes these phenomena, Sandelowski never paints nurses as innocent victims of nasty, overbearing physicians. In their perennial attempt to find "a socially valued place and distinctive identity," Sandelowski argues, many members of the profession have, albeit unwittingly, adopted common gender stereotypes that perpetuate the oppression of nurses.
One segment of the profession, Sandelowski contends, has bought into the notion that the complex practical, technical work that ordinary nurses perform is indeed simple and know-nothing.
Typically conceived of as nothing more than the physician's hand, and persistently caught in the Western cultural dichotomy between merely manual and highly prized mental, or intellectual, work, nurses have struggled to show that nursing is largely brain work. In the process, however, they have inadvertently complied with the prevailing cultural practice of denigrating the very "body-knowledge" that is the forte of the nurse.
This is particularly evident in the nurse-practitioner movement, which so many elite nurses now promote. "The key factor differentiating nurse practitioners from other nurses," she writes, "is both the use of medical instruments and the use of instruments in ways previously denied nurses." But, she points out, in our bottom-line-driven healthcare system "the role emerges as largely economically and 'medically-driven'.... The traditional image is maintained of nurses as the extra hands and eyes of physicians willingly and cheaply filling voids and bridging gaps in health care."
Other segments of the profession, Sandelowski argues, have opposed nurses' emotional and social work to their technological activities, arguing that technology is somehow an inauthentic nursing activity, while "caring" is both authentic and an essential "antidote to technology." Sandelowski shrewdly insists that in opposing "nursing/touch and technology," the profession has been "identified both with and against technology and thus, in an ironic way, with and against itself."
While it is not the purpose of these books to offer advice about dealing with the many problems nursing confronts, they implicitly point to one incontrovertible solution: We can appreciate what nurses do in the present only if we understand how their work has been constructed in the past and what they have contributed--and can contribute--to our healthcare system.
Understanding and analyzing nursing's decades-long struggle for "a socially valued place and distinctive identity" is not an academic exercise. It is central to reversing the chronic underfunding of the nursing services most of us will eventually depend on in hospitals and other healthcare institutions, and also the undereducation of the nursing work force at almost all levels of practice. And it is critical to any solution to the severe nursing shortage, which, if not quickly and effectively addressed, will have disastrous consequences as the population grows older and sicker.
In the next few weeks the Senate will hold hearings and vote on legislation that would outlaw the cloning of human embryos, either for the purpose of medical experimentation or the birth of a human being. The House already passed a similar bill in July. Until now the cloning debate has been viewed in Washington and the media as a classic struggle pitting social conservatives, antiabortion activists and the Catholic Church against the scientific community and progressive forces, with Republicans lined up on one side and Democrats on the other. Below the surface, however, another reality is beginning to take shape. Although reluctant to acknowledge it, some social conservatives and some left activists find common ground on the cloning issue [see Ralph Brave, "Governing the Genome," December 10, 2001]. An example of this convergence is a statement issued by sixty-seven prominent left progressives on January 23 supporting legislation to outlaw the cloning of human embryos.
The progressives backing this legislation worry that the market for human eggs that would be created by such research will provide unethical incentives for women to undergo health-threatening hormone treatment and surgery. They are also concerned about the increasing bioindustrialization of life by the scientific community and life science companies and are shocked that clonal human embryos have been patented and declared to be human inventions. On the other hand, few, if any, on the left oppose research on adult stem cells, which can be taken from people after birth and which have proved promising in animal studies and clinical trials. This approach poses none of the ethical, social or economic risks of strategies using embryo stem cells.
What about cloning a human being? Most members of Congress on both sides of the aisle would oppose a clonal birth. But for many in Congress, and in the scientific community and the biotech industry as well, opposition is solely based on the fact that the cloning technique is still unsafe and could pose a risk of producing a malformed baby. Far fewer members of either party would be against cloning a human baby were the procedure to become safe and reliable. After all, argue proponents, if an infertile couple desires to pass on their genetic inheritance by producing clones of one or both partners, shouldn't they be able to exercise their right of choice in the newly emerging biotech marketplace? Moreover, we are told not to be overly concerned, because even though the clone will have the exact same genetic makeup as the original, it will develop differently because its social and environmental context will be different from that of the donor.
What unites social conservatives and progressives on cloning issues is their commitment to the intrinsic value of life and their opposition to what they perceive to be a purely utilitarian perspective on biotech issues. To be sure, the social conservatives and left activists differ in the "life issues" they embrace and champion. The former crusade for what they regard as the rights of the unborn and family values and rail against infanticide, euthanasia and pornography. The latter speak out on behalf of the poor, women, abused children, fellow animals and the global environment. Both groups come together in opposition to cloning--but for different reasons.
Many on the left argue that with cloning the new progeny become the ultimate shopping experience--designed in advance, produced to specification and purchased in the biological marketplace. Cloning is, first and foremost, an act of production, not creation. Using the new biotechnologies, a living being is produced with the same degree of engineering as we have come to expect on an assembly line. For the first time in the history of our species, we can dictate, in advance, the final genetic constitution of the offspring. The child is no longer a unique creation--one of a kind--but rather an engineered reproduction.
The left also warns that cloning opens the way to a commercial eugenics civilization. Already life science companies have leaped ahead of the political game being played out in Congress and the media by patenting human embryos and stem cells, giving them upfront ownership and control of a new form of reproductive commerce, with frightening implications for the future of society. Many on the left worry that human cloning, embryonic stem cell research and, soon, designer babies, lay the groundwork for a new form of biocolonialism, in which global life science companies become the ultimate arbiters of the evolutionary process itself.
Neither the social conservatives nor the left activists are entirely comfortable with the new alliance, and they will continue to disagree in many areas. But on biotech issues both of these groups will increasingly break ranks with their traditional political affiliations--the social conservatives with market libertarians and the left activists with social democratic parties.
The biotech era will bring with it a very different constellation of political visions and social forces just as the industrial era did. The current debate over cloning human embryos and stem cell research is already loosening the old alliances and categories. It is just the beginning of the new biopolitics.
Drug companies influence research; they also affect what gets published.
Organic farming critic Dennis Avery is supported by generous contributions from several chemical companies, all of whom profit from the sale of products prohibited in organic production.
The war on terror is threatening to overshadow a far more deadly threat—the AIDS epidemic.
Attorney General John Ashcroft throws out Oregon's assisted suicide law, against the wishes of a majority of Oregonians and in defiance of a 1997 Supreme Court ruling.
Talk about good times for Washington's mercenary culture. Even as officials scrambled to explain why they had not acted more quickly to protect postal workers from anthrax contamination--or to deal with the public's fears regarding the disease--they were showing solicitous concern for Bayer, the maker of the anthrax-fighting antibiotic Cipro.
Faced with the choice of protecting public health or protecting a corporation's intellectual property, Health and Human Services Secretary Tommy Thompson instinctively chose to stand by Bayer, whose Cipro patent doesn't expire until late 2003. Never mind that it could take Bayer twenty months, working nonstop, to meet the government's target of a sixty-day supply for 12 million people, while generic drug companies say they could jointly reach that goal in three months. Initially, Thompson said he had no authority to override Bayer's patent, and it was only after public and Congressional criticism that he used his leverage to force Bayer to reduce its price for Cipro. Of course, if Thompson were to invoke federal law allowing the compulsory licensing of Bayer's Cipro patent to meet the current emergency (paying the company a fair royalty), he would be hard-pressed to keep arguing against similar measures to address the AIDS epidemic in the developing world.
The highly profitable pharmaceutical industry has invested heavily--doubling its campaign contributions between 1996 and 2000 to more than $26 million--to insure that it gets a Congress and Administration friendly to its interests. And it has paid off. In July the House soundly defeated an amendment sponsored by Bernie Sanders that would have allowed US wholesalers and pharmacies to import FDA-approved US-made drugs sold overseas. Given the price differential, such a change could have saved Americans $30 billion or more a year. According to Public Campaign, members who voted to protect Big Pharma from competition received, on average, $9,000 in campaign contributions from that lobby in 1999-2000, compared with $2,800 to members who voted the other way.
Nor are the drug companies alone in enjoying a special level of concern in Washington. Emboldened by Congress's hasty and over-generous bailout of the airlines, leaders of the insurance industry threatened to take the economy down with them if they too weren't promised a multibillion-dollar rescue package. Hollywood wants a tax break to keep it from moving studios abroad. Restaurants and hotels want taxpayers to subsidize 100 percent of the cost of their customers' three-martini lunches and golf junkets. Travel agents, car rental agencies and amusement parks want to give everybody a $500 tax credit to bolster their businesses. And every money-making corporation that ever got caught trying to avoid paying its fair share of taxes now hopes that this is the moment to kill off the alternative minimum tax. Meanwhile, the hundreds of thousands of workers who are out of a job since September 11, or barely hanging on, can't get Congress to extend their unemployment benefits or to help them keep their healthcare.
The lesson for an anxious public wondering whether the government can protect them--from sickness, from joblessness, from being treated as second-class citizens--is that it's time to throw the money-changers out of the temple. While battling terrorism abroad, we must also fight corporate greed here at home.
John Elias, my patient, has a dilemma. He can't afford to buy his medicines and also pay his rent. I'm sure he won't give up his apartment just to keep his veins filled with my chemical suggestions. But he is willing to take whatever free drug samples I provide. Luckily, drug company representatives visit my office regularly and drop off oversize, brightly colored boxes of pills, one or two pills per box. Sometimes I can fill a plastic bag with enough medicine to supply a patient's needs. Still, my sample closet is not as well stocked as the local pharmacy.
The explosion of samples occurs most often when two drug companies are competing over a similar product. When I have one set of pills, it's Elias's diabetes that's treated; when I have another set, it's the hypertension. He does not die, but his blood pressure goes up and down, and his blood sweetens with rising sugar, which lowers whenever I happen to have the right pills. Elias leaves my office smiling, more comfortable with his predicament than I am.
"See you in a month, Doc. And don't worry. I got enough pills here to last me a good ten days."
I do worry--about the remaining twenty days, about his risk of a heart attack or a stroke--but samples arrive at the drug company's rate, not in response to my urgent requests.
Elias is disabled, the result of a spine operation that didn't go his way. He has Medicare, but like millions of other disabled and elderly Americans, he's unable to afford the secondary insurance that would include a drug plan. He earns too much in his part-time clerical job to qualify for Medicaid, which also covers prescriptions, or to be accepted into a drug company's "Share the Care" program. He does qualify for New York State's EPIC plan, which allows some Medicare patients to fill all their prescriptions for under $100 per month, but he says he can't afford even that. He says he won't consider leaving his job to get Medicaid as others have done; he's proud of the fact that he can still work.
Elias lives in his wheelchair; the levers and locks are extensions of his arms, the wheels his legs. He navigates the street outside my office, leaning back on two wheels to jump the curb. His arching wheelies are another man's sidestep. But he has not managed to navigate his other diseases the way he has his paralysis. When I tell him the dangers of not controlling his diabetes and his high blood pressure, his smile fades. "When you're out, then I'm out," he says simply.
Meanwhile, the same company that makes his diabetes pill offers to fly me, all expenses paid and with a $1,000 stipend, to a frolicking weekend in Naples, Florida, where I would hear lectures for three hours a day on a drug I already prescribe, before adjourning to the surf and a sightseeing sunset booze cruise. The competitor invites me to the corporate box at the ballgame, with a lobster buffet and a live calypso band to entertain us between innings.
The drug salesman infiltrates the somber atmosphere of my medical office, trailed by a huge sample case on tiny wheels. It's uncanny: He knows how much of his drug I prescribe, and he wrongly assumes that I will respond to his enticements. He provides catered lunches to my office staff where the only apparent cost is listening to him harp on about a product that he freely admits I know more about than he does.
Despite the money spent on massive advertising, the manufacturers insist that exorbitant drug prices are the result of research and development. Several of the industry's best researchers are former professors who have been wooed away from the universities for higher salaries and better laboratories, and for every participant in the drug pipeline, from discovery to production, the excitement is almost palpable. New medicines for arthritis, hypertension, high cholesterol and diabetes improve the quality of life with fewer side effects. However, the new drugs are sold in Canada and Europe for a much lower price--a $15 pill in Detroit may cost $5 across the river in Windsor, Ontario--and there are foreign chemists producing these drugs in the laboratory and companies selling them for a fraction of their cost in the United States.
The more expensive the drug, the more difficult it is to determine how it is going to be paid for. Recently, a new wonder drug for arthritis became available in two formulations, one oral, the other intravenous. The choice of which form to use illustrates a basic problem in reimbursement. Since Medicare pays only for the more expensive intravenous, patients are being hospitalized unnecessarily to receive it.
As a doctor, I'm frustrated by the current system's inability to consistently provide for a patient's medicinal needs. Clearly, there is a need for government to intervene, but it's crucial that this intervention include an understanding of inflated costs and a plan for combating this inflation. As Medicare expands to cover pills, will the federal government drive a hard bargain and negotiate a lower price per pill the way HMOs, hospitals and other countries already do? I don't see how taxpayers can avoid being penalized if the government agrees to pay top dollar.
This year, after many insufficient attempts to maintain his health with samples, Elias wheels into my office with, if wheels were legs, an almost detectable swagger. All his years in service as a clerk have finally paid off. He is now the recipient of secondary insurance with a drug plan. He is one of the lucky ones. Now all his medications will be covered, at least for the moment.
"I'm ready to be healthy," he says with a grin that reveals his neglected teeth. "Lay those prescriptions on me."