Sunday, May 7, 2017

Healthy Stools

There's been a lot of talk about healthcare, and I'd like to do some defining of terms when it comes to health, medicine, and what it means to be healthy.

Medical care and Health Care are different. This, I believe, is at the root of the problem with our insurance system. That is a blog post for another day. Medical care provides medicine, operations, and concrete solutions to clear diagnoses and problems. The goal of medical care is to make some one who is sick, better. This is important! Health care, I would argue, includes medical care as I've just defined it, but goes on to also focus on preventing medical problems before they arise (good medicine is awesome, but isn't not getting sick even awesomer?!), educating patients on medical concerns that may arise in the future, addressing ones hopes and fears in relation to living, dying, and just getting through daily life with as much purpose, energy, physical and emotional wellness possible. (our insurance system was set up to address medical care, but research and experience have lead the medical community to want to provide health care...but like I said, a blog post for another day).

Our health (and therefore our care of it) comes from 3 different places. I often describe this to patients as a three-legged-stool which, without any one leg, wouldn't be complete.

One leg is made of the health related factors that we are born with; our genetics. In medicine we call these non-modifiable factors. You have no control over them. This includes your genetic predisposition for cancer, or diabetes, or any number of illness. It also includes your race, body type to some extent, and some behavioral tendencies as well. One day these may become more modifiable, though I expect even then, our genes will have a large influence over our health.

One leg is made of health factors that are largely up to us. What you eat, if you smoke, how much you drink, if you exercise, if you wear a seat belt, what type of physical and emotional risks you take...etc. We call these modifiable risk factors. They are aspects of health that can be changed by your actions. Though, it is important to point out that while all of us have choices, for some of us the healthy choices are easier, more obvious, more available. For others, they are options in theory, but in reality much harder to choose, even if desired.

The last leg is made of health factors that happen to you because of your surroundings. They didn't have to happen, and are therefore technically modifiable, but they are also largely out of your control. They are modifiable by someone - your parents, the government, your city officials, those with more power and influence than you, but you yourself can't do much to change them. Some examples might be - having a parent who smokes, causing respiratory harm to a child; a city with high lead content in its water causing lead poisoning; what your school serves for lunch; the safety of your neighborhood.

Health care (care for one's health), I would argue, can be seen in a similar 3 legged stool analogy - if you remove any one leg, the goal of improved health becomes much harder.

One leg is the patient - they can choose to follow medical advice, take medications, alter modifiable risk factors, and be an active participant in getting or staying healthy. We all acknowledge that there is some degree of personal responsibility in the movement towards health. It is important for one's mental and emotional well being to find ways to be in control of one's health.

One leg is the doctor or other health care provider, and her or his specific recommendations and treatments. It's the medical professional's job to explain diagnoses in clear terms, review treatment options, discuss goals of care, and pick a plan going forward that is both evidence based and realistic for the patient.

The final leg is the medical industrial complex - insurance companies, pharmaceutical companies, regulatory organizations. From what medication is covered, to how many doctor visits are allowed in a year, to how many days of rehab you are allotted, to which doctors you can see, to how much your doctor will get paid for the care they provide, these groups have a lot of power.

I like the stool analogy because it demonstrates how reliant each leg is on the other one in order to create a sturdy, safe, reliable system of care. If your genetics are so strong in predisposing you to a certain illness, then sometimes there isn't much medicine or you can do to help change that as much as you'd like. If your environment leaves you with so few reasonably healthy options for food, activity, education, mental well being, it is hard to over power that with pure will power or medical advice. If you put no effort into wanting to improve your health, even the best doctor in the world won't get far in making you healthier. If you are highly motivated, but have a doctor who suggest culturally or economically unrealistic treatments, you feel stuck. If your insurance, or the price of a medication, or even the existence of an approved medication, is out of line with your needs and reality, then even the best health care goals and plans won't help you very much.

Whether we like it or not, these three pieces are woven together to make this system we've created called Health Care. A less than holy trinity. But, as power and influence shifts more to one leg, we become unbalanced. Sometimes this unbalance is non-modifiable (genetics) or very hard to modify (systemic poverty and all its causes), and sometimes it is hard, but slightly more modifiable (policy, law, regulations, encouraging evidence based medicine).

We're all faced with a different set of modifiable and non-modifiable factors that affect our health. But for many, there are aspects of their health which should be modifiable that have become non-modifiable, and this is the greatest task the health care world has to address right now.

PS - extra props if you got and enjoyed the pun in this blog title. :)

Sunday, January 29, 2017

Nazis and Refugees

My ancestors were both Nazis and refugees. So are most of us.

I was born in Germany, and half of my family is German. My grandparents and great grandparents lived in the eastern German countryside, with a few of them also in Berlin. There's not exact information about what they all were doing during WWII, but the evidence generally indicates that some escaped to the countryside to avoid all conflict, and others, though not my direct grandparents, were likely Nazis.

When the war ended, my grandparents were still in eastern Germany. The Berlin contingent experienced the soviet blockade in the 1940s, and moved as far West in the city as they could afford. The eastern Germany group was forced into the Russian labor camps. While they weren't concentration camps, conditions were bad, food was scarce, lives were lost, and my grandmother was raped. They were, somewhat miraculously, released, and returned to eastern Germany to settle down once again. There, my dad was born. When it became apparent that conflict with the Soviets was not going to end, and the Iron Curtain began to fall, they escaped on literally one of the last trains to cross from East to West Germany for the next 30 years. The needed refuge. They lived in Hamburg and Berlin for the rest of their days. There I was born, in West Germany. My baby clothes and toys are marked, "Made in West Germany." **

We moved to the US in the late 80s, after seeing the Berlin wall come down. My father brought me a piece of it - graffiti red and black on one side, and grey concrete on the other.

I loved my German-ness. I enjoyed our few remaining traditions, being able to speak German, getting to travel internationally at a young age. It made me feel unique. Until 6th grade. Our history class did projects on injustices throughout history. At least half of them were about the Holocaust. It took me years to figure out how I could feel ashamed and sorry for something that happened before I was born. I could have gone off-campus to take German as my required foreign language. Instead, I took Spanish.

This (his)story may sound uniquely dramatic, but it's not. Not really.

Most of us have within us, within our families, within our culture or country or religion, stories of being oppressors and being oppressed. Perhaps not to this degree. Nazis, after all, are essentially the gold standard example for oppression, injustice, and hate. They may not be our personal stories, but we carry them with us. We exist, because of and in spite of them. Some of our stories are neater, more obviously lacking of evil and oppression, and perhaps more filled with mercy. Some are messier, making us feel dirty and wishing we could dissociate from that part of our unchangeable identity.

I've thought again and again about how to hold these two identities at the same time. I've wondered, what I would have done, had I been alive back then.

At any given moment, we all hold the ability to enact either hatred or mercy. It's a grace in and of itself that we're able to choose mercy and kindness as often as we do. At times we are the oppressed, the refugee- powerless, alone, vulnerable, the object of oppression. Some face this intensely and physically. At times we are also the oppressor, or at least given a choice of being the oppressor- powerful, safe, able to harm others. Some experience this in large, dramatic ways; all of us experience it in smaller, day to day actions and choices.

Just as my family history holds both evil and escape, hatred and harmony, mercilessness and mercy, so do I. So do we all.

Let us be refugees from our own hate and fear- to flee from evil and darkness, and run with abandon towards goodness and light; to find refuge in something outside of our selves.



** while my family were not refugees when they came to the US, they were relatively well-off immigrants, they were also descendants from one of the largest terror organizations, in modern times. Yet, we had no trouble getting into the US.