On locking up mentally ill people...

Ms. Froma Harrop urged America to bring back locked mental facilities (Gazette Times, October 5) by citing horrific crimes and public nuisance committed by mentally ill people who “shouldn’t be out and about”; and she rightly pointed out that many of these individuals end up in county jails. But to conclude that the problem can be solved in clean, well-staffed psychiatric hospitals and “just make sure that they are locked” seems rather simplistic and insensitive.

President Kennedy’s Community Mental Health Act of 1963 - closing many psychiatric hospitals, failed not because of its good moral intention, but because America failed to build community centers and staff that would deliver the new compassionate out-patient care model. 

As Ms. Harrop admitted, most mentally ill people are not dangerous. Only 5% of crimes committed in the US are linked to a mental condition, and the diagnosis of mental disorder encompasses a diverse range of illnesses, very few of which need locked psychiatric facilities. And let’s not forget that incarceration itself carries significant devastating effects.

We can better use our resources by having more accessible mental health providers and clinics, and improving social determinants of health to mitigate factors that contribute to mental instability - risks such as family dysfunction, childhood trauma, juvenile delinquency, housing insecurity, poor education, and environmental and racial injustice. The list is long and complex,  and we lack the political will rather than resources to do it right. We can do better, but not by just building facilities to lock people in.

(Submitted on Oct 7, published in the GT on Oct 19, 2023)

More on Gun Regulations

I would like to thank Professor Wolf (GT opinion, April 28, 2023) for putting the Second Amendment in its proper historical perspective, and for emphasizing that the right of the people to bear arms was in reference to a well-regulated militia (i.e., our National Guard). However, to repeal it would be an impossible goal in the current political climate.

First, an amendment must be passed by a two-third majority vote in both of the House and Senate, or by a constitutional convention called for by two-thirds of the state legislatures. Then three-quarters of the voting states have to ratify it. I don’t see how we can gather such a super-majority nationally, even when most Americans support some degree of gun control. 

There are however other ways to achieve reasonable gun regulations. We can vote out legislators who refuse to restrict private ownership of assault-style weapon or take donations from the National Rifle Association (NRA). We must demand reforms inside the Supreme Court, whose members, appointed for life, no longer feel accountable for their extremist ideologies. The NRA is just an extension of the gun industry, so we should its end its tax-exempt status as a 501(c)(4) social welfare organization. We can stop the easy availability of firearms by enforcing expanded background checks and by adopting buyback programs that worked well in other countries. Most of all, we must dissociate ourselves from the myth of the American Rambo gun culture, and teach our children how to be strong and safe without having to carry a gun.

(Submitted on May 3, 2023; published in the Gazette Times, Corvallis, June 7, 2023)

Medicare For All

Why do Americans often say we have the best medicine in the world, yet many cannot access and pay for the health care when needed?

We have many effective tools to prevent diseases (e.g., vaccines) and to mitigate complications of many illnesses (e.g., statins for cardiovascular disease, Paxlovid for COVID-19) – medical interventions that should decrease health care costs -- yet these costs are increasing every year.

There are no simple answers to complicated issues, yet some are rather obvious but ignored or hushed. The bottom line is that the medical industrial complex, made of pharmaceutical and insurance companies, hospitals and private medical providers, will charge us “what the market is willing to pay.”

The Moderna and Pfizer COVID vaccines offer an example. The U.S. government provided $337 million in long-term capital to research the mRNA technology, then invested nearly $32 billion to help develop, produce and purchase COVID vaccines through March 2022, while these two companies made more than $100 billion in global revenues from sales in 2020-21 alone.

Yet for a vaccine that eventually costs only $1 to $3 per dose to manufacture, these companies have announced plans to charge $130 a dose in the U.S. when our government stops its vaccination program subsidies. They justified the new price as “consistent with the value” of the vaccine.

So how is the market value of a medical product determined? Basically, the marketer would use the estimated financial burden a particular disease causes to society, then aim the pricing around that target, to make the use of its product “cost-effective” enough to be recommended by official agencies and medical providers.

What the market is willing to pay is the price-fixing power of the companies, accounting for the cost of production, distribution, promotion and substantial payouts to corporate shareholders, the amount of these rewards being two or three times more than what they spent on research and development. Lucrative patents would keep competitors away and allow companies to control the market, while government regulations are minimized through lobbying.

In the end, medical advances seldom decrease care costs, since potential cost savings from appropriate medical interventions are scooped up as corporate profits. It is no surprise that our health care is the most expensive system in the industrialized world, accounting for 18.3% of our gross domestic product, while for Europeans it is around 11%, and with better outcomes in most health measures.

What can we do about this? While it is impossible to outline detailed solutions in a short essay, let’s start with two fundamental changes.

First, we have to stop believing in myths: (1) that our current system offers choices -- it does not: Providers and patients are boxed into medical and financial options set by insurance companies;

And (2), that everything run by the government is bad -- The U.S. Department of Veterans Affairs, Medicare and Medicaid services provide good essential services at lower administrative costs than private companies (3% vs. 18%, respectively); private Medicare Advantage Plans have not been proven to deliver better clinical outcomes than traditional Medicare, but eventually cost more to taxpayers.

Second, health care should not be treated as a market commodity, commercialized and manipulated by financial investors. While some investment profits are necessary to support medical progress, health care should be a shared social responsibility driven by scientific evidence and operating under public governance.

In the end, we all pay for each other’s illnesses. A healthy population is fundamental to societal safety and productivity. We can’t let private for-profit corporations decide who can afford health care. Medicare for All is the only reasonable solution.

(Published in the “As I See It” opinion column of the Gazette Times, Corvallis and Herald Democrat, Albany, April 13, 2023)

Covid-19 - Third year and beyond

Three years into the Covid-19 pandemic, with endless streams of disease statistics, confusing public health recommendations, disinformation in social media leading to a vicious culture war on vaccines and facial masking, it is understandable that the public is tired about this topic. There is also an emerging acceptance of Covid as “just another cold or flu”, with minor health consequences. However, this pandemic has significantly changed our sense of the world, and we cannot easily walk away from it – not yet.

While the influenza and coronaviruses share some clinical similarities, the SARS-CoV-2 stands out as being more dangerous in causing widespread tissue inflammation attributed to an overactive immune response called “cytokine storm”. Scientists are also investigating the possibility of an associated viral toxin capable of causing damage to cell linings within many organs of the body, contributing to what is known as “vascular leak”. Although most recover within a year, 5 to 30% of Covid patients may develop a variety of chronic health issues (“long Covid”), from mild impairment to debilitating fatigue and multi-organ complications, most commonly respiratory, cardiovascular and neurocognitive symptoms. We should be ready for a looming crisis in how to provide and pay for the care of these chronic illnesses.

Another aspect of SARS-CoV-2 is its ability to mutate and escape our immune system more than any other viruses, even if one has mounted a hybrid immunity from vaccination and past infection. At the time of this writing, fortunately, currently used vaccines have shown continuous, albeit waning, protection against severe disease and death. However, as the virus rapidly evolves, the efficacy of current vaccines, therapies like monoclonal antibodies and antiviral drugs, or mitigating measures against new strains needs frequent re-evaluations.

As we reopen ourselves to the joy of safer travel, cultural and social activities, we should keep in mind that this virus is going to be with us for some time, and Covid-19 will not be our last pandemic of this century. Conditions for new variants to emerge continue to be present as viruses replicate in persons with low immunity level, and as new pathogens can jump to human communities from animal reservoirs.

Historians of medicine have studied how human communities responded to past pandemics, from the medieval plagues to the more recent HIV-AIDS infection, and little has changed in our behavior: fear, distrust and blame; but also our capacity for resilience and compassion. We are now too familiar with regional and global disruptions in social and economic activities, population migration, and setbacks in the care of other pre-existing medical problems. Covid’s toll on personal mental and physical health, and on educational and development delay in children will haunt us for years to come.

And while the Covid-19 pandemic has accelerated the development and application of some beneficial information technologies, it also brought to wider consciousness our social inequalities and exposed the vulnerability of national healthcare systems and global health governance. The infectivity of viruses does not discriminate nor stop at neighborhood fences or national borders, but disease tolls are highest among the working poor and their families who cannot afford healthcare or online professional and educational opportunities.

In the final analysis, controlling pandemics cannot be limited to disease surveillance, medical interventions and vaccines. We need stronger social engagement to ensure that health policies and medical recommendations are well trusted and do not compound more burden on the already most disadvantaged individuals. We have the scientific and technical tools to stop emerging diseases from becoming devastating pandemics. Let’s hope that we also have the moral conscience and the political will to do so.

The dark side of capitalism

On Nov 28 the Gazette Times paper ran an opinion piece from the Las Vegas Review Journal that claims “the US and its free market-oriented economic system has created much wealth for its citizens, as entrepreneurs make money by providing things that other people want”. It also quoted rock-star Bono saying that “capitalism creates prosperity by allowing people to keep the fruit of their creativity and labor”.

While this may be true, there is a darker side to capitalism as well. What followed 16^th century Dutch and British investors financing adventurers to look for spices and precious minerals around the world was four centuries of European colonization of Africa, Asia and the Americas. 

Under the pretense of Christianizing or civilizing primitive “savages”, gun boats followed missionaries, with capitalistic entrepreneurs not far behind, enslaving the labor of native populations, ravaging their lands and looting their cultural treasures, making money by bringing Europeans what they want. 

We know from our own history that capitalistic greed was behind slavery and oversea sweat shops, and if there is wealth, it has always been concentrated in a few, while the masses labor in overtime and falls behind in rents and loans. 

Free-markets sound like good competition, but it’s often on the back of cheap labor and devastated natural resources. When Mr. Bono said “globalization has brought more people out of poverty than any other-ism”, I wish he would also acknowledge that it should only be done without human exploitation, something that capitalism does not have a good historical record of."

(Submitted Dec 1, published in the GT Dec 18, 2022)