A view from a European medical academic who spends time in the US

American medicine has much to be proud of. Since World War II, the National Institutes of Health has sparked a revolution in academic biomedical research. There are world-leading academic hospitals delivering the best-quality health care, such as Johns Hopkins, the Mayo Clinic, Mass General, and the Hospital for Special Surgery, among others. Cancer care and outcomes are the world’s best. But there are also problems on a huge scale, which means that the US’s world-leading health expenditure (16% of GNP) is delivering health care that is worse than in much of Europe in terms of clearly analyzable indicators, such as infant mortality or length of life. European countries like the UK typically spend 8%–10% of GNP on health care. But that is not to say that European or British medical care doesn’t have its own problems, as certain aspects — such as the UK’s cancer survival rates — are worse than in the US. The lower-percentage cost of health care in Europe covers all the population, while the US’s 16% still leaves 45 million uncovered. Clearly there is an unanswerable case for major reform in order to deliver value for money, not just for the lucky ones able to avail themselves of the best hospitals, or of quality cancer care, but for all the population. The humanitarian principle — quality health care for all — that the European nations have espoused, though practised in different ways, leaves none of the population disadvantaged and uncovered. The 16% of GNP spent on health care in the US is having dire economic consequences. That each of Detroit’s US car manufacturers’ vehicles allegedly has about $1,000 of health care costs in its price is hard to comprehend, but its consequences are apparent. Costs of 16% and rising are clearly unsustainable. That most personal bankruptcies in the US are due to health care costs is also amazing. From a distance some of the causes of the cost differences of the US and European systems can be seen. Three are worth highlighting. The greater litigiousness of the US has led to “defensive medicine,” with its unnecessary tests and treatment. This requires reform of the medico-legal interface to avoid blaming physicians for unfortunate but unpredictable events. Reducing claims and medical insurance costs would help reduce the total cost of health care. The culture of health insurers trying to make a profit from delivering health insurance is another problem that has been well documented; they cut costs by excluding coverage and care and having plans whose coverage is very difficult to understand. Wendell Potter, the Senior Fellow on Health Care for the Center for Media and Democracy, in his testimony to the US Senate Committee has clearly documented this problem (1). A controversial issue is the appropriateness of intensive care for late-stage terminally ill patients with no hope of recovery, with the Terri Schiavo case as a most dramatic example (2). Americans pay a huge cost for health care, and some estimate that half of lifetime medical costs occur in the last year of life; far more patients with terminal illness die after weeks in intensive care in US than Europe. Having been in the US on holiday recently (August 2009), I saw some of the televised town hall debates. It is sad to see firsthand the misinformation and misunderstanding of many angry participants, frightened of change, frightened of losing benefits, frightened of “socialized” medicine like Britain’s National Health Service (NHS), while not realizing what a poor deal they actually have from the current system, compared to their European and Canadian cousins. The degree of misinformation is clearly illustrated by fears that chronic disease patients would be left to die. It was said by Investor’s Business Daily in July 2009 that prominent scientist Professor Stephen Hawking (with Lou Gehrig’s disease) would be left to die by socialized medicine in the UK’s NHS (3). This sadly reflects the gross politicization of this debate. Hawking, as is well known, lives in the UK and has been kept alive for an amazingly long time by the care and devotion of the NHS. Enough said. It is not appreciated by many that health care for the uninsured in the US is still paid for, by cross-subsidies. Instead of receiving lower-cost routine care from primary care physicians early in the disease process, these patients will eventually turn up when much more ill in the emergency rooms and then get very expensive care, costs that the hospitals recoup by averaging out over all their other, insured customers. So there are plenty of problems to be solved. Perhaps the first step toward solving them is for an appreciation that there are proven ways of delivering health care that is both cheaper and better for most of the population than the current style in the US. There is no need to look across the Atlantic, where cultures are different. Just look closer, north, to Canada. The Canadians are all insured, there are no health care bankruptcies, and they live longer than in the US. There is a strong case for major reform: it should provide a win for health and a win for the economy.

Health care reform: without a correct diagnosis, there is no cure

A persistent headache is a symptom, but the underlying cause can be anything from a migraine to a brain tumor. Good medicine means identifying and treating the cause as well as the symptom. The same is true in health care reform. Though most Americans are satisfied with their own health care, they also see the need for substantial reform. Unfortunately, the well-meaning plans currently presented to Congress are the wrong therapy because they mistake the symptoms for the underlying disease. Nearly everyone agrees on the symptoms: rapidly growing health expenditures, diminished access to affordable insurance causing many to be uninsured, and inadequate quality and outcomes for the dollars spent. But what are the root causes? While there are many contributing factors, three merit special attention. First, there is our inefficient and inequitable system of tax-advantaged, employer-based health insurance. While the federal tax code promotes overspending by making the majority unaware of the true cost of their insurance and care, the code is grossly unfair to the self-employed, small businesses, workers who stick with a bad job because they need the coverage, and workers who lose their jobs after getting sick. This employer-based system arose not by thoughtful design but as an unforeseen result of price controls during World War II and subsequent tax policy. How this developed and persisted despite its unfairness and maladaptive consequences is a powerful illustration of the law of unintended consequences and the fact that government can take six decades or more to fix its obvious mistakes. Second, in health care as in other markets, real progress depends on innovation. Yet health care markets rarely conduct successful experiments with new ways of paying for and organizing health care delivery. Why? Although health care markets have some unique attributes, these are not the explanation for lack of successful innovation. Rather, health insurance markets suffer from overregulation, which limits innovation in both insurance and new ways of delivering medical care. Third, we have Medicaid and Medicare. These enormous federal programs address critical needs by delivering health care to the poor, the disabled, and the elderly. These programs pay providers by administrative pricing formulas that are well documented to promote both overuse and underuse of appropriate care, have led to rising expenditures decoupled from better health, and obligate massive future deficits that everyone agrees are unsustainable. They are also rife with fraud and abuse. And yet the current political debate and the several and incomplete versions of “reform” proposals do little to address these core problems. Proposals such as those that would create a new public insurance program, for example, would likely magnify them and create a new generation of problems that will be as difficult to fix as Medicare has proven to be. Why does the current set of reforms fall short? One reason is that all changes must pass through the political process. For example, any effort at Medicare reform rapidly morphs into a struggle for influence between insurers and pharmaceutical companies, big-city academic health centers and hospitals in rural areas, specialists and primary care providers, federal and state governments, and on down the line. Sadly, innovators — and all too often patients — get lost in these power struggles. Any reform effort that fails to correct the acknowledged fiscal and organizational flaws of Medicare and Medicaid while extending the political gridlock that attends it to a broader segment of the health care system is doomed to failure. Some have offered novel approaches to “payment reform,” but none of these can realistically claim to both increase quality and reduce costs, while being acceptable to Congress. One proposal would create a new executive branch commission to propose changes to Medicare benefits and price controls that Congress could only override with a supermajority vote. While such an experiment might have the potential to reduce political gridlock, it would centralize power in a manner that seems exceptionally risky for a field that accounts for one-sixth of our economy and affects the lives of hundreds of millions of people. I anticipate many new advances in diagnostics, therapeutics, and devices over the coming decades. Optimal development and application of these will flow from a decentralized and innovative health care market and will be suppressed by a system that relies on politics and an all-powerful commission. Some have proposed that comprehensive reform must be achieved quickly, capitalizing on a sense of crisis. I see unacceptable risks to this approach. Instead of achieving a far-reaching and necessary solution for our economy and the nation’s health, the necessity of pleasing enough special interests to get a bill passed will exacerbate our long-term crisis of cost and access. Who can tell what deals within a thousand-page bill that few, apart from lobbyists, have read will influence the state of health care for decades to come? Now that a vote on health care reform will not occur until at least the fall, we should seize this opportunity by stepping back, making the right diagnosis, and then applying therapies that address the underlying disease. Here are a few ideas, based on the diagnoses discussed above, that may work. As with any therapy, these should be introduced as pilot programs, to be extended only if data reveal the desired outcomes. While such an approach will not fulfill the wish to produce a dramatic cure through a single stroke of legislation, it may avoid the pitfalls of the latter approach and have a greater likelihood of reducing the number of uninsured while controlling costs and enhancing outcomes. I propose this without any relationship to the partisan politics of the day that substitutes slogans and misinformation on both sides for meaningful analysis. First, make the tax shelter for health insurance, currently limited to employers, independent of employment. This single, and morally imperative, step would enable the uninsured to use tax-sheltered money to buy health insurance for themselves while permitting insured employees, who are currently limited to a few employer-selected health insurance choices, to become more central in decision making. Second, identify and eliminate the many barriers to entry and innovation in the health care and insurance marketplace. Eliminating what are often hidden barriers to competition will encourage entrepreneurs to offer lower-cost ways of financing and delivering health care, approaches that will deliver greater health care value for the dollars spent. Third, make a serious effort, despite the context of widespread political demagoguery, toward deeply reforming Medicare and Medicaid. As one of many possible examples, try giving some Medicare and Medicaid enrollees earned income credits so they can make cost-conscious decisions among competing health plans. The sicker and less affluent should receive larger transfers, so they can buy adequate coverage. Among other benefits, such an experiment could break the logjam in payment reform and reliance on fee for service and centralized price controls. Reducing rather than increasing the role of politics in health care decisions, while providing assistance for those in need, these pilot therapies would have the salutary effect of placing patients and innovators in a more central role as we determine the future of health care in America. And we would then, at last, be able to align the treatment with the disease, a fundamental principle of responsible medicine. Addendum. I coauthored an article on health care reform and its underlying issues in 1994, and although it was written fifteen years ago, some of the concepts within this article may be relevant today (1). In addition, a recent article in the Atlantic magazine addresses key issues underlying this discussion that I find quite compelling but could not address due to considerations of length (2).

Social representations of history, wars and politics in Latin America, Europe and Africa

This study analyzes how people perceive world history on three continents: Latin America, Europe and Africa. A total of 1179 university students form Argentina, Brazil, Peru, Portugal, Spain, Guinea-Bissau, and Cape Verde were asked to evaluate world events and leaders in terms of their valence and importance. The results demonstrated that social representations of history show a Euro/North American-centric, long-term positive evaluation, recency, and socio- centric bias. Euro/North American-centric events and leaders were found to be rated as more important and were more positively perceived in general. Distant political events, like French or American Revolution, were considered to be more positive than XX century similar events, which supports the long-term positive evaluation bias hypothesis. The hypothesis on recency bias was partially substantiated. Confirming the existence of such bias, World War II was rated as more important than the previous XX century wars and revolutions. Socio-centric bias also received partial support. African participants rated Mandela as a more important leader than other participants did. Latin Americans rated Che Guevara less positively, which suggests that some leaders are generally idealized icons, not based on group belongingness. However, results did not bring support to the centrality of war hypothesis. Wars were indeed negatively evaluated and World War II was rated as an important and negative event. Nevertheless, war- and politics-related events were not perceived as more important than the Industrial Revolution, suggesting that people appraise the importance of long-term socioeconomic factors of history when responding to close-ended quantitative measures (vs. open-ended salience measures). Results are discussed in the framework of social representations of history.El estudio analiza como las personas perciben la historia mundial en tres continentes: Latinoamérica, Europa y África. 1179 estudiantes universitarios de Argentina, Brasil, Perú, Portugal, España, Guinea-Bissau y Cabo Verde evaluaron una lista de eventos mundiales y líderes en lo que concierne a su valoración e importancia. Los resultados han mostrado que la representación social de la historia se caracteriza por un Euro centrismo, una evaluación positiva a largo plazo, y por sesgos socio-céntricos. Los eventos “Occidentales” (vinculados a Europa y Norteamérica) fueron evaluados como más importantes y percibidos más positivamente que los no-Occidentales. Eventos políticos distantes, como la Revolución Francesa o Americana, fueron evaluados más positivamente que eventos similares del siglo XX, apoyando la hipótesis de la evaluación positiva del pasado lejano. La hipótesis del sesgo de recencia o proximidad fue parcialmente confirmada, ya que la II Guerra Mundial fue evaluada como más importante que revoluciones o guerras anteriores al siglo XX. El sesgo socio-céntrico también recibe apoyo parcial. Los africanos consideraron a Mandela como un líder más importante comparado con los otros participantes. Los Latinos americanos evaluaron Che Guevara menos positivamente, lo que sugiere que ciertos líderes son generalmente íconos idealizados, y su valoración positiva no se basa en la proximidad o la pertenencia grupal. Sin embargo, los resultados no apoyaron la hipótesis de la centralidad de la guerra. Las guerras fueron efectivamente evaluadas negativamente y la II Guerra Mundial fue evaluado como la guerra más importante y como un evento muy negativo. No obstante, las guerras y eventos políticos relacionados con la violencia no fueron percibidos como más importantes que la Revolución industrial, sugiriendo que las personas valoran la importancia general de los factores históricos socioeconómicos cuando responden a medidas cuantitativas cerradas (vs. medidas abiertas). Los resultados se analizan desde el marco teórico de las representaciones sociales de la Historia

Suomi

Suicide Prevention in Later Life: A Glass Half Full, or Half Empty?

In most countries of the world, older adults kill themselves at higher rates than any other age group. Given that the leading edge of the large post-World War II “baby boom” cohort will reach the age of 65 in 2011, demographers predict a rapid rise in the number of seniors taking their own lives in subsequent decades. The need for effective approaches to late-life suicide prevention is pressing. As a basis for development of prevention strategies, retrospective case-control studies have defined factors that place older adults at risk for suicide. Psychiatric illness is present in almost all older adults who take their own lives, most often an affective disorder. Physical illness and functional impairment as well as social factors, primarily family discord and social isolation, are independent risk factors as well (1). Although it is uncommon for elders to seek psychiatric care, studies show that up to three-quarters of older adults who die by suicide were seen by their primary care provider in their last month, and up to a third in their last week of life (1). Primary care, therefore, represents an important venue for mounting late-life suicide prevention interventions. Yet it is also well established that affective illness is frequently undiagnosed and inadequately treated in primary care practice. Based on the chronic disease model and building on work by Katon and others (2), the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) was designed to improve outcomes of depression—and thereby reduce the rate of suicidal ideation—by employing a collaborative stepped-care approach. In this issue, Alexopoulos and colleagues report outcomes after 24 months of the PROSPECT intervention (3). The study design included random assignment of 20 primary care practices to deliver either the intervention or care as usual. From over 9,000 patients screened, 599 patients age 60 or older with a diagnosis of major or minor depression were selected. Depression care managers assigned to the active treatment practices collaborated with primary care physicians in the detection, algorithm-based treatment, and outcome assessment of depressed patients over 24 months of care. As an alternative to antidepressant medications, care managers could provide interpersonal psychotherapy to patients as indicated. The results reported here show that patients in the intervention arm had a significantly greater decline in suicidal ideation than usual-care patients over 24 months and that a significantly greater proportion of patients with major depression who received collaborative care achieved remission at the 4-, 8-, and 24-month follow-up assessments. Improved outcomes were associated with the greater likelihood of receiving antidepressants and/or psychotherapy, but only in patients with major depression; those with minor depression were equally responsive to the depression care management protocol and usual care. The significance of the PROSPECT study’s findings derives in part from their demonstration of improved outcomes over an extended follow-up period. Depression is a chronic and recurring illness, and knowing the impact of an intervention over longer periods is critical to understanding the strengths and weaknesses of the model. True, the intervention must continue to be refined: in the intervention arm of the PROSPECT study, the rate of remission among patients with major depression was 45%. Nonetheless, the benefit to depressed elders and their families seems clear. Access through a care manager to algorithm-driven treatment, decision support for the primary care provider, and systematic follow-up to monitor treatment response and support patient adherence all contribute to maintaining high treatment utilization rates and thereby reducing depressive symptoms over an extended period. It is promising, too, that patients in the intervention arm had a significantly greater decline in suicidal ideation than usual-care patients. The close associations between suicide and major depression in later life and between suicidal ideation and self-destructive behavior imply that the study’s findings are relevant to the public health goal of reducing the number of suicide deaths among seniors. Even so, it is hard to anticipate what impact the PROSPECT intervention would have on late-life suicidal behavior, either attempts or completed suicides, if it were widely disseminated. Suicidal ideation is a complex construct, and its measurement raises as many questions as it answers. Because of the low base rate of suicidal ideation and the complexity of its measurement, PROSPECT study analyses focused on “active suicide desire.” This construct included items concerning the wish to die and the wish to live, the connection of which to suicidal behavior is uncertain. For which elderly depressed primary care patients are thoughts of death indeed symptoms of their affective illness, and for which patients is a waning will to live best understood as a developmental response to the challenges of aging? And perhaps most important, who among them will go on to translate thought into potentially lethal action? As yet, research has no answers for these questions; the relationship of suicidal ideation to attempted and completed suicide in later life remains obscure. There are other challenges to late-life suicide prevention that the PROSPECT study helps to highlight. Epidemiologic data on completed suicide, the ultimate objective of preventive interventions, indicate that men are at far greater risk than women, a disparity that is even more pronounced in the old-old age group (4) (Figure 1). Among the U.S. population age 75 and older, the rate of suicide is almost 10 times greater for men than for women (35.7 versus 3.7 suicides per 100,000 in 2006). This gender disparity in suicide rates reflects in part the tendency of elderly men to use the most immediately lethal means, firearms, to end their lives; in the United States, over 79% of suicides among elderly men are by firearm. Because over 71% of PROSPECT study participants were female, the study sample can tell us little about the effectiveness of the intervention on reducing suicidal ideation specifically in the highest risk group of elderly depressed men. FIGURE 1 U.S. Suicide Rates, by Age, Race, and Gender, 2006a The several studies that have tested interventions specifically targeting completed suicide in older adults raise additional concerns. Although none used a randomized controlled design, it is important to note that where there was a signal indicating possible effectiveness, it tended to be for women only. The Gotland study, for example, found that systematic education and training of primary care providers in the detection and treatment of depression on the island of Gotland resulted in significantly fewer suicides (all age groups) compared with other regions of Sweden (5). Subsequent analyses, however, revealed that the effect was specific to women (6). In an evaluation of the Tele-Help/Tele-Check intervention, which provided supportive services to at-risk elders in Padua, Italy, De Leo and colleagues (7) too found that a significantly lower standardized mortality ratio in seniors who received the intervention was wholly accounted for by reduction in suicides among women. More recently, Oyama and colleagues conducted a series of multifaceted interventions to increase detection of depression, referral to care, and engagement in supportive social activities for rural Japanese elders (8–12). In each of five studies, they found significantly fewer suicides among women who lived in counties that received the intervention relative to demographically comparable counties that did not. Among men, however, the intervention appeared to have had a significant effect in only one of the five studies (10). Alexopoulos and colleagues’ work raises new hope not only for successful treatment of depression in later life but also for the effective reduction of suicidal ideation and therefore of suicide. Yet questions remain. How do we do better? How do we ensure that the impact on depression translates to lower rates of suicide? What, if any, modifications are needed to ensure that men, the highest risk group in later life, are effectively engaged and treated by collaborative care interventions? There is work to be done.

Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist RecoveryEdited by Terri Tanielian and Lisa H. Jaycox; Santa Monica, California, RAND Corporation, 2008, 498 pages, $55.50

Order online and save! See order form for details. for new and recent publications that provide objective analysis and effective solutions addressing the challenges facing public and private sectors around the world. RAND is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. The R AND Corporation is committed to finding effective solutions to important policy issues, and that mission is more important now than ever before. Concerns about health care, education, the global economic crisis, and ongoing security challenges in the Middle East and elsewhere present problems for governments and private sectors around the world. For 60 years, R AND has worked to help confront challenges such as these by providing objective analysis of important problems and the possible solutions to them. R AND's commitment to making a difference is evident in the broad variety of insightful and influential titles highlighted within these pages. R AND's impact on social issues is exemplified by Invisible Wounds of War (see facing page), which has received close to 3,000 media citations and continues to make headlines across the country. This research shows that nearly 1 in 5 service members returning from Iraq and Afghanistan are afflicted by post-traumatic stress disorder or major depression—but that only slightly more than half have sought treatment—and recommends effective treatments based on evidence-based care. Reparable Harm (see page 2) examines the racial and ethnic disparities faced by boys and men of color and how these disparities lead to serious disadvantages; it also identifies programs, practices, and policies that are helping to improve opportunities for this group. Moving Los Angeles (page 3) offers short-term solutions to the region with the most severe traffic congestion in the United States, strategies that may also be appropriate for other cities. R AND is equally focused on helping to address critical security challenges. How Terrorist Groups End examines hundreds of terrorist groups that have come and gone since 1968 and offers lessons for U.S. efforts against al Qa'ida, while In Their Own Words looks at how the historical writings of jihadis provide unique insight into their mentality (see both on page 6). Iran's Political, Economic, and Demographic Vulnerabilities and Pacific Currents offer valuable insights into security challenges in Iran and China, respectively (both on page 8). The R AND Series on Counterinsurgency (pages 10–11) provides lessons that are already proving useful for U.S. and allied troops in Iraq …

Dark Medicine: Rationalizing Unethical Medical Researchedited by William R. Lafleur, Gernot Böhme, and Susumu Shimazono; Bloomington, Indiana University Press, 2007, 258 pages, $19.95

The Prevalence of Power-Sharing: Exploring the Patterns of Post-Election Peace

Why are some elections followed by armed conflict, while others are not? This article begins to explore this question by mapping the prevalence of power-sharing agreements and patterns of post-election peace in states shattered by civil war. While democracy builds on the notion of free political competition and uncertain electoral outcomes, power-sharing reduces the uncertainty by ensuring political power for certain groups. Nevertheless, new data presented in this article – the Post-Accord Elections (PAE) data collection – shows that the issues of peace, power-sharing and democracy have become intertwined as the vast majority of contemporary peace agreements provide for both power-sharing and elections. First, in contrast to previous research which has suggested that power-sharing is a tool for ending violence, this study shows that conflict often continues after an agreement has been signed, even if it includes provisions for power-sharing. Second, this investigation shows no evidence of power-sharing facilitating the holding of elections. On the contrary, it is more common that elections are held following a peace process without power-sharing. Third, a period of power-sharing ahead of the elections does not seem to provide for postelection peace. Rather, such elections are similarly dangerous as post-accord elections held without a period of power-sharing. The good news is that power-sharing does not seem to have a negative effect on post-election peace.

Power-Sharing, Conflict and Transition in Burundi: Twenty Years of Trial and Error

For the past twenty years, Burundi has experimented with power-sharing as an instrument of political liberalisation, democratisation and conflict resolution. This contribution analyses the different meanings the concept of power-sharing has had throughout Burundi's recent and extremely violent political transition, in particular during the lengthy peace process. It shows how national and international actors have found inspiration in the toolbox of consociationalism to negotiate and design the Arusha Peace and Reconciliation Agreement for Burundi signed in August 2000 and its post-transition Constitution. Power-sharing has been instrumental in achieving the – short-term – objective of war termination. It has also de-ethnicised political competition and reduced the (potentially) destabilising effect of elections. Measured against more ambitious state-building objectives (democracy, rule of law, accountable and effective governance), power-sharing has (so far) not been able to make a difference. Several factors and developments threaten the “survival” of the power-sharing model in Burundi.

Using Power-Sharing to Win a War: The Implementation of the Lomé Agreement in Sierra Leone

To end the civil war in Sierra Leone the government and the Revolutionary United Front (RUF) signed a peace agreement guaranteeing power-sharing in July 1999. Such power-sharing is a widely used, often recommended political arrangement to overcome deep divisions between groups. However, scholars disagree on whether power-sharing causes peace, or, on the contrary, causes continuing violence. One reason for this is the literature's tendency to neglect how power-sharing is actually put into place. But post-agreement implementation is essential if we are to judge the performance of power-sharing. Therefore, we investigate the role played by power-sharing in terminating the civil war in Sierra Leone. We argue that the government was able to use the peace agreement to pursue its goal of ending the war through marginalising the RUF.