Anonymous 2023

The Medical Industrial Nightmare

On a Sunday morning during my internal medicine rotation, I had just finished working out when I noticed some mild abdominal pain. Thinking it would resolve on its own, I went about my studying for the day, but the pain only seemed to worsen. I had a meeting that evening, but I barely made it down the hall from my apartment, as each step I took sent shooting pains up my side. Pressure on my abdomen elicited severe pain that shot to my shoulder and brought tears to my eyes. Worried about appendicitis, I knew that I should go to the ED. However, as a medical student subsisting on loans, I feared that I would not be able to afford the cost. I went to Urgent Care instead, hoping for a lower fee, but I was told that they did not have the capabilities to evaluate me there. At the ED, I was diagnosed with a ruptured hemorrhagic ovarian cyst. A CT scan and multiple ultrasounds later, my bill totaled $15,000. I was fortunate enough to only have to pay a fraction of that cost due to insurance. However, my first personal experience with the ED reminded me of the many patients without insurance whom I had encountered while scribing in the ED prior to starting medical school. I recall a specific instance in which a patient without insurance presented following a car accident. The provider whom I was working with felt that a head CT was strongly indicated; however, the patient kept refusing due to concerns regarding the cost. I do not blame her - most people cannot afford to pay thousands of dollars at the drop of a hat. The provider kept insisting until the patient agreed, and she was rushed to emergency surgery after a brain bleed was found on the CT. The feeling of knowing that the patient would have died had the imaging not been done has stayed with me since that day. That patient should not have had to make that choice between death and cost of treatment.
Healthcare is a human right that should be provided to everyone regardless of their income.

Capitalist Realism and Mental Health

Heartbreakingly, that patient is by far not the only one who has had to face the crippling expenses of healthcare in the United States. In “Cost of Living,” Emily Maloney writes, “My health insurance at the time occupied the space between terrible and nonexistent. I couldn’t imagine the amount of money I’d spent—the debt I’d incurred—in attempting to end my life. Suicide should be cheaper, I remembered thinking. Probably half the costs were for psychiatry, for an illness it turned out I never really had. I was depressed, but a lot of people were depressed in college, it seemed. I only tried to kill myself after I began taking—and then stopped taking—all the medications I’d been prescribed, twenty-six in all. All for what turned out to be a vitamin deficiency, combined with hypothyroidism and a neurologically based developmental disorder”. She goes on to describe how she was endlessly harassed by debt collectors to pay five figures while she desperately picked up back to back shifts at $12.50 an hour. It seems so inhumane that after someone has reached the lowest point in their life, they are saddled with debt that they could never feasibly pay off in their lifetime. It’s not as if the stressors that lead to a suicide attempt simply disappear after the person continues to live. Then, they are forced to bear the unbearable weight of its financial cost on top of all of that. As medical students, we are constantly told that the purpose of healthcare is to take care of our patients. But I wonder, how could the current American healthcare system ever be interpreted as taking care of others? How is what happened to Emily “care” at all?

To take a closer look at mental health in particular, in Capitalist Realism, Mark Fisher writes: “The chemico-biologization of mental illness is of course strictly commensurate with its
de-politicization . . . all mental illnesses are neurologically instantiated, but this says nothing about their causation”. We are taught over and over again, not only as medical students, but also as members of the public, that depression equals low serotonin. I would argue that this is by design - if you believe that your mental illness is simply an imbalance of chemicals in your brain, then you have no reason to question the validity of capitalism or to reflect on its effects on your well-being. However, the truth is that behind those low levels of serotonin are deep social and structural issues. Maya Surya Pillay, a South African medical student, writes about the patients that she has seen in the psychiatric ward. She details their stories - the girl whose
step-brother tried to kill her, the intellectually disabled woman whose boyfriend beat her, the woman who believed that her neighbors were cursing her with darker skin. She writes about unwanted pregnancies, drug use in primary school, dead mothers, lost jobs, and starvation. “I wanted to take them by the shoulders and scream of course you are miserable. Of course you are paranoid. Of course you hear a voice telling you to kill yourself. Of course you want to die. The world has been so cruel to you that no-one could expect you to bear it. If you have gone mad YOU ARE RIGHT TO HAVE GONE MAD,” she writes. Pillay’s examples perfectly illustrate the political model of mental illness - under late capitalism, most of us struggle to survive. We spend our days fearing for our safety, whether it is our physical, emotional, mental, or financial safety, or more realistically, all of them combined. So, of course we are depressed, anxious, and unwell - how can we be well when our basic needs are not met? When healthcare is not a human right but a privilege only granted to those who can afford it? When minimum wage is not nearly enough to subsist on? When life itself hangs in the balance? The “mental health crisis” is unemployment, massive wealth disparity, domestic abuse. Until those issues are addressed - until human rights are actually treated as rights - the crisis won’t be resolved.

My own experience rotating through inpatient child psychiatry opened my eyes to the lack of social services for children in the United States. Many of the children on the unit had been admitted to the unit before. The story was often the same: a child is suicidal, they are admitted to the hospital, they are “acutely stabilized,” they are sent back to the abusive environment that made them suicidal in the first place, they become suicidal again, they are sent back to the unit… During this rotation, one of my attendings shared with me that among many other failures, DHS had knowingly allowed several of her pediatric patients to starve to death. The harsh reality is that there is not nearly enough social support for children in this country - even the entities that are supposed to protect them fail to do so. I watched multiple police officers tackle children to the ground while I was on the unit. A provider who was also present at the time commented that one of the children “belonged in jail.” The child in question had come from a severely abusive and food insecure environment and had attempted suicide by ingesting hand sanitizer. He had been provoked by another patient on the unit and had hit her. Of course, that was not the right response, but it shocked me that the provider seemed unable to see that given the child’s history, he may have formed a defensive reaction to perceived threats to his safety. Further, the patient was black, and it is very likely that this influenced the provider’s comments (despite the black lives matter pin that he wore). In light of this experience, I am not tremendously reassured that children are properly treated when they are admitted to psychiatric units. The patient I mentioned was actually sent to juvenile detention but was subsequently sent back to the unit due to COVID-19 concerns at the detention center. I found it difficult to understand how the children on the unit were supposed to heal in the face of aggression and little empathy from police, security, nursing, and staff on a daily basis.

Medicine is not a Science

“Medicine is not a science. Medicine is politics manifesting in flesh, bone, hormone, virus, the torn vagina, the overdose, the tuberculoma, the crushed skull,” Maya Surya Pillay declares. I remember a time, not too long ago, when I was working two minimum wage jobs without any healthcare benefits. I did not have access to insurance and had to pay excessive fees for dental care after I hit my head and chipped a tooth. Seeking care for myself at Planned Parenthood made me realize that it would cost several hundred dollars to see a provider and that it was not nearly as affordable as I had perceived it to be. I saw these barriers to care amplified during my clinical rotations and volunteer experiences at Mobile Clinic and Free Mental Health Clinic (FMHC). Whether it was a two-year-old who received a low quality valve replacement for a congenital heart condition due to her mother’s social situation or a couple who had to pay several thousand dollars out of pocket to terminate a non-viable pregnancy, I saw the pain in these families’ eyes and knew that there had to be a better way. At FMHC, I encountered homeless patients and became frustrated that their trauma and mental health issues were being covered up with medications when there were clear structural issues that needed to be addressed. Questioning how a person is expected to be healthy and well when almost none of their basic needs are met led me to read about housing initiatives in Europe that are built around providing services to tenants. I learned that these initiatives differ widely from many in the United States that apply a “staircase model”, which involves moving through various stages of temporary accommodations before obtaining permanent residence.

During 2022, it has seemed that the United States has had a dark agenda - more than a disregard for human health and life, its legislators have actively pushed for and enacted
life-ending regulations. As a pediatrician in training, I have especially noticed the effects of such legislation on children.

Formula Shortage
To begin with, my pediatric gastroenterology rotation quickly opened my eyes to the ramifications of the formula shortage. I met many families who could not access adequate formula for their babies. For patients with cow’s milk protein allergy, hydrolyzed formula was even harder to come by. I had heard about a manufacturing plant shutdown due to contamination, but the more I learned about the baby formula industry, the more enraged I became. In February 2022, the Abbott Nutrition facility, a key manufacturer of baby formula in the United States, was shut down after the FDA and CDC identified a bacterial outbreak at the plant. Five babies who had consumed formula from the plant contracted bacterial infections, and two of them died. As a result, production was halted, leading to a national formula shortage. A whistleblower document showed that the plant falsified reports, released untested formula, and hid safety information from inspectors. In 2014, the baby formula industry successfully lobbied against FDA proposals to decrease risk of contamination with Salmonella and Cronobacter sakazakii, which led to this year’s plant shutdown. It is not as if the industry could not afford to increase safety spending - last year, Abbott spent $5 billion buying its own stock. Instead, it is parents who end up having to pay for the industry’s greed, with some having to resort to eBay, where formula may cost over six times the retail price. To make matters worse, the U.S. strictly limits imports of European formula brands, although studies have shown that EU safety and nutrition standards are higher than those in the U.S. Thus, American legislators have allowed the industry to avoid safety regulations, leading to preventable illness and death in babies, and have refused alternative sources of formula that could save babies’ lives.

Criminalization of Abortion
The recent, heartbreaking overturning of Roe v. Wade is another stark example of the ways that the U.S. is neglecting women’s and children’s lives. I am using the term “women” to mean people with uteruses/ovaries. 47,000 women across the world die from unsafe abortions each year, and 5 million are hospitalized with serious complications such as bleeding and infection. With the overturning of Roe, the United States becomes one of the countries with the most restrictive abortion laws in the world. The decision contradicts the evidence that shows that banning abortion results in greater mortality. For example, when Chile criminalized abortion in 1989, illegal abortions became a primary cause of maternal mortality. Rather than banning abortion, non-partisan research has shown that the policies that reduce abortions include acknowledging basic rights such as access to contraceptives, comprehensive sex education, universal healthcare, paid family leave, welfare funding, housing security, and livable wages. According to Harvard Medical School, abortion is “the removal of pregnancy tissue, products of conception or the fetus and placenta (afterbirth) from the uterus”. In the US, over 90% of abortions occur due to unplanned pregnancy, and about 50% of all pregnancies in the U.S. are unplanned each year. They are also performed when the fetus is found to be abnormal or the mother’s health is at risk (therapeutic abortion). The treatment for potentially fatal conditions such as ectopic pregnancy, septic uterus, and miscarriage is abortion. In addition to health risks, forced pregnancy and birth can make it more difficult to continue education, career, and life plans; escape poverty, and leave an abusive partner. Mothers who are forced to carry to term must bear the burden of the cost of the physical and mental healthcare required to heal their bodies and cope with the trauma of forced birth, potentially in the context of rape or incest. Further, there are no adequate structures in place to fund adoption and food, shelter, and education for children born to mothers forced to carry to term.

In a study conducted by the Washington University School of Medicine, it was found that providing free contraceptives reduced unplanned pregnancies and decreased abortion rates by 62-78% when compared to the national rate (4.4 to 7.5 per 1,000 women, compared to 19.6 per 1,000 women). Moreover, a University of Michigan study showed that the young adult provision of the ACA, which allowed young people to stay on their parents’ insurance until the age of 26, reduced abortion rates in women aged 20-24 by 9-14% when compared to women who could not access this eligibility. Long-term hormonal birth control use increased by 68%. However, these results did not translate to women of color, who are less likely to access insurance through their parents’ plans, which helped to show that the lack of affordability of birth control without insurance is a primary contributor to unplanned pregnancies. Furthermore, contraceptives can reduce risk of ovarian and endometrial cancers, and some types are used to treat endometriosis, polycystic ovary syndrome (PCOS), uterine fibroids, and heavy menstruation. Birth control is not only preventive care and treatment for very painful conditions, but also a means of empowering women to control their educations, careers, and lives. Thus, the criminalization of abortion and continued lack of social services in the U.S. harms both women and the children they are forced to give birth to.

Police Brutality
Furthermore, the militarization of the police in the United States has resulted in the loss of children’s lives far too many times, including recently, at the highly publicized Uvalde school shooting, in which nineteen police officers stood outside a classroom while children were murdered inside. Due to the Pentagon’s 1033 Program, military equipment has been transferred to police departments across the country. Simultaneously, SWAT team presence in cities and towns has expanded despite their regular activities consisting of using military methods to violently serve drug warrants rather than responding to crises. Many officers aspire to join SWAT teams and emulate their attitudes as a result. Even outside of SWAT teams, police officers are trained to view every civilian as a threat to their lives and to “always have a plan to kill everyone they encounter” even though fatality rates for police are “far less than those in logging, commercial fishing, and trash collecting”. Nonetheless, police officers are trained to believe that they are always in danger, and as a result, to shoot without question. All of this adds up to a dynamic of “over-policing and under-protection” in which “police are hypervigilant about petty offenses but unresponsive to more serious criminal activity”.12 In Texas, hairdressers are required to undergo more training hours than police officers. In addition, there are no standards for SWAT training in the U.S. So, police officers are not appropriately trained, and the training they do receive focuses on brutalizing civilians during everyday encounters. The result is civilian death in both daily interactions with police and crises such as mass shootings. Innocent people, such as Breonna Taylor, are killed by police who are taught to view civilians, especially people of color, as threats, and children are killed in school shootings, because police are not taught to do their jobs.

With inadequate baby formula, fewer abortions, and increased gun violence and police brutality in the United States, even more than life itself, the issue is about “who gets to live and how, and who decides”.13

The Medical Industrial Complex

Horrifically, the answer to the question I have been asking all along - what motivates the U.S. government to legislate and operate in a manner that sacrifices children’s lives and well-being? - lies in the medical industrial complex. It lies in profit and in the way that the United States was very intentionally structurally designed to maximize the wealth of those in power at the expense of everyone else. In 2007, the Department of Justice found the orthopedic medical device industry to be illegally bribing surgeons, often with training grants and consulting contracts.
Although the companies were fined $311 million and subjected to new corporate compliance measures, the industry continues to subsidize the salaries of one fourth of new orthopedists. Similarly, the Physician Payments Sunshine Act, which was supposed to require corporations to make consulting contracts and gifts public, has in reality made little difference. Instead of bribing individuals directly, they simply direct their money to third party foundations instead, which then makes its way to orthopedic departments.

In fact, the device companies fund specific orthopedic subspecialties that will use their products, shaping the field to the detriment of patients. One example is orthopedic treatment of age-related back problems, which used to consist of removing small pieces of bone or fusing two vertebrae together. However, newer methods fuse several vertebrae from multiple sides, with increased cost and risk of complications but no improvement in outcomes. Of course, surgeons and medical device companies favor them despite this, since these surgeries translate to higher reimbursements. Further, although 85% of adults will have lower back pain at some point in their lives, 75% will experience resolution of the pain without any intervention at all. Regardless, $17.6 billion per year was spent on back surgery in 2004, triple the amount spent in 1998. In 2010, Depuy Spine, Inc. spent $2 million to pay for 25 new spine surgeons. Thus, the industry pressures doctors into finding patients to undergo these procedures, which of course, benefits the implant and equipment companies. It follows that nonsurgical treatments of chronic back pain are completely dismissed by device manufacturers, although in many cases, evidence shows that nonoperative approaches are superior to surgical ones. Unfortunately, the Accreditation Council for Graduate Medical Education (ACGME) refuses to ban outside funding of training programs although it has the authority to do so. The American Academy of Orthopedic Surgeons (AAOS) harasses and threatens any members who try to speak out against fellowship funding. So, hospitals and clinics continue to fund their training programs with industry money, with some even taking additional federal money for the same fellowships.14

The medical device industry’s influence on the practice of healthcare is just one example of how the medical industrial complex hurts patients. I have also explored the costs of the capitalist structure of healthcare in the United States, which manifest not only financially, but also in terms of people’s lives and well-being. Americans who cannot afford the often exorbitant cost of healthcare must choose between crippling debt and loss of health or life. The system is designed to make us think that our poor mental health is our own fault, something wrong with our brain chemistry, so that we are distracted from the real reason that we are struggling - the fact that our very human rights are not acknowledged in this country and that we are not, in actuality, guaranteed the rights to “life, liberty, and the pursuit of happiness.” In fact, capitalism relies on maintaining classism so that those who lack resources (often minorities) can be exploited for the gain of those in power. Thus, the United States is not interested in social reform, not even for the benefit of its children. To the contrary, children are harmed and killed every day in the United States, due to completely preventable reasons - corrupt baby formula companies knowingly distributing contaminated product, forced birth legislation dooming children to traumatic lives (inadequate adoption/foster care resources) or deaths (genetic defects that are incompatible with life), and a highly militarized police that does not hesitate to shoot children in the streets but stands idly by while children are gunned down in schools. The simple truth is that until there is radical change in the way the U.S. legislates (i.e. who the legislators are), then American healthcare will continue to be unsustainable and in violation of our human rights.

Conclusion

I would like to end with the words of Alexandria Ocasio-Cortez:

“My honest view is that things are likely going to get harder before they get better, and we will need to stick together.

What is important in moments like these is not to think in binaries. Good/bad, screwed/not screwed. There is no doubt that things are bad. Some things, really bad. And they may likely get worse. But that does not preclude the fact that slowly but surely, some good can be growing as other things fall apart. This is not some syrupy sweet silver lining case for optimism. Rather, it is really about a choice all of us will have to make in life, either consciously or unconsciously: will I be a person who is safe and creates good for others? Will I be a person who stands up? Will I be a person who primarily minds my business and serves myself or try to be part of something bigger? Or will I just be a passive, “neutral” observer of it all?

What I sometimes tell my staff is that the world we are fighting for is already here. It exists in small spaces, places, and communities. We don’t have to deal with the insurmountable burden of coming up with novel solutions to all the world’s problems. Much of our work is about scaling existing solutions, many created by small committed groups of people, that others haven’t seen or don’t even know are around the corner. So while we can’t change the world in a day, we CAN and do have the power to make our own world within our four walls, or our own blocks. We can grow from there with the faith that somewhere out there, everywhere, others are doing the same. And we will come together. That’s why if you’re a parent, how you parent matters. If you’re a neighbor, how you are a neighbor matters. Many of our biggest problems are results of massively scaled up isolation from others. That means many of our solutions can be found in creating community.

Ultimately, we live in this world and in this time. We have no choice but to engage in it while we’re here. Even running away is a form of engagement. So will your engagement hurt or heal? Build or bring down? There is no neutral choice, so we can at least do our best to make good ones and learn and do better the next day.

You are allowed to be scared. To grieve. To be angry. But you are also allowed to create good, to be soft, and to enjoy the small reprieves. Struggle lasts as long as we do.”

References

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