My dad’s favourite saying was, “Bugger you, Jack. I’m all right.” He’d say it when someone cut him off on the road, or when my brother and I stole the last pack of biscuits. It’s a fair summation of the social policies of our recent governments. You can even imagine the Ironman, with his this-is-all-a-big-joke smile, chanting it three times in a row while Madam Speaker nods her pristine bun and bleeding lipstick, aping Thatcher.
Small government. Personal responsibility. Have a go. Down with the leaner. I’m beginning to think that the bedrock of the political conservative is his belief that everyone’s just like him. As if they think that guy on the street corner with a hat between his knees could, if he really wanted to, get up, comb the grease and the hallucinations out of his godforsaken hair, and run for parliament.
There’s something missing in this belief system. The kind of imagination necessary to generate empathy, perhaps. A knowledge of history. And step by step, our rich country moves towards precipitous inequity.
Hospitals and doctors are good at treating diseased organs, and yet we now spend a rocketing amount of our time trying and failing to patch up social catastrophes. Forty thousand dollars ripped off the street becomes millions in the hospital.
I leave my house to ride to work, where there is no time for day-dreams. But when I get home I plan to ask Agnes if she ever dreams of the snow.
A Pain in the Tooth
We spend a lot of time in queues. People will wait in line for a seat at a momentarily hip ramen joint, to secure a trickle of government assistance or some discount Louis Vuitton. All day every day they’re waiting for treatment outside hospitals’ emergency departments. We trade in our time and comfort for the things we need or really want. The older and richer you are, the less time you will squander anticipating your turn.
In primary school I spent an inordinate amount of time queuing for things I didn’t want: vaccinations, nit inspections, a check-up in the dental van.
The Commonwealth-funded van would visit our school a few times each year. A short-tempered trainee dentist and his female assistant ran it, and there’d be one kid mouth-open in the recliner and another kid ready in a seat to the side. I copped a lot of pain in that van. One time the dentist wouldn’t believe that his giant needle had failed to numb the tooth he was drilling, and yelled at me to stop edging down the seat as I tried to escape. I experienced the most memorable pain while waiting for them to treat my classmate Patrick. He was only up there for a few minutes before the assistant asked him the colour of his toothbrush. Patrick said it was yellow. The assistant sneered, “Is that so? We’re surprised you can even remember. You do realise that your breath smells so bad the dentist has had to put on a mask?”
The van staff made no effort to disguise their hatred of this job. They were wheeled out to the freeway suburbs, time pressured, physically cramped, preposterously young, completely unsupervised and without a single parent to thank them. But they had to learn on someone. Might as well be on those who had no other way to pay except with a bit of suffering. Turns out we were lucky. Born a couple of decades earlier and I may have had the lot extracted and replaced with a set of “low-maintenance”, “germ-free” dentures. If not for free, then perhaps as a twenty-first birthday present or “dental dowry” (reassurance that a future wife’s teeth wouldn’t send you bankrupt). At the time of my contact with that shakily benevolent van, 60 per cent of men and 71 per cent of women over the age of sixty-five in Australia were edentulous. That is, they were completely toothless.
Compared to the current state of publicly funded dental services in Australia, the dental van sounds as luxurious as cut-price Louis Vuitton. If you are poor you can still get free dental treatment, but you’ll wait up to seven years. We may have been mildly tortured and occasionally humiliated, but that dental van prevented a lot of future trouble.
People rarely get all their teeth removed anymore, and when they do it’s generally at their own request. When you’re in a queue that’s seven years long and have a sore tooth, a request for “definitive” treatment is hardly surprising. Only 14 per cent of Australian dentists work in the public system. I’ve never met any of them but I’d completely understand if they’re in a permanent bad mood. The exclusion of dental care from Medicare was supported by dental associations worried that government funding would bring with it government control. What profession would choose that over the riches available in the free market?
Both of my daughters had braces fitted last year. One had extremely prominent front teeth caused by a vigorous thumb-sucking habit. The other had a minor overlapping of her two front teeth. They saw the orthodontist – a man with gleaming white offices, terrifically attractive assistants and exquisite shoes – and he recommended the braces and a three-year payment plan. The braces hurt them for a few days and thereafter caused no major issues. But this week they came home from their check-up with their little cheeks swollen up like a chipmunk’s. Their teeth were so straight by now I’d half expected him to declare further bracing unnecessary. Instead, he’d inserted sets of fat medieval-looking springs: a scheduled part of the treatment I’d apparently forgotten. The girls authoritatively told me the springs were necessary to “correct their overbites”. They noticed my sceptical look and told me – wide-eyed – that if they didn’t get the minor abnormality fixed they might need “jaw surgery” later on. Then they refused dinner and miserably took to bed.
I remembered the horror of being a young girl too intensely to have insisted my daughters learn to live with buck teeth. Dental malformation has become a potent signifier of poverty and a long list of other unjustifiable assumptions that I’m sorry about but not prepared to use my own children to protest. But to move an entire jaw forward, to inflict that kind of pain on a couple of twelve-year-olds who looked perfectly fine? I needed evidence that the intervention would prevent a serious long-term health problem. So, guilt-stricken and conflicted, I spent a night among the dentistry journals. The sceptical look on my face found no reason to remove itself. There is virtually no evidence that “malocclusion” affects the health of the “masticatory apparatus” unless the overbite is “traumatic”, the incisors self-mutilating or the teeth wildly impacted. The studies even fail to prove any emotional ill effects of dental irregularity.
Our primary-school suffering saved our teeth and provided a generation of dentists with intensive training. My daughters’ pain was serving nothing more than a fairytale of bite perfection. In a country where dentistry costs big dollars, children are lucky if their parents can pay. When it comes to orthodontics, parents should question exactly what it is they’re buying into.
Looking for Trouble
I had a mammogram request slip folded into the side pocket of my purse for two years. My GP gave it to me when I turned forty, telling me the time had come to start being screened. I put it in my purse and mostly forgot about it, feeling a slight tug of anxiety whenever it emerged in a wad of receipts. I’ll get to it soon, I’d think. Plan made. Every now and then, in the middle of the night, I’d worry: Maybe I have a cancer in me somewhere, growing quietly, waiting to burst into my bloodstream, spraying metastases to bone, liver and lung. I’d better get that mammogram. And then I’d fall asleep. So I was relieved when I started reading papers in major medical journals that claimed mass screening for breast cancer caused more harm than good. Off the hook.
Screening is a thing doctors do to healthy people, people without symptoms or signs of disease. The aim is to detect disease early so that it may be treated, and death or debility may be averted. It’s pretty hard not to be comforted by a good screen. We get screened for skin, cervical, breast, bowel and prostate cancer. We get screened for diabetes, osteoporosis, high blood pressure and cholesterol. Newborns are screened for phenylketonuria, cystic fibrosis and hypothyroidism. There have been calls to screen people for dementia, for pre-diabetes, for obesity. I see my dermatologist once a year and get her to hunt my skin for melanomas. When I leave her office
with the all-clear, I feel a sense of deep relief at having escaped death once again. Unfortunately, this is not the best way to detect skin cancer. The best way is to know your own skin and watch it vigilantly for deviations yourself. To the heavily freckled this proposition is laughable.
Some forms of population screening seem unambiguously good. The neonatal program causes little harm and saves lives. Whereas screening for “early dementia” is probably a bad idea, given that should your doctor detect it there’s nothing you can do except dread the future, and watch your family question your decisions and start speaking to you really slowly. Being searched for disease can be injurious.
In Australia, more than 3000 men die each year from advanced prostate cancer. However, a large proportion of men who live long lives will die with their prostate harbouring a cancer that is neither symptomatic nor a contributor to their demise. Public health organisations in most countries, including Australia, no longer recommend mass screening (using the prostate-specific antigen, or PSA, blood test) among asymptomatic men. This is because the program has been repeatedly shown to cause far more harm to the healthy than benefit to the “sick”. The data vary, but the most positive figures show that for every 1000 men tested for ten years, two men will avoid dying from prostate cancer, two will avoid cancer that spreads around their body, eighty-seven will have a biopsy due to a falsely positive test, twenty-eight will be diagnosed with a cancer that would never harm them during their lifetime, and twenty-five will have their prostate removed or irradiated unnecessarily.
A man can live without his prostate gland. If you tell people they have cancer in an organ they don’t need, most opt to have it removed. The problem is that removing it leaves a large number of men impotent, incontinent or both. An 80-year-old man in my clinic started crying. “They didn’t tell me it could happen,” he said, and looked down at himself with disgust. “What’s the point of living now, like this, useless?” Before you get the simple, painless, free blood test, it’s important that you know the facts: you are ten times more likely to be rendered impotent than to have your life saved.
In 2014 the Swiss Medical Board recommended that Switzerland’s breast cancer screening program cease. The board’s reasoning was based on American data showing that for every life saved (about 1 per 1000 women screened), between 70 and 100 women screened have an unnecessary biopsy, and between 3 and 14 women are treated with surgery, radiation and/or chemotherapy unnecessarily. The recommendation caused an uproar: it was against international consensus guidelines; it might “upset women”.
Mobile health-screening vans have started popping up all over the place in Australia. They do the rounds of churches and RSLs, setting up shop for a day like Girl Guide cookie sellers. They are advertised heavily, quoting statistics like “80 per cent of strokes can be prevented”. That is true, but they are prevented by things like exercise and avoiding smoking, not by paying a private company to perform a single ECG and a Doppler ultrasound of your neck arteries from a van in a church car park. In the US, these health-screen businesses work with private hospitals that lend their name and logo for legitimacy. When the tests show something abnormal you are directed to the hospital, an institution that will be rewarded financially for doing things to you: fancier tests, appointments, interventions, treatments. This may or may not act as a disincentive for doctors to tell you the truth, which is that you should go home and stay away from privately operated mobile health-screening vans.
It’s easy to convince people that a check-up is a good idea. Who knows what bad things might be happening in your body without you knowing? But screening for disease is not the passive, completely benign process it appears to be. Some screens confer a sense of security that may be illusory. Some may lead you to harm, while others save lives. Before you consent to being screened for anything, ask about the benefits and the risks given your particular medical history. What might you lose if you sign up for years, waiting to see if you’re the one in a thousand?
Mind the Gaps
A week before the announcement that private health insurance premiums would rise by an average of 6.2 per cent from 1 April 2015, I sat in an audience of 200 or so doctors for my hospital’s weekly grand round. Everyone meets in a hall, stacks a plate with lunch and listens to what is usually an in-house lecture. This grand round was about internal cardiac defibrillators. An ICD is a little box wedged in a patient’s chest and wired into their dodgy heart. When the heart starts to vibrate instead of pump, the device delivers a whopping shock to get it back in rhythm. It’s like walking around with a mini CPR team under your skin. When I was an intern I looked after a patient whose ICD had started firing repeatedly for no apparent reason. He said it was like being kicked in the chest by a horse, over and over. Even though we’d switched it off, he lay perfectly still in the hospital bed, staring down at his body like he wished he could step out of it and get as far away as possible.
Mid-presentation, and just in passing, the cardiologist mentioned that public hospitals purchase standard ICD units from the manufacturers for around $12,000, whereas private hospitals pay up to $45,000. No one raised an eyebrow. We all just kept on listening and chewing, immune to more evidence of the madness of our two-tiered system and, frankly, not really giving a damn what companies charge private hospitals. It’s their free market. When I heard that private insurance premiums were being raised to almost three times the rate of inflation, I wasn’t surprised.
As a salaried doctor in a public hospital I rarely think about the private system. Except when a patient is transferred to us from a private hospital because they are too sick to be treated there or the surgery’s gone terribly wrong. Or in the rare instance a patient asks to be transferred to a private hospital. A fully insured patient of mine requested private hospital rehabilitation after breaking her hip, but her fund wouldn’t pay for the rehab until she’d spent seven days in an acute bed, and then they’d cover a maximum of two weeks of private rehabilitation, regardless of her need. I started to wonder: leaving aside services not covered by Medicare, such as dental care, why do we have private insurance that overlaps with our universal health care system?
I asked around. The best a bunch of public physicians could come up with is that private health insurance means that you wait a few months less for elective surgery, get your own room and can choose your doctor. Private insurance doesn’t cover all the “gaps”, the sometimes profligate mark-ups doctors add to Medicare-set prices in what we call “Private Land”. You can end up paying thousands for the privilege of getting a private hip or baby.
An OECD working paper on health insurance in Australia states, “Among the countries with large private health coverage, Australia is a fascinating case.” As one learns in grand rounds, fascinating cases are usually quite ill. Private insurance apparently takes pressure off the public system and contributes to Medicare “sustainability”. Health insurance companies generate large profits (13.6 per cent gross on average). But they also have astonishingly high administrative costs – far higher than Medicare – which cut into these profits. The government has to cajole us to pay for this cover: there are penalties and levies if you don’t have it, and up to 30 per cent of the fees are subsidised by government. These insurance subsidies currently cost taxpayers more than $6 billion a year and this figure is set to rise. The system is a fine way of directing funds to the wealthiest households.
Contrary to what we have been led to believe, there is evidence in Australia and internationally that private health care leads to increased health costs (by abolishing centralised cost controls) and to longer waiting times for public surgery, particularly urgent surgery: partly because public hospitals have to compete for staff, and doctors can earn far more in a private hospital, and partly due to “over-servicing” willing customers. Even though around 50 per cent of the population has private coverage, there has been little change in per capita demand for public hospital services. When we’re really sick, we prefer to be treated as
a citizen, not a customer.
The main industries to benefit from private insurance are those hawking it and the private hospital sector. Both have powerful lobbies. If a privately insured patient comes to a public hospital, they can elect to sign up as a private patient. This is mostly a benevolent and much-needed donation. You get the same treatment as if you were a public patient, even though an insurance company funds part of your care. The insurance and private hospital industry lobbyists accuse cash-strapped public hospitals of bullying patients into donating their insurance. It greatly troubles them, they say, that this practice may leave public patients “stranded on elective surgery waiting lists”. They propose that the government urgently creates incentives for public hospitals to shunt more insured patients into Private Land. Preferably the simple, profitable patients. The alternative solution – to stop “incentivising” anything private and directly fund more public hospital activity – is unthinkable.
The gigantic props that taxpayers provide to private insurance companies divert substantial funds from the public system. Billions of tax dollars are spent aiding the richest half of the population to choose expensive surgeons and single rooms, to get prompt elective procedures. It’s the only kind of “queue jumping” the government is willing to support.
Health Care, American Style
It’s the end of 2013, months before the world will hold its collective breath because a handful of congressmen don’t want the United States to provide health insurance for the 47 million of its citizens who don’t have it. I’m in the Deep South, having a beer with a senator’s chief of staff, and he’s trying to explain to me why Obamacare is such a bad thing. It’s something to do with the deficit, with taxes and small business, and I’m not following, not even when he shows me a pretty pie chart on his laptop. I’m embarrassed at his effort and at my failure, and I keep wanting to say, “Stop, save your breath, you’re trying to convince a nobody.”
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