5/2: The Coming of Corporation.

As the journey continues into the history of American medicine, Paul Starr offers elegant an elegant summation of very through book, he also paints a detailed picture of today’s health care sector--even if his ‘today’ was thirty years ago. The observations he made and prediction of the pattern of growth of corporation in the healthcare sector are as valid today as they were in 1980s.

Foreign-Trained doctors (aka Foreign Medical Graduates).
Presumably a product of the shortage of doctors, but in reality a way to bridge access disparities in less fortunate populations, foreign-trained doctors, who came to be affectionately called FMG, found America to be a medical haven. It was common knowledge among medical graduates that as a doctor in America you will either be rich or live comfortably trying. As Starr pointed out, this has created remarkable ethnic diversity in the medical field and perhaps was also to the immediate advantage of immigrant populations who may reside in the same practice area as the physician, which often naturally happens because of the way immigrants tend to ‘group’ themselves in certain districts, cities, or around major religious establishment.  

The Breakdown of the Doctor-Patient Relationship.
Medicine’s “authority and strategic position” have indeed slowly “eroded” over time. And I believe that the breakdown and weakening of the relationship between the doctor and his patients, partially because of increasing specialization, has contributed to this erosion of position of authority. The doctor went from a confidante who knew all family members by name, who frequently has seen the inside of their home on many occasions, and who took phone calls from concerned patients to a person simply doing their job. Doctors became more entrepreneurial and patients sensed it. This air of business about doctors made them seem all the less trustworthy, and all the more potentially adversaries; hence, as Paul Starr noted, the increase in medical malpractice suits.

The Culture of Medicine.
At the end of the chapter, Paul Starr makes an excellent summation: the culture of medicine has shifted from domination by ideals like professionalism and voluntarism, to a profit centered focus. The shift, once happens, is irreversible but its effects can be mitigated. With the age of corporate medicine here to stay, the biggest challenge is equitable access, I agree with Starr, because corporations are not charities. I looked up recent articles and editorials by the author to note how he had viewed the health care reform efforts, not necessarily the mandate or the individual items on the bill, but rather the efforts themselves. I came across this article here .While he has a lot to say about the reform, he lauds the attempt of the organization of health care around justice and efficiency. In my follow up of issues pertaining to health care reform, Paul Starr will definitely be on my list of authors to consult.
And as Paul Starr suggests, “a trend is not necessarily fate.” The choice, and with it the future, lies in America’s hands.

4/2: End of a Mandate.

We Pay More But Are Now Healthier?
As times were changing, concern over rising costs and lack of a corresponding health increase troubled the American Public. We, in Egypt, can relate. Costs of medical care in Egypt are rising exponentially-- while health indicators and mortality rates seem constant. Most health improvements are because of governmental efforts aided by international organizations. Hepatitis C is rampant, chronic renal failure is a scourge, and smoking-related respiratory illnesses are at an all-time high. This strains the financial capacity of the Egyptian people, most of whom are uninsured, and consequently many are unable to make ends meet. The affluent Egyptians, however, are paying hefty sums to private medical institutes (physicians, laboratories, and hospitals) to receive care that can be described as less-than-optimum, to say the least. Estimating the exact expenditures is difficult but judging by the number of private group practices and hospitals opening up in wealthy neighborhoods, the medical profession in Egypt must be doing fine. Illustrative of the case of quality or the lack thereof, in the Egyptian medical care system is the fact that no Egyptian official ever seeks treatment in an Egyptian hospital!

Market Tolerance and Rising Health care costs.
I found the concept of the “market tolerance” very enlightening. Starr argues that it is the tolerance of the market that allowed health care costs to skyrocket unchecked-- not just the facts the higher expectations or to advances in science. The argument for the fact that the practice of fee-for-service inherently set up the stage for providers accumulating riches on the expense of the society is self-evident to me. Third parties shielding patients and providers from the true cost of treatment has definitely contributed to the market tolerance.
This is not necessarily the case, however, around other corners of the globe where patients are less educated and providers are more authoritative. The issue of authority plays a very important role especially in countries where out-of-pocket expenditures are common, and government reimbursement is tainted with the hues of corruption. 

3/2: The Liberal Years.

America: the Land of Scientific Progress.
When Starr brings up the private vs. public research funding issues, I can’t help but wonder whether modern Medicine would have been what it is today if it weren’t for the interest of private sponsors in medical research. Would issues of advancement have been superseded by the importance of access and primary?
All the scientific breakthroughs Paul Starr mentions make the liberal years a good time to be an American scientist and an even better time to be a scientist interested in medical research.  America as a “leader for the free world” was living up to its promise.

The Polio Epic Battle.
Starr recounts succinctly the winning battle America had waged against Poliomyelitis. My first reaction was:”ah! That’s why Americans believe that almost anything can be cure.” I would like to contrast this with Egypt’s battle against Bilharziasis. As an endemic disease known to Egyptian as far back as the Pharaonic times, Bilharziasis had claimed many Egyptian lives and reduced the quality of life of many more. Organized efforts in treating the disease where usually Colonial in nature. True cure came with injections with Antimonium Tartaratum (tartar emetic) with mass injection programs in the mid 1960’s. The miracle oral drug, Praziquantel, did not become available except years later. These cures came as the result of research and development in other more advanced countries. The Egyptians had a sense of powerlessness against death and disease. When Hepatitis C, at epidemic proportions, was linked to use of tartar emetic ‘unclean’ injections, it fueled the general helpless attitude of the Egyptian population. It seemed as though as soon as you beat a disease, another--fiercer--one appears. This attitude, of course, came mixed with the right amount of fatalism to make it seem like the belief of a pious, not powerless, people.
The danger in this attitude lies in the fact that people who do not sufficiently believe in science cannot be mobilized to fund science. In modern Egypt, you can see a few “run for the cure” pink-ribbon (or hijab!) campaigns a l’americain, but these are merely organized social functions where the elite and upper-middle class convene and educate amongst themselves.
Of course, if appealing to rationality and common sense does not work, playing on the emotional strings of the Egyptians pays off well. As in the case of Hospital 57357, a pediatric cancer hospital funded entirely through donations and fundraising. The fundraisers created huge marketing campaigns featuring pediatric cancer patients, and the people donated to ease their suffering. These efforts are commendable, needless to say,  but the problem is with no financial support for local research oriented towards local community needs, it might not be too far in the future that patended drugs and medications become just unaffordable in Egypt on a large scale--and then charity will not suffice I am afraid. 

2/2: The Triumph of Accommodation.

In a Utopian society, doctors definitely set their fees according to what their patients could pay. But in the real world, where we all live, this can only hoped to be true. This principle was mentioned by Starr in this chapter, and once before in book one, as if it was a given. I highly doubt that. This would be better stated as: doctors set their fees in order to get from their patients the maximum they could pay. And when the state is paying, if regulations are not tight, then it becomes,”the most the state is willing to pay.”

This cost issue, recognized by a Union in Butler when they questioned that bargaining for more medical benefits seemed to benefit the medical professionals more than the union’s members, as Starr points out, is central to regulating soaring costs of healthcare and it follows that price negotiation with providers could be at the heart of any meaningful health care reform meant to provide more access to people who need it.

The key to realizing why there was a “triumph of accommodation” in my opinion was that physicians benefited greatly from the insurance system as it stood; they were always paid the rates they set without negotiations, they were guaranteed payment for their services, and they enjoyed their professional liberty to the fullest. Physicians were ‘masters’ of the medical profession and they did not see any faults with the system. It was only natural that they resist any changes lest they undermine their authority and money-making potential. 

Book Two: Chapter One: The Mirage of Reform.

In reading Starr’s discussion of health insurance, and its predecessor life insurance, I was in for a surprise. I had no idea that Americans were so keen on avoiding a “pauper burial” and funding expenses for their ‘final’ illness-- I wonder how that could have ascertained at a time prior to the person’s demise. Could the vast success of these programs have been the direct result of extensive marketing campaigns by the “army of insurance agents” Paul Starr refers to. The modern equivalent to this would be something I see in my own community: people buying graveyards and spending lavishly to ensure that they get a good spot, whatever that may be. Investment in the afterlife seems to be popular across ages and cultures, but not the need to provide medical care for those who cannot afford it.

With all the media coverage of the ongoing debate about the Affordable Care Act, so deprecatingly named the Obamacare and after reading this chapter, it seems as though aborting plans for national health insurance is somehow part of the way Americans always prefer to shape their healthcare system.
The development of health insurance was far from a philanthropic, empathic act. It was all about business and any efforts opposing the liberal enterprise are frowned at--or even repelled. The way Starr eloquently summarizes the situation as a battle between two opponents, both representing beliefs deeply rooted in the American belief system: liberty and efficiency. And public opinion being “malleable” is easily played up by making one case or the other seem more righteous, or more in line with American values.
Paul Starr argues that whether one side or the other wins has nothing to do with one set of values being more deeply rooted in the American people; and that the imbalance of resources ironically was in both sides’ favor. I find these observations enlightening. I had yet to see lack of resources as an advantage, but it made a whole lot of sense in this context.

Capitalism and Chapter 6

The Escape from Corporation.

Throughout the book and up and until that point Paul Starr had maintained a neutral tone with regards to physicians, their professional authorities, and their achievements in that respect, but in this chapter Starr’s observations seemed to take on a more disapproving tone.
We can see at one point how Starr paints a picture of physicians as a self-serving, almost ‘whiny’, group where he states that they “have a dislike for socialized medicine…and a distaste for corporate capitalism.” On page 205, he explains how doctors withheld medical records in order to prevent the hospital associations from reducing unnecessary procedures--now he has them sounding like the mob!! While this may very well have happened, I am just curious to the extent and prevalence of such unethical (almost criminal) behavior. He also asserts that the Mayos “aimlessly” created group practice-with no ideological motives or goals in mind. In a sense, Starr is denying that doctors successfully created working corporate models of their own.
It seems as though Starr is subliminally suggesting that physicians “escaped” from corporation because of an inherent character flaw; they are a power-hungry, money-hoarding, self-serving bunch who does not want to be regulated or controlled by any outsiders.
The way Paul Starr argues for the case of capitalism not favoring medicine over public health, it becomes clear that he is not being very objective in this chapter. He states that “it is difficult to see why capitalism… would have benefited by favoring medical care over public health.” I find this statement hard to fathom. I had to read it twice. Stop. Then read it again before I burst out laughing! Really? What about Big Pharma? Keep in mind that this statement is not made in reference to any particular time period; it is a general statement which stems from Paul Starr’s ideology. Even if Starr is a full-fledged capitalist, he still should have evaluated the case objectively before issuing such qualifying statements. Ignoring the effects of pharmaceutical companies and lobbying efforts on therapeutic medicine and public health is a tad dogmatic, in my opinion.
The intricate interplay between research and development, pharmaceutical companies, and physicians made medical practice what it is today-- a practice aimed at symptomatic management. This warrants examination, especially by a scholar like Starr, because, after all, Big Pharma operates, and is shielded by, capitalism. 

Reflection on "The Boundaries of Public Health."

It was quite surprising for me to read about how the relationship between public health advocates and physicians in the United States was tense at its best, and downright rivalrous at times of peak competition--such as in the case of dispensaries. The interaction between medicine and public health in Egypt has always been that of a subspecialty with its parent occupation. Public health practitioners were invariably physicians by training.
This is not to say that public health fared any better in Egypt. The focus, like everywhere else, was shifted to individual health behavior instead of social or environmental reform, but it is that public health practitioners in Egypt were more ‘in synch’ with the medical profession and did not, at any point in time, consider themselves outsiders. Indeed, many --probably an understatement -- public health officials sought to also be practicing physicians. I always found this to be an oxymoron-- physicians focus on the individual, public health officials on the population…how can one cater to both needs?
Physicians do not easily adopt the preventive mind set, even in practices like pediatrics. Because of long waiting time and financial costs, most mothers visit them only when the child suffers an ailment. Well-child visits are not very common in Egypt and those who adhere to them are not even sure that they matter in the big scheme of things.
It can be argued that the greatest, and perhaps only, public health service offered by pediatricians is vaccination--and that is, of course, because there is money to be made and incentives by the pharmaceutical companies.
When I was practicing clinical medicine in a university hospital catering to the poor, I realized that a little public health efforts can go a long way in improving the health of the Egyptian population. With malnutrition and Trachoma rampant in lower-class Egyptian children, the need for social reform and basic sanitary measures is self-evident.
The schism between public health and medicine is universal--despite physician’s best efforts to apply principles of preventive medicine. The problem, actually, lies therein. Public health became reduced to preventive medicine in many countries; the socio ecological model of health was abandoned and the burden of improving one’s health fell largely on the individual. 

Notes on Chapter Four: The Reconstitution of the Hospital.

As Paul Starr examines the development of the hospitals in the United States, I came across a couple of thought-provoking points.

Heterogeneity within the Same Nation.
I found the detailed account of the how different types of hospitals became more popular in certain areas in the U.S. more than others very interesting. I guess it is the vastness of America that makes this possible. I personally struggle with the concept of heterogeneity of prevalent sources of institutional medicine within the same country because in Egypt most development occurred in the Nile Valley and in a few coastal cities-- mostly Alexandria. With homogenous ethnicities in Egypt, the state control was greater, just as Starr had predicted.

Surgical Practice and Hospital-based Medicine.
While it is common knowledge that the advent of antisepsis and aseptic techniques were behind revolutionizing surgical practice, I had previously failed to make the connection between the boom in the number of hospitals and their increasing focus on acute care (indeed, post-surgical care). This realization is important because it also sheds light on another phenomenon that occurred in Egypt with the increase in numbers and capacity of hospitals, surgeons became more and more influential in the medical circle --partially due to the fact that they had hospital admission privileges. They were instantaneously transformed in Egyptian society from mere ‘butchers’ or ‘barbers’ to the true healers in the medical profession: a surgeon performing an appendectomy weeds out and removes the source of pain; the patient is completely cured as opposed to someone consulting a physician who offers only temporary relief.
Surgery became the most coveted specialty, granting prestige and the most monetary benefits.

The Consolidation of the Professional Authority: Egypt vs. the United States.

Paul Starr continues his detailed analysis of the development of the professional authority that granted physicians their elitist status. This analysis, as it came to unfold, in chapter three has made me realize that the circumstances affecting the interplay of medicine and class/status in modern Egypt is eerily similar to mid-nineteenth century America--except that it is only reversed!
Medicine’s professional authority was well-established in the pre-revolution Egypt. Physicians were regarded as the crème de la crème, and higher education was only reserved to those who could afford it and were sufficiently high-up on the socioeconomical ladder to pass the admission interview, rightfully called by the Egyptians ‘screening for social appropriateness.’
with the 1952 coup d’état, medical schools were free to all, and they also became mandated to accept larger numbers of students (three of four times the numbers they were originally accepting.) The admission interview was canceled by the state’s regulatory authorities, thus granting access to applicants with lower social position. As time went by and the social fabric of physicians became more and more varied, authority weakened and medicine became more of a ‘get rich’ scheme among the lower-class whose children were showing scholastic achievement and merit.
A term was even coined for their opportunistic dreams: “the five eins.” Ein being a letter of the Arabic alphabet with which started the Arabic words denoting the five, most coveted, dreams of the doctors-to-be: a busy clinic, a luxury car , a mansion(!) , a bride (sexism typical of the patriarchal Egyptian medical society) and a tall apartment building. This era in Egypt has signaled a movement away from the prevalence of medical philanthropy which existed in the days of the monarch and towards weary regard of physicians as businessmen trying to make money. The physician went from being an educated ‘pasha’ with inheritance to spare to a ‘nouveau-riche’ who benefits from sickness and medical procedures. This weakened the authority-- and created fierce competition between the new graduates seeking the riches offered by practicing medicine. Interestingly, many of those disillusioned with how much monetary success Egypt has to offer sought to emigrate to the U.S. and practice there--since, rumor has it, and there is more money to be made by physicians in the Unites States than anywhere else.
The “consolidation of authority” for Egyptian medicine came years later, when the phenomenon Starr describes as “the renewal of legitimate complexity” occurred in Egypt. The renewed faith and restored authority was because of ‘westernization’ of physicians and other practitioners. Knowledge and science, clearly, were more advanced in the West--so it followed that doctors trained, even if partially, in the west should be granted special status and authority. A mere “Member of the Royal College of such and such” was almost a sure-fire way to make the society, patients and colleagues alike, listen more closely.

Notes on "The Expansion of the Market."

Coming into public health lacking any business background, or business sense for that matter, the concept of market forces exerting a large effect on the medical profession was completely alien to me. Yet, as I have come to learn through the author’s clever use of imagery and examples, it would be foolish to ignore market forces and the role it historically played in shaping the medical profession and granting its practitioners societal status.

The market forces did much more for medicine, in my opinion, than is explicitly outlined in the chapter. The scientific aspect of medicine must have depended throughout history on the need for, and the belief in, medicine. The market creating need for physicians’ services and their authority growing, research and development --and the funds available for them-- were more a la mode. This has a snowballing effect. Medical advanced enlarge the market potential and opportunity, while a larger market base creates “a dependency”--as Starr so eloquently puts it.

I found Starr’s account of the eighteenth century in America as the pre- ‘laissez faire’ era very intriguing because America, at least to someone who is not cognizant of American history, might just seem to always have been all about economic laissez faire. The notion that at a certain point in American history some prices were fixed by government was quite surprising. I had previously assumed that a nation has to either be capitalist or socialist at heart, and that that America, the land of capitalism, must have started out that way. In light of that, I am viewing Egypt’s transition into Capitalism as something that just needs time to be completed, as opposed to my previous skepticism.

While this chapter has been very enlightening, some of the points made by the author raised a few questions in my mind. Paul Starr mentions professional overcrowding, and then goes on to describe the arduous journeys physicians had to take in the time prior to decent transportation and hard roads being readily available. With such an abundance of physicians, why was there apparent maldistribution? The way I see it, there might have been a doctor at every corner with no licensing requirements and no formal education required.

I am also wondering whether the rise of sovereignty of medicine can be examined thoroughly through a socio-economical analysis--one which does not incorporate technological advanced into account. The way Paul Starr dismissed lack of technology as reason for the lack of training of nineteenth century physicians seemed just too simplistic for my liking. Why did he deem it completely irrelevant? Although his argument is well-founded, and well supported with references, the role of the technological advances is important enough to merit closer scrutiny. 

Reflections on the Introduction and Chapter 1

Living in the twenty first century, medicine seems to have alwas reigned supreme, and doctors relishing in power and authority--not to mention riches in many instances--are notions so entrenched in society that it is hardly possible to imagine a time where this was not the case. Paul Starr starts out his book by challenging my views of how cultural and social authorities have been at the fingertips of doctors and physician since the dawn of the profession.In my readings, I have come to extract the following points of interest:

The roots of Medical Authority in Egypt.
The author brings up the fact that when medical knowledge is esoteric and lies within the hands the culturally endowed, the profession as a whole enjoys authority. I believe this case can be extended beyond the Nineteenth century England which the author uses as an example to include ancient Egypt where medicine was not only esoteric but also sacred. This got me wondering whether the status physicians enjoy in Egypt now can be dated back to that tradition.
Is Democratic Medicine Making People Happy
The distinction between ‘democratic medicine’ and medicine in a hierarchical society made a lot of sense to me. People who are more accepting of societal rank grant authority easier than those who view themselves on a par with physicians. The disillusionment and disenchantment that eventually follows as the society matures is the real problem, in my opinion. When patients grant power and follow advice but to no avail, they eventually withdraw their trust --sometimes from the profession as a whole-- and try to go back to the ‘domestic medicine’ that was once popular. I believe this is the case nowadays, with the revived trend in allopathic/traditional medicine, homeopathy, Aruyveda and what not. It seems to be that many people don’t really appreciate the lack of an air of mystery or occult around medicine anymore. They interpret cancers, diabetes, and hypertension and all the other the rampant chronic diseases in our society as an undeniable proof that modern medicine does not get the whole picture. There is still something missing. What Starr called “the spirit of rationalism” appears to be dimming, and slowly replaced by mystification and a shift away from ‘democratic medicine’ by the masses.
The Qualification and Licensing of Practitioners.
It had never occurred to be before how qualification and licensing were central to the medical profession. They, in part, are what made medicine a profession as opposed to a trade or just an ‘occupation’.
While American practitioners fought the battle early for English-like, authoritative, professional societies and licensing bodies.  The battle is being fought now in Egypt with the Egyptian medical syndicate trying to establish the “Egyptian Fellowship” as a   board of medical  authority.
As the medical profession was prospering in Egypt and doing just fine with no such bodies, medical societies in Egypt were merely honorary. This book got me thinking that perhaps the shift is caused by democratization (subtle but still there) of the Egyptian society.