Late last year there was a five part series in the LA Times about the problems at King-Drew Medical Center, and in a blog piece I tried to put it in a little context. I promised then that I would say more later and with today being Dr. Martin Luther King’s holiday, it seems like a good day to do that.
These group under three predominant areas. 1) the scale of inner-city poverty and its impact on health care. 2) The relationship between community and authority. 3) The management of a large scale health care systems in a world of electoral machines. Inner city poverty and its impact on health care. There isn’t too much more to be said about the impact of inner city crime and violence on facilities like King-Drew, LA County, Cook County and others. But there are several factors that are less well known. One is that the ratio of physicians to population is much lower and of course the ratio of the uninsured (and for that matter undocumented) to the general population is much greater in neighborhoods served by this type of hospital. The added costs of serving this population are to some extent recognized by the subsidies within the Medicaid program called DiSH payments (DSH stands for disproportionate share hospitals). But in the end even those with good insurance in these areas (predominantly Medicare recipients) receive services and surgery at much lower rates than those in the wealthier suburbs. One well known study focused on the extent to which blacks receive , but a Dartmouth study in fact shows that it’s . Of course the correlation between being in a poor area and being a minority is very close, particularly in inner cities. And it’s also true that general health measures are much worse for people in those areas, with things like asthma rates in the Bronx and some parts of southern California being much worse than national averages, and even the by what’s happening in the inner cities.But it’s not absolute. In fact if you look at minorities who are wealthier than average (or as wealthy as average whites), as Mike Magee did late last year in his Health Politics site, you find that it’s not race but class and income that make the greatest difference in health status and outcomes:
Looking at the number of deaths per 100,000 person-years in adult men with incomes under $10,000 per year, blacks have 21 percent more deaths than whites. This difference declines to 4 percent for those with incomes from $15,000 to $25,000. But when you turn the numbers sideways, comparing whites with incomes below $10,000 with whites with incomes of $15,000 to $25,000 per year, the higher income group has 240 percent fewer deaths. A similar comparison among blacks shows 275 percent fewer deaths among those with higher incomes.
We also know that class and education has a huge bearing on health status, and greater relative levels of inequality have a big impact too. So you’d expect a greater differential in the US, than in a country with relatively greater income equality like Japan, and that’s what you get. So the end result is that if most of the poorer people are crowded into one part of a state or metro area, there will be fewer facilities and personnel to care for them, yet they’ll have worse health problems.There’s also the physical geographic extent of this ghetto-ization. For example the series in the LA Times on King-Drew compared the LA County-owned hospitals unfavorably with the public hospitals in the SF Bay Area, but my impression is that the poor areas of Los Angeles are much larger and much more obviously segregated from the Beverly Hills and Brentwoods than those in San Francisco area. This may be true to in say Chicago versus New York (but again I might be wrong). But my guess is that the pure mix of patients is poorer at King-Drew than in equivalent hospitals in other cities.So while King-Drew obviously has serious, serious problems, by definition any medical center serving the areas of Watts and Compton is going to have to deal with things that are outside the range of the normal American hospital experience.2) The relationship between community and authority. One of the major themes coming through in the LA Times series is the lack of the trust between the local activists in Watts (who represent "the need") and the LA County Board of Supervisors (who represent "the money"). Part of this is based on race. I remember the Harris Poll some months before the OJ verdict that showed that 65% of black Americans thought OJ was set up while something like 85% of whites thought he was guilty, which gave you a hint as to how things were going to go with a majority black jury. Los Angeles is the city of the Watts riot, the CIA’s involvement (however peripheral) in the crack epidemic, the Rodney King beating and later riots and the Rampart cops scandal. There isn’t exactly a lot of trust between the haves and the have-nots. Again I’m too much of a traditional sociologist to be convinced this is entirely race and culture-based. For example back in my home town of London I was told back in the 1980s that the conviction rate by a jury for burglary in the Crown Court in Knightsbridge was 75% while in the poor east End neighborhood of Shoreditch it was under 25%. The joke was that wealthy jurors in Knightsbridge were convinced that the burglar might be trying to steal their VCR, while in Shoreditch the jurors would expect to be able to buy that VCR cheap from the thief. All joking aside, there are examples all over the American west of small predominantly white communities that don’t trust outsiders and authorities without going all the way and becoming the next Timothy McVeigh. So I’m not convinced that the conflict between the LA County and the people in Watts is just about race. But it certainly is between those who are out of power and those who control it. And of course if King-Drew were to go away, part of the raison d’etre of that struggle overall would go with it.3) The management of a large scale health care systems in a world of electoral machines. Finally, whenever you have a huge public health system like that of New York or Los Angeles, you are going to inevitably have to deal with the politicization of running it. Just understanding the bureaucracy of hiring and firing in these huge government departments boggles the mind of those of us used to the private sector. The delivery of favors and appointments in returns for influence, votes, and union members’ electoral work continues to be standard practice in most city governments in the US (and has its direct equivalent at a national level!). When so much of the budget flows into the health system, it is by its nature going to get politicized. That may be using the poverty of health system as a political pawn to blackmail the politicians to handing over more funds (Santa Clara Valley Medical Center’s Bob Sillen is a master at this), or it may be simply having the hospital as a focus for wider community activism.The key is that the hospital is very visible as an employer and as a community resource. Even if the hospital was taken away in return for fair and complete subsidies for other care or coverage, no one responsible is going to agree to that swop. Why not? Because you can’t parade a cut in a subsidy or a tax credit on the news, but you can show a hospital ward that has to close. And the legitimate concern of everyone in Watts is not just how bad is King-Drew, but what would they replace it with? And the answer in today’s America may be something much less.
There’s a new contributor today on THCB. Blunter worked at the FDA for many, many years and understands from the inside many of the problems with the agency that have been documented in many places, such as this Forbes article. He responded to my notion that the problem is simply the speed of the drug approval process and suggests that the issues go way deeper. What he says about the management of the agency, the culture of secrecy and the information obfuscation is well worth taking seriously:
You and those following the travails of the Food and Drug Administration (FDA) are on the wrong track if your views of the FDA problems are focused on the rate of drug approvals and postmarketing reports. When it is finally revealed that gutless FDA executives sold User Fees as a solution (politically naive) instead of addressing the real management and public policy issues, the crux of the present problem is clarified. There is nothing inherently wicked about user fees but the original and subsequent managers didn’t press the other fundiing and management needsWithin a year of the first user fee enactment (about 12 years ago), FDA was meeting the new deadlines without hiring or training any new MD’s. And a whole reserve of physicians receiving premium pay and scientists are secreted away in the FDA halls in "non-traditional" endeavors—mainly management—often beyond their expertise and capabilities. Examples abound where FDA top execs are ignorant of basic management responsibilities and skills in themselves and their subordinates, beginning at the Commissioner’s Office.Look at EPA, NASA, NHTSA (and its potential model NTSB) and compare basic budgets to that of FDA which regulates vastly more of the GDP. What regulatee would object to paying a few million dollars to get a statutory deadline and perhaps as little as an additional week or two of sales. Just divide $1 or $8 billion by 365 to see the daily return. And the user fee concept is spreading to devices, animal drugs, food, cosmetics.FDA seeks an analysis and report by the National Academy of Science or other prestigious group as a CYA tactic. There are lots of similar reports lying around comatose from past misadventures. However, the tactic permits FDA and other Administration folks to say it is inappropriate to discuss specifics of the latest debacle(s) before receipt of the blue ribbon report. Hence, we have FDA on autopilot until the dust and fervor clears and a new executive crew gets in that can say that "it wasn’t on our watch".This present controversy and period may end up as little more than a footnoted historic anecdote in the next report of the next FDA crises a few years hence. The answer involves leadership with a new and skilled management team, to make the FDA a safe and effective environment for FDA scientists (among the best) to do their best work, create a transparency in the work FDA does, and cause the Congress to accept responsibility for funding a mission that has no peer in the Federal government. For sure, more funding which would be effectively applied will be needed but unlikely to do much good so long as the current management and culture is allowed to continue.Presently, outsiders who want or need information on FDA decisions, and the like, are channeled through a Freedom of Information process which takes two years or more just to get around to the request, and then some more time and redactions to get the info out, if indeed any is released. It has been a long-standing, recognized management incompetence, worse in the Center for Drug Regulation than anywhere else (probably in the whole government). There is no transparency in what FDA is acting on, or ability for any one to compare in real time other similar data by scientists or others, who may have data of their own or seek to learn from the existing records FDA has passed upon. And when it comes to other than medical and scientific data, the likelihood of getting anything at all to look at several years down the road is even more remote.And there has been no effort in the last near decade to do anything about it, like introduce management or data submission processes to make the system workable. Human clinical data and drug experience (appropriately clad to protect patient privacy) is a public resource, not a trade secret, for example. But you’d never know it at FDA.Ironically, the FDA cannot be suspended on life support while a solution is devised or changes made. But there is hope. Under Jimmy Carter, the prevailing view was the Presidency had grown too complex and demanding for one person, and the talk was how to divide it. Then came along Ronald Reagan, The Bushes, and Clinton, and those discussions are footnotes on history. What can an effective and motivated leader do? A lot. Still don’t believe that FDA’s lack of leadership isnn’t just an issue but the issue. Look at the Forbes Magazine story and survey (mentioned on one of your earlier blogs) and see that the need for leadership at FDA outranks the closest competitor by three times or more.