Recently, I went on a gambling boat. It wasn't that the student loans had gone into default, or that I owed money and liked having kneecaps. The occasion was the Annual Banquet for the Environmental Health Department at the Volusia County Health Department. Although I was looking forward to the evening, I have to confess to a bit of trepidation. I don't know about you, but I have a bad memory for faces and names. When someone comes up to me at work, at least I can glance down at their badge and get a first name out of it. When people are out of their context, however, it can be difficult. I am eternally grateful for the ability to nod and smile. A lot.
Before the ship leaves the port, you're given the speech about safety afloat, which prompted a flight attendant friend of mine to involuntarily gesture toward the exits. (This is the same friend who has decided that in the event of a real emergency in an airplane, there will be little need for a calm announcement from the flight crew, because the blazing fireball in the middle of the cabin would probably give it away.)
The boat leaves the dock at 7 p.m., but apparently the gambling can t start until you get outside of territorial waters. So as the engines rumble and the boat moves farther from the dock, you see a mass migration of patrons from the free buffet (consisting of rolled cold cuts, small bread rolls and industrial strength cafeteria cookies) to seats at the gaming tables and slot machines. Standing on the balcony above the casino, you see them assume their positions. I suppose the positive way to look at it would be that they re eager soldiers in the combat against the odds. To me, they seem like endless herds of deer in headlights. When you look at them closely, you get the eerie feeling that you can almost predict what's going to happen to many of them. The older person by the slot machine is about to lose a Social Security check. The young woman at the blackjack table will have a smaller bank account when the evening's through. And the very intense man fidgeting next to the craps table is not going to pay off that debt tonight, but will only invite another.
I started to feel very badly for these people. Granted, my concern may well be misplaced. It's up to us as individuals to decide what to do with our money and whether to confront the prospect of loss. If you've got the money to blow, nobody else depends upon it and you're not going to feel it the next day, you've got the perfect right to toss it away. I realize that it may just be me who doesn't delight in walking into a casino with 500 bucks knowing that two hours and three drinks later, most of it will be gone. But I couldn't help thinking that the casino was taking advantage of these people, preying on their desire to hit the jackpot, to win enough to take them out of their own lives for just a short time.
I know that the casino sees them differently. They re people and customers, but mostly they re revenue centers. The boat sees the patrons as numbers. There's nothing wrong with that: it's reflective of the system in which we live. The paradox that struck me is that despite my mental protestations to the contrary, this is exactly how I've come to see people in public health.
The idea of people as numbers is anathema to most of us in health care. We are told over and over in our education that each person is an individual, with their own wants, needs and desires. (It's true that we often don't go into depth in identifying our individual patients. We easily fall into the habit of referring to the "guy in Treatment Room 4." But he's still referred to as a separate and distinct being). To that extent, our entire health-care system is driven toward the needs of the individual. Patients who need health care, especially within the hospital, are provided with virtually unlimited resources. It's not just the individual patients who are favored. The system also caters to the individual physician, hospital, health-care plan and even to the attorney. Efforts to look at the bigger picture of health care throughout the country, especially when proposed solutions might affect the nearly unlimited autonomy of the individual, are summarily dismissed out of hand.
This blind adherence to the cult of the individual (a social phenonmena by no means limited to the health-care industry) prevents us from seeing the forest for the trees. We can't look at the health of the population if we're focused on the health of the individual. Sometimes it s true that, as Mr. Spock noted, "The needs of the many outweigh the needs of the few, or the one."
Public health professionals strive to be the Spocks of the health-care universe (well, all except for the part where Vulcans mate once every seven years. We've got it down to five). We look at numbers first and then at individuals. We speak in terms of rates immunization, births, deaths without seeing the person behind the number. In a sense, that's the idea. It helps one to focus on the greater problems, the needs of the many. One person may truly have a crying need for service, but if that's the only individual with that problem, the needs of others may well render the individual need a moot point.
It's a utilitarian approach (though applied with compassion) and one that may not be well understood by those involved in the personal health-care industry. The number of uninsured and underinsured citizens without health-care access means something very real to public health. I fear it sometimes means very little to many practitioners who, using financial screens to admit patients to their office practice, consider caring for the underserved as a necessary evil to hospital staff membership.
To be honest, I really can't blame them for holding that view. Their office needs to make a living for the staff, and they simply can't do it by providing endless charity care. The side effect is that the only time they see the problem of the uninsured is when they're asked to come to the ED to see victims of a train wreck (to their credit, they usually respond without hesitation). But it does explain why it's hard for physicians "on the ground" to grasp the magnitude of the problem, or to even look at care from a community perspective. It's all a matter of where you're standing.
What makes the public health view so interesting is not just that it looks at people as numbers, but that it sees this as a good thing. As noted, this goes against the grain of almost everything we've been taught over the years. Nonetheless, it is not only required for effective programming in public health, but seems to be a requisite skill for management as well.More on that next week...