NORTHFIELD, MINN. -- When I was a child it was unthinkable to begin a school day without saying the Pledge of Allegiance. The pledge is short, but it contains the essential truths about our country. Day after day we learned that we are "one nation," "indivisible," "with liberty and justice for all.
I was thinking about the pledge when I read the recent report on "disability adjusted" life expectancies from the World Health Organization (WHO). Disability-adjusted life expectancies measure the years of "healthy life" in various countries. Japan led the nations of the world with an expectancy of 74½ years of healthy life. Australia came in second with 73.2 years. We Americans were dismayed to learn that our healthy life expectancy -- 70 years -- put us in 24th place.
A spokesperson for the WHO noted that the United States is "not doing well" in spite of the fact that we spend more on health care than any other nation.
This is where the pledge comes in. When it comes to health care, we are definitely a nation that favors "liberty" over "justice."
We Americans are paranoid about losing our right to choose; we will go to great lengths to ensure that we can get the care we want, no matter how expensive, no matter how experimental. Here in Minnesota, when certain HMOs refused to pay for a controversial treatment for breast cancer, the Legislature went to work to protect our liberty. In short order our representatives passed a bill mandating HMO payment for the dubious therapy. It is now widely agreed that the treatment is ineffective, but only after millions of health care dollars were spent to protect our freedom to choose.
We are frightened of government intervention in health care. When Bill (and Hillary) Clinton suggested simplifying America's chaotic health insurance system, Sen. Dave Durenberger asked if we wanted our health care system run like the U.S. Postal Service. It was his attempt at a scare tactic, but many of us answered, "Huh?" The USPS is efficient and reliable -- can you imagine running the post office the way we run health care? Think of tens of thousands of private, for-profit post offices setting their own rates, negotiating with "postage maintenance organizations," being bought up by large corporations that limit the type of patrons that can be accepted and the amount of time a clerk can spend with each customer. A nightmare! After visiting the local clinic -- now managed by an HMO -- even those who agreed with Durenberger are having second thoughts.
But the organization of American medical care has far more serious consequences than the long waits and bureaucratic run-around that we middle-class folk experience. The WHO report goes on to note that the poorest people in the United States have healthy life expectancies characteristic of sub-Sahara Africa in the 1950s. Meanwhile the richest Americans can expect healthy lives equivalent to those found in Japan and Australia.
Of course long and healthy lives are not just the result of the way medical services are delivered. When I teach my course on "Health and Society" I often call attention to the great disparity that exists between infant mortality rates in the United States and other countries like ours in Europe and Asia: For all our wonderful technology we consistently rank 21st or 22nd in the world. Inevitably a bright young premedical student -- feeling defensive about our advanced medical system -- will respond: "Yes, but in those countries the 'welfare' systems allow everyone to be well-housed and well-fed."
It is one of those delightful "teachable moments." I wait a moment or two and respond, "Yes . . . and your point is?"
Soon the class realizes that good health care for moms and babies is more than heroic intervention with the best technology after a rough and ill-fed pregnancy. Justice in health care requires sharing our resources, our medicine, our food, our housing, our education.
If we are unwilling to work to promote justice in this important arena, perhaps we should change the pledge: "One nation, quite divided, with liberty, but not justice, for all."
Raymond DeVries teaches sociology are St. Olaf College in Northfield, Minn.
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