The Nature of Health: How America Lost, and Can Regain,

a Basic Human Value

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The Nature of Health
How America lost, and can
regain, a basic human value

MICHAEL FINE M.D.

and
JAMES W. PETERS

Foreword by
ROBERT S. LAWRENCE M.D.

Radcliffe Publishing
Oxford • New York
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2007 by Michael Fine and James W. Peters

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contents

Foreword by Robert S. Lawrence vii

Michael Fine’s preface xi
Jim Peters’ preface xiii
About the authors xvi
Introduction xvii

PART ONE WHAT HEALTH IS NOT 1

Demented and Contracted 3
1 The health we have 9
2 The health we buy 15
3 What we measure is not health 21
4 Medications are not health 29
5 Medicine is not health either 37
6 Science is business, not health 43
Hancock County 48

PART TWO WHAT WENT WRONG AND WHY 53

The Happy Victim 54
7 The human tsunami 59
8 The reductive trap 75
9 The trap is sprung 83
10 How longevity kidnapped health 91
11 Medical services and communities 97
12 The zero-sum game 103
Three People, Three Aortas 117
PART THREE WHAT HEALTH IS 125
A. Fib 127
13 What Webster thinks 131
14 Old villages, new lives 141
15 Toward a social definition of health 145
16 Health and community together 151
17 Health and fairness 165
Amish Boy 169

PART FOUR WHAT’S NEXT? 173

18 Who gets what? 175
19 How should it look? 187
20 How should we pay for it? 199
21 Which doctors? 213

References 225
Bibliography 237
foreword

The litany of problems associated with health and healthcare in the United
States seems to lengthen each week. We Americans are just under five
percent of the global population yet consume almost half of the global
health budget. We are approaching $2 trillion per year in expenditures
while leaving 15 percent of our fellow citizens without health insurance.
As the debate swirls among presidential hopefuls about how to fix and
reform the healthcare system and the Congress prepares to appropriate
additional funds to expand SCHIP (State Children’s Health Insurance
Program), President George W. Bush says about those children without
health insurance, “I mean, people have access to health care in America.
After all, you just go to an emergency room.”1 Despite the clumsiness of
his speech and the callousness of his remarks, the President’s views are
shared by enough Americans to help explain why we remain one of the
few OECD (Organization for Economic Cooperation and Development)
countries without a health system providing universal access to healthcare.
Mexico and Turkey join us in this dubious category among the 30 member
countries. All other high and upper income countries of the OECD are in
compliance with Article 12 of the International Covenant on Economic,
Social and Cultural Rights (ICESCR), which asks that steps be taken to
create conditions “which would assure to all medical service and medical
attention in the event of sickness.”2 But I forget — the United States is also
the only OECD country not to have ratified the ICESCR.
Historians, political scientists, and other scholars debate whether
our failure to ratify ICESCR (and a number of other social justice cov-
enants constituting the body of international human rights law) and to
embrace the concept of a right to health reflects de Tocqueville’s concept
of American Exceptionalism or is a manifestation of a deep-rooted commit-
ment to American sovereignty or both. In Democracy in America Alexis

vii
viii The nature of health

de Tocqueville identified the values of liberty, egalitarianism, individ-

ualism, populism, and laissez-faire as the key elements to our success as a
democratic republic.3 Notably absent from these values is a commitment
to community or the value of social cohesion, and therein lies the dilemma
and explains how we can be so passionately committed to civil and political
rights, indeed be John Winthrop’s “City on a hill,” while tolerating with
almost pathologic indifference enormous inequities in health status, educa-
tional opportunity, job security, and livelihood in this, the richest country
on earth.
Murray and his colleagues documented the burden of suffering in the
United States in a recent study of health inequalities using data aggregated
at the county level, by gender, by race/ethnicity, and by income. They
noted, “The gap between the highest and lowest life expectancies for race-
county combinations in the United States is over 35 years. We divided the
race-county combinations of the US population into eight distinct groups,
referred to as the ‘eight Americas,’ to explore the causes of the disparities
that can inform specific public health intervention policies and programs.”4
Asian-American women in Bergen County, N.J., had the highest average life
expectancy in the nation at 91 years, and Native American men in several
South Dakota counties had the lowest life expectancy at 58 years. Seven
Colorado counties, two Iowa counties and Montgomery County, MD, were
tied for the highest average life expectancy at 81.3 years while six South
Dakota counties had the lowest average life expectancy at 66.6 years. At
the state level, Hawaii recorded the highest average life expectancy at 80
years, followed by Minnesota at 78.8 years. The District of Columbia — the
seat of our national government and often regarded as the power center of
the world — had the lowest average life expectancy at 72 years, followed
by Mississippi at 73.6 years.
Our neighbors to the north grappled with health disparities decades
before we began to pay attention. Pierre Trudeau, elected Prime Minister
of Canada in 1968, asked Marc Lalonde, Minister of Health and Welfare
from 1972–77, to chair a commission on the causes of health inequalities
and disparities among Canadians. A New Perspective on the Health of
Canadians — commonly referred to as the Lalonde report — was presented
to the House of Commons in 1974. The report identified two objectives
for improving the health of Canadians and narrowing the gap between
the healthiest and the sickest: 1) reforming the healthcare system to
improve access to care, and 2) reducing health risk by greater attention to
prevention of health problems and promotion of good health. The report
also introduced the concept of “health fields” or the domains of influence
on health status that deserved attention. The four fields are healthcare
services, environment, biology, and behavior. The Lalonde commission
 Foreword ix

concluded that differences in health promoting and health damaging

behaviors accounted for about 40 percent of the disparities in health status
among Canadians with each of the other three fields contributing about
20 percent. Of course, had the definition of environment been expanded
beyond the physical environment (“horse kicks and lightning strikes,” as
one Canadian wryly observed) to include the economic and social envi-
ronment, then much of the difference in health promoting and health
damaging behavior would be linked to the environment as well. Lalonde
believed that good health was the foundation on which social programs
were built and that the healthcare system was only one of the necessary
methods to maintain and improve health. Reducing poverty, preventing
violence, protecting the environment, expanding educational opportunity,
and assuring equity became as important to increasing the health of
Canadians as improvements in the healthcare system.
In 1986, WHO convened the first International Conference on
Health Promotion in Ottawa and adopted the Ottawa Charter for Health
Promotion, defining health promotion as a “process of enabling people to
increase control over the determinants of health, to improve their health.”5
The United States was one of the participating countries in the conference
but the lessons brought home from Ottawa had no discernible impact on
health policy during the Reagan era.
So here we find ourselves mired in a system that consumes an ever-
increasing share of our national income without diminishing health
disparities among our people or improving our standing in the world
ranking of healthy societies. How did we get to this place and what can
we do about it? In this book Michael Fine and James Peters present a
provocative analysis of the meaning of health and the way in which clinical
medicine is practiced in the United States in the early years of this new
century. They bring their analysis to life with clinical stories about real
patients suffering the real indignities imposed by our dysfunctional system
of clinical care and the failures of jury-rigged safety nets. These stories
illustrate the historic and philosophic discussion of the meaning of health,
the illness experience, the role of social capital in health, and the challenges
to medical professionalism posed by the commodification of medicine.
We Americans remain ambivalent about whether healthcare is a right or a
privilege, and this ambivalence is reflected in our tolerance of living with
45 million of our fellow citizens uninsured while simultaneously expecting
and demanding the maximum application of life-saving and life-extending
treatments for ourselves and our families. When the authors say that
“health is the ability to have relationships, not the demand of living forever
. . . health is the love of others,” they correctly focus on the very essence
of being human. Their definition of health as “the biological, social, and
x The nature of health

psychological ability that affords an equal opportunity for each individual

to function in the relationships appropriate to his or her cultural context at
any point in the life cycle” moves us beyond the WHO definition of health
as “a state of complete physical, mental and social well-being and not merely
the absence of disease or infirmity” to capture our true nature as social
beings functioning within the context of family, friendships, and other
social networks. This expanded concept of health provides a framework for
addressing Rudolf Virchow’s “barriers that obstruct the normal completion
of the life cycle,” and honors the stirring sentiments expressed in Articles 1,
3, and 23 of the Universal Declaration of Human Rights:

1. All human beings are born free and equal in dignity and rights. They
are endowed with reason and conscience and should act towards one
another in a spirit of brotherhood.
3. Everyone has the right to life, liberty and security of person.
23. Everyone, as a member of society, has the right to social security and
is entitled to realization, through national effort and international
cooperation and in accordance with the organization and resources
of each state, of the economic, social and cultural rights indispensable
for his dignity and the free development of his personality.6

The authors have given us much to think about, and the healthy debate this
book will engender promises to move us forward in the quest for decency,
fairness, and justice in health and healthcare for all Americans.

Robert S. Lawrence, M.D.

Professor of Environmental Health Sciences,
Health Policy, and International Health
Johns Hopkins Bloomberg School of Public Health
Professor of Medicine, Johns Hopkins School of Medicine
Michael Fine’s preface

The idea in this book that is most likely to prompt controversy – that we
should not spend public money on medical services after an individual
reaches the average expected life span – is not the book’s most important
idea. The most important idea – that health is the equal ability of individ-
uals to function in the relationships important to them at any point in their
life cycle, in the context of their culture – is barely new or controversial
at all. Understanding that longevity is not health, and is, after a certain
age, a consumer commodity; that we only wish to live as long as others in
our culture; that we look at longevity as fairness, not health; and that the
United States does not have a healthcare system but rather the medical
services sector of the national economy – these ideas are neither new nor
revolutionary. But we hope they are liberating to people who are trying to
make sense of the healthcare mess in the United States.
What is new, here, is the construction of a healthcare system from the
ground up, using an understanding of what health is. The healthcare system
we present is a healthcare system after all; that is, it is an integrated system
of moving parts, each of which has a role to play in producing a product,
and that product is health, as we have defined it.
We rely on a few central assumptions: that justice is fairness, that we
cannot have a sustainable society unless everyone has equal opportunities
(because inequality creates social instability), that it is possible to build and
sustain local communities in 21st-century America, and that we all want a
healthcare system that is personal, rational, affordable, efficient, and just.
A word on who we are, and on the experiences that produced this book.
One of us is a healthcare administrator and writer, with 25 years’ experience
working in and thinking about healthcare systems from the perspective
of explaining those systems to the people who will use them. The other is
a community organizer and primary-care physician, who has worked in

xi
xii The nature of health

America’s poorest communities, both urban and rural, as well as worked

with government, with healthcare institutions, and with middle-income
communities. He has listened to what people want, what people need, what
works and what does not, and watched, with amazement, as what started
as a noble profession dissolved into an industrial behemoth that exists to
extract wealth from the communities it purports to serve.
Many thanks are in order: to my family, Carol Levitt Fine, Gabriel
and Rosie Fine, who put up with my disappearances from dinner and
appearances at wee hours of the morning to search the internet, dining
room tables covered with paper, and dinner table conversations about the
meaning of health, a topic no 13 year old should ever be forced to bear.
To my patients, who I can’t name, but who have shared their lives and
stories, answered patiently when I asked them what they thought health
was, and who ultimately take care of me. To many friends, who listened
patiently and provided counsel: Paul Stekler, Roberta and Jerry Ehrlich,
Ellen and Uri Bar-Zemer, Richard Godfrey, Nancy Evans, Tom Sorger
and Miriam Weizenbaum, Sam Frank, Chris Koller, Greg Carter, Sam
Mirmirami, Christine Heenan, Rick Reamer, Rabbi Wayne Franklin, Eric
Hirsch, Paul Housberg, Sheila Haggerty, Joshua Gutman, Anne Nolan,
Elizabeth Roberts, Ken Thompson, Bob Lawrence and David Rothman. To
my colleagues at the Institute for Medicine as a Profession, who inspire me
when we meet, and bear with my many wild and unorthodox ideas. To my
professional partners and co-workers, who dealt with my being sequestered
many mornings and helped provide exquisite patient care in my absence:
Drs Carol Levitt, Barbara Jablow, Christine Kennedy, Chris Campanile,
Ken Sperber, Cristina Mitchell, and Michael Klein, and everyone who
now works or has ever worked at Hillside Avenue Family & Community
Medicine. To my co-workers and colleagues on the Scituate Health Plan,
who make health – real health – happen. To my brother and sister-in-law,
Paul and Amy Fine, the source of wisdom and lots of experience with the
publishing process. To my parents, Adell and Seymour Fine, the source of
endless succor and support, as well as the name of this book. To Emmy
Liscord and Rachelle Noorpavar, research assistants extraordinaire, who
did all the actual grunt work of making this book real. And finally, to James
Peters, whose discipline, intellectual curiosity and patience made this book
happen.
James Peters’ preface

Our book goes back several years, to a conversation in Michael’s medical

office. You see, along with being Michael’s co-author I’m his patient as well.
For that matter, so is my son, Geoff, and before his recent death, so was
my father.
Before I became Michael’s patient, I knew him slightly through our mu-
tual attendance at a few meetings held for some forgotten business-planning
purpose within the heath system where I directed communications, public
affairs and marketing activities and Michael was a Young Turk among the
primary-care physicians. Then my internist at the time was nailed for some
hanky-panky with one of his lady patients and lost his practice. I needed
to find a new doctor, so I asked the person who does physician referral for
the system to recommend someone. “Oh, Michael Fine would be great,” she
said without hesitation, “but he’s not taking any new patients, so here are
some others to consider . . .” Never lacking gall, I sent Michael an e-mail
anyway, asking if he would take me on. With his characteristic kindness and
humility he mailed back that he would be “honored” to have me as a patient
– not typical physician language, at least in my experience.
Some months later, during my first visit to his office, I mentioned that I
had recently left Lifespan, the system where I had worked, and was intend-
ing to make a living as a writer. After almost 30 years of corporate work I
was overdue for a change. I had written all my life and knew enough about
management, medical issues and technology to be able to make a reason-
able living as a freelancer. Michael said that he had been toying for several
years with some ideas for a book about the meaning of health, but hadn’t
taken the time to follow through. He had written a sort of first chapter sev-
eral years back, he said. We agreed that maybe we should consider working
together on the book and a few days later he sent me the chapter to see if
I had any interest.

xiii
xiv The nature of health

I liked the ideas in the essay very much. It outlined the social and cul-
tural context of health and broadly criticized the status quo. I had long ago
concluded that the United States had a wasteful, disorganized and unjust
medical process that desperately needed fundamental reform. The notion
of a book that would consider health in a philosophical and sociological
light intrigued me. We soon met to discuss how to organize what turned
out to be a long-term project.
We began with a set of 55 questions, everything from: “What is the
name of this book?” to “What do we mean by health?” to “Are people in
other countries healthier than we are?” to “Every reform has bombed out
– is real reform possible?”
From there we blocked an initial outline and assigned ourselves either
the writer or editor role for the first draft of each chapter. As we developed
and added to the manuscript we continued to swap writing and editing
roles – a practice that we continued through the final manuscript. We also
began weekly Thursday-morning sessions at local coffee shops, during
which we’d puzzle over our text, recent medical and policy news and
whatever ideas about the book either of us had hatched since our previous
meeting. Now that we’re finished, I miss those skull sessions very much.
Perhaps they weren’t the most efficient route to a completed book but they
were closer to those heady and exhilarating late-night college discussions
with good friends than anything I can recall in many years.
Along the way, I suggested that we should mine some recollections from
Michael’s clinical career and create a series of stories or vignettes to explain
how he had adopted certain ideas and points of view and to punctuate
the book’s expository text with these more personal experiences. These
vignettes are naturally in Michael’s first-person voice, while in the rest of
the book “we” expresses our shared opinions.
As in any substantial project, a good many other people have helped us
along the way. Michael has mentioned some of them in his preface. I should
add several others here.
My wife Janet has listened to me talk about this project far more than
any patient and supportive friend deserves. I thank her for her support and
confidence in this and countless other things.
Our daughter, Alicia, a doctoral candidate in medical anthropology,
has offered helpful insight and expert guidance on several topics within
the book.
Craig Schuler, John Schibler, Sue Mellen and Luisa Deprez have also
taken the time to read various iterations of the manuscript and to offer
valuable comments. I sincerely thank them all.
Finally Michael and I must tip our hats to the patient and hospitable
folks at the Kountry Kitchen in Greenville, Rhode Island, were we met
 Preface xv

every Thursday morning for nearly three years, nursing countless cups of
tea and coffee and talking, talking, talking.
about the authors

Michael Fine M.D. is a family physician who is also trained as a community

organizer, and divides his time between practices in urban Pawtucket, Rhode
Island, and rural Scituate, Rhode Island. He is the Physician Operating
Officer of Hillside Avenue Family and Community Medicine, the largest
family practice in Rhode Island, and Physician-in-Chief of the Rhode Island
and Miriam Hospitals Departments of Family and Community Medicine.
Fine’s professional life has revolved around using healthcare as a focus
for community organizing, practicing family medicine, and advocacy and
organizing in communities across the United States.
Dr. Fine lives in Scituate, Rhode Island with his wife Carol Levitt
M.D. (also a family physician), and their two children, Gabriel, 17, and
Rosie, 15.

James W. Peters is a Rhode Island-based writer and consultant in strategic

communications. During his 35-year career he has managed communica-
tions, government relations, marketing and other administrative functions
for large integrated healthcare systems in Maine, California and Rhode
Island.
Peters is a 1969 graduate of Fordham University, where he studied com-
munications and philosophy and spent a year of independent study under
the late Marshall McLuhan. He has won many national and international
awards for a wide variety of projects, films, scripts, and publications and
has consulted on numerous communications projects for governmental,
political, corporate and non-profit clients.

xvi
introduction

Healthcare consumes over 16 percent of our gross national product, but

many people are left out and very few Americans are truly secure in our
access to medical services. At the same time, our communities – our villages
– have largely succumbed to an impersonal, fragmented environment in
which families and relationships are often unable to withstand the assaults
of long commutes, isolation, anxiety and materialism. Compared with other
industrialized nations, we spend through the nose on medical services and
have little health to show for our spending.
When Americans complain about the medical services industry, our
criticisms usually concern cost, quality, fairness, and access. Among our
common characterizations are these:
◗ Healthcare costs too much (now absorbing about one of every six
dollars in the national economy).
◗ The medical services system is cumbersome, impersonal and bureau-
cratic.
◗ There are huge disparities in who gets what service or what resource,
inequities arising from race and class, and age. These inequities often
determine who gets to live, how we get to live, and for how long.
◗ Our spending on medical services has exploded, while our spending
on other social services, particularly housing and education, has
collapsed.
◗ The medical industry spews out information that seems to change every
week, so that last week’s gospel is this week’s threat.
◗ The industry appears more interested in selling than in fashioning a
system that is caring, rational, personal, and just.
◗ The “providers” (medical institutions and professionals) have designed
the system for their own convenience rather than that of patients.

xvii
xviii The nature of health

Amid all these criticisms, we live in a culture that likes to finger a culprit
when things are not as we would like them. If the medical services system
does not suit us, culprits abound:
◗ Doctors are too greedy.
◗ Patients have unrealistic expectations.
◗ Specialists use their market power to enrich themselves at the expense
of the system.
◗ Primary-care doctors want to go home early, and so are not accessible
to real people with real people’s schedules and problems.
◗ Hospital boards want only to run high-tech, high-visibility glamour
programs, which they support at the expense of healthcare to the
community.
◗ Communities do not want to pay for public health.
◗ Insurance companies are only interested in dollars, and not in people
or communities.
◗ Government is either too involved, creating vast bureaucracies that
perpetuate themselves without really doing much to improve health,
or too little engaged, refusing to create a one-payer, universal-access
system, thus making us the only country in the industrialized world
without universal access to healthcare.

All of these observations, critiques and complaints have some justification,

but they also all ignore the two central problems about health. The first is
that being healthy in the United States today is very difficult, because we
have largely wiped out community, which, as we will soon discuss, is a neces-
sary condition of health. The second problem is that the medical services we
are buying and selling are really not what we want when we define health.
There is a huge disconnect between the vast enterprise we call “healthcare”
and the reality of health. That is the fundamental argument of this book.
We lost sight of the meaning of health gradually and by accident. Life
span – the expected period for which a person is expected to live – is easy
to measure, while health is both hard to define and hard to measure, so we
began to substitute longevity – a long life – as a stand-in for health, and
pretty soon began to believe that longevity is health. In fact, measurement
can and in this context does function as a trap. We measure a thing because
it can be measured, and then we find our system trying to supply what
we measure, not because it is what we want, but because it is what we can
measure, and thus disseminate. Because we can easily measure life span,
and people desire a long life span, our system is almost totally devoted to
supplying longevity. If you are a hammer, said Mark Twain, you think the
world is a nail.
But the health we want is not really longevity at all, but rather the equal
 Introduction xix

opportunity to function in the relationships appropriate to our culture and

our place in the life cycle, which is a much more robust sense of health
than mere longevity. This book argues that health is the ability to be part
of a family and community that is supportive and secure. Our society’s
disappointment with its medical services industry arises from numerous
inefficiencies, true, but even more it stems from the fact that the health
we are paying for is very different from what we actually want. We seek
the ability to be with our families and our friends, and to see our children
grow up. Instead, it often seems that healthcare gives us harangues about
risk reduction, aimed at providing us an unending life, the manipulation of
body image, so we can all aspire to look like an image crafted on Madison
Avenue, and the relief of any discomfort or deviation from an externally
defined ideal. We are all playing – and losing – a high stakes game of Three
Card Monte; we put our money down where the card was but, all of a
sudden – no money and no card.
Health, both in individuals and communities, describes our ability to
function as people in relationships. Thus, health is not possible unless the
context of those relationships – families, communities, even states and
nations – is intact and functioning as well. Still, it is the village, the com-
munity, where people experience health. Urban or rural, rich or poor, the
character of the community affects the subjective experience of well-being.
The objective conditions of the community may influence both longevity
and happiness, but that does not change the fundamental requisite, namely,
that individuals cannot be healthy without functioning families and com-
munities for individuals to be healthy in.
Our widespread confusion about the meaning of health largely explains
why the medical services system in the United States in an expensive
failure. But even if we can revive a robust definition of health, and steer
toward it, health will not happen. Our culture, which might best be called
postmodern consumer capitalism, eats social infrastructure for breakfast.
Postmodern consumer capitalism is successful to the extent it can atomize
individuals, families, and communities into the smallest unit of analysis
that can trigger the purchase of a product. This perverse market system
has triumphed by deconstructing the families and communities that are
necessary for health security.1
The death of community in America is the roadblock the healthcare
system must get around if it is to be about health for all, and not just profit
for a few. How we understand health necessarily determines what the
healthcare system looks like. If we want to fix the many problems of the
current system, we must first understand, and agree on, what health is. In
recognizing the function of community in the well-being of individuals, we
have arrived at this definition:
xx The nature of health

Health is the biological, social, and psychological ability that affords an

equal opportunity for each individual to function in the relationships
appropriate to his or her cultural context at any point in the life cycle.

If health is as much about community as it is about longevity, our healthcare

system will need to refocus on helping people enter into and maintain
relationships. It will need to focus on building, supporting, or regenerating
community itself, in the hope that with the regeneration of community will
come the capacity to help people lengthen their lives, relieve pain and feel
secure in the world as it is. Is so much change possible? If we did not think
so, we would not have written this book.
 PART ONE

what health is not

“Should medicine ever fulfill its great ends, it must enter into the
larger political and social life of our time; it must indicate the barriers
that obstruct the normal completion of the life cycle and remove
them. Should this ever come to pass, Medicine, what ever it may
then be, will become the common good of all.”
— Die Einheitsbestrebungen in der wissenschaftlichen Medizin

“The physicians are the natural attorneys of the poor and the social
problems should largely be solved by them.”
— Rudolf Virchow

“Places have the power to transform – people, nations, even ideas.”

— Bruce Feiler

“Analysis belongs to science, and gives us knowledge; philosophy

must provide a synthesis for wisdom.”
— Will Durant, The Story of Philosophy (1926)

“Any game becomes important when you know and love the
players.”
— W. P. Kinsella

A senior professor of medicine was making rounds at the hospital

with his usual retinue of medical students, interns, residents, and
fellows. They stopped at the bed of a strong-looking 28 year old.
An intern presented the case: this was a well 28 year old who had
suffered eight hours of vomiting and diarrhea the previous day. His
symptoms had completely resolved. All his x-rays, blood and urine
testing had been normal. He was, said the intern, a completely
healthy man.
“A healthy person?” queried the professor. He paused and sur-
veyed the assembled trainees, all on edge in anticipation of the next
difficult question, letting the weight of the moment sink in. “A healthy
person . . . Can anyone give me a definition of a healthy person?”
There was a long, uncomfortable silence, as the group of young
doctors eyed their professor and each other, each terrified of making
a mistake.
“I think I know,” said one of the fellows, the one with a answer
always ready. “It’s simple. A healthy person is a person who has not
yet been adequately examined.”
— An old medical school joke
 What health is not 3

DEMENTED AND CONTRACTED

One early spring Saturday in 1984, when I was an intern on call at an urban
community hospital, the emergency room doctor beeped me. “2191, 2191,”
the beeper said, a number that still makes all my muscles tense, my heart
pound, my breath quicken, and the hair on the back of my neck stand up.
Interns then would typically be called to the emergency room five to ten
times a day, and asked to assume the care of people who had just come
in. Their situations were not well known yet. They were people who could
crash and die, people who could scream and yell, people who could complain
and threaten. Sometimes they were people whose medical care we would,
inadvertently, screw up, leading to their worsening incapacity or death
and to a lifetime of finger pointing and recrimination for us, the interns.
The common thing any of us knew about those people was that someone
with the power to decide had determined that they should be admitted
to the hospital, and that the intern was responsible for admitting them,
then finding the problem and fixing it, whatever the problem happened
to be.
An admission is a frightening time for an intern, because all that is known
about the patient is what the emergency room doctor, who washes his or her
hands of responsibility for the admitted person’s life and health by calling
“2191” and talking to the intern, knows and can tell. And sometimes the
emergency room doctor, in a hurry to be absolved of responsibility, does not
know or tell the intern very much at all.
What I heard that snowy, early spring, was “demented and contracted”.
“An old woman (70? 80? 90?), lives in a nursing home, demented and
contracted. No history obtainable. A GI bleeder. She had thrown up blood.”
Sometimes, what you hear is what you get. What I found when I went
to the emergency room to meet the old woman and begin her treatment
was nothing more, and nothing less than what I had heard: demented and
contracted. She lay on her side in a bed, her arms and knees bent in a fetal
position. She could not talk. Could not walk. She lay in a bed and was fed.
Bed sores. No family. A scribbled record from the nursing home; a barely
legible few words from the warehouse where they had 50 of them all the
same. Vomiting blood. No history, no sense of what she was like before her
admission to a nursing home, or when that happened, no sense of who she
was or what she felt. She had thrown up blood in the nursing home twice,
but her blood count was still normal. No bleeding from the rectum. No sense
of the human being, the person in the body, the self. No sense of self or
dignity. A body in a bed who had thrown up blood. But in the next 28 hours,
that poor old demented and contracted woman would help me understand