Final Reflection

For our final process reflection, I’d like to touch on something we only started talking about in the final few weeks of class. Right before Thanksgiving, professor Guseva challenged us to have our own version of the Conversation Project with our families. Honestly, I didn’t think I would actually do it, but the night before thanksgiving it happened and suddenly I understood something I had never quite understood before. My Mom, Dad, sister and I were lounging in my parents’ room after a big dinner with lots of elderly family members and I spontaneously decided to tell them that we had been learning about a movement that was encouraging people to talk with their families about the level of care each member would want in the even that the other members had to make a decision about the life of their loved one.

The attitude that we have around death, and death denying itself is so powerful that my sister, who received a masters in public health last year, tried shut it down before anyone could even answer. And then my Dad responded that he wouldn’t want us to go to extreme measures to resuscitate him if it would mean his quality of life would be poor. To that, my Mom, half kidding, said “Well we’ll see about that…I’ll make the decision if I think otherwise.”

And then I realized that in my incredibly tight-knit, but practical, well-educated family, we love each other too much to have this conversation, or at least that’s what we tell ourselves. Death denying goes beyond the doctor-patient setting or the patient-self dynamic; we try to protect our loved ones so much that we’re unwilling to even consider the possibility of death. From a more cynical point of view, it’s the only guarantee we have in this life and yet we cannot accept it even when we know we need to talk about it. This moment really made me realize that if my own family can’t handle this, we need to reconstruct the cultural boundary around death, and we need to do so immediately.

Analytical Posting : Treating A.D.H.D

Earlier this month, the New York Times published an article describing a new method to treat A.D.H. D. in children. Basically, Akili Interactive Labs is a company that develops “electronic medicine” using high-quality, interactive video games. Recently, they came out with Project: EVO, a computer program “created to improve attention and reduce impulsivity in children with attention deficit hyperactivity disorder.” However, while the creation of a treatment that doesn’t force children as young as three and four to be medicated seems to be a wonderful new development, Project: EVO already sparks some concerns.

On one hand, it’s remarkable that there is a group of cognitive neuroscientists, biomedical scientists and experts in medical devices that is committed to treating children with A.D.H.D. without using drugs in a culture that is constantly using medication solve problems. The theory behind the whole brain training industry that targets children with A.D.H.D. along with adults who are trying to prevent dementia and other age-related cognitive ailments, is that people will be able to improve cognitive functions by using interactive, repetitive, and increasingly difficult exercises to strengthen the brain the same way lifting weights at the gym strengths other muscles in the body. “Electronic medicine,” as opposed to drugs could be a great alternative for parents who worry about side effects of drugs like amphetamine and methylphenidate that are typically used to treat A.D.H.D.

However, the problem with that last point is that doctors are not being encouraged to prescribe electronic treatment over standard drugs; rather, they are to prescribe both to children. Especially considering the video games are recommended for half an hour a day, five times a week for four weeks, they could be more stigmatizing for children and they wouldn’t actually replace the potentially harmful side effects from drugs. Kids who use Project: EVO could also later have an increased dependence on screen time, which is proven to, at times, end up being harmful to the development and health of children.

Also, I can’t help but worry about one more thing in the context of our discussions about the ways in which pharmaceutical companies medicalize illnesses. According to the article, “Shire, which manufactures Adderall, was an early investor in Akili and helped design the recent pilot study.” Shire has a vested interest in seeing increased treatment of A.D.H.D. in order to sell more Adderall. This is clear conflict of interest that could skew reports on the true effectiveness of Project: EVO. Unfortunately, what could be happening here is that a franchise is being made out of the treatment of A.D.H.D. And when business gets in the way of medicine, it is the patients who suffer.

Timmerman’s Social Death

According to Timmerman’s article on Social Death as a Self-fulfilling prophecy:

“In most resuscitative efforts of patients with assumed low social viability, these signs were dismissed or explained away (Timmermans 1999a). In the drug overdose case, an EKG monitor registered an irregular rhythm, but the physician in charge dismissed this observation with, “This machine has an imagination of its own.” Along the same lines, staff who noticed signs of life were considered “inexperienced,” and I heard one physician admonish a nurse who noticed heart tones that “she shouldn’t have listened.”

What do attitudes like these say about doctors, medical culture, and American culture today? More specifically, is the problem with medical culture (taught within the “hidden curriculum” we learned about) or with the inherent character of doctors and those who want to become doctors? Or…is it bigger than that—is this ability to flippantly place value on another person’s lives, less representative of a unique doctor culture, and more representative of American culture as a whole?

Medicalization–is it a bad thing?

What’s the problem with medicalization? If people with anxiety are better able to live their lives with medication that they’re given once they’re diagnosed with SAD, then what’s so bad about it? Shouldn’t the greater fear be that there are people who aren’t getting treatment because their symptoms aren’t recognized?

At the very least, how can doctors and healthcare providers draw the line between medicalization and overdiagnosis or even misdiagnosis?

First Native American Birth Center

This year, thanks to the combined efforts of Nicolle Gonzales, Brittany Simplicio, and the nonprofit “Changing Woman Initiative,” a plan has been put into place to create the first ever Native American birth center. Gonzales and Simplicio are two of only fourteen certified nurse midwives who are Native American. The pair have a firsthand understanding of how frequently Native American women suffer the consequences of being minorities with a low socioeconomic status when it comes to health, and, more specifically, pregnancy, birth, and neonatal care.

On this topic, I have mixed feelings.

On one hand, Native American women will have better access to pregnancy and birth care, but I also wonder, how in the world is this first ever birth center for this already largely underserved group of people? How much has this group had suffer as the result their inability to access a birth center?

There is no greater illustration of how institutional racism and mishandled bureaucracy directly harm health outcomes for Native American people than what we see with Indian Health Services (IHS), particularly at the Santa Fe location where Gonzales used to work. Due to underfunding, native women only have access to prenatal care because the labor and delivery ward was shut down in 2008. When I see that, I immediately wonder and worry: when a native woman does go into labor, how far does she have to travel to safely give birth? Does she have access to a safe, clean place if she gives labor at home? How far is the nearest hospital if something goes wrong? The answer all of these to these questions are provided nowhere other than the disproportionately high rates of infant mortality among Native American people.
To add insult to injury, at the Santa Fe location, women are provided neonatal care through IHS, which is funded by the federal government, but for delivery at a hospital, they must apply for Medicaid. The interaction between IHS and Medicaid—for all medical procedures, not just birth—has created a confusing mess for native American people who don’t realize they’re eligible for both.

Gonzales and Simplicio explain that “poverty, discrimination, geography, and racism” have created cultural disparities that leave Native American people less healthy than they should be. These disparities manifest as “higher rates of gestational diabetes, increased rates of postpartum depression, and higher rates of preterm birth and low birth weights.”

It’s just amazing to me that it could take this long to finally give Native American people access to a service that might have saved an unknown number of lives had it been provided earlier.

Discussion Question post- “Social Conditions as Fundamental Causes of Health Inequalities”

According to Jo C. Phelan, Bruce G. Link and Parisa Tehranifar

“if we redistribute resources in the population so as to reduce the degree of resource inequality, inequalities in health should also decrease. Policies relevant to fundamental causes of disease form a major part of the national agenda, whether this involves the minimum wage, housing for homeless and low-income people, capital-gains and estate taxes, parenting leave, social security, head-start programs and college-admission policies, regulation of lending practices, or other initiatives of this type.”

Is it still possible to improve the health care system and health outcomes for Americans without taking on all of this? Do we have to re-create our whole system just to fix this part of it?

Reflection 1: Ok, so now what?

My greatest and most pressing challenges in this class have begun with the question: “Ok, so…now what?”. Let me break that down a little. First of all, I’m not in this class because I want to be a doctor, pharmacist, or health insurer; more specifically, when we all graduate and become a part of the working world, I know won’t be someone who can make a direct difference for patients who are being shafted by the system. Here at BU, I study sociology and public health, so I’m left staring at pages and pages of all of these problems, wondering “what can I do?”

I deeply feel the conflict of whether I’ll work in sociology in medicine (where I might work with doctors to see how to improve outcomes and satisfaction within the system) and sociology of medicine (where I could be critical and work to reinvent the systems altogether).

I take one step further and realize that I’ve never been concerned about healthcare for Americans until I took this class. My parents have great comprehensive (and expensive) healthcare through BU because my Dad is a professor here. From here I think about the fact that many of the people who have the most power and prestige in this country are the ones who are already satisfied and are, therefore, uninterested in changing the system that hurts so many others. I feel a personal connection to—and guilt about—Rothman’s argument that the system is the way it is because of the selfishness of the middle class. I think he means me.

And that brings me to my last concern, on a greater scale. Between the middle class’s failure, and the stakeholder mobilization theory that Quadagno address’s, I fear that we are, for lack of a better word, screwed. We see so many other countries where health care systems are better in terms of life expectancy, cost effectiveness, infant mortality rates, access to care, universal coverage for care, and every other factor that helps determine how good a healthcare system is. I fear that the independent, by-the-bootstraps American ideology our culture clings on to, will stop us from adopting a similar that helps saves the lives and dollars of the American people. Can I blame republicans? Is that fair? Is it me and my parents, not pushing hard enough for change? If we know our system is bad, and we know it needs to change but the country is divided, is there still a hope to change it?

So here I am, stuck, wondering, “Now what?”

The Art of Fearmongering by Elizabeth Wurtzel

Analyzed by Eve Zuckoff

Earlier this week, author Elizabeth Wurtzel wrote an opinion piece for the New York Times, titled The Breast Cancer Gene and Me, in which she describes discovering she had breast cancer as a result of the BRCA mutation. She underwent chemotherapy, radiation, and three surgeries in a six-month period that ended in a double mastectomy. Her conclusion to her ordeal was that all Ashkenazi Jewish women (like herself) should be tested for the BRCA mutation because some studies suggest the risk is ten times higher among this population than the general public.

My concern with articles such as this comes in two parts.

First, although the genetic risk of the BRCA mutation may be higher among women of Ashkenazi Jewish descent, there is still a large body of evidence that the mutation may not lead to breast cancer. In fact, Wurtzel acknowledges “the statistics vary wildly” but goes on to make her point that  “they are scary at the low end…[and] if you are BRCA-positive, you get breast cancer.” Not only do inaccurate statements like this reflect the quick reflex of overtreatment in the current system, they serve as effective scare tactics to make patients—and their families—all the more paranoid.

Wurtzel’s piece directly contributes to the fear mongering of diagnoses, which leads to overtreatment. Already, women who may or may not at some point in their life find that they have breast cancer, are opting for double mastectomies when the more proper response may simply be more frequent screenings, further testing, and other low-impact methods.

Even Hadassah, one of the most influential Jewish Women’s groups, has supported research on BRCA, only to have its president come out and say “testing is not for everyone,” giving a side-eye to the overtreatment of the BRCA mutation among Ashkenazi Jewish women.

My second concern is based on how this article takes advantage of the concern of loved ones, and what it says in general about the future of the American health care system. I realized how important it was for me to choose this article after my Dad sent it in an email to me, my sister, and my mother, three Ashkenazi Jewish women, noting “on your next visit to a doctor, I hope you will set this in motion.” My Dad, a well-educated journalist and father of a young woman with a master’s degree in public health, bought it. And I don’t blame him. We, the public, the patients, would do anything to protect our loved ones. I fear that even with policy changes, even if pharmaceutical companies and insurance companies change their practices, we, out of love, will continue to over-treat ourselves out of fear for the worst. The “too much love” problem is one that even this ambitious public health student has no idea how to solve.

The Breast Cancer Gene and Me is simply one of many of articles written by well-intentioned people affected by a terrible illness. That said, it inherently hits a sensitive spot among readers and feeds into a culture of fear, overtreatment, and increased costs to everyone as a result of a broken system.