Broken Bones and Open Borders

Here’s an exciting life update: I broke my wrist.  I’m not going to go into how it happened, except to state that it did not involve alcohol and that my cover story is that it involved a fight with zombie ninja pirates.  Not a huge deal, but definitely a frustrating and unneeded at a stressful time of the year.  At least I could get a jet black cast that matched my wardrobe.

Immediately after the “incident,” I pushed myself through five hours of statistics in the library before heading off to a review session, at which point some of the more reasonable students in my program convinced me to go to the hospital to get my now comically swollen arm x-rayed.  They bid me adieu with the standard but ominous NHS send-off: “I hope you don’t have to wait too long.”

I’ve approached every experience I’ve had with the NHS so far as if it is the ultimate show-down between private and socialized medicine, with me as scorekeeper.  I’m ready to concede now, though, that – as enthusiastic as I am about participant-observation as a mode of research – the experiences of an accident-prone twenty-three-year-old are probably not sufficient for making a conclusive declaration about either system’s relative merits.  Sure, I didn’t have to wait more a few hours, and I definitely appreciate the $0 bill—but then again, I don’t have cancer and am not waiting for elective surgery.  Thus, I’m abandoning wholesale evaluation in favour of something a bit more obscure: metaphor and symbolism.

One thing that hit me during this most recent visit to an NHS “Accident and Emergency” Room was how little information they wanted about me.  Of course, they wanted to know my date of birth, medical history, and all about my injury.  But certain things we in the U.S. are accustomed to putting into endless forms – occupation, address, nationality, insurance – just don’t matter that much.  The NHS’s goal is to serve the person in front of them, not track them down with a bill or pick a fight with an insurance company.

The brilliance of it is that the NHS is, at least in some ways, impossible to exploit: I can lie or misrepresent myself to no end, and it doesn’t much matter, because the system doesn’t much care who I am so long as I need medical treatment.  We live in a world where government’s exist to categorize and classify and monitor—and yet the NHS is, in a weird way, surprisingly anonymous.  Somewhat counterintuitively, this makes me feel much more like a human being and less like a statistic.

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This week in class, we’re discussing “statelessness.”  By “stateless,” we don’t mean refugees who have been ejected from their nations; instead, the term refers to people who literally have no nationality at all and thus—in a world where there is practically no designation more important than citizenship—do not really exist.  It’s a form of non-status that affects fifteen million people worldwide, non-persons ranging from Turkish Cypriots to the children of undocumented immigrants in countries that do not grant birthright citizenship.

All of the literature we’ve read on statelessness focuses on the stateless people as the problem: how, in the modern world, does anyone manage to have no birth certificate or passport?  And how do we fit these square pegs into the round holes of the nation-state system?  How do you legislate for people that are, just by merit of their persisting physical presence, lawless?  I think these are all stupid questions, to be honest.  For most stateless people, having no nationality is a horrible thing—but for some (I’m thinking, for example, of Roma, some indigenous groups, communards), perhaps it reflects their realization of how absurd our modern ideas of citizenship are.

The recent crackdown in Arizona has thrust immigration back into my brain in a big way again for the first time since I stopped taking classes with Professor Fernandez-Kelly at Princeton.  Freshman year, I spent dozens of hours collecting statistics and studies about undocumented immigration, in the hopes that the accumulation of piles of data would convince people that immigration is actually good for all concerned.  With the benefit of a few years of experience—and having watched comprehensive immigration fail over and over—I’m convinced that advocates for sane immigration policy need to go beyond reason.  We need to ask why it is that so much hinges on the lotteries of birth, and why categories and boundaries are so important.

When I think about problems like “statelessness”, I can’t help but think that the problem isn’t with the people, but with the states that throw up barriers between them.  My utopian imagination is once again drawn to a vision of a borderless world, in which we find a better way to sort ourselves than by pre-natal dice-rolls and invisible lines scrawled across the map.  I imagine states that exist to support whomever knocks on the door—acknowledging that we are, after all, in this together—rather than bringing one group in and leaving another outside.

It’s a weird time to live in Europe.  With politicians across the continent talking about gut-wrenching cuts to public services, I can’t help but think that I’m witness to the demise of one of the world’s great political experiments: social democracy.  Of course, I’m pretty sure the creators of the NHS didn’t have such lofty goals as universal citizenship in mind, but—metaphorically at least—I think they’ve created something that reaches towards them.  I’ll be sad if I have to see that go.

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Jukebox: Gaslight Anthem – The Boxer

A wholly unsatisfying (for the reader, that is) treatise on the NHS

Great Britain’s National Health Service is (choose one):

  1. A shining example of the power of government to provide health care for everyone.
  2. A bloated and sclerotic bureaucracy which demonstrates the impossibility of effective socialized medicine.
  3. Both

As the debate over health care reaches new heights of absurdity—with the label “socialized medicine” continuing to be the ultimate insult—I figured its time I share my experience with Britain’s National Health Service.  Given that the NHS has been characterized as anything from “evil and Orwellian” to one of civilization’s “greatest achievement,” I am cognizant that I am not able to add anything profound to the debate.  And, to some extent, the fact that I can’t offer anything of substance is, at least obliquely, the point of this post (read on!)

– – – – –

Although I very much want to be a believer in socialized medicine, I had heard stories about the NHS—byzantine bureaucracy and endless waits—before I came here.  As a result, I was a bit tentative when the time came for my first encounter with the fabled system.  This cross-cultural experience came when my I was down to just a few weeks left of my medication, I decided to walk over the surgery (British for doctor’s office) affiliated with Worcester College.  I went to the desk asking for an appointment, expecting that, with luck, I might get an appointment for the next month.  To my surprise, the medical assistant booked me for that afternoon.  I was keenly attuned to notice any differences, anything with which I wasn’t familiar, but up through seeing the doctor, I couldn’t much tell that I wasn’t at home in the U.S.

After I saw the doctor, I returned to the front desk.  After standing for a few seconds, awkwardly, the clerk turned to me and asked if she could help me.  I said something to the tune of “I’d like to pay now.”  She clearly didn’t understand what I was talking about, so I prompted, “Will you send the bill to my address?”  While I knew that health care in the U.K. was publicly subsidized, I found it hard to imagine that I – not an English taxpayer and not a resident – could possibly get off so easily.  Despite my best efforts, though, I left without spending a penny.  Nonetheless, I figured that the charges would hit me when it came time to fill my prescription.  I walked to the chemist, and handed over my script.  I asked how much it would cost and—without even bothering to check what medicine I was ordering—the clerk told me £7.20, the price of nearly all medications in the U.K.

I can’t help but draw some comparisons to the United States, where I am, supposedly, one of the “winners” of the private health care system.  I’ve been on my parents’ high quality insurance before I was born, and have never thought twice about medical care because of cost.  For me, though, the contrast between health care in the U.S. and U.K. is both quantifiable and undeniable: what cost me £7.20 in the U.K. would have cost me $160 in co-pays in the U.S. (insurance covers a whopping $26—thank you Aetna!)  While my insurance isn’t paying for my medication, they are busily sending me notices attempting to get me to help them sue the insurance company of the guy who I ran into during reunions at Princeton, which is idiotic.  Moreover, I’m getting my wisdom teeth out over break—which is totally unnecessary at this point in time—because come my 23rd birthday, I will be off my parents’ insurance and have no coverage when I am in the U.S.

In short, my experience with the NHS was unambiguously positive, both absolutely and relatively.   The only tell-tale sign of the NHS supposed sclerotic inefficiency was a brochure I picked up during my short stint in the waiting room.  The cover advertised a bold new plan to reduce waiting times between doctor referrals and evaluations by a specialist.  When I opened it up, it announced that most patients would now wait no more than eighteen weeks! Bear in mind, that’s the wait for an evaluation—not treatment.  Still, this didn’t strike me as particularly significant, until I friend of mine got sick.  She went to the doctor in extreme, debilitating pain.  While she got to see a General Practitioner promptly, this was hardly any solace: she left with some pain relievers and an appointment to see a specialist—in February. For her, public health care clearly wasn’t working, so she traded what she described as a decrepit NHS hospital with overworked doctors for a private one, where she got prompt and state-of-the-art treatment, all paid for by her American health insurance.  Even as a progressive advocate of a government role in health care, like myself, she had to admit that being treated by the NHS didn’t exactly leave her enthusiastic about socialized medicine.

– – – – –

Our wildly different experiences are not easy to reconcile.  In fact, it’s somewhat hard to believe that we were both served by the same system, and so it’s hard to look at the two and come up with any useful lessons for the health care debate.  Basically, our two stories perfectly capture a fairly reasonable evaluation of the trade-offs endemic to socialized medicine.  In one system, you have universal and quality primary care.  In another, you get cutting edge technology and specialization.  It’s good to live in one system over the long term; it’s better to get sick in another system.  One rations health care based on minimizing costs and maximizing the good of society; the other rations it based on ability to pay and gives no-holds-barred treatment to those who can.

The social scientist in me, though, is left unsatisfied; I hate the idea that, in answer to my quiz above, the answer is inevitably option three, “both.”  I find it hard to accept that all systems are simply “equal but different.”  There are always trade-offs, but I like to believe that, occasionally, there are “facts” about societies which are indeed “knowable.”  And so, in that spirit of inquiry, I poked around and found a few facts about health care in the U.K. and the U.S:

–         For all the talk of avoiding “government-run healthcare” in the U.S., we already have it—it’s just terribly inefficient.  The United States government pays for over half of all health care in the United States—but manages to cover only one-third of the population in doing so.  The United Kingdom’s government spends less per capita, but covers essentially everyone.

–         Overall, the United Kingdom pays around 40% as much per capita as the United States does.  For that price, the get the same number of doctors, substantially more nurses, and a greater number of hospital beds.

Ultimately, of course, the inputs of health care (doctors, money, technology) are irrelevant—what matters is outcomes:

–           There’s been some political hay made over the fact that the U.K. has higher death rates from cancer, as a result of failure to adopt high-tech treatments.  Overall, though, the U.K. still does fine: they have a lower infant mortality rate and a slightly higher life expectancy.*

–         My own personal experience, from talking to Europeans from all sorts of different countries, is that pretty much everyone thinks their health care system is flawed.  But Britons are certainly more satisfied with their health care system than Americans are.

What occurs to me as I watch the debate over health care reform in the U.S., though, is how little these kinds of statistics and comparative analyses actually matter.  No one really seems persuaded by the “fact” that the U.S. ranks near Cuba in health care or that France covers more people for less cost.  What politicians, pundits, and the public do seem to find convincing our stories.  We care about narratives: Barack Obama talks about the woman with terminal cancer being booted off of her insurance plan; lefty magazines relate the sad tale of a father of three joining the army to get healthcare for his wife; Republicans claim that the NHS would have let ultra-genius Stephan Hawking die.  Somehow, these isolated anecdotes are more convincing than the statistics I cited above.  And, while I like to think of myself as a rational person, I get it; I am far more convinced of the merits of nationalized health care by my thirty minutes in an NHS doctor’s office than I am by any article, however well researched, I could ever read.

– – – – –

I promised at the outset that I would come to a disappointing conclusion, and I will not fail to disappoint.  From a political perspective, I find the un-convincing nature of statistics and data to be somewhat terrifying: it worries me that more American’s believe in angels than anthropogenic climate change, or that people can seriously claim undocumented immigrants don’t learn English when by the 2nd generation 95% of them do. From my place in academia, though, there is something reassuring and validating about the strange and irrational way people come to decisions about the world around them.  Ethnography often seems to be the stunted stepchild of social research, an inferior method that lacks the rigor of numbers and statistics.  And yet, while qualitative research is often dismissed as mere storytelling, the fact is that personal experience have an incredible power to frame how we understand in the world, a power which graphs and tables lack.  The stories we tell matter, however partial, disjointed, and unrepresented they are.  And so, I beseech you, support universal health care, because if you do, all our medication will only cost £7.20 and the receptionists will be way nicer.  It must be true, because it happened to me.

* As an interesting aside, the life expectancy at 65 in the U.S. is higher.  That is to say, Americans overall don’t live longer, but they DO live longer if they make it to retirement.  Probably not by coincidence, retirement is when Americans get universal, government-run health care, of the kind Joe Lieberman just decided the rest of us don’t deserve.

And at that, I reiterate, fuck you Joe Lieberman.

Smile! At least you’re poor!

So, here are some research findings with interesting implications for contemporary policy debates in the U.S.:

Kenyans—despite living in a country with nine times the infant mortality rate of the United States and living twenty-two fewer years—report being as satisfied with their health care system as Americans are.

Afghanis, for their part, are part of the fourth most impoverished nationality in the world.  They also report above-average levels of happiness.  In fact, Afghanis smile significantly more frequently than do the notoriously chipper Cubans.

I haven’t posted very frequently (or at all) on the things I’m learning on the academic front.  While my brain is certainly being stuffed full of all sorts of knowledge, I generally don’t see much aim in me publicly regurgitating it if I don’t have anything to add.  That said, I’ve made it a point to attend public lectures and seminars here, and some of them—like Carol Graham’s lecture on the economics of happiness today—are too fascinating not to share.

Some of her results are straightforward and unsurprising.  Higher income countries are, on the whole, happier than lower income ones, though the benefits to increased income fall drastically after a certain point (it’s not much better to be American than Portuguese).  Married people are a lot happier than unmarried ones (though the causality might run both ways—that is, happy people get married rather than married people get happy).  Education doesn’t have much impact on happiness either way, while unemployment has massive negative effects on self-reported well-being.  Happiness declines over a person’s lifetime until they are about forty-five, after which point it starts to rise.  People over eighty are the happiest people in the world.  Centenarians are pretty much living on cloud nine 24/7.

Five times as rich as Columbians, and we're no happier.

Okay, so no mind-blowing so far.  Where it gets interesting is in the adaptability of human happiness to stress, shock, and trauma.  Reported happiness in the U.S. dropped significantly in the 2008 economic crisis; if you superimpose a graph of happiness on the stock market, they track almost perfectly, until the start of 2009.  After then, happiness rebounded much faster than shares; in fact, Americans are now as happy as they were in the good times of 2007, even though they are materially much worse off.  The same inelasticity of happiness can be seen in more extreme examples: Afghans, for example, are relatively unaffected by corruption and crime, presumably because they’re so used to it.  On an individual basis, people who are victims of horribly accident and become paralyzed eventually make their way back to their previous level of happiness, despite facing disabilities we would assume would be quite depressing.

Before I go on, I should acknowledge that there are all sorts of problems with the study of “happiness.”  What, after all, is happiness, and what do people mean when they say they are happy?  Jackie’s students in Thailand, when asked, “How are you?” respond “I am happy” in the same way an American would say “I am fine.”  How people describe their happiness is heavily dependent on how you ask the question: the response to an open-ended question about happiness is very different from one in which a person is asked to compare their current life to the best possible life they can imagine.  People are much less like to say they are happy, in response to a survey, if the question is asked after queries about their job or home life.

Methodological problems aside, though, what I learned has some interesting implications.  The indomitable adaptability of human beings becomes inconvenient and confusing, from an international development perspective, when we apply it to economic growth.  People who bump up to a higher income bracket—either because they won the lottery or got a raise—are initially quite pleased but tend to “adapt” back to their previous level of happiness, as if nothing had changed.  More broadly, countries seem to keep to their previous level of happiness in spite of economic growth.  The United States has had a four-fold increase in GDP per capita in the last half-century, but we are no happier for it.  Japan’s income per head has quintupled over that same period, but there happiness has actually declined.  The process of economic growth itself actually seems to make people unhappy: as a species, we like being rich, but we don’t much appreciate the instability and change required to get there.

This brings us back to the contented Kenyans and the cheery Afghans.  There are so many reasons why I think it’s “bad” that Kenyans have nearly non-existent healthcare and Afghans lack basic freedoms and security.  And yet, from a utilitarian point of view, it is challenging to explain, why, exactly, these deprivations need to be corrected.  What, after all, is the point of development if it doesn’t make people any happier?  People seem to want clinics, schools, roads, and factories, but if these things aren’t ultimately going to make their lives any better, what’s the point?

From another perspective, there is something hopeful about the idea that more is not necessarily better.  As I prepare to go to London tomorrow to demonstrate against inaction on global warming, it is increasingly apparent to me that the implicit assumption of international development is a sham.  We like to envision a world where everyone can attain a Western standard of living, but it’s increasingly obvious that the biosphere could never support it.  At least now I know that giving up on this illusion doesn’t mean much, since it wouldn’t make us happier anyway.

A Brief Rant – Read a Book, Joe Wilon

I didn’t watch Obama’s speech last night, partially because I was passed out sick (those parasites take a long time to die), partially because I’m already convinced that whatever Obama pushes is the best feasible option for health care reform, and partially because I’m sickened by the prospect of what that “best feasible option” likely actually is. Like everyone else, though, I’ve been following last night’s “big news,” which is, of course, Congressman Joe Wilson’s verbal outburst, telling Obama “You lie!” when the President announced his plan wouldn’t cover undocumented immigrants. While I’ve been trying all morning to share a few choice thoughts with Mr. Wilson, his website appears to have crashed from high traffic, so in an effort at mental catharsis I am posting them here.

I am not – repeat, not – particularly offended that a congressman would have the audacity to heckle a sitting President during a speech to Congress. While the sheer lunacy of Republicans (calling healthcare reform Nazism, for example) puts this sentiment to the test, I generally believe that we shouldn’t overly resign ourselves to respectful, silent awe of our leaders. I rather prefer the British model, where the Prime Minister has to stand weekly and be badgered from all angles and all issues, decorum be damned.

No, what annoys me far more is the moral inconsistency and factual inaccuracy that underlie the position behind Wilson’s verbal expulsion. I’ll deal with the former first. Even if we accept that undocumented aliens are “criminals,” does that really exclude them from health care? After all, we provide health care to those we incarcerate and (at least, supposedly) even provide health care to “illegal enemy combatants” and prisoners of war. While I shudder to think of how Wilson would respond to this point—frankly, I imagine it’s more likely he would say “no” to health care for all the aforementioned groups—I think that our particular obsession with not giving health care to immigrants is a bit out of line with our general social consensus about health care being a right for all.

Of course, the crux of the issue is the Republican terror that offering health care to immigrants will create an incentive for them to come here, breaking the law (something no one worries about with members of the Taliban). While I personally find this argument to be stupid beyond all reason, a cursory engagement with some “facts” would probably be more helpful for Wilson than to hear me tell him he’s an idiot. First off, coming to the United States is physically very challenging and dangerous, which is why nearly anyone who has looked at the demographic composition of undocumented immigrants has discovered that they are generally young, healthy individuals, despite sensationalized reports of migrants carrying tuberculosis and AIDS into the United States.* Most importantly, migrants simply do not come to the United States to take advantage of social services: a statistically negligible proportion of migrants in one study reported interest in tapping health care or welfare benefits as their motivation for coming to the U.S.** Migrants come to work, plain and simple, and tend to keep their heads down otherwise (part of why their crime rate – when immigration violations are factored out – is also low).

Once Wilson’s website is back up, I’ll send this along. Of course, none of these arguments—particularly the ones I am supporting using social science research—have any significance in the public debate. I’m okay with screaming at a wall, if the alternative is to be silent, though.

*Doug Massey, 2002, “Beyond Smoke and Mirrors.”
**Berk, Marc, Claudia Schur, Leo Chavez and Martin Frankel, 2000, “Health Care Use Among Undocumented Latino Immigrants.”

Going Native, Part II

There are borders to how far I wanted to go with the whole “living like a Ugandan” thing. For example, Ugandans have high rates of rather exotic maladies and afflictions. I was hoping to avoid that part of life in the third world, but that’s not how it turned out.

For the sake of the children, I will spare everyone the gory details of what happened, or is happening – except that it involves insects living inside the bed of my hotel and now living, well, somewhere inside me. It’s one of those kind of afflictions that I had heard about but had a very difficult time imagining anyone ever actually got, because it sounds simultaneously both painful and hilariously absurd. Anyway, after a few days of trying to tough it out, I conceded that some medical care was in order.

But what medical care? As the ongoing debate about health care in the U.S. lays bare, there is nothing intuitive about the system I am used to. Medical school. Hospitals. Doctors and nurses. Pharmacies. These are universal labels that we apply to very different things in different places. Given how different I know health care in the U.S. and the U.K. to be, I realized that Ugandan health care might very well be totally foreign to me. When I thought about it, totally absurd questions started bouncing through my brain. Do they have doctors here? How do I know they’re really a doctor? Will they have a framed diploma on the wall, a front office full of forms and records, a nurse to clean me up first? How do I pay? If I go in with an open wound, will I leave with HIV?

Given the circumstances, I got my answers from the same source I always do: a Ugandan. I pulled one of my researchers aside, and asked him to point me in the direction of a clinic. I added that I wanted a good place, a clean place (as if he – by merit of being Ugandan – might recommend someplace that is dirty and bad). Ultimately, I have to admit that these questions were code for what I really wanted to know. Deep down, I knew that for my peace of mind, I wanted to go to the clinic where the white people go, where I knew they spoke English and might offer services familiar to a Westerner. So much for going native. I’m in rural Masaka, though, and so my team leader told me that I had no option but to go to the single local clinic. I’ll admit it: I was scared.

It occurs to me that my mentality about this whole “living like a Ugandan” thing is a bit like Sarah Palin lauding her daughter’s choice to not get an abortion, while missing the distinction between people making the choice to save their babies and have that choice made for them by the government. It’s easy to pat myself on the back for trying local cuisine, staying in local spots, and adopting local customs, but in the end, each decision was mine to make to make. I always knew that – for the cost of just a few thousand shillings – I could have all the comforts I am used to. When I no longer had a choice – when I had to accept the whole package of living like a Ugandan – it was terrifying.

We walked to a nearby clinic, which had a completely inconspicuous front nestled between a tiny grocery and a stationary store. The front room had nothing to indicate that it was a doctor’s office except for a few government issued posters about avoiding malaria and boiling water to kill bacteria (no water here that does not come in a bottle is remotely safe to drink). The woman behind the reception desk – who appeared to be cooking dinner on a stove in the corner while her five-or-so-year-old daughter ran around – greeted me by joking “I’m the doctor.” She probably sensed the panic on my face when it hit me that my “doctor” was about twenty-two, because she quickly retracted her statement and said the doctor would be in soon. When the doctor came in, he took me to the only other room in the clinic, which was only about 10 foot square. Medical equipment was sparse – there was a stethoscope, a box of gloves, and some bandages. I’m sure everything that really mattered was clean, but the room itself did not have the antiseptic atmosphere I’m used to (the dried blood on the walls didn’t help).

And yet, all in all, it was a good experience. The doctor sat with me for thirty minutes, did everything himself, and explained what was going on in detail, despite the language barrier between us. I can’t help but compare it to a few months ago, when I broke my nose and spent four hours in Princeton Medical Center, a top-notch U.S. hospital, in order to get a battery of tests that the doctor – who spent all of three minutes with me – never explained. PMC cost $4,000; the Masaka Clinic cost 10,000 shillings (5 dollars).

The entire experience was a good reminder of a maxim I repeated to myself last summer, when I was living in one of Brooklyn’s worst neighborhoods: even in the worst places people live, there are still people living. What I mean is that you can be in the ghetto – where the crime rate is sky high and drug use is rampant – and the majority of people are just simply existing like anyone else. Things here are bad and there are many, many things that can go wrong, but the reality is that what I got was the whole extent of the health care to which most Ugandan’s have access – and it was okay. That’s not to say I don’t think it’s criminal that I can get a $3000 CAT scan for a broken nose and people here can’t afford a $15 malaria treatment, but the whole experience has been a good reminder that just because something is different doesn’t necessarily mean it’s crappy.

** Addendum: I am back in Kampala, and went to the reassuringly boring (that is, familiarly Western – there was even a fish tank) clinic that all the Mzungu go to. It looks like I am not going to die. Feel free to google “Mango flies” if you really want to know more.