The Atlantic – September 2019

THE ATLANTIC SEPTEMBER 2019 11

Origin of Species in 1859 at
age 50, but he published The
Descent of Man in 1871, books
on reproduction in plants in
1876 and 1877, and his final
book in 1881, the year before
his death, at 73. By then, dete-
riorating health had confined
him to his house and garden,
so he wrote about earthworms.
A better example of declin-
ing creativity would have
been Albert Einstein. His
“miracle year” came in 1905, at
age 26, and he published his
theory of general relativity in
1915, at 36. Nothing thereafter
came close, and his lifelong
ambition, a unified field theory,
escaped him.
Lawrence I. Bonchek, M.D.
LANCASTER, PA.

Arthur Brooks writes almost

entirely of the experience of

men (and of men of a certain era,

socioeconomic class, and race).

Although a reader might be able

to infer something of the experi-

ence of women in his article, he

effectively ignores them.

So what of the women whose

careers have moved forward

in fits and starts, due to time

spent parenting or the need to

counter legal, cultural, societal,

or institutional restrictions?

What of the women who never

had the chance at a career, if

indeed they wanted one? Do

they feel the same sensations of

decline? To what stage do they

now move?

Shana Judge

ALBUQUERQUE, N.M.

The Worst Patients

in the World

Americans are hypochondriacs,

yet we skip our checkups. We

demand drugs we don’t need,

and fail to take the ones we do.

No wonder the U.S. leads the

world in health spending, David

H. Freedman wrote in July.

I found this article to be a

refreshing departure from

most writing about health

care. Of course culture matters.

As a medical anthropologist,

however, I thought David

H. Freedman missed a key

factor in health outcomes.

Many people who have the

worst compliance rates and

outcomes (Freedman lists

smokers, diabetics, and people

with sedentary lifestyles as

examples) also have the same

socioeconomic status. In other

words, they’re broke or too

busy to do everything they’re

supposed to.

While I agree that more

attention needs to be paid to

how American culture affects

our health-care choices, I’d hate

to see money and social class

fall out of the analysis. These

factors also affect how people

perceive their doctors. I grew up

in farm country and my family—

who often couldn’t afford all

the recommended treatments

or travel the two hours it would

take to see specialists—viewed

hospitals and clinics with

suspicion. Local cultures and

medical institutions affect and

shape each other. Both have to

change for Americans to have

any chance at a better health-

care system.

Theresa MacPhail

BROOKLYN, N.Y.

We can all acknowledge that

a sedentary lifestyle, poor

nutrition, and “toxic” habits

contribute to abysmal Ameri-

can health-care outcomes. But

maybe the American attitude

toward health care is not the

fundamental cause. This

attitude might be a reflection of

larger social and cultural forces

in our country.

Americans have long been

known for entitlement and

a flair for dramatic hero-

ism. Our health-care system

amplifies those traits, with its

emphasis on high-cost and

high- intervention care over

preventative care and lifestyle

changes. We demonize figures

of authority and are inher-

ently skeptical of advice from

experts. Easily offended, we

insist on ensuring comfort

rather than knowing truth.

Creating cultural change will

require far more than simply

modifying health-care incen-

tives. Treating the problem

is usually more difficult than

treating the symptoms.

David J. Berman, M.D.

BALTIMORE, MD.

Formal international compari-

sons consistently point to the

much higher prices paid in

the United States for medical

services as the primary culprit

behind our high medical spend-

ing. Prices paid in the U.S. far

exceed those paid abroad even

as Americans consume fewer

units of service (such as doctor

visits) relative to the OECD

average. Were over consumption

the cause of our over spending,

we might argue about why—are

Americans, as David Freedman

contends, both unhealthy and

too demanding, or are we the

victims of pill pushers, greedy

doctors, and the wasteful

dis organization of health care?

But one cannot possibly attri-

bute over pricing to unhealthy

behaviors. In fact, our behaviors

are no less healthy than peer

countries’. Yes, we lead the

developed world in obesity

(though Europe is not far

behind), but we have one of

the lowest smoking rates and

consume less alcohol per capita

than most European countries.

Jon Kingsdale, Ph.D.

JAMAICA PLAIN, MASS.

For the most part, David Freed-

man hits the nail on the head.

As a neurosurgeon, I know all

too well how difficult some

patients can be.

Mr. Freedman postulates

that Medicare for All would

provide an incentive to push

“patients to embrace care that’s

less flashy but may do more

good” by “refusing to pay for

unnecessarily expensive care.”

Unfortunately, it’s not that

simple. The problem is that

much of medicine falls outside

of established clinical guide-

lines. Very few conditions have

treatment algorithms that have

been tested in well-designed

studies. In fact, physicians are

surprised when patients seem

to adhere to the “textbook.”

Decisions regarding medical

care come about through the

patient-physician relation-

ship. As Mr. Freedman says,

this relationship isn’t always

healthy. However, inserting

governmental control to artifi-

cially diminish “unnecessarily

expensive care” will only strain

this relationship further and

lead to greater dissatisfaction

on both sides. Mr. Freedman

correctly identifies one of the

problems in American health

care; he is just incorrect when

he alludes to a solution.

Anthony DiGiorgio, D.O., M.H.A.

NEW ORLEANS, LA.

It’s one thing for a medical-

data wonk (or a physician who

follows what these wonks

say blindly) to declare that a

treatment is unnecessary and/

or expensive. It’s quite another

thing for the patient. Say

you’re a patient who desires a

treatment that will extend your

life by only a few months to

a year, is very expensive, has

nasty side effects, and may

not succeed. But it’s really,

really important for you to see

a family member graduate

from high school or college;

to attend a family member’s

wedding or a reunion; to cross

off items on your bucket list. It

doesn’t matter if your “quality

of life” as defined by some arbi-

trary measure declines.

Even if your chance of

survival is only 20 percent,

15 percent, 10 percent, or

5 percent, why should you be

denied that chance?

Sue McKeown

GAHANNA, OHIO