THE ATLANTIC SEPTEMBER 2019 11Origin 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 frommost 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 figuresof 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 forunnecessarily 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