The shock over the recent discovery of kidneys for sale in the US is just another example of how we may often choose to remain oblivious to those things, those actions that threaten or challenge the ethical constructs of how we view the life and the world at large. The WHO estimates that at least 10 % of all kidney transplants are from paid donors often obtained by illegal transaction performed in less than optimal surroundings and circumstances……but now we know that these are also occurring in prestigious institutions in the United States and the public is outraged. But is it, really? In a free market society, isn’t everything and anyone for sale? Most will say, absolutely not. American law does not permit the exchange of organs for material or pecuniary gain but yet, it is still happening - seemingly without redress. So where do we go from here? Without legal intervention and regulation, these practices are likely to continue. But there is a fear that the forces of economics may result in an exploitation of the disadvantaged and bring us back to the historical controversy of whether one life is more valuable than another…and though that makes for an easy answer, with the consideration of America’s past, it  poses  an extremely awkward  question.

The healthcare debate has become manifestly vociferous over the past weeks as Americans decidedly flex their democratic muscle in a debate that is increasingly dividing the lines. The Obama administration have given us scant details about what to really expect and the angst is growing as contrived and misinformed ideas from both sides replace the missing factual richness of the explanations we deserve and have been expecting. As far as I, as a surgeon, am concerned, HR 3200 will (finally) address the Sustainable Growth Rate issue. The resultant plan will not require physician participation and there will be a greater focus on Physician Quality Reporting Initiative. An alternative plan will come into existence. Private insurance companies are up in arms. Private insurees are up in arms too - concerned that they will be unable to access their doctors and be subjected to the “substandard care” akin to that provided in other wealthy countries in Europe and Asia.

The only silence seems to be from the uninsured. Strangely, not one of the 37 million of them seems to object. Might they know something we don’t?

Michael Jackson’s death dominated the world press and also seemingly eclipsed Farah Fawcett’s untimely demise too. The lack of information, the right information about why she may have died offered an opportunity for a public health focus on anal cancer - how it is prevented and how it is treated. Many still do not know much about this condition and what causes it. The Livestrong phenomenon that raised awareness for testicular cancer might have found a similar audience with anal cancer. We almost had this opportunity with Farah Fawcett but alas, still - we refuse to talk about it.

I suspect that access is a more complex notion than we give it credit for. There are very intricate reasons why some Americans are denied access - some of which were predictably engineered in the 1940s by established custodians of American social and urban planning. Now we have some races who live in complete isolation, living only among themselves in over 500 of the total 3200 plus counties in the country. I examined access as a function of opportunity and utilization and found that geography DOES matter. We  reported this in two articles this month in The Journal of the American College of Surgeons and Archives of Surgery.

Racial clustering and access to colorectal surgeons, gastroenterologists, and radiation oncologists by African Americans and Asian Americans in the United States: a county-level data analysis. Hayanga AJ, Waljee AK, Kaiser HE, Chang DC, Morris AM. Arch Surg. 2009 Jun;144(6):532-5

Residential segregation and access to surgical care by minority populations in US counties.  Hayanga AJ, Kaiser HE, Sinha R, Berenholtz SM, Makary M, Chang D. J Am Coll Surg. 2009 Jun;208(6):1017-22

If you are distrustful of the health system and you have no exposure to the system except through distant strangers, you will be less likely to wish to use those services until too late. This has important preventive health implications. These populations do not get screened, get diagnosed late and die earlier.  This has received a certain amount of attention.

http://www.thedoctorschannel.com/video/2071.html

http://www.healthfinder.gov/news/newsstory.aspx?docid=628090
http://www.redorbit.com/news/health/1704005/research_finds_segregation_reduces_access_to_surgical_care

http://cancer.med.upenn.edu/resources/article.cfm?c=3&s=8&ss=23&Year=2009&Month=06&id=16305

http://www.eurekalert.org/pub_releases/2009-06/jaaj-ucw061109.php

http://www.physorg.com/news164302548.html

http://esciencenews.com/articles/2009/06/11/study.finds.segregation.decreases.access.surgical.care.minorities

http://www.sciencecentric.com/news/article.php?q=09061606-us-counties-with-more-african-american-patients-may-have-fewer-colorectal-cancer-specialists

http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Racial-Clustering-Linked-With-Access-to-Colon-Canc/ArticleNewsFeed/Article/detail/604058?contextCategoryId=46736

America has significant health challenges but without addressing the effect of racial clustering and geography, there is little to believe that health disparities in access in  the US will be resolved before 2010 like the federal government promised many years ago.

In order to expand coverage to the estimated 40 million Americans
without healthcare, the Obama healthcare plan is likely to require the
assistance of all Americans. The mere availability of an increased
budget beyond the current 640 billion dollars will likely be
insufficient and instead require a more judicious approach in how care
is rendered without merely relying on increasing capacity in monetary
terms. One can envisage a triage system that would use algorithimic
modelling to identify patients with multiple organ dysfunction,
increased age, lethal comorbidities and poor predictive survival and,
from the outset, make the recommendation for a less aggressive
approach. This is likely to constitute a revolution in medical
decision making in healthcare in the US, affecting both patient and
provide alike. Might we actually have to lower our expectations about just how aggressive care can be in futile situations? Unseeming though it may sound, the judicious use of healthcare resources has been a trademark of all other OECD countries that have offered universal healthcare and if the US is finally ready to join Asian and European counterparts of similar economic stature, she may be best advised to rethink how the resources we have available are used.