Health Care is Not a Right or Freedom, Health Care is a War on Disease

By Michael Halliwell

Michael Halliwell gave this speech on October 28, 2004 at the Petaluma Campus of Santa Rosa Junior College. It sets forth his approach to health care reform, and does not contain any reference to any current candidate in the 6th CD.

For some time now advocates of a single-payer health care system have been totally dominant in what members of this political faction call the "Democratic wing of the Democratic Party." In the recent Democratic presidential primaries, John Kerry won the bidding war for the support of this most liberal element of the Democratic Party, by promising a federal takeover from private insurers of "catastrophic" health care costs -- meaning the expenditures for treating most life-threatening illnesses. Senator Kerry says that his plan would be "purely voluntary," but since taxes to pay for it would be levied against the employer class(i.e. the top 2% of taxpayers) it is unrealistic to expect many employers to pay these taxes and to stay out of the health care program they are paying for.

Inevitably the sort of health care program that Kerry advocates must adopt a "standard benefits package" to keep costs from skyrocketing, and soon this standard package must be made mandatory. Otherwise those who prefer health care the way it used to be provided will go outside the system and doctors unhappy with a regimented approach to health care will sell their services to the highest bidders, in order to retain their autonomy. Whenever proponents of an income-redistribution scheme are unsure they can attract, or hold onto, majority support for their program, they often proclaim what they are advocating to be a fundamental right, thereby paving the way for adoption of their programs by the courts, when they cannot win enough elections to secure this result through the legislative process. The Democratic presidential nominee has been forthright in saying that he considers health care to be a fundamental human right, and he points to the nearly universal recognition of this right by other economically advanced nations in the world. However, these other nations combined have made far fewer medical advances than the United States has. If four decades ago when Canada took this step, America had followed her lead and gone over to a similar single payer health care system (with its centralized allocation of medical resources and its refusal to pay even a small share of the development cost of new therapies) tens of millions of people around the world who are now leading productive lives would now be dead.

The sort of rights which the Framers of our Constitution enshrined in that document are basic God-given freedoms which must be protected from infringement by the most powerful segments of society -- at any given point in time (in the long run we all face the risk of being among the less powerful). Health care is not a right in this sense. Although it took a civil war to extend this principle to the whole population, our fundamental creed is that no person is entitled to the fruits of the labor of another person without paying for them. This does not mean that, where there is a stable political consensus to do so, we should not establish programs to provide a safety net, which ensures that no one is denied basic necessities such as food and education. However, the need for medical care is open-ended. We have seen how civilization has benefited from the extension of human life expectancy, and we want as much more of this as we can get. Health care is not a freedom which must be protected from infringement by the powerful -- it is a war where we must unite as best we can against a common foe.

The war against premature death has become a very personal one for me since my wife was diagnosed with a very aggressive form of breast cancer at the age of 48. Betty is holding her own and has avoided a recurrence on account of a much more aggressive therapy than is the standard for breast cancer. However, had the sort of health care reform which the Clintons sought to enact been in force at the time our battle against breast cancer began, Betty would have died a long time ago. Because they were committed to providing first-class health care to everyone, the Clintons tried to squeeze everything out of their standard benefits package which had not been proven to be cost-effective. One of the items eliminated was mammograms from women in their forties (whose efficacy was misjudged on account of a methodological blunder in a very influential Canadian Breast Cancer Screening Trial). However, Betty was following the recommendation of the American Cancer Society that women in their forties have a mammogram every two years, when her scheduled screening turned up a suspicious lump in her left breast that turned out to be a pre-cancerous condition (atypical hyperplasia). Because the phrase "pre-cancerous condition" sounded ominous to us, we decided on our own to have another mammogram only a year later. (Thanks to the efforts of John Edwards and the other trial lawyers who have become a financial mainstay for the Democratic Party -- malpractice lawsuits for overlooking a breast cancer on a mammogram have become the third most lucrative type, behind only mistakes in brain surgery and delivering babies. If mammograms cost then what they do now -- to set aside enough money to pay for huge malpractice awards, we may well not have made this decision.) On this mammogram the radiologist found a cancer in Betty's right breast (which was growing so fast that there was no sign at all of it -- even though he knew where to look -- on the previous year's mammogram). Because cancer in one breast indicates a much higher than normal risk that cancer will develop later in the other breast and that breast had already been found to have atypical hyperplasia, and because of the fast growth rate in the cancer which had been found, Betty and I decided that a bilateral mastectomy was the safest way to proceed. It turned out that in spite of the "all clear" appearance of the left breast that it had also turned cancerous. Faced with this ominous situation, Betty has avoided a recurrence because she has continued to receive chemotherapy and hormonal therapy (with relatively brief interruptions in one or the other) ever since her mastectomy. Due to serious flaws in the chemotherapy and hormonal therapy trials which have set the standard durations for these treatments, Betty would not have been able to receive adequate treatment under ClintonCare, even if her breast cancers had been detected before they had become so advanced that no known therapy would do any good.

Marin County has the highest rate of breast cancer in the nation. However, recent data have shown that San Francisco may be catching up and Sonoma County is not far behind. If an effective political defense against creeping toward a single payer system and away from more diversified health care cannot be mounted in this highly educated area, where can women expect to improve their chances of survival from this disease? About a generation ago breast cancer and testicular cancer both had a five-year survival rate of 65%; since then health research allocation decisions (made mostly by men as is the case nearly everywhere in country as dominated by glass ceilings as ours still is) have produced a therapy for testicular cancer that has raised the survival rate to nearly 100%. Meanwhile the survival rate from breast cancer has improved only slightly -- even though the potential for early detection and limiting the spread of cancer cells to other parts of the body is similar for both cancers, because they start outside the main body cavity. A higher priority for a male cancer than for a female one is only part of the problem, however. The standards for breast cancer therapy change far too slowly, because it is more important that they provide protection against malpractice lawsuits for doctors, than to provide protection against recurrences for patients. Instead of doing something to move away from this "defensive medicine" by reining in malpractice lawsuits, the representatives of Marin County in both houses of Congress are collecting campaign contributions from trial lawyers hand-over-fist, and are leading advocates for KerryCare (as they were for ClintonCare), which will help to close the gap between death rates of people in this area, and other areas with lower income and education, by INCREASING the death rate for breast cancer and other diseases where individualized treatment is vital. Moreover, none of our incumbent representativese in Congress from this area seem able to scrape together the few million dollars needed to bring breast cancer detection equipment in our locality up to the current state of the art. This pitiful performance is not what one would expect from female legislators, and it reminds me of what many British women used to say about Maggie Thatcher. "It is all very confusing when someone who looks like us, thinks like them."

Betty Halliwell's fight against breast cancer has been thirteen years of trying to make her one advantage, the early detection and removal of her tumors, stand up against a tumor growth rate, that has the greatest potential for recurrence found anywhere in the medical literature. (The March 1992 issue of the Journal of Clinical Oncology reports a 22% five-year recurrence rate for a category of tumors with a slightly higher upper size limit than Betty's primary cancer, the same estrogen receptor status, and which, like hers, had not spread to the lymph nodes; according to the relationships found between tumor growth rate and recurrence risk, a breast cancer with the same growth rate as Betty's had the worst prognosis of the 247 tumors examined.) Fortunately, this warning that Betty was at the 99.6 percentile in terms of her risk of recurrence, was published almost exactly when when she reached the six-month point where it is recommended that post-operative chemotherapy stop. After an extensive search I was able to find a cancer specialist who was willing to continue chemotherapy and hormonal therapy far beyond their recommended maximum durations.

Since I teach statistics, I expected that all we could do was "go down fighting," because I didn't expect that simply extending the use of standard therapies would be sufficient to hold in check the most agressive of breast cancers. However, it eventually became apparent that hormonal therapy was slowing down the breast cancer growth rate to the point where chemotherapy could be spread out enough for normal tissues to fully recover between doses, and that four cycles of chemotherapy per year were sufficient to "harvest" the minority of breast cancer cells which seem to be stimulated by long-term hormonal therapy. There is no apparent reason that a continuing therapy which can hold the most aggressive breast cancer in check for thirteen years, would not work for any breast cancer if it is caught at a sufficiently early stage. Accordingly, at long last, I CAN SEE AN ADVANTAGE TO FIGHTING A FREQUENTLY LETHAL DISEASE FROM THE VERY WORST POSITION ON THE BATTLEFIELD -- IF WE CAN HOLD THIS POSITION WE CAN WIN THE WAR. Early detection is the essential element, and very frequent mammograms, ultrasound, examining discharges from the breast for cancer cells and periodic breast examination by trained professionals may all be needed to obtain this goal. But for women whose cancers are anything like Betty's, early detection probably means that several hundred million cancer cells have been scattered around the body, before the primary tumor has been removed. Even the most extended therapy probably only reduces this number by a factor of ten or a hundred, but perhaps this is enough for host defenses that protect us against invading bacteria, to avoid being "overloaded" and at least hold in check scattered tumor colonies that become large enough to become a local irritant. This is not a cure, but if we can refine "tumor markers" for circulating breast cancer cells to the detection sensitivity they have for testicular cancer cells, it may become necessary to employ protective therapy only when the body tumor burden is large enough to be detected. IN THE MEANTIME, WOMEN IN MARIN COUNTY AND ELSEWHERE DETERIMINED TO DIE OF SOMETHING OTHER THAN BREAST CANCER, CAN FOLLOW THE BATTLE ORDER GIVEN TO THE AMERICAN PARATROOPERS WHOSE RESPONSIBILITY WAS TO PREVENT A NAZI COUNTERATTACK ACROSS THE ORNE RIVER BRIDGE NEAR ST. MERE EGLISE DURING THE NORMANDY INVASION: HOLD UNTIL RELIEVED.