Public health is a truly public good.
Let me give an example.
Yesterday was the Biggest Guy’s last day here before he headed back East. So here were our schedules:
Tenacious G took me to the doctor, where the packing was taken out of my nose…wow!! Who knew all that stuff would fit?? And I don’t even have that big a nose!! We stopped off and had brunch at a café on the way home from the Doctor’s office.
Biggest Guy slept in, as he’d been out with friends the night before. When we got home from the doctor, we went to the car wash, then I crashed for a few hours (made easier, now that I can breathe). When I woke up, we took Biggest Guy down to the beach in Redondo for a walk, some time to talk, and a snack. Then we came home, he went out to dinner, and when he came home, we took him to the airport, where, after secondary screening, he left.
What the hell does this have to do with public health? Here goes.
I’m guessing that we each swapped germs with maybe a hundred people that day. TG and I shook the doctor’s hand; we were served brunch by a server at the café, and water and tea by the busboy; the guys at the car wash sat inside the car; we walked down the bike path in Redondo, where we brushed against (as opposed to walking past) thirty or forty people; we had lunch, where we were again served and bussed; finally, we handed bags over to screeners, got tickets from ticket agents, and probably brushed against another ten or fifteen people. I’m sure each of us used a public restroom at least once that day.
So our health…our physical health, as opposed to our moral, or spiritual health, is dependent on the physical health of roughly a hundred strangers we each encountered that day.
For a long time, the growth of cities was essentially self-limiting. It was limited both by economics, in that the ‘support area’ for the city had a size limited by transportation technologies. But there was another, darker limit, which was plague. Periodically, a germ culture would arise in the human petri dishes of cities, and lots of people would die.
As noted above, it’s hard to prevent this, because it’s hard to live in cities and not contact lots of other people.
So you and I have a direct interest in the health of every person we contact in the course of a day.
I want everyone I contact to have access to a doctor for that ugly rash, dripping nose, draining sore…not only out of humane considerations, but because I want it to be cured before they come in contact with me and mine.
The ultimate social capital a society can create is embodied in healthy and productive people. But so far, we have three systems for delivering health care in most of the Western world…and none of them seem to work.
Our system here in Southern California is imploding as we speak.
The LA Times (intrusive registration required, or just use ‘laexaminer/laexaminer’ – thanks Matt) has one of the ‘deep and slow’ series running on this. The first story is on the slow-motion collapse of the trauma network, triggered by the crisis in emergency room healthcare.

“People call 911 and they think if we bring them in, they’ll get seen by the doctor faster,” said Los Angeles Fire Department paramedic Orville Wright, who waited more than two hours last week with a respiratory patient at Martin Luther King Jr./Drew Medical Center. “That’s not the case.”
Hospital officials say the most critically ill patients are treated immediately. But paramedics and some emergency physicians say the congestion is endangering patients’ lives.
The danger extends beyond the ER. While paramedics are waiting for a bed to open up in the emergency room, ambulance responses are often delayed in the communities they cover. If an ambulance is taken out of commission, response times in its service area increase by four to five minutes on average, fire officials say.
Ambulance backups are worsening because more patients are seeking emergency-room care, even as hospitals are closing ERs. In the last decade, more than 20 ERs have shut down in Los Angeles County, narrowing treatment options in a sprawling region of 9.6 million people.

Today’s story is about the larger decisions being made to try and keep the public health system afloat.

One night a few years ago, a man crashed his car into the side of Los Angeles County-USC Medical Center. In his hand, doctors recall, was a crumpled piece of paper from a local physician’s office. On it was a map showing how to get to the Boyle Heights hospital and the words: “You are having a heart attack. Go to County-USC.”
County-USC doctors recount this story to illustrate a dynamic that makes them both proud and frustrated: People who are turned away from other medical facilities for lack of funds come from across the region and the state, even from abroad, to L.A. County’s public hospitals for a wide range of essentially free medical care.
But the strain of caring for the poor and uninsured is forcing local officials to reconsider the amount of care they offer. The health department is asking the Board of Supervisors this week to adopt a strategy that would reduce the number of places patients can receive general medical care but, for the time being, preserve high-end hospital care and emergency rooms.
By doing that, the county will be attempting what critics say is an impossible balancing act—maintaining its commitment to take all comers, even while making it more difficult for patients to find medical help. It may also run the risk of flooding already overburdened emergency rooms with patients who have been unable to get basic medical care.
“We have been providing a higher level of services to the uninsured than any other county in this state,” Supervisor Gloria Molina said. “We’re going to have to downsize the number of services we provide. They’re just going to have to drive farther, wait longer.”
The supervisors will debate what would be the deepest cuts ever made to the $2.4-billion health department—closing nearly a dozen clinics, reducing beds at County-USC by more than 10%, and ending inpatient services at High Desert Hospital in the Antelope Valley.

I’m not advocating specific policies yet. Along with a lot of other people, I’m jumping up and down pointing at the horizon, and saying “there’s an iceberg right up there!! DID YOU HEAR ME?? THERE’S AN ICEBERG UP THERE!!”…as the band tunes up to play “Nearer My God to Thee.”
More tomorrow, gotta go.