Health Care Systems

There is an outbreak of measles in the Upper East Side of Manhattan.  I think it is safe to say that the Upper East Side has a relatively well designed and functioning healthcare system, particularly when compared to much of the world.  And yet even here in this comparatively well cared for part of the world there has been a significant outbreak of a completely preventable disease.  Measles can have very serious complications which include include swelling of the brain and death, among others, and it is spectacularly uncomfortable to suffer.  This is not even the only recent outbreak of measles in New York City, which suffered an outbreak of 58 cases in Brooklyn last year as well.  Most importantly several of the child victims of this most recent outbreak were children too young to have been vaccinated, the most vulnerable population and the most important to protect.

The fact that the United States’ health care system has not managed to adequately educate people about the critical importance of vaccination to build herd immunity and protect those who are too young to be vaccinated speaks to one of the greatest challenges of constructing a successful health care system.  While there has been controversy surrounding vaccination and speculation about its connection to autism and other “complications” none of this has been based in fact, and there is a wealth of medical evidence to the contrary.  However, people believe the thing that frightens them most, which is not often the most accurate information.  This is why it is critical that the people responsible for the United States health care system need to beef up the educational and outreach based parts of our process.  People need to fully understand that by not vaccinating their children they are endangering the lives of others too young to even have the option of protection.

The population who is currently failing to vaccinate their children against measles (and thus also mumps and rubella, as the vaccination is given at the same time for all three) is for the most part: English speaking, well educated, and middle to upper class.  This means that none of the primary broader social determinants of poor health in low and middle income countries is playing a part.  This is, in other words, a population that should know better.  It isn’t fair to be so judgmental, however.  Health care is complicated, and diseases are terrifying, particularly for parents.  It is the responsibility of the public health community to see these issues and find ways to deal with them.  Anything from public awareness campaigns to clinic hours in local community centers to school vaccination programs and requirements are options that can be built into the health care system itself.  

Health care systems need to be based on the populations they will be caring for, but more importantly they need to take into account the incredible complexity of health care.  Wellness is a conceptual moving target, and there is no way to deal with it if you aren’t creating a system that is as flexible and changeable as it is.  In the US you can see a need for increased educational campaigns about the critical importance of vaccination to protect those who are too young from falling ill.  In the Farmer reading the example of the catastrophic Haitian earthquake made the same point.  There was no way for the small, underfunded, and deeply rigid healthcare system in Haiti to adapt to the new needs of its target population.  Because of the quake a whole new set of health issues became the top priorities including cholera that was actually brought by the aid workers themselves.  These kinds of complications are inevitable, and must be a part of health system development.  It is clear that from the best funded to the worst, one of the greatest challenges for health care system designers is coming up with processes that people will understand and abide by.  This tendency not to listen, understand, and comply is a part of human nature, and one of the main issues that a well designed health care system can potentially alleviate.