(No, I’m not going to get all Kumbaya on you.) Listen:

We’re all in this thing together, whatever it is. That “limited resources” bit you remember from Econ 101? It applies to health care, too.

Look, the lesser argument has been made many times over, by the likes of Paul Farmer and other radicals who have fought battles in Infectious Disease: that if we don’t control infections in one population, they spread to other populations and make us all sicker. That if we don’t treat multi-drug resistant TB in Haiti, Peru, or the prisons of Russia, then we Americans will be fighting the MDR-TB here at home. (Similarly in the infectious disease world is the fact that vaccine “herd immunity” is becoming less useful, as our international lifestyles put us into contact with people who were born outside the US and never got measles vaccines, for example, and may be contagious.)

But the greater argument for our interconnectedness is this: that by allowing whole swarms of people (often but not always the un- or under-insured) to go without necessary chronic care and necessary follow-up, they eventually become sicker and more complex. And this, my friends, creates problems for all of us. Because sicker and more complex patients require more doctors and more time and more hospitalizations. And more hospitalizations that take more time, because sicker and more complex patients have more things that will go wrong with them.

How does this get back to you, oh-self-concerned one? Because when there’s more sick patients, there’s less time for you , when you’re sick. Some say that patients will get worse care and will be seen slower in the Emergency Department. While this may be true to some extent, triage — the sickest people to the front of the line — often takes care of much of this. But because there’s simple more people (quantity, not necessarily quality), your mom with the broken hip is seen slower, and fewer minutes are spent on her since there’s more patients total. It’s no wonder hospitals are stuffed to capacity.

So take a system with sick people, discourage them from seeking primary care by:

1. having them pay for primary care when they themselves often don’t see any benefit from it and
2. discourage doctors from going into primary care by making it a nightmare of:
   • paperwork
   • referrals
   • tons of complex, sick patients to be seen in 15 minutes and
   • little pay compared to other doctors

And you’ve got what we have today: any number of people who are sick, complex, and take up tons of time, energy and resources. And no matter how you spin it, it ends up creating worse care for us all.

We as doctors tell our patients to do certain things to stay healthy — and often pay more money to buy these pills – when often patients don’t see one lick of good from our recommendations. All they see is a lower blood pressure number, and money out of their pockets for expensive pills. (That is, until they stop taking their pills, or have a really bad consequence of their disease, then they see it.) Throw in any number of health care and physician scandals in the past decade, and it’s no wonder they’re skeptical.

In order for us to receive better care and to fight the constant ambulance diversions and hospital overflows, we’ve got to ensure that people take care of themselves. And that starts by removing the barriers to self-care.

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