Don't blame the sick
SINCE I WAS a child I thought that being sick or injured was the worst thing that could happen to a person. That feeling grew out of the shock of seeing a blind man selling pencils on the front steps of an exposition hall on a bitterly cold January night when I was 7 . Tugged along by my father's hand, I passed by the man quickly, but I was startled that the cold wind was bringing tears to his clouded eyes. That image has stayed with me. I came to believe that unless you were reasonably healthy and free of pain, much of the rest of life would be closed off -- and that healing the sick was the most important thing anyone could do.
I still believe that. The measure of a decent healthcare system is how well it honors its commitment to the sick. By that measure, we are not doing very well. Healthcare has become a commodity distributed according to the ability to pay, not a social good distributed according to medical need. On average, the sickest are least able to pay, so those most in need are sometimes denied care simply because they can't afford it, while the healthy and well-insured may get a surfeit of attention. We have shifted our focus from the sick to the well.
Many people justify the shift by blaming the victims: if people would only take care of themselves, they probably wouldn't get sick in the first place. They should have watched their diet or exercised more or gotten their blood pressure checked. With the encouragement of incessant health tips in the media, many have come to believe that they can control their own health, that illness is a failure and wellness a virtue. That view is reflected in a growing emphasis on preventive care. West Virginia has gone so far as to require Medicaid beneficiaries to sign a "personal responsibility" contract that commits them "to do my best to stay healthy" and specifies what they must do. Beneficiaries who don't sign a contract or meet its goals within a year will lose some of their benefits -- even though presumably they will need them more.
But the sober fact is that except for a few important measures, such as immunizing children, practicing safe sex and not smoking cigarettes , we still know relatively little about how to prevent diseases. We know some risks for some major killers, such as high blood pressure and heart disease. But overall, known risk factors (except poverty) account for only a small proportion of illness, and it is not always clear that modifying them will help. It's easy to exaggerate their importance simply because we know about them. We need to remember that people get sick mainly because of bad luck, not bad choices. If we really knew how to prevent disease, the West Virginia program would still be harsh. Since we don't, it's also likely to be futile.
The notion that illness is largely optional plays into the hands of private insurers, who have financial interests in concentrating on services for healthy people -- sometimes called the "worried well." If they put their resources into yoga classes and massage therapy, which are cheaper than caring for sick people, they will preferentially attract the young and fit. Since the healthy outnumber the sick, these plans will also look good in satisfaction surveys. The focus on the well is reflected in our new vocabulary. Instead of medical care, we now talk about healthcare, which is delivered not by medical groups, but by health maintenance organizations. And we speak of consumers, not patients, as though they were choosing from a dinner menu rather than being treated for a disease. We are seeing a tyranny of the healthy, backed by commercial interests -- and also by a public health establishment so committed to the laudable goal of preventing disease that it sometimes promises more than it can deliver in our current state of knowledge.
Almost all of us will be seriously ill at some point, no matter how much we try to avert it. At that time, what we will desperately want is compassionate and highly skilled medical care -- doctors and nurses, not yoga instructors and massage therapists. Yes, we should try to prevent illness when possible, but we should be more realistic about what we can do. The essence of a decent healthcare system is still caring for the sick.
Marcia Angell, a senior lecturer at Harvard Medical School, is a guest columnist. 
