It’s hard to imagine all the ways medical care is failing in the United States. That’s medical care with a small “m” and “c.” The Medical Care Section of APHA of course is alive and well and kicking. Whether we are a match for the magnitude and multitude of problems in need of reform in our health care system remains to be seen, but as long as there is a hope and vision, we have to be its protagonist.
As I write this, the New York Times today (June 10, 2006) has yet another article about how Hillary Clinton believes in health reform but “realizes” that “her cardinal sin in 1993-94 was overestimating the public's appetite for change” and is “intent on not repeating the error.” Never mind that at the eve of the 1994 defeat of the Clintons' terrible managed competition plan (crafted by the big insurers at Jackson Hole, who then double crossed them, unscrupulously attacking the plan via Harry and Louise ads) that polls showed that more than 70 percent of the population favored universal publicly financed national health insurance — strong support that continues to the present.
It’s hard to know where to start in enumerating all of the dysfunctional aspects of our current system and misguided responses and reforms. If (as the proverb goes) what the fool does in the end, the wise person does at the beginning, our Section continues to serve as both the conscience and wisdom for public health and the medical care delivery system. While the foolish urge piecemeal reforms (perhaps gestures would be a better word), profit driven competition, more “consumer driven” (meaning consumer “burden”), stripped down insurance plans (leaving patients uncovered, e.g., no maternity coverage for childbearing age women), “report cards” to lubricate market competition with misguided “pay-for-performance” schemes, Medicare Part D (what Ted Kennedy referred to as “the worst piece of federal health legislation ever”), etc., the Medical Care Section continues to be the voice — both inside and outside APHA — for rational and comprehensive reform.
Continuing a more than half century tradition of advocacy for progressive reform of medical care delivery and financing, our members and Section have continued to advocate for single payer health reform. While we have no singular strategy of how to get from here to there, many of our efforts have worked to keep APHA on course in its commitment to this fundamental change in how we organize medical care and public health. Our newly designed brochure (copies available from me and in future from our under-construction newly designed Web site) highlights our motto “Medical Care for All.”
So here, from the perspective of your new chair, are some of the day-to-day work we’ve been doing:
Program: Putting together a great program for the 134th Annual Meeting in Boston. As our new Program Chair Kathy Virgo reports elsewhere, we have had a good response to the call for abstracts, and using our new review criteria and process, we have selected via a broad participatory peer review process the contributed papers we will feature.
We’re struggling with fitting our Section meetings in around the new more compressed Annual Meeting schedule (for the past several years the Opening Session on Sunday and the Closing Session on Wednesday). Finding a time for the business meetings of the Section committees has been a particular challenge. We also continue to struggle with how to cram in all of the more bureaucratic matters we need to cover (e.g., resolutions, candidates) with my (and others’) strong desire to open up more of our meeting times for discussion of issues and strategic advocacy debate. I believe we have carved out a few more opportunities, but I am still not satisfied. We’ll have to continuously try to rethink and do more re-engineering to open up more “space” for discussion as well as use members' scarce and precious time most effectively.
MidYear Meeting: I have only attended a few of these meetings in the past, but now see what I have been missing. This is the real opportunity for give-and-take discussion amongst ourselves and with the APHA leadership. We were joined by Drs. Georges Benjamin (executive director) and Walter Tsou (past APHA president) and a good representation of our leadership activists. I prepared a more detailed set of minutes (probably more detailed than anybody desired, but I did want to capture as much of the discussion as possible) that are available either from me, or on our future Web site. Thus, I will not dwell on details here.
Medical Care Journal: I had the somewhat intimidating responsibility of chairing the Search Committee for the next editors for our official journal. We interviewed the leading candidates (during the Annual Meeting last December) and were, frankly, blown away; the proposal and applicants from the University of Alabama — Jeroan Allison and Catarina Kiefe — were unanimously selected as the next co-editors. We were most impressed by their commitment to creatively reshaping the Journal, as well as their own record of working together on a number of impressive health services research endeavors.
They officially start their term at the end of 2006, but both joined us (Jeroan for the entire day) at the Midyear Meeting in February along with Colleen McHorney (outgoing current co-editor along with Carol Ashton) for a far ranging and reaching discussion of the future of the Journal. Topics covered included the future of “special supplements,” relevance and approach to the “impact factor” of the Journal (Medical Care was #1 among health services research journals in 2003), how Medical Care should respond to the “open access” paradigm, and how to increase the connections between Medical Care and the Section (including the Section contributing ideas for theme issues and writing policy-oriented editorials and commentaries).
I’m eager for other members of the Section to meet Catarina and Jeroan (one of many good reasons to attend our future business meetings) as well as to try to live up to their high expectations about what our Section can contribute to the Journal (e.g., improvement ideas, position papers, editorials, outreach). Thanks to the ongoing editors Colleen and Carol as well as the search committee members: Arlene Ash (search committee co-chair), Julie Zito, Olie Fein, and Morris Weinberger (another former editor).
Section Membership and Leadership: Like the majority of Sections in APHA, Medical Care has seen a decline in membership, in our case from 1,330 members in 2004 to 1,271 members in 2005. We have seen such 4 percent annual declines for each of the past five years, for a variety of reasons we both recognize and anticipate as well as reasons we need to better understand. As federal and local public health budgets have been cut, so has funding for participation in APHA in general, particularly for travel and attendance to the Annual Meeting. Membership dues are costly. And benefits are hard to quantitate or fall short of what we would hope (for example, why can’t a free or very low-cost subscription to Medical Care be included with a Medical Care Section membership rather than a subscription costing nearly $300/year additional).
A number of members have found “professional homes” in other discipline-specific organizations — a phenomenon which particularly affects membership in Medical Care, as we represent and are comprised of many disciplines. Despite the misimpression that Medical Care is predominantly physicians, only a minority of our Section members and leadership are MDs. One of the most inspiring moments in our Midyear Meeting was when, in introducing themselves, attendees gave unsolicited comments on why they joined. For example, Darryl Gaskin (our Solicited Program chair) talked about being “apolitical” when he came to APHA but found our Section, which “stood for universal access, single payer, social justice issues, and tackles issues that really resonated with me,” finding a spot within APHA which he is both “comfortable supporting and admires the people he works with.”
How to convert this sentiment echoed by many of our members, into more generalized outreach and organizing, to help the Section realize its fullest potential is one of our greatest challenges. Jim Wohlleb, our continuing and dedicated Membership Chair, is working with me and others to get under that hood of what drives members to join and leave, and to help implement strategies to get more gas in the tank.
Continuing quality Section leadership has been given a boost with our latest slate of nominations for offices and officer. Past Chair John Wayne worked with a number of individuals to both volunteer and recommend others. He prepared a great slate. I’m particularly pleased that Gail Bellamy has stepped forward for the chair-elect position. She is someone I feel a special kinship and respect for, being “kin” in the patient safety and quality improvement movement (we had overlapping AHRQ grants) and whose views (often refreshingly different from my own) I have especially valued at our meetings.
Section Communication: Website, List Serve, Newsletter, Members Electronic Voice, Conference Calls, and More. The nuts and bolts of building and maintaining the Section as well as effectively organizing our advocacy efforts hinge on these communication functions. Presently (except for the monthly conference calls) they are more under-construction than in good shape. This is where I plan to invest the lion's share of my efforts in order to practice the campers ethic in my two year tenure as Section chair (campers ethic = leave the camp site cleaner than you found it). Along with a Task Force that we have set up to work with the new APHA IT initiative, I have a number of ideas of where we need to go to make big leaps in this area. These include a content-rich, user friendly site, unencumbered to the greatest extent possible by some of the limitations to free speech that have become recent issues in APHA. The site should feature links to each member and their interests, views, and recommendations (what to read, where we should go) and help to link people with similar interests or areas of work. I will even include various outlines I have prepared for our recent meetings and leadership conference calls (so for now, you can e-mail me directly if you wish to see a copy).
Concluding Comments: I want to end with an important e-mail I received this spring from Carol Miller (Section member, rural health activist, and former New Mexico Green Party Candidate for Congress) which I reproduce with her kind permission. It articulates why she has not been active in APHA in recent years:
Thank you all for helping me keep a shred of interest in APHA. I gave up my APHA activism about 5 years ago because it was endlessly frustrating. I served 14 years on the Governing Council, years on my section council, two terms as affiliate president, etc.
Nothing ever changed. No wonderful policies ever became the mission of the organization as a whole. No great president or executive board member ever brought lasting change to the organization as a whole. Centrism is APHA and we activists are tolerated at best. I have accepted that APHA is a dinosaur and that the good people within the association have never been able to push it or change it. I'm feeling cynical today, so feel free to prove me wrong.
While this may seem to be a “down” note on which to end these comments from the chair, I believe Carol’s views soberly represents the profound challenge for those of us who want to work with and within APHA. They should serve as a starting point for future and ongoing discussions.
Edwardo Galeano (wonderful Uruguayan poet and historian) spoke in Chicago last month and was asked what is fundamentally the same question: “Mr. Galeano, given what is happening in the world and what you have written about the amazing spirit and movements of people in Latin America, are you optimistic or pessimistic?” He answered (something to the effect) that his sense of hopefulness vs. discouragement changes every hour of every day. He wakes up hopeful, gets discouraged in a few hours, only to become more optimistic and hopeful again at a later hour. Buoyed by real things that he sees accomplished by real people, his spirits and optimism lift despite the seemingly omnipotent power of the anti-people (and anti public health) forces we are up against.
Pete Seeger recently mused that he sees exactly 50/50 odds that the human race will be around in 100 years. This means, according to him, that the odds are so precariously balanced that each and any of us could help tip it in the right direction. So to Carol’s challenge, and our current and future members, the question is not just being hopeful or cynical but figuring out how to direct our advocacy and activism, our research and outreach and how we can best make APHA part of the solution.