ROANOKE TIMES
Copyright (c) 1996, Roanoke Times
DATE: Sunday, April 21, 1996 TAG: 9604190079
SECTION: BUSINESS PAGE: 1 EDITION: METRO
COLUMN: Health Care
SOURCE: SANDRA BROWN KELLY
An old man and a child need the same antibiotic and there's only enough for one dose. Should the youngster get the pill because he is just starting to live? Or is the wisdom of the old man needed more.
Dr. Laban Otieno, a dentist born in Kisumu, Kenya, posed this situation at a recent conference on Health Care in the Sister Cities. He didn't get any answers; he didn't expect any.
Otieno was merely illustrating what Roanoke and its sister cities -Kisumu; Pskov, Russia; and Wonju, Korea - found in common about their health care programs after exploring the topic one Friday evening and Saturday morning in late March.
The cities, and their countries, have only so much money to spend on health care and, therefore, have to make choices about who gets treatment and medication.
Otieno, who has lived and practiced in Minneapolis since the 1970s, evoked the image of one of Kenya's "natural" resources to describe the problems of establishing a health care system in a country that is still developing.
"When you are beginning to eat an elephant, where do you begin if you have to eat the whole thing?" Otieno said.
Instead of top-down planning, Kenya lets communities decide what they need, and then the national government tries to provide it. The government also is trying to educate people about how to stay healthy.
But Kenya is fighting diseases that industrialized nations no longer worry about, he said. It needs everything related to health care - equipment, drugs, medical educators and money for research.
Rationing is a "touchy subject," but it's a reality, Otieno said.
Certainly no country knows that better than Russia, explained Dr. Ludmilla Stepanova, director of public health for Pskov.
Because of Russia's overall weak economy, last year money for health care was cut in half.
"It is not difficult to imagine the problems that we are living with," she said.
Russia, like Kenya, faces diseases that Americans rarely think about. In 1993, Pskov had an "epidemic" increase in diptheria cases among adults and children, she said. Through isolation of the sick and vaccination programs, the disease is now on the decrease, she said.
The problems in Wonju are more comparable to those in Roanoke and elsewhere in this country. Hospitals are being squeezed financially. There is a surplus of doctors, and the population is aging. We're even dying of the same things, cancer and circulatory diseases.
Korea has universal health insurance that costs workers about 3 percent of their gross salaries, but it doesn't cover everything and doesn't pay 100 percent of what it does cover, said Dr. Shee Juhn Chung.
As of this year, insurance covers a CAT scan, he said. Chung, a cardiologist, is a visiting professor of health administration at the Medical College of Virginia, but he also is chief of cardiology and internal medicine at Sung So Presbyterian Hospital in An Dong, Korea.
"Dollars are at the bottom of it," Chung said. "How much money are we willing to spend for health care compared to other expenditures?"
"There's never any escape from allocating what you've got," said Theodore Marmor, a professor of public policy management at Yale.
Marmor, author of "Understanding Health Care Reform," was invited to the gathering at Roanoke College to help the group look for ways to benefit from each other's experiences.
Right off, Marmor warned that it wasn't possible to transplant a health care system from one culture to another. Forget the "junket view," he said, meaning you visit somewhere, see something you like and then try to bring it back intact for your culture.
But don't fall victim, either, he cautioned, to "narrow-minded provincialism," where you don't think there's anything to learn from a system that is vastly different.
Look for a common thread, he said.
The need to allocate resources turned out to be that thread.
Only sometimes Americans don't realize they ration and perhaps aren't paying enough attention to how much more of it they may have to do, participants suggested.
The British ration health care by making people stand in line, Marmor said. In this country, we ration it by insurance.
If you have a lot of insurance, you can get a lot of health care. If you don't have a lot of it, you have a harder time getting specialty care.
Also, if a bone-marrow transplant is denied, that's rationing. Triage, where victims are treated based on urgency of medical need and chance for survival, is another form of rationing.
And statistics suggest that we ought to be doing more of it.
America spends 14.4 percent of its resources on health care. That's 5 percent more than Japan and Germany, but Americans are not any healthier for it.
"We're paying for a lot of things that are marginal," said Dr. James Holman.
Holman, who represented Roanoke's health care system at the sister cities meeting, has a private practice in infertility. He spends most of his time, however, as senior vice president of medical affairs for Carilion Health System in Roanoke. Carilion was a sponsor of the conference along with the college and Roanoke Sister Cities Program.
Holman, who said he believes managed care will make our health system better, has first-hand knowledge, however, of how it also will limit services, especially if the services have limited good results.
As recently as six years ago, insurance companies would pay for the diagnosis of a couple's infertility problems and for most treatments for the problem, Holman said.
Some insurance companies will pay for the diagnostic tests, but not for treatment, he said.
Readjusting our health care system is going to be painful, said Yale's Marmor.
"On what basis do we ration?"
How would you answer that?
Sandra Brown Kelly can be reached at 981-3393, or 1-800-346-1234, ext. 303, or at skelly2180@AOL.COM
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