By CRG staff - interview with George Annas

George Annas, JD, MPH, is a member of the Board of Directors of the Council for Responsible Genetics. He is the Edward R. Utley Professor and Chair of the Department of Health Law, Bioethics & Human Rights of Boston University School of Public Health, and Professor in the Boston University School of Medicine and School of Law. He is the cofounder of Global Lawyers and Physicians, a transnational professional association of lawyers and physicians working together to promote human rights and health.


There has been a lot of political talk about health care and health insurance reform recently. Do you see anything coming of it?

I think for insurance reform (and we now call it "insurance reform" rather than health care reform) the cornerstone needs to be insurance coverage for everybody. But the real problem with health care in America is the health care system itself. People may have insurance, but we still need to change the primary care system so they can actually get access.

It's not going to happen overnight. That's the problem with politics: your time horizon is the next election. And we will have to wait a few years to make judgments about how well this is working - whatever "this" is.

Probably one of the biggest questions is whether health care should be dealt with as its own issue - it's big enough to be its own issue - or as part of economic recovery. The question is there for health insurance, too, unless you're doing away with health insurance for a single-payer system, which we're not doing anytime soon. I think we should. It makes perfect sense - the inefficiency of these multiple insurance policies is overwhelming.

How might new policy address the racial and class-based disparities in health care access and health insurance coverage - either ideally or in actuality?

For one, we can get people insured. It's just unconscionable in a developed country that we have 50 million uninsured.

Then there's getting everyone access to health care. People say "everyone has access to health care." Yes - when it's an emergency! That's not health care, that's just emergency care. And the most interesting thing about that is that we do see medical emergency care as a right. You do have the legal right to care if you have an emergency, and I've always thought we should try to generalize that: we have a right to health care in this country. Not just to preserve your life, but your health. And I think that's the direction we're going, but it's going to take a while.

Now, about the race and class disparities. If you're really poor, you can qualify for Medicaid - but no one is proposing 'Medicaid for all!' Now, a lot of people like 'Medicare for all.' That's a great plan. You don't hear any citizen groups saying "We need to reform Medicare!" The doctors' groups say it should pay them a little more, but it's a very popular plan.

'Medicare for all' would cover everybody. It would significantly reduce class and racial disparities, but by itself could not solve the problems of health care delivery and geographic disparities. .

After BiDil, is there any more serious talk about racialized medicine?

Not really, though it depends on who's talking. The problem with linking race and medicine is that it's really not based on race, it's based on genes, and genes don't track for race. It's very strange.

Private companies are pushing DNA ancestry tests, and some of them seem to suggest that, in the future at least, those test results could have some sort of health implications. What do you think?

That seems unlikely. We love simple solutions to complicated problems, but that doesn't mean there is one. You hear that Japanese people don't have obesity problems like we do here - but when Japanese people move to America it's different. So even if a condition has a genetic component, you can't say it's everything. With something like obesity, there's definitely an environmental component, which includes access to healthy food.

Even though in many ways we in America live unhealthy lives, we're very health conscious. And there are ways in which we are healthy, too - we rank poorly compared to a lot of the world, but we live longer than we used to.

Do you think that's in spite of or because of our health care?

It certainly has little to do with medical care. The AMA put out a statement after Obama's speech to their organization that life expectancy in the U.S. has gone up by 10 years over the last few decades because of our medicine. Well, that's not true - medicine is not irrelevant, especially in drugs to reduce heart disease, but it's not the overall driver, rather public health and education are.

Can health care delivery be effectively addressed as a national issue? It seems that it would be difficult in the way that education is difficult to address at a national level - just standardized testing and providing or withholding funds.

Education is a good analogy - everybody has the right to education, but we've seen that a lot of public schools are bad, so there are private alternatives. That's the way it will be with health care, too: the way the system is set up, the rich will always be able to buy themselves better health care. And I think that's fine - that's not the problem. The problem is poor people and middle class people not being able to afford or to get decent access to health care.

Where this can be a national issue is through a national standard of care. Right now there are wide variations in the U.S.

You mean in standard of care?

Standard of care and cost of care. Boston is a classic example: we have the most expensive health care in the country, by far. And so we say, "We have the best care in the world!" Well, no - we have the most care in the world as well as the most expensive care in the world.

This is probably the most controversial area in the whole discussion: do we set up some kind of national system? One of my favorite things the Clintons did was their response to the Harry and Louise ads back in the 90's. In the ads, there was a couple called Harry and Louise sitting in the kitchen, going over their health care options. The line at the end is, referring to the government: "They choose, we lose."

So the Clintons, Bill and Hillary, made a spoof on Harry and Louise. It was very funny - they were sitting there like Harry and Louise, talking about the Clinton health plan. And at one point, Hillary turns to Bill and says, "It says here, on page thirty-five thousand, five hundred and ten, that ultimately we all die!" And Bill and Hillary face the camera and say, "There's got to be a better way!"

As in, 'Why should we settle for eventually dying?'

Right! It was all very tongue-in-cheek, of course. And the next day, on the news, Sam Donaldson said, "That's a mistake. You can't talk about dying to Americans." And then, in fact, the White House pulled the ad. Sam Donaldson was right: you can't make it seem that 'we're all going to die' is the centerpiece of your health plan!

At the same time, the key to a sustainable health care plan is a recognition of limits. We don't recognize that in this country. Now we have this whole movement of personalized medicine based on your genome - how insane is that? Even if it works, we can't afford the health care system we already have - now we're going to have a special designer drug, just for you? That's never going to happen, except for the very rich.

But some DNA tests can have predictive value. Couldn't that reduce health care costs, if people take preventative action?

Possibly. If you learn you have a susceptibility to diabetes, for example, you can start taking action and reduce medical costs later. Of course, at some point you're still going to get sick and die - but if you find out about the conditions you really have to take care of and you know what to do about it, sure, it could be a big saver. On the other hand, not everyone with a genetic susceptibility to disease will actually develop the disease, so in their case preventive interventions will just increase cost without health benefits.

Of course, you could also find out you have something incurable - and then what?

That's the other thing. As soon as they found the Huntington's gene, the thought was that everyone would want to go get screened. Well, as it turns out, very few people at risk  wanted to get screened at all, because there's no cure.

With most of the consumer genetic tests, can't you choose not to find out something you don't want to know?

Right, that's what James Watson  did when he had his genome analyzed, he didn't want to know whether he had early onset Alzheimer's. Well, for him it wouldn't be early onset any longer!

A colleague of mine, Bob Green,  did a study to see how people would react to learning that they had the gene for early onset Alzheimer's. Overall  people react pretty well. They don't become overly depressed, they don't kill themselves or do all the things that many imagined they would do. One thing he found is that most people, since this is a genetic condition, have family members who have it - so finding out they are at high risk is not such a shock.

And after all, we're all going to die - and we've managed to deny that, and to internalize that denial, very well. We're not going around every day saying, "Oh my God, I'm going to die so what's the point?"

It seems like being told about your likelihood of getting a certain condition, the concreteness of it, might make it harder to ignore. Though you could just start denying that, too ...

Right - we can deny it if it's something we can't do anything about. Now, if we can do something about it, that makes it harder - it becomes more than just a genetic lottery. Smoking is a good example. We know that smoking is bad for you, and that you've got to stop. And lots of people do - but there's the pleasure aspect, and a tradeoff.

There's a great British study, actually, that shows how smokers actually reduce the money spent on healthcare and social security. So if you're just interested in how much the government spends on the elderly you'd encourage smoking - because they die earlier. Of course it's not all that surprising that we save money if people die younger.

But we also  spend almost half of our medical care dollars in the last year of life, and we always will. And there's nothing wrong with that, because you can't predict when your last year of life is going to be - and the sicker you are, the more medical interventions are available. If you actually knew, however, when someone would die, we could save a lot of money (assuming, which I do, that most people would reject extremely invasive end-of-life care that had little, if any, benefit).

The amount of medicine that anybody can consume is infinite. It really is. Ivan Illich said that death is the "ultimate form of consumer resistance." The only way you can say 'no' is to die! And that's one thing you'll never hear discussed during the health care debate: death. Because in many ways, we built our notion of medicine around the idea that nobody dies.

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