Second of two columns on American public health issues.
In Saturday's column on public health and the pharmaceutical industry, the case was made that a public health policy driven by the profit motive leads to bad health policy and expanded federal budget deficits. Profit is a great driver of the free enterprise system but is a bad match with core public policies.
Reviews published in the two most recent issues of the New York Review of Books (NYRB), taking the psychiatric profession to task for the shameful influence of the pharmaceutical industry, demonstrate the potentially destructive impulse of the profit motive.
Psychiatry has almost dropped its original reliance on therapy in favor of pills, despite evidence that therapy or, surprisingly, exercise are usually just as effective for depression as the new prescription drugs. There is more money in prescribing pills. Diagnosis of mental illness has expanded dramatically so that, as the review author ironically reports, "It looks though it will be harder and harder to be normal."
Particularly damaging is her report that diagnoses of children's disorders have doubled multiple times in the last decade, so that half a million children now take antipsychotic drugs with potentially dangerous and sometimes lethal side effects.
As the author points out, the problem with "troubled children" is often troubled families in troubled circumstances. Careful exploration of their environment makes more sense as a starter. Many psychiatrists are also prescribing drugs "off-label" which allows them to speculate (with industry encouragement) in the prescription of drugs not approved by the FDA for the diagnoses being treated.
The core polices of the American "social contract" changed in the last century to include basic employment rights and old age security. Today we are locked in the leftovers of the struggle to extend health security to everyone, not just seniors and the very poor, a form of social security taken for granted in every other major democracy. The inclusion of mental health treatment has been a part of that struggle.
The effort to universalize a minimum level of public health care should not be derailed by the problems that arise from congressional choices of administrative format. Mental health is certainly an appropriate addition to universal health care services even if there are flaws in the delivery as there are in other health delivery systems. We should focus on improvement.
But democracy is crippled when the voice of the independent citizen is drowned out or distorted through control of the organs of debate by big business, pharmaceutical or otherwise. Large economic interests are overrepresented by their ability to persuade the marginally knowledgeable voter (that's most of us), directly through independent advertising and indirectly through campaign contributions to favorites. Add massive lobbying activity supporting superior access to the ear of our representatives, and it is not surprising that the voice of the public is gravely disadvantaged.
The national legislature is in deadlock over the heart of the legislative function: taxation and expenditure. All have acknowledged for some time that our tax code is a mess, handing out unjustifiable bargains to the undeserving, resulting in minimal or no taxes being made by behemoth corporations and billionaire beneficiaries.
We were sold a design for government that allowed, at the same time, vastly reduced taxes with loopholes for the wealthy and the opening of two wars. We are told the resulting deficit can only be cured by cutting preexisting health benefits. How can it be that so many Americans swallow this pill?
Corporate interests represent only the profit-making interest of the shareholder, not the more complex interests of each shareholder as a human being or citizen. For this reason, this column has previously recommended that the law require a shareholder vote on corporate political expenditures.
These NYRB reviews indicate that legal or professional code revisions are required to prevent "off-label" prescriptions except in controlled instances. Doctors should be restrained from investing in the drugs they prescribe. Tax codes should take from the pharmaceutical industry the tax deductions given it for advertising drugs that only a doctor can prescribe to a gullible public.
John Havelock has taught public policy at UAA since his retirement as a professor of justice. He also is a former Alaska attorney general.