The Daily Tar HeelMonday, January 22, 19901 1 ;
Opinion
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! Unaffordable malpractice insurance
keeps 85 percent of North Carolina's
qualified family physicians from offer
ing pre-natal and birth services. Obste
tricians, specialists who treat only preg
nant women, are also affected. They
cannot locate where lower physician
irtcomes make insurance too expen
sive, and rural practice pays much less
than urban practice. So, in 25 or so rural
N.C. counties, doctors cannot afford to
deliver babies. Called the malpractice
insurance problem, having physicians
trained for but not providing obstetric
medicine contributes to the state's
abysmal infant death rate.
The problem extends to urban areas,
too, where the family physician's in
come, the lowest of doctors in all types
of practice, is not enough to purchase
insurance needed to offer obstetric care.
. That pregnant women in rural coun
ties are forced to choose between long
distance medicine or none at all is not
questioned. Neither is the overburdened
market for obstetric medicine, often
too expensive for poor families, nor the
combined effect of the problem. North
Carolina ranks 50th nationwide in in
fant mortality, and solutions range from
the N.C. Institute of Medicine's recent
call for mandatory health insurance to
Gov. Jim Martin's $ 1 6 million prenatal
care proposal for teenage mothers.
But not addressed by either Gov.
Martin or the Institute of Medicine is
the role of malpractice insurance. State
wide, family physicians have been
forced out of the baby business, and
obstetricians can't fill the gap. Physician-provided
care is thus completely
absent from the fight against infant
mortality in one-fourth of our state,
those 25 or so rural counties.
Although the infant mortality prob
lem does not solely rest in rural coun
ties, N.C. Insurance Commissioner Jim
Long proposed in 1988 an insurance
subsidy for doctors willing to practice
in rural counties lacking adequate health
care. Long said that his proposal would
help those doctors pay malpractice
insurance costs that have increased six
fold over the last six years. The result?
"Prenatal care and hospital facilities,"
said Mr. Long, for women currently
without.
In justifying his proposal, Mr. Long
also stated that North Carolina suffers
in" a way not reported by infant death
statistics. He said that complications of
pregnancy resulting in post-natal health
problems go untreated due to a lack of
nearby medical care. That situation hurts
more than just the babies and their
parents. Long explained, for babies with
problems that could have been avoided
burden public and private health insur
ance systems, many for the rest of their
lives. Gov. Martin also made that point
inhis recent proposal, but he referred to
the problem in its statewide context,
not just in rural areas.
Despite the attraction of Long's
proposal and the need for physician
services on a statewide basis, lobbyists
approach state off rials with an alterna
tive solution to the problem. A state
wide doctors' group calls for tort re
form, claiming that rewriting the law
governing malpractice suits will guar
antee full-service medicine in rural
counties. Tort reform, that view goes,
would lower malpractice insurance
costs for all doctors by capping the
amount of money available to those
who sue.
Chris Hood
Guest Writer
Commissioner Long's position on
tort reform is that it is unnecessary.
"We are a good state to write insurance
coverages in," he said in 1988. And he
gave the reason: "We are not as liti
gious as other states. Jury awards are
very conservative in North Carolina."
Still, the doctors' lobbying effort is
understandable. Malpractice suits
threaten all of them, not just family
physicians trained in obstetric care or
obstetricians who might locate in rural
counties. Even adding the family phy
sician in non-rural practice who could
be covered by a subsidy, Long's pro
posal would aid only a portion of state
doctors.
For pregnant women and their fami
lies, though, tort reform advocacy stalls
a direct solution for providing needed
doctor services. Why? Urging new laws
over who can sue and how much they
can win encounters powerful resistance
from lawyers, who promise a colossal
battle. Tort reform thus diverts support
from a subsidy by subordinating it to a
pending political brawl.
Avoiding that high-stakes conflict,
Long proposed a practical way to alle
viate the crisis. And if the following
statement is valid, much less prophetic,
then time has run out: "The tough situ
ation is down the line two or three
years," said a spokesman for the N.C.
Medical Society in 1988, "when this
(the malpractice insurance problem)
has an effect on infant mortality."
Supporting the call for a subsidy is
an additional fact of the infant mortal
ity problem, one related to Gov.
Martin's proposal for extending Medi
caid coverage to teens. Dr. Bret Wil
liams, author of the definitive study of
N.C.'s infant death rate, recently stated:
"It doesn't matter if a pregnant teen
ager has insurance, if she has no place
to go." The market for obstetric treat
ment is overburdened throughout the
state, and a subsidy for family physi
cians statewide would provide access
to those who even with Medicaid can
not find care. It would also lower costs
for other pregnant women who choose
the family physician's services, for
obstetricians are more expensive.
Finally, the cost for a comprehen
sive subsidy compares favorably to
Gov. Martin's $16 million Medicaid
based plan. Based upon rates published
by Mr. Long's office in 1988, counties
currently lacking services added to the
cost of covering as many as three fam
ily physicians in the remaining 75
counties amounts to less than $10 mil
lion, less than two-thirds the price of
the governor's plan. Moreover, a sub
sidy, whether rural-only or statewide,
would be light years away from the cost
in public and private dollars required
by the N.C. Institute of Medicine's
mandatory insurance plan.
Taxpayers spend an ocean of dollars
on both patient insurance such as
Medicaid and physician training at state
medical schools, so why not a rela
tively inexpensive plan to make avail
able the urgently needed services that
doctors provide?
Chris Hood is a senior interdiscipli
nary studies major from Southern Pines.
SXURVUG- OVT AT '
1
A meglecfecl vision) for UNC
m i J
Chancellor Paul Hardin, in his Uni
versity Day address Oct. 12, outlined
his vision for the University. The chan
cellor painted noble, broad strokes on
his canvas, depicting the missions of
a "complete university": to learn, to
teach, to serve. Hardin chose not to
use the opportunity to address a vi
sion for the needs of the University
and, particularly, the student body.
He did call on each student to con
sider teaching as a career a valu
able message. The future of education
depends upon a strengthened and at
tentive generation of teachers at all
levels of the system. But as important
as this call was, it didn't even scratch
the surface of what UNC needs to
address in the '90s.
This week's headlines have con
firmed the dire financial straits UNC is
in. Cutbacks and hiring freezes do far
more than prevent a photocopy from
being made or a position from being
filled they cause frustration and
damage morale. UNC cannot afford a
sagging morale with its weaknesses
in faculty and staff salaries and bene
fits. There are no easy fixes to budg-
Brien Lewis
Guest Writer
etary woes which face the state, but
Hardin i on target in his requests for
financial flexibility. My vision of
Carolina is of a proud, accountable
servant of the state and an institution
that is the master of its own house.
Even as sectors of our university
community struggle to get by on a
yealy basis, it seems at times that
there are buckets of money to be had
around here. More than $30 million
was raised for a basketball shrine, $12
million for an alumni playpen and the
equivalent of 15 full Morehead schol
arships was used to buy out a football
coach. Surely there are more pressing
uses for these easily-generated funds.
There are graduate students scraping
by to stay in school so that they can fill
the thinning professorial ranks. Thou
sands of undergraduates are accumu
lating substantial loan burdens. Build
ings are overdue for major repairs.
Parking and child care are lacking or
non-existent. Why is money so hard
to come by for these projects? Some
how I think UNC would have sur
vived without a Dean Dome and a
Hole-In-The-Woods. Will we remain
the admirable institution we long to
be if we cannot retain graduate stu
dents and staff? My vision of Caro
lina is of a progressive university that
utilizes its friends and alumni to pro
tect and enhance its valued resources.
I could write exhaustively of spe
cific needs and desires for UNC in the
'90s: a Black Cultural Center to edu
cate all and bring our community
together on a new cultural and inter
personal level; an academic minor to
complement a strengthened curricu
lum; a food service where the only
mandatory component is an excellent
product; a barrier-free campus for
handicapped citizens; a library that is
flourishing instead of wounded; a
clean, green campus that is safe any
time, day or night; textbooks that aren't
the price of a used car and a tuition
policy that isn't treated like a break
able piggy bank.
The student body is a transitory en--
tity. We lack the historical perspective. ,
of a faculty member and we are not'
faced with the pressures of an adminij
. . .
things we have freshness and a spe
cial brand of optimistic enthusiasm.
We are not yet mired in place. For
students are not simply another inter
est group at UNC. We are told repeat
edly by other segments of the Univer
sity community that we are the future.
We must take up that mantle and wear
it prominently and proudly. My vi
sion for UNC is of a university un
afraid of being rejuvenated and chal
lenged by its students and willing to
respond to their ideas.
For too long our mission has been!
divided: students are here "to learn.",
faculty "to teach" and the institution's
resources "to serve." UNC needs a!
renewed commitment and a united'
mission, with all of us serving and
teaching and learning from each other.
Brien Lewis, a senior political sci'
ence major from Toronto, Canada, is
the student body president.
View toward diseases recjyiires chaim
ge
The people of the developing world
today face many health problems which
are virtually nonexistent in the indus
trialized world. I propose that to im
prove the health status of these people
there must first be a fundamental change
in the accepted explanations of disease
causation. Specifically, the individual
istic explanations which are held by the
majority today must give way to more
accurate structural explanations if we
are to effectively combat many health
problems in the developing world.
Individualistic explanations of pub
lic health problems focus on what makes
the people suffering from a disease
Don Taylor
Guest Writer
different from those people not suf
fering from it. They compare the
groups and define the causes of the
problem as the differences between
the groups alone. This seems logical
on the surface, but this type of expla
nation is flawed. Let's look at cholera
to illustrate my point.
Cholera is an infectious diarrheal
disease which continues to be en-
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demic in many developing countries.
The causal agent is the Vibrio Chol
erae bacterium. But, is it also the true
cause of cholera?
Individualistic explanations for the
persistence of cholerafocus on the
differences between us and the people
suffering from the problem: They are
dirty and ignorant, they don't boil
their drinking water, they don't have
or use toilets, etc. By focusing only on
the differences between the people
affected by cholera and those not
affected, we absolve ourselves from
any responsibility for the problem.
I purport that structural explana
tions are more accurate in illustrating
the primary causes of cholera, focus
ing on inherent qualities of the sys
tems in which people live. Poor water
supply, exploitative economic condi
tions and lack of governmental infra
structure in the developing world are
related structural explanations for con
tinued cholera infection. The net trans
fer of wealth from developing nations
to the West, coupled with the fact that
basic sanitation is not a high priority,
leaves most citizens of developing
nations without clean drinking water
and waste disposal. The lack of basic
services should not be underestimated
as an explanation. It was not vaccines
or boiling water which precipitated
the biggest drop in deaths from infec
tious diseased in the United States but
the provision of safe water and better
living conditions. The world's eco
nomic, political and societal institu
tions not only make possible but en
sure that some of our global society
will continue to die from cholera.
The real tragedy in the general ac
ceptance of individualistic explana
tions of disease is the ineffectiveness
of the prevention measures which
follow this view. Boiling of water,
use of a basically ineffective vaccine
and "education" about cholera are
typical prevention strategies produced
from individualistic explanations.
They focus on the individual's ac
tions and attempt to get him to act to
protect himself. But how does one
keep boiled water for a household of
15 when they have only one three
gallon pot? And why should they have
to take special actions when we are
protected by turning the faucet?
Truly effective prevention meas.-i
ures only come from structural expla
nations of disease. If tube wells or
proper pipe water systems are proVi
vided to the people now suffering
from cholera, then the rate of the
disease will drop dramatically. This
type of prevention is so effective
because it alters the structural envi-
ronment which now allows cholera to
exist and does not rely on individual
action to provide protection from,
disease. But this type of prevention,
calls for major capital outlays and'
intuitively a shift in the responsibility
for the eradication of the disease. It"
challenges the status quo.
Changing the way we think of dis
ease causation is a radical change. It
causes us to look at overall structures
operating in the world. Continuation in.
our present way of thinking makes it,
inevitable that certain members of
society will contract diseases eradi-.
cated in the West. Structural causation
theory will not allow us to simply blame
those suffering for the fact the problem
exists, but calls us to accept some of the
responsibility for ending much of the
world's unnecessary suffering.
I am not trying to say that people
have no individual responsibility for
their own health, nor do all health prob-.
lems fit this conceptual framework as!
nicely as cholera. I simply think that in!
order for us to translate genuine con-!
cern into positive, tangible results, we!
must re-examine the way we think of
disease causation. We must realize
that blaming individuals for a health!
problem without even considering the!
institutions and structures in which!
the problem exists, is shortsighted.!
Until we address the structural causes!
of disease and implement the politi-!
cally tough prevention measures
which are called for by these explana
tions, cholera and other "ancient"
diseases will continue to silently kilt
thousands of our fellow global citi
zens. ;
Don Taylor is a senior health pol
icy and administration major in th
School of Public Health.