HEALTH CARE/Joan Retsinas

Terrorists at the Table

A democracy sometimes resembles a raucous boardinghouse, where people are clamoring -- first, to get to the table -- next, to gobble up most of the food. Not everybody makes it to the table; not everybody gets much to eat. And the people sitting at the head tend to stay there for years. Yet the jostling for position marks the soul of government; and however unfair and irrational the division of bounty, we recognize that this boardinghouse ultimately draws its legitimacy from an inchoate popular will. So, mindful that democracy, however inefficient or even unjust, is far better than the alternative, we watch to see whether energy, or education, or the military, or space, or whatever, will jostle its way to dominance.

Terrorists have elbowed their way to the table, pushing aside familiar faces. The terrorists have forced lethal and contagious diseases upon our health policy agenda: anthrax, plague, smallpox, tularemia -- or their specters. Over the next few years taxpayers will be spending billions to combat them. Yet before the ubiquitous headlines rivet us to the here-and-now, obliterating the news of long ago, circa 2000, it is a useful exercise to reflect back on the health policy casualties of this new war -- the faces no longer at the table. We scarcely have time to mourn them, but we should, because recognizing the new configuration at the boardinghouse table might give us heightened resolve to push the terrorists away.

Casualty #1: health insurance reform. Governments at war do not launch major domestic welfare programs. So national health insurance -- stuck on the periphery of the Congressional table -- is off everybody's agenda. Even though the combination of a recession and 12% premium increases will leave more Americans without insurance, Congress is unlikely to step in. As for Medicare, enrollees already face increases in co-payments and deductibles; physicians face lower reimbursement. Expanded coverage for drugs is unlikely. The patients' rights legislation has lost momentum: nobody is complaining about cheap HMOs. Everybody in an HMO is just hoping that it has enough antibiotics to ward off the epidemic-of-the-moment when it hits their city.

Casualty #2: attention to diseases of widespread prevalence, and suffering, yet low mortality. Death trumps disability. Physicians in the psychically long-ago pre-terrorism past worried about arthritis and asthma. The Centers for Disease Control issued updates to keep physicians abreast on the latest regimens. Physicians also worried about stroke, hypertension, the flu, diabetes, obesity, depression, Alzheimer's, infertility, acne, impotence ... (Some of the maladies seem like luxuries of a prosperous peacetime.) Those familiar diseases persist -- millions of Americans suffer from them. But new ones -- more accurately, new to the United States, because we had been lucky enough to relegate them to the footnotes of textbooks -- are claiming attention. The architects of Sept. 11 re-introduced these long-standing scourges. Physicians who never studied anthrax, never saw a case of smallpox, never learned how to treat the plague are now scrambling to learn the basics. And panicked patients are trying to distinguish the symptoms of flu -- rarely fatal -- from the almost always fatal symptoms of inhalation anthrax.

Casualty #3: research into those familiar diseases. Over the past decade researchers have been investigating multiple sclerosis, cancer, AIDS, heart disease, aging ... The list goes on and on. Three months ago the debate was about stem cells: would 60 lines suffice? Today researchers are working on vaccinations for smallpox, a quicker screen for anthrax, a plan to "irradiate" the nation's mail. Most medical research is tied to federal dollars; unless we expand the pool of research money (unlikely in a recession), we cannot expand researchers' agenda.

The headlines proclaim the brave new world of healthcare. We are pouring money into hospitals -- not to raise salaries or update equipment, but to build anthrax-decontamination chambers. We are updating laboratories -- seeking quicker diagnostic tests for diseases most physicians have never seen. Instead of expanding health insurance for children, we are debating legislation that would mandate smallpox vaccinations -- once scientists whip up 200+ million doses. Government is wielding its power to lower costs of drugs -- but for anti-anthrax antibiotics.

Soon the world of health policy post-Sept. 11 will become routine -- just as the soldiers in airports now meld into the background. Yet during this time of war, we should remember that world of peacetime. The raucous boardinghouse of a democracy persists -- note the continued congressional debates over anti-terrorism bills -- but the terrorists have stormed their way to the table, shaping health care spending. The predictable response is sadness tinged with regret. And rage.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I.

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