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Current Affairs - April 7, 2020

"Current Affairs editors Nathan J. Robinson and Eli Massey recentlyspoke toDr. Abdul El-Sayed, CNN contributor, former head of the Detroit health department, host of theAmerica Dissectedpodcast, and occasional Current Affairswriter. Dr. El-Sayed is also the author of a new book,Healing Politics: A Doctor’s Journey into the Heart of our Political Epidemic.The transcript has been lightly edited for grammar and clarity. Transcript by Rachel Calvert."

NATHAN J. ROBINSON

I’d actually like to start by talking to [you about the book], because even though it was written before the onset of the present crisis, and I don’t know if the word “coronavirus” even appears… it probably does not, because it went to press, and then all of this happened, right?

ABDUL EL-SAYED

Yeah, that’s right. It’s a sort of weird moment to have written a book about the underlying epidemic of insecurity in a moment where we’re facing a pandemic, now that everybody’s watching in real time. 

NJR:

Right. And that’s the thing, right? The book could not be more relevant to the present crisis in one way, because one of the central themes of Healing Politics is that you can’t really think about problems in medicine as being isolated from politics and broader questions of social structure.

Reading it, I realized you kind of had a similar awakening as you were training to become a doctor that I had when I was training to become a lawyer, where you’re trying to help individual clients—or patients, in your case, and then you realize it’s impossible to actually solve their problems without thinking about social and political context. And you became a social epidemiologist in your academic work, focused on health inequality. And then eventually, you explicitly entered politics, and you ran a campaign for governor of Michigan that wecoveredin Current Affairs*. So before we get to the present crisis, I’d like to start by talking about the book, and your story of how you came to understand problems of medicine as problems of politics.* 

AES

Yeah, that’s right, Nathan. So for me, my interest in a career in health started really when I was quite young. I’d travel back and forth between the suburb of Detroit where I grew up and Alexandria, Egypt where my father grew up. And there I’d hang out with my grandmother, the wisest, the most intelligent human I have yet to meet in my life, but she never got to go to school. And she lost two infants before the age of one, of eight to whom she gave birth. And so a recognition that not everybody’s health was the same was clear to me. But the crazy thing is, right, I’d travel 10 years difference in life expectancy in those 12 hours it would take me to go from Oakland County in Michigan to Alexandria. I could travel the same 10-year life expectancy gap driving 25 minutes south to Detroit. So what became really obvious quite quickly is that what health opportunities people have are a function of what opportunities people have. And health, insofar as not everybody has equal access to a healthy, long life—it is a resource, like many other resources, and the choices that we make about who gets access to resources, and who doesn’t, pattern themselves into people’s lives. And so for me, sort of moving through my career, I thought I was gonna do something about that working with one patient at a time. And I, in medical school, had a number of patients who disabused me of that sense—and then moved up into public health academia, thinking that if I could describe, as an epidemiologist, the patterning of social access to health and disease, then well-meaning people in policy positions would fix it, only to appreciate that actually that’s not how the world works. And so became a policy person myself, and was the health commissioner in the city of Detroit where I got the opportunity to rebuild the health department there after privatization. And then realized that so many of the decisions that even a health department makes are patterned by the political decisions that elected officials make. And at that point, that’s when I decided to run for office. 

NJR:

Yeah, we really had the same path in some ways, because I went to law school, and I was like “Oh, I’m going to be a public defender,” and then I was like, “Oh, these problems are too systemic.” So then I went to graduate school, and I was going to be a sociologist studying the legal system. I was in social policy school, and thought, “Oh, I’ll just recommend the good policies.” But then you realize that you can write as many papers as you like on what ought to be done, and nobody reads them.

AES:

That’s right. And one of the things I really appreciate about your work in Current Affairs is that you are really quick to identify the misincentives in the system, wherein rich and powerful people leverage their money and their power to consistently hoover up—to use a Britishism—more and more of that money and power. And so I sort of talk about this insecurity epidemic, and talk about this idea of a paradoxical insecurity, where you have people who truly do, 100 percent, benefit from the system. But their benefit from the system comes at the cost of so many other people who lose basic access to securities that so many of us should get to take for granted in the richest, most powerful country in the world. And then, in seeing their difference, they realize that they’ve got to put as much space between themselves and others. And so paradoxically, they just accelerate the system that creates this inequity. And so, if we’re going to take on inequities—whether they’re in health, or in access to legal services, or in access to housing, or in access to healthy food, or you name the thing—it means taking on the structures by which access to these resources are patterned, and standing up to people in power and people with money who want to continue to corrupt the system. 

NJR:

It seems to me like the paradigmatic case of a public health crisis that is really a political crisis from your home state of Michigan is the Flint water crisis, right? On the surface you can look at is as, well, it’s kids getting sick, we just need to solve the problem of kids getting sick. But it’s a crisis that has political origins, and that can’t be solved unless you change who has power. It’s a crisis that is a crisis of medicine and health, but it is linked to havingemergency managersrather than elected city officials. It is linked to neglect. It is linked to globalization. You can tie it to so many political things, and you can’t really get the politics out of it if you want to understand it well.

AES

No. If you think that the Flint water crisis happened the minute the water was changed, then you’re not paying attention, right? The Flint water crisis actually happened well before the water was changed. It happened when we made decisions about who got to live where in the context of the great migration. We made decisions about what institutions got to dictate the flow of resources—and in this case, General Motors and the state of Michigan. It happened when we allowed our state government to fundamentally take the right to democratic self-determination away from communities that had been left behind because of a system of white flight. And then when the government-appointed czar over Flint then made a decision to cut costs by pennies a day, and changed the water source, that’s when the downstream consequences caused the Flint water crisis. And that’s when the societal pathology pierced the skin, and got under the skin, so to speak.

And so we have to be thinking well beyond the biology of epidemics and pandemics if we wanna understand why they happen. And so, in writing this book, I diagnosed this epidemic of insecurity with the recognition that unless you are able to deal with the social and political circumstances in which decisions are made, the ways that those decisions poured through the racism and marginalization from the past into the present and into our future, then we can’t really begin to deal with it.

And so this pandemic—yes, it’s about a virus, but it’s also about a host and an environment in which that virus was able to spread, because we had gutted the government resources that we needed to protect people. We had left them living on the ragged edge of society, living paycheck to paycheck, working gigs, paying huge levels of debt, worried about when they’re gonna be evicted, without the capacity to get healthcare. And then when those two things come together, that’s when you get the house of cards scenario that we’re dealing with right now. 

NJR:

You’ve been a staunch advocate of Medicare for All, and in fact you’ve written articles for Current Affairs*, one called* “Don’t Let Medicare for All Be Rebranded,”anddoneacouple videosfor us on it. And I take it, the position here is also that healthcare financing and the provision of healthcare, that kind of system, can’t be separated. And I assume you’ve had some frustration with fellow physicians who don’t necessarily see the problems of medicine as problems of the structure by which medicine is financed, and you’d probably encourage other doctors to think about single payer as one of the tools in healing.

AES

Well, I’ll speak to that in a couple of ways. It is a conceit of medicine that we only start caring about a patient’s health after they walk into our clinic or hospital. And we don’t pay as much attention to the 99 percent of the time where they’re out in the world asking, “what is it that makes them sick out there before they ever come in here. And what barriers do people have to coming in?” I do think doctors think a lot about those things now, but it has been unfortunately the conceit of medicine that we haven’t. And my frustration with the institution of medicine is that we don’t think enough about those things. And so in the book, I talk about my frustration with that, and that fact that we get a selected number of patients who are selected on their ability to pay. And insofar as we’re patterning access to healthcare on whether or not it makes a set of institutions a dollar or not, then we are going to miss, systematically, the sickest most vulnerable people who need our care the most. And so, Medicare for all is about taking out the paywall to healthcare. It’s about saying that we, in a society that prides itself on our might and our power, should not be conditioning access to something as fundamental as healthcare to whether or not a set of institutions can make money off of it. And when we do, the consequences are always going to mean that we’re excluding people based on their ability to pay, and we’re failing to help keep them healthy in the moments that matter most to them, rather than in the moments that matter most to the bottom lines of the CEOs who run the healthcare system. And so it is a moral question, right? The idea that this is somehow just a technical question seems to be the conventional wisdom of the moment, right? This is just a set of technical calculations that if we get it right, we can provide everybody healthcare, and the systems can make money. That’s bullshit. That’s just not how the world works. It is a moral question about whether or not we want to continue to pattern access to something as critical as healthcare on whether or not somebody can make money off of it or not. ...
See full interview at Current Affairs