Why individual and community are both undermined by Trump, and both need to be placed at the center of compassionate care as part of anti-Trumpism
The righteous battle to keep ACA from being dismantled saved health insurance for millions. That was salutary in all senses. But the larger terms of the conflict are worth addressing -- because they illuminate both why Trump is to be fought, and what we have to do to make healthcare work.
Healthcare is an ongoing balance between care for the patient and care for the population. On the one hand, we want each individual to get the support, healing, diagnosis, and treatment that they want and need, no matter who they are. This would be patient centered care not in its popular buzzword formulation, but in a difficult and true sense: care tailored to the patient even when he or she is “inappropriate,” “demanding,” or “difficult” -- even when they look different, smell bad, speak a different language, or are completely unable to navigate the healthcare system, which means they can be frustrating and burdensome to overtaxed health care workers.
Such true patient centered care requires well trained clinicians, educated with this goal in mind; systems which are flexible and coordinated enough to deliver such individualized care; and the institutional permission to depart from metrics which might not be well founded in strong evidence -- or even from those so founded, in the service of individual care.
On the other hand, we want to make sure we are stewards of population health. (I am writing this from the perspective of an internal medicine/primary care doctor who realizes that the “we” is a tricky business. Many a public health practitioner and researcher would rightly say that healthcare is not health, and doctors are certainly not the primus inter pares when it comes to making populations healthy. Nevertheless….)
There are ways in which populations can be helped to live longer with less disease and fewer symptoms through making medications, surgeries, and other treatments available to thousands, even millions of people. What’s more, such interventions are only effective for some if they are given a chance to be ineffective (or potentially harmful) for others. How to balance such risks and harms is ethically complicated, and health care systems and structures in the US have done a bad job at it. But in a best case scenario, this is part of healthcare too: not tailoring care to the individual, but recommending and carrying out what is grounded in science and an understanding of what the community says it needs.
The person and the community, the individual and the group: this twin poles are obviously the axes of much intellectual work. What I can speak to is how Trump, as a natural extension of certain GOP policies, is attempting both to undermine these poles and to make clear just how fundamental they are in understanding healthcare’s importance to a healthy liberal polity.
The person as worthy of respect is a basic tenet of true patient-centered care. Yet this person is denied respect in the current regime through assault on Muslims (in the Trumpian philosophy considered dangerous a priori); African Americans (against whom police brutality is not considered a topic of importance in Trump’s Department of Justice); women; and even many white Americans. Any individual, through attack on their autonomy, might be denied the basic right to belong which makes their health a matter of import for society at large.
Further, we recognize the importance of groups of people in our efforts to improve health. Communities as self-governing and self-defining entities are problematic enough to a nation state (when can they be recognized? When are they suppressed?) but certainly one of the leitmotifs in our nation’s wrongs has been the experience of African Americans, something which demands an accounting and (for many) reparations. There is no true equality in healthcare without recognition of violence done, and no redress of this violence without a base in evidence and ethics. Undermining our nation’s commitment to health services and patient centered research (through weakening AHRQ and PCORI), and denigrating and ignoring science in general, together with a disdain for ethics in the highest elected realms, dig a pit where the structure of population health should be.
Thus the person and the community are both at risk in the Trump era, and restoring the dignity of both can help bring our nation closer to the good and make each individual the proper beneficiary of respect and healing. The Trump-era question for those opposing the priorities of him and his party is this: how best to balance individual and group concerns? Can each advocate for all? Should we focus our attention on those we know, or those who need it most? Are universal rights (e.g., access to health care for all) or redress of disparities (ending racism in care) more important? Is economic inequality or racism to be addressed as a primary target?
Opposing evil -- to name Trump plainly -- demands directing our resources and deciding on priorities, thus it is no secret that there will be disagreement, dissension, and debate among anti-Trump agitators in healthcare. But, ideally, such prioritization will help us decide how to advance care after, or despite, Trump.