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Aestas horribilis: Taking tragedy for granted
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Toward the end of 1992, Queen Elizabeth II of Great Britain referred to a year of misfortune that had befallen the British royal family as “annus horribilis.”
As I write this editorial, I feel much the same about the summer that has just passed — aestas horribilis — with death, misery and destruction wrought upon the Mexican, Caribbean and U.S. populations by a series of hurricanes, earthquakes, gunmen and political extremists.
I feel almost overwhelmed by grief at the plight of those in Mexico, the Caribbean, Florida and Texas, who must surely be victims of the phenomenon of global warming — truly not “fake news” — that has led to such extreme weather changes. I also am increasingly angry at the inability of the governments of the world, particularly the one in Washington, D.C., to address this in a responsible fashion.
An unexpected complication of the natural disasters above is the sudden, potentially catastrophic shortage of IV fluids and lines which, through a quirk of fate and/or business, appear to be predominantly produced in Puerto Rico. In all the breast-beating and public pronouncements from government about what they are hoping to do for the population of Puerto Rico (perhaps too little, too late), I have not yet heard any government official proffering a plan to deal with this looming additional disaster!
Right to bear arms
As a physician committed to preservation of life, I have the same sense of outrage, consequent upon the death and injury wrought by a crazed arms-bearing lunatic in Las Vegas, as I felt when I heard of the carnage amongst little children at a school in Sandy Hook, Connecticut, in 2012 and the subsequent failure of Congress to address the issue in a meaningful fashion.
I do understand the political clout of the National Rifle Association and the craven cumulative response of our politicians. I also respect that the right to bear arms is embedded in the Constitution. However, I simply cannot fathom the logic of a nation that allows anyone — sane or demented — to have the right to purchase rapid-repeating rifles and other equally dangerous weapons and, thus, to wreak the carnage seen at a concert early this month in Las Vegas. Rich Schapiro, writing in New York’s Daily News, noted that there has been nearly one mass shooting (of at least four people) per day in the United States since Sandy Hook, resulting in more than 1,700 deaths and more than 6,000 injuries.
As a physician, I feel that I must speak out against this continued madness in the United Sates.
Lack of focus on health care
Sadly, in parallel, the continued lack of responsible attention to our health care system by our federal and state politicians will have potentially much more catastrophic long-term consequences for the large population of patients with cancer and their families in the United States.
Although the media has correctly focused its dramatic attention on the thousands of victims of hurricanes Harvey, Irma and Maria, in addition to the earthquake victims of Mexico, who is attempting to protect those being attacked by cancer in concert with an inadequate health care system, constituting a much larger population? I have written previously of the consequences of failure to provide adequate coverage for chronic and catastrophic diseases in the United States, and the likely increase in deaths, morbidity and financial cost.
What is less obvious, but certainly important, is the burgeoning fiscal consequences for patients and their families of trying to combat cancer.
In a report in Journal of Oncology Practice, Veenstra and colleagues reported that nearly one-third of families with survivors of breast cancer are financially disadvantaged after combating early-stage breast cancer, that there is long-term disruption of employment of the spouses of survivors, and that many of those spouses who can work continue in employment predominantly to maintain better health insurance and afford continuing care. Many of these spouses reported a fear of changing jobs because of the potential implications for their family’s health insurance. Although the researchers acknowledged several potential flaws in this study, the data are very concerning and provocative and, if further validated, need to be factored into future community planning for cancer care.
There is increasing evidence that bankruptcies and other dimensions of financial ruin are further confounding those who deal with cancer, be they patients or their supporting families.
Ramsey and colleagues have shown that patients with cancer were nearly three times more likely to go bankrupt than people without cancer, and that younger patients had bankruptcy rates two to five times higher than people aged older than 65 years; perhaps this suggests that Medicare insurance may mitigate risk in the older group. Imagine the consequences of the decisions of a government that reduces Medicare and Medicaid payments while undermining national safety-net health insurance!
‘Inured to tragedy’
Of importance, government is certainly not the sole culprit.
The extraordinary increment in prices leveled by the pharmaceutical industry for targeted therapies compounded by the refusal of many clinicians to engage their patients in the extant trials that are attempting to validate predictive and prognostic markers of these million-dollar agents is only part of the problem.
Another issue is the hubris, or self-interest, of oncologists who continue to flail about expensively, treating ever-increasing numbers of patients with resistant tumors with agents that simply don’t work rather than engaging palliative care. Do they not recognize that this harms the patients by increasing their physical and fiscal toxicity with little chance of benefit, while also harming the community by contributing substantially to the rising costs of care?
Perhaps it is time for both government and the health insurance industry to create well-informed (not politically motivated) and meaningful approaches to this problem, rather than reducing support for those most at risk, and/or targeting patients who are prepared to participate in clinical trials that might improve the situation.
As a nation, we are at risk for becoming inured to tragedy and chaos, simply beaten by the constancy of bad news, political ineptness and assertions that adverse occurrences are “fake news.” As a democratic, voting population, it is becoming increasingly important for us to exercise the one lever that we still have left — it can be found in any polling booth.
References:
Ramsey S, et al. Health Aff (Millwood). 2013;doi:10.1377/hlthaff.2012.1263.
Schaprio R. Over 1,700 dead and nearly one mass shooting a day since Sandy Hook, but Congress has done nothing. Daily News. Available at: www.nydailynews.com/news/national/1-700-dead-mass-shooting-day-sandy-hook-article-1.3539717. Accessed on Oct. 4, 2017.
Veenstra CM, et al. J Oncol Pract. 2017;doi:10.1200/JOP.2017.023606.
For more information:
Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, is HemOnc Today’s Chief Medical Editor for Oncology. He also is president of Levine Cancer Institute at Carolinas HealthCare System. He can be reached at derek.raghavan@carolinashealthcare.org.
Disclosure: Raghavan reports no relevant financial disclosures.