Hell is Paved With Good Intentions

Human test subjects from the Tuskegee Syphilis...
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Recently I worked in an occupational health setting, at a clinic for employees of a call-center: a warehouse of a building filled with rows of Dilbert-like low cubicles with people on telephones, fielding customer complaints. Women workers would come in to clinic with bladder infections from not wanting to take bathroom breaks. They have to clock out for bathroom breaks and they get penalty points if they take too many bathroom breaks during one shift. Too many points and they get fired. Taking a diuretic for high blood pressure, or being pregnant, can be bad for job security at this site. Not surprisingly, stress-related health problems like headaches, heart palpitations, and depression are commonly diagnosed at this employee clinic. The purpose of work-site clinics such as this one is to maximize the bottom line for the company—keep workers as healthy as possible, and then fire them when they aren’t healthy anymore. The clinic is also designed to reduce the overall health care cost to the company. The irony, of course, is that many of the employees say they have to keep their jobs to keep their health benefits so that they can get health care for job-induced health problems. These are all issues not unique to this particular company.

This is much different work for me than all the clinical work I’ve done within the health care safety net. Although there are overlaps. For one thing, many of my homeless young adult patients worked for call centers like this when they were transitioning out of homelessness. These are the sorts of low-wage, low-skill, entry-level jobs available to people without a college degree, without work experience. Working at the call center has increased my understanding of what my homeless young adult patients meant when they spoke about such work: it’s a job, it pays the bills, but it’s depressing work because almost everyone is angry at you on the phone and you have to be nice to them or you’ll get fired. It has given me a new appreciation for how stressful it can be for all of those anonymous help desk people I have to deal with at times.

Ours is the only country in the world to primarily tie health care to work. Blame Rosie the Riveter. Employer-sponsored health care started in our country during WWII, when the scarcity of workers, combined with a national wage freeze, made the benefit package—including health care—a way for companies to attract and retain employees. It continued even after the war—and wage freezes—ended. People came to expect it.

What started off as a good idea has turned into a bad one. Employer-sponsored health care drags down our national economy. It does this by limiting entrepreneurship—people are less likely to strike out on their own to start a small business if they can’t afford health insurance in the private market. It is also a drain on the national economy since we have more disgruntled—and therefore less efficient—workers staying in jobs they hate just to keep their health benefits. It contributes to the fracturing of the US health care system due to multiple health insurance companies vying for business with companies offering health plans—and drives up overall health care costs through increased insurance company administrative costs. Some of these problems are addressed in the Affordable Care Act, but since our health care system is a highly complex adaptive system, powerful interest groups such as insurance companies have already plotted ways to circumvent these changes and continue making huge profits.

To use another famous quote from George Bernard Shaw’s “Maxims for Revolutionists”: “Hell is paved with good intentions, not bad ones.” I am always wary of occupational health programs due to the complex ethical issues involved: role conflict, invasion of privacy, and paternalism/coercion related to health promotion activities. I also remember that the notorious Tuskegee Syphilis Study had its roots in an otherwise well-meaning occupational health program. It began in 1932 in Macon County, Alabama, still one of the poorest counties in the US. Funded by a Northern philanthropist family and operated through a local Agricultural Extension program, it provided comprehensive mobile health care—including screening and treatment for syphilis (commonly called ‘bad blood’)—to poor black farm workers. These men had access to very little health care. Well-planned and well intentioned, the occupational health program was a success until the Great Depression forced a major scale-back of the program.

The rest of this is perhaps a familiar story, but one worth repeating. The US Public Health Service, and subsequently the CDC, stepped in to take over the program, under the guise of a treatment and research project for syphilis. The doctors told the study participants, all poor and mostly illiterate black men, that they were receiving first-rate medical care—including treatment for bad blood—for free. Eunice Rivers, a black public health nurse from the area, helped recruit and retain participants. She did community-based outreach to black churches and schools. At her suggestion, the researchers offered the men free burial. This was highly valued since the greatest disgrace was to die so poor you couldn’t get a proper burial. The men were deceived and received no treatment for syphilis, even though penicillin was available as an easy cure. The study continued until 1972, when a San Francisco-based journalist—tipped off by an internal CDC whistleblower—persevered to bring the public’s attention to the awful facts of the study. Some of the white male doctors and researchers involved still see nothing unethical in what they did. Eunice Rivers needed a job and she sincerely thought she was providing good nursing care to “her men.”

“The hallmark of the Tuskegee Study, and a key to its 40 year life, was its culturally-sensitive, community-based approach,” wrote Stephen Thomas in his article “The Legacy of Tuskegee: AIDs and African-Americans” (Jan/Feb 2000, Body Positive Magazine.) This is a good reminder of how good intentions—and good approaches to health care—can go to hell.

I feel uneasy about working in an occupational health setting, and I doubt I’ll return to work at that employee clinic. I didn’t feel right patching the workers up to return to their high-stress, low-paying jobs, sitting in the endless rows of cubicles under flickering fluorescent lights. But this means that I am rapidly running out of morally acceptable (to me) places to work within the US health care system. Perhaps next I will try jail health.

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