Monday, 27 June 2011

American Medical Association

Even as recently as two years ago, the idea that I would attend a meeting of the American Medical Association was vanishingly remote. But once on the slippery slope... As President of the BMA, I was the official representative at the AMA annual House of Delegates meeting in Chicago. Having met some of the senior AMA people at World Medical Association (WMA) meetings, I could almost “pass” as one of them. But not quite. I had two distinct but contrasting impressions.

The first relates, of course, to the social determinants of health. The incoming AMA President, Peter Carmel and I had met at the WMA meetings in Vancouver and Sydney. He is a paediatric neurosurgeon and I immediately thought there was a grace, an urbanity and humanity about him. After my talk in Sydney he said: I have heard you speak three times now. The first time I thought it was common sense; the second, I realised you had evidence; the third it was clear you are a bomb thrower. I would like you to come to Chicago and I want to expose you to 500 right wingers. Given that the meeting is mostly political, with delegates debating motions – it is accepted that the earth is not flat – there was no such opportunity. Pity. But he did introduce me to several AMA people by telling them how important it was to take note of the social determinants of health.

He even referred to it in his inaugural address, which was impressive. He talked not politics but of the role of the physician that involves empathy and integrity and desire to help. He said his heroes had always been doctors, including his own father. I was struck that religion features highly. He was sworn in, hand on bible, and ending with “so help me God”. The whole proceedings were opened by a Rabbi – Peter Carmel’s Jewish background was an important feature of the proceedings and his three children, their spouses and 6 of 7 of his grandchildren were there – and closed by a bishop. I was asked how it differed from the BMA. I told them that the BMA President has to do without God’s help. The counterfactual might be interesting.

The second abiding impression was that the AMA endorsed Obamacare – the affordable care act. One has to remember the slightly surreal nature of the debate in the US. Romney, when governor of Massachusetts, passed an act that arguably is the basis for Obamacare. As Governor, the act was introduced with great fanfare and it is highly popular in the state. But it is anathema to the Republican right. Today, Romney has somehow to distance himself from something of which, yesterday, he was justifiably proud if he wants the republican presidential nomination, which he is seeking.

Remarkably, perhaps, the AMA has approved Obamacare but there was still a three hour debate on the subject in Chicago. Particularly contentious was the requirement for individuals to have health insurance. People spoke “eloquently” of the fact that America was founded on freedom and forcing individuals to have health insurance was an erosion of that freedom. So is mandatory car insurance and taxation, but I suppose this is a step too far. It would appear that these defenders of liberty would rather have avoidable sickness and people refused care because of inability to pay than have further erosions of freedom.

In his blog Paul Krugman has an interesting take on this notion of freedom. Below is a direct quote from Paul Krugman’s blog:


Matt Yglesias is having fun with a study from the Mercatus Center purporting to rank states by their levels of freedom. I was disappointed to discover that New Jersey is only the second most tyrannical regime, behind New York.

One of Matt’s readers does the correlations, and finds that:

The Mercatus Institute’s freedom score was significantly linked to (by state)- lower educational attainment (measured by percent of Bachelor degrees or higher), lower population density, lower per capita GDP, increased infant mortality, increased accident mortality, increased incidence of suicide, increased firearm mortality, decreased industrial R&D, and increased income inequality.

This suggests that New Hampshire, which Mercatus considers the freest state (with South Dakota just behind) has its state motto slightly off. It should be “Live free and die.”

So much for freedom, or at least this bizarre version of it – the freedom to be denied medical care when you get sick.


  1. Hello Professor Marmot
    Thanks for this tolerant piece on our foibles. Next time you are here on this side, perhaps I can help connect you to the physicians who are addressing the social processes and determinants of health..
    Ken Thompson MD
    University of Pittsburgh

  2. Well said as always! I so admire your work.

    What I do not understand is how politicians here in the states cannot see the obvious. How are we to have a thriving economy when so many people are burdened with the debt of expensive health care?
    Politicians argue for less spending, and yet this country spends more on health care than any other, without improved results.

    A healthy and debt free populace would result in only positive benefits for the US economy, and the other countries invested in it.

    To add to your title; Fair society, healthy lives, and a thriving world economy.

    Thank you so much for your work!