On the economic geography of health care

"Health care in America is in crisis" is a serious understatement. It will only get worse!

Consider, for instance, employment.  We tend to assume that health care is a growing industry and, therefore, that is where the income stream is, right?  Yes, jobs are there, but ...

Yet for every higher-paying job held by workers like nurses and doctors, more than six workers such as orderlies, phlebotomists and cooks make less than $15 an hour. Nationwide, 70 percent of hospital service workers make less than $15 an hour, NELP found. In the Midwest, it's 71 percent.

Now, the $15/hr might sound like quite a compensation to a person in Bihar.  But, ahem, a cup of coffee is not 15 rupees either; there is the cost of living:

Most counties in the U.S. have a cost of living across industries that isn't covered by minimum wage incomes, according to a recent blog post from Amy Glasmeier, a professor and co-chair at the Massachusetts Institute of Technology's economic geography and regional planning Ph. D program.
For instance, in Chicago, a single parent of one child needs to earn $24.67 an hour to meet a definition of living wage, while a person living alone there needs at least $12.33, based on a living-wage calculator  developed by Glasmeier in conjunction with MIT.

At least the cities are better, when one looks at health care in rural America; "half of the country's rural counties now don't have hospitals with obstetric services":

Maternity care is disappearing from America's rural counties, and for the 28 million women of reproductive age living in those areas, pregnancy and childbirth are becoming more complicated—and more dangerous.

One important factor is nothing but dollars and cents:

If hospitals want to offer obstetric services, they need to be ready for a baby to be born at any time—they need to have a bed available, the equipment available for mom and for baby, clinicians and staff available that have the necessary skills. That's a substantial expense. If a hospital's revenues are limited because it has a low volume of births—as many rural hospitals do—or if revenues are unpredictable, that creates a really difficult administrative problem.

It is exactly in such situations that we expect the government to step in where the market fails, right?  Especially when you consider this: "Medicaid funds about half of all births in the United States, and an even greater percentage of births in rural hospitals."  So, if these health care services for pregnant women are gone ...?

State and federal programs to support the rural maternity workforce are crucial. There ought to be programs to support training in emergency births in rural communities that lose obstetric care, and to support the costs of providing maternity care in communities where there are willing providers.

trump and his 63 million voters can fix this all with a complete repeal of Obamacare, right?

On life and death in India. Now "Congo Fever" :(

The Economist has one of the best opening lines ever in some of the recent journalism stories I have read recently:

YOU can be killed by an exotic variety of diseases in India.

Isn't that the case!

About four or five years ago, I was shocked when I first read about a Dengue Fever epidemic in India, and then even more shocked when I met one who was down with that fever.  And then the last time when I was there, I find out that an aunt had Chikungunya and took months to recover.  A couple of days before I left the country I called my friend's parents to say hi to them, and his mother said that she still has pain--months after a Chikungunya infection.  The good thing is that these women (all women? really?) recovered well enough.

Up until all these, I thought Dengue and Chikungunya were infections that we had to watch out for while in Africa.  I suppose there is phenomenal globalization in infectious diseases too. 

Anyway, what is the latest exotic killer in India, you ask? "Congo Fever:"

A tick-borne virus, endemic to parts of Africa, the Middle East and elsewhere, it passes easily from livestock to man, and then between humans. Horrible symptoms include fever, internal bleeding and liver failure. Some 30% of infected humans die, usually within a couple of weeks.
The authorities in Gujarat, western India, were therefore alarmed when in January a medical intern died of the disease, formally known as Crimean-Congo haemorrhagic fever. Earlier in the month it killed three others: a patient, plus a doctor and nurse who had cared for her. These appear to be the first recorded deaths in India from the illness. On February 5th doctors reported two more cases in Gujarat. The fever’s arrival is a mystery.

It is crazy!

It is unfortunate that rural development and health do not attract enough attention in India.  Politicians and governments are far more interested in urban-oriented investments with whatever money is left after they have swindled. 

Indian officials acknowledge that the country needs to increase investment in irrigation, encourage competition in wholesale and retail markets, and provide targeted food subsidies to the poor. And they also have to provide more education and jobs to villagers, so fewer people are forced to live off the land.
Experts say India needs to make changes like some of the ones China made, beginning in the late 1970s, when it started investing heavily in agriculture and eased regulations on farming.
As recently as 1977, Chinese and Indian farmers harvested roughly the same amount of wheat for each acre that they planted. But by 2009, United Nations data shows that wheat yields were 1.7 times higher in China than in India.
Kaushik Basu, a Cornell University professor who is also the chief economic adviser to India’s finance minister, says he now sees more willingness by Indian officials to reform agriculture policies.
But outside experts like Mr. Gulati are skeptical that real change will come from the government. The ruling coalition has been hobbled by corruption scandals, and an energized opposition last year effectively blocked proceedings in Parliament.

The country is rapidly devolving into a bizarre version of "democratic oligarchy" ... the phenomenal amounts being spent on cricket is evidence enough.

I hope a few more people will follow the example that Wipro's Azim Premji is setting with his philanthropy:

Crowing about having gone to Crow

I learn a lot through my students.

When I tell students this, their facial expressions don't suggest that they believe me.  They probably think I am mouthing off some platitude.  But, I am dead serious.

One example is this: I pay attention to their descriptions of towns and high schools.  It gives me a phenomenally insightful view into a world that I might not otherwise know about.  And then, when I get a chance, I swing by those communities. 

Given that I grew up in a different part of the world, and given that I moved here from California, through my students I learn a lot about Oregon, its land and peoples.  And then, in some other class when a student says a town's name and I am able to relate my experiences with that town, that student and the rest of the class begin to see me as one of their own.  Yes, I can see that difference in their body language, their sudden warmth and respect ...

My first this way was about Astoria, many years ago ... That student was blown away with my stories of the tram by the waterfront and a restaurant in town.

Thus, over the years I have been to communities that I might not have visited otherwise.  I have now that much more of a feel for the places from where our students come.

Last year, one student was very hesitant to talk about her town--Crow.  I told her that I had seen signboards pointing to Crow, but that I had never been there.  She dismissed it as not worth a visit .. that it is a very small town ... but, I knew it was worth a visit, and that I would learn a lot.

And I did.



Crow is in a fantastically scenic setting.  It was late in the afternoon on a wonderful summer day--about 75 degrees, sunny, with scattered white clouds against a remarkably blue sky--when I was driving around that part of the country. Yes, it is country--large acreage homes with animals, trees, vineyards, ...

As I was driving, it occurred to me it could easily compete with the rural landscape outside of Firenze (Florence) that I vivdly remember from my only trip there twelve summers ago.  The small little church, the high school which definitely could be a focal point of the community, the gas-station/mini-mart ... what politicians would easily refer to the salt of the earth America.  I loved it.

I stopped for a bit to watch a few cows wandering about.  There was something soothing in watching those animals against the slowly yellowing setting Sun.

Thanks to that student, "H."

Now, I wish some of these students would invite me over, so that I can get a taste of the food their mothers and grandmothers cook :)

Update (August 20th):
"H." emailed me the following:

Hi Dr. Khe,

This made my day! I'm really happy you went out to Crow    If you ever head out that way again, let me know! I can meet you down there sometime and take you home for dinner at my grandma's. It's even further outside of civilization than the high school and the Crow store.

Thanks for the update!

All right, an open dinner invite :)

Are New Yorkers simply detestable?

Steven Chapman on Why it's time to bury the myth of rural virtue:

In 2007, a survey of 8th graders by the Monitoring the Future project at the University of Michigan found that country kids were 26 percent more likely to experiment with drugs than middle-schoolers elsewhere. Overall methamphetamine consumption among adults and teens is more than 50 percent higher in the country.The story with alcohol is worse still. ... Nor is the countryside exempt from social problems often associated with the inner city—such as, if you'll forgive me, out-of-wedlock births. ...The highest rates of births to unwed mothers are in Mississippi and New Mexico, both of which have high rural populations. The most urban states, New Jersey and California, do better than the average in out-of-wedlock births.

Jon Stewart got ticked off for the same big-town-bashing that certain politicians engage in, implying that big towns are nothing but immoral in every possible way. Watch him here: