Posted on October 25, 1993 in Washington Watch

The American political scene has come to be dominated by the issue of health care like not other issue in the past generation. It has played an important role in U.S. politics for the past three years, and will for some time to come, but it is incredibly complex.

Dr. Mohammad Akhtar, a Pakistani American, is one of the leading medical professionals in the U.S. As Commissioner of Public Health in Washington, DC, he has become an outspoken advocate in the American debate on health care.

Dr. Akhtar came to his post in 1991 from a distinguished career in medicine. After receiving his medical degree in Lahore, Pakistan in 1967, Dr. Akhtar came to the U.S. to the U.S. to finish his training. During the 1970’s and 1980’s he held major posts in the health departments in the states of Michigan and Missouri. Then, in 1987, he returned to his native Pakistan as Principal of the College of Community Medicine in Lahore and also as Chairman of that institution’s Department of Public Health and Hospital Administration.

Dr. Akhtar returned to the U.S. in 1991 and was appointed by Washington’s Mayor to serve as Commissioner of Public Health. In this capacity, he is responsible for safeguarding the health of the city’s 650,000 residents, supervising its 1,700 health care employees and overseeing its budget of $156 million.

Within a short period of time, Dr. Akhtar has made major innovations. He instituted a comprehensive school health project which placed nurses in every school and provided health services and education to the city’s children. Dr. Akhtar also developed a five-year AIDS plan, a city-wide immunization campaign to inoculate Washington’s children against disease, and he has created mobile medical clinics to bring health care services to the poorest neighborhoods in the area.

Dr. Akhtar speaks passionately about the city of Washington (simply called “DC” by most of its residents, of which I am one). DC provides a shocking case study in the health care crisis facing the U.S.

Like most major U.S. cities, there are two Washingtons. An affluent white part of the city with the best hospitals, best doctors and people wealthy enough to afford health care. The other Washington, more than 60% of the city, is desperately poor, largely black, with pressing problems of unemployment, drug abuse, violence, and rampant teenage sex.

The result of these widespread social problems is a devastating health care crisis. 112,000 residents of the city (one-sixth of DC’s total population) have no health insurance. They therefore cannot afford health care and don’t seek it unless they become severely ill. Then they go to the overcrowded emergency rooms of the city’s hospitals for concentrated care which they then cannot pay for.

Another 100,000 DC residents are on Medicaid—the nation’s limited health care program. They do receive treatment, 50% of which is paid by the DC government and 50% of which is paid by the federal government. The annual Medicaid bill for the DC government is over $300 million. After the running of the city itself, health care is the biggest industry in Washington.

As a result of poverty, poor health care, bad diets, drug abuse, and teenage sex, the health care problems of the city’s poor are overwhelming. High blood pressure, high rates of heart disease and cancer, the highest rate of death and injury through violence in the country, and a shockingly high level of infant mortality and babies born with serious defects. Infant mortality is a useful index of the quality of health care in a country. The U.S.’s rate of 8 to 9 deaths per 1,000 live births is good but not in the top 10 among the nations of the world. By comparison, the rate in DC is 20 deaths per 1,00 live births, and in the poor areas of the city the rate jumps to 40 per 1,000. This is roughly equal to the rate of many of the poorest developing nations.

Dr. Akhtar notes that DC’s problems are not unique. The health care crisis in New York, Chicago, Los Angeles and most major U.S. cities is very similar.

But DC’s problems are different in one respect. All other cities with health care crises are in states where the state governments provide additional revenues to assist the poorer and more challenged cities. While Atlanta, for example, is as hard-hit by health care problems as is DC, Atlanta can be helped by the State of Georgia, which can provide revenues derived from taxing their cities’ more wealthy suburbs.

DC, by contrast, is a city without state authority, and so it cannot make its own policy or raise adequate taxes, because the residents of its suburbs live in other states. And so the city government of Washington faces serious problems.

Recently, Dr. Akhtar challenged the nation by proposing comprehensive health care reform in DC. Calling President Bill Clinton’s health care reform program inadequate to meet Washington’s needs, Dr. Akhtar proposed a more radical approach.

The President’s health care reform program is based on what has been termed a “managed competition” model. In proposing his reform program, the President was responding to what many Americans are convinced is one of our nation’s most pressing problems. Consider the following:
· 37,000,000 Americans do not have health insurance.
· 22,000,000 Americans have only partial health insurance.
· Every month 2,000,000 more Americans lose their health insurance.
· 14% of the entire gross domestic product (GDP) of the U.S. goes to pay for health care.

The President’s goal in his reform program was to reduce costs and provide universal coverage to all Americans. The “managed competition” approach creates large groups of buyers, so that instead of buying health insurance as a number of small groups, groups will be pooled together with the hoped-for result that costs will come down. In the President’s system, every American will receive a “health security card” and will be eligible to join one of the large groups buying health insurance. And those who can’t afford to pay the group’s premium will be provided with the support to do so.

What Dr. Akhtar proposes for the city is what is called the “single-payer” model of health insurance. Using this approach, Dr. Akhtar proposes that rather than competition, the government will create a single group insurance program to which every citizen will belong. In this model, the government will take charge, regulate cost, guarantee service and reduce the 25% administrative costs that are currently charged by the private insurance companies.

Dr. Akhtar argues that by using the “single payer” model, DC will ensure that everyone will have the same access to health care and costs for the overall system will be lower.

While the President’s plan does allow individual states (or, in this case, Washington, DC) to develop alternative models if they see fit, Dr. Akhtar’s proposals generated significant press coverage during the past few weeks, putting him in the center of the nation’s health care debate.

Dr. Akhtar praises President Clinton for having raised the issue of health care and for putting a proposal before Congress. He feels, however, that the President’s plan “has compromised too much” and, in any case, won’t solve the desperate problems faced by the city of Washington.

Both Dr. Akhtar’s proposal and that of the President have come under attack from the powerful medical and health insurance lobbies, together referred to as the health care lobby. Tens of millions of dollars are being spent on television advertising to defeat the President, and the lobby (which has also made tens of millions of dollars in campaign contributions in recent years) is putting pressure on Congress to stop any reform.

But Dr. Akhtar is made from stern stuff and he seems ready to face the challenge. It is important that this Muslim American is taking a leadership role. He is proud of his ethnic background and has played a leadership role among immigrant doctors in the U.S. For two years he served as the President of the American College of International Physicians. There are, as Dr. Akhtar says, 125,000 foreign-born doctors in the U.S.—25,000 of whom are Muslim.

He reports that he has faced discrimination in his life, but he says “everyone who first comes to this country faces it…the Irish, Jews, Arabs, Italians. They were all first met with resistance.” The way this doctor dealt with the problem was “not to cry, but to prepare myself, to compete, be the best, and make it!”

Dr. Akhtar has advice for his colleagues who are immigrants from other countries. “Don’t forget your native lands,” he says, and he proposes a number of contributions they can make. First, they can send medical books, journals, and equipment back to hospitals in their countries. He also suggests that they can return for a time to their native countries as he did to Pakistan, to teach, or provide care or to live for a short period of time and help prepare the young for the profession of medicine.

Finally, he suggests that they should always look for ways, as he did, to synthesize the good in both countries’ systems—the American system and their native system—so as to help bring the best of both together. In fact, many of Dr. Akhtar’s most interesting innovations in DC health care have come as a result of applying lessons he learned in Pakistan to the poor of Washington. Promoting the use of nurse midwives, training older women to become nurses’ aids, and instituting what Dr. Akhtar terms “culturally sensitive” health care are all ideas he imported from his experiences in Pakistan.

Mohammad Akhtar has already made a significant contribution to health care in the U.S.—and as the debate over reform continues, his contribution will only increase.

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