#HealthcarePathologies series Imagine if you worked at a hospital that had a McDonald's in the lobby. Since McDonald's has become shorthand for an entire unhealthy way of eating, this would seem like a bad choice for a hospital (although approximately 20 hospitals in the US do). Why, you might ask one of your colleagues, did the hospital, which like all hospitals gives lip service to nutrition, keep this franchise? They need the money, he'd say. Duh. In the same imaginary hospital, there might be pharmaceutical and medical device reps seated around small coffee shop tables, hawking their wares near the main entrance. McDonald's might only dominate the side entrance, but the smell would be pervasive. It would be a little embarrassing to walk by the golden arches, or maybe even angering to see the profiteering on display at both entrances. Would hospital administrators care so little about actual health that they'd flaunt their commitment to the profit motive so flagrantly? However, one day, let's say the hospital was able to shutter the McDonalds. Finally, after months of renovations, a new logo was revealed. Panera. Whole grains, greens and coffees. Surely in such an imaginary setting, the staff would be excited. It would smell better. It would have trendy, Instagrammable decor - as nice as the hospital administrative offices. I too like Panera orange frosted scones, as a treat*. Healthier than McDonalds**, maybe.
But take a few steps back from our imagination and let me show you how both franchises are essentially the same.
Several years ago I went with a friend to a medical conference called Healthy Lives, Healthy Kitchens. It is an annual event co-hosted by the Harvard School of Public Health and the Center for Culinary Arts. I don't treat patients and so none of the discussion was related to me developing my practice. I went to learn, spend time with my friend and get Continuing Medical Education credits (CME). I expected discussion of superfoods, clean eating and agrabusiness. More Panera, less McDonalds. But that was not what they were serving.
Instead, their main message was simple -just cooking your own food at home can be the needed step to better health. Food was centered not as a commodity and not as 'medicine', but as support for good health. They broadened the discussion beyond personal health and your food choices to the health of communities and environmental justice. The advice they gave (and give every year at this annual conference) is rooted in public health. It is common sense and low cost:
How to be healthier? Prepare your food at home. Eat 5 fruits and vegetables each day. Wash your hands. Get a good night's sleep and moderate exercise.
Dr. Eisenberg, one of the organizers of this conference, introduced teaching kitchens. Several dozen of these exist at hospitals around the world. Some are permanent and some are popup stands. Although they vary in size and adapt to their community, each teaches patients simple low cost ways to cook from home. Imagine if instead of a franchise fast food restaurant, our imaginary hospital had a large teaching kitchen. Such a kitchen could be a community catalyst for improved personal and public health. Although a teaching kitchen would be better for public health, I now see that a franchise restaurant demonstrates the actual values of a modern American hospital. I've learned more about hospital administration since attending that conference, and one thing is clear: hospitals are not a place of community service. Most hospitals in the US are non-profit, with roots in religious orders' charity efforts. Because of these origins, hospitals are considered a public charity - hence the charitable balls and fundraising drives. This branding still clings to our modern hospitals, burnishing them with a veneer of goodwill. The charity label disguises the true nature of hospitals - both profit and nonprofit hospitals are big, profitable businesses. As an industry, they are second only to commercial banking. They are the largest individual contributors to US healthcare costs, with Americans spending over $1 trillion a year at hospitals. ***.
Despite making so much money, (which gets classified as surplus operating expenses, as they cannot claim a profit), and reimbursing CEOs at corporate rates ($2-6M), not-for-profit hospitals are still considered charities. Charity is not a neutral word. It means on one hand that they don't pay taxes (not sales taxes, property taxes, state, nor federal), and on the other, they can accept tax-deductible donations, borrow money cheaply and even purchase drugs at cheaper prices. Nonprofit hospitals are required to offset this public largess with charity care, but many monitors have raised concerns that hospitals don't provide an equivalent dollar amount of care for the tax-benefit they receive.**** I was naive. And I'm trying to correct that. My first lesson about hospitals? Even with the charity label, hospitals are still in this to make money. Having a teaching kitchen, where people are students and not customers, would be too far out of the paradigm of patient as consumer to even consider. No matter what sort of food is being sold, a profitable restaurant chain in the lobby serving customers is much more in keeping with the hospital brand than a public health kitchen ever could be. In the grand scheme of things to care about, why do I even care about what sort of hospital food is offered? Because where the hospital chooses to spend money tells us about their values, and the values that under-gird American health care need to be changed. A decommodified teaching kitchen inverts the values of American medical care:
We neglect public health and glorify the individual.
We shame, scold and cajole individuals, rather than make changes to benefit us all.
We require retail price payment, for portions that are unhealthy and calories that are unneeded - the same way much of the care we deliver is overpriced, excessive and unnecessary.
Panera is not priced for people to eat every meal there. So too is basic medical care out of reach for many people. Our healthcare is administered from a place of scarcity, the opposite of universal.
Chain restaurants are branded experiences, just as hospitals, insurance companies and physician groups 'brand' themselves and spend money on advertising and political lobbying to promote their business - but lack resources when a pandemic hits.
To make the kind of change embodied in the promise of a teaching kitchen would mean reordering how we imagine, deliver and pay for care. And I don't know if Americans are able to imagine that.
*540 calories each. **I recently went to a Panera and couldn't find anything to eat! This is because I prefer to eat less than 700 calories for lunch, and I have a pretty big appetite. Instead I went to the hospital cafeteria where I had a slice of turkey meatloaf and steamed veggies for about 400 calories total. ***Hospitals are reported to be the 2nd most profitable industry in the US, just behind commercial banking. (I had to reread that to really take it in). Hospital systems have been consolidating for years, ensuring fewer choices or, in the case of rural hospitals, no choice at all, and also guaranteeing price monopolies. ****Comparing the Value of Nonprofit Hospitals’ Tax Exemption to Their Community Benefits https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5813653/ Further reading: An example of a wonderful teaching kitchen: https://www.bmc.org/nourishing-our-community/preventive-food-pantry Health care from an RN's perspective: http://wdtw.org/stories
Racism in concrete: Disparities
"The inequities we document reflect generations of deficient investment in the health care of communities of color. The term “structural racism” – the perpetuation of racial inequities by cultural, economic and political systems that are often inherited from the past and reproduced in the present – seems peculiarly apropos as a description of these stark inequities."