In the United States, we are having a national debate about inequality. The very rich are getting very much richer. And everyone is agonizing about the lack of upward mobility that is so central to the American dream.
Obamacare at its core is a simple attempt to address one dimension of inequality of income and opportunity. It provides subsidies (paid in part by the wealthy) to low-income folk so they can purchase high-deductible health insurance (that should work well, right?) and it expands Medicaid to include the working poor.
In the rich Persian Gulf states, money is no object for those countries aiming to build state-of-the-art medical care facilities for their citizens. But they are also starting to address bigger questions about providing health insurance to the entire population, including expatriates who live and work in their countries, often on a temporary basis.
Visiting Dubai the day Pete Seeger died struck a chord with me: All rich countries have a moral obligation to consider the health and health care of all their residents. While providing health insurance may seem like an important step, it is only a partial step toward improving health and health care for all. Innovation in care delivery using inexpensive technologies may be the key to health for all. It's what Pete would have wanted.
My Journey to Dubai
I was asked to give a talk to a leading group of hospital CEOs in the Arab world. They were coming together to attend a massive medical meeting (Arab Health Congress 2014) in Dubai, and my client was holding a private event for some of the top leaders.
Since Dubai was on my bucket list, I jumped at the opportunity, even though it was logistically challenging because the meeting was wedged between obligations in Monterey County, Calif., and Phoenix. (I may be the only guy ever who was in town for the Dubai Open and the Phoenix Open given they are held the same week.)
My itinerary was made easier because Emirates has a direct flight from San Francisco to Dubai that goes straight over the North Pole. Trust me, flying 15 hours first class on Emirates just once makes up for a lifetime flying in the back of the bus on United.
Not only was this a top 1 percent experience, it was a top 0.1 percent experience and a metaphor for the global economy. Business class is pulling away from economy and first class is unattainable, but if you are in it, it's sweet.
Recent studies by economists at the University of California, Berkeley, and the Paris School of Economics show the widening gap at the top. As Annie Lowrey of The New York Times succinctly put it after reviewing their work (Feb. 10, 2014): "For now, it is a very good time to be very, very rich. The 1 percent are doing well. The 0.01 percent — they're doing even better."
Dubai is a metaphor for the global economy. Fabulously wealthy sheikhs shower generous incomes on the 20 percent of the population who are Emirati citizens. The other 80 percent of the population (mostly from India, Pakistan and Bangladesh for the construction and menial work, and Brits and other global travelers for the professional jobs) make better incomes in this nearly tax-free environment than they would at home.
I got a chance to see a bit of Dubai and chat with leaders in the region in my three days there. Massive skyscrapers (including the tallest building in the world, the Burj Kalifa) rise from what was barren desert only 30 years ago. It is an urban dream of glitzy hotels and towering office buildings with an otherworldly quality: like Las Vegas without the cleavage.
The wealth is apparent in the over-the-top shopping malls, where Western ex-pats mingle with fully veiled Dubai matrons, kids in tow. The Dubai Mall boasts 1,200 luxury stores, an aquarium that rivals that of Monterey Bay, and a decent ice rink where I watched ice hockey practice. (They need to work on their slap shots.) The slightly older, but equally huge and fancy Mall of the Emirates boasts its own internal ski slope. Man over environment. Pete Seeger would be concerned about the global climate effects of making snow in 130-degree temperatures.
While new Dubai is a modern urban fantasyland, the older part of the city around Dubai Creek is a little less glitzy and home to the traditional gold and spice souks. There you see what life might be like for the armies of workers who come to work in construction — a lot grittier, a lot more third-world. Not unlike the short ride from the Upper East Side to the Bronx, or Palo Alto to East Palo Alto, or Pacific Palisades to Compton.
Their Health Care Issues
So what is keeping their health care CEOs up at night?
Money is no object. As one observer told me: Money is no object. Gulf CEOs can buy the fanciest technology and they do. New modern facilities are being built around the gulf, including American-backed brand names like Mayo, Cleveland Clinic and Johns Hopkins. In Qatar, Sidra Medical and Research Center aims to be the leading women and children's research and clinical facility in the world. I joked with some American hospital CEOs when I got back that when I hear "money is no object" from them, it usually means they don't accept Medicaid and they are not in an exchange.
Health care is a superior good. Economists agree that health care is a superior good, namely that a country will spend proportionally more on health care as national income per capita rises. Yet, most of the rich Arab countries like the United Arab Emirates, Qatar, Kuwait, Bahrain and Saudi Arabia in particular, while they have very high per capita incomes (higher than the United States in some cases), they spend a very low share of gross domestic product on health care.
Qatar, with all its wealth, spends less than 2 percent of GDP on health. While this will surely rise over time as the investments they are making become operational, it will not reach levels of the developed world for three reasons:
- they have very young populations;
- they have high fertility rates and, therefore, will remain relatively young;
- most importantly, 80 percent of the resident population are temporary workers who will leave before they reach the age of morbidity.
People are the problem. Even with deep pockets, the gulf states all struggle with getting enough trained human resources. While they can draw some top-flight North American and European clinical leaders, they also have to tap resources from other parts of the Arab world, including Egypt and Iran, where well-trained physicians are attracted to the economic opportunities in the gulf. This creates problems for these other countries as they lose their own precious manpower, a problem exacerbated by the medical needs associated with countries such as Syria, embroiled in armed conflict.
And then, when you attract the polyglot staff, how do you manage care delivery when your people may have been trained in 50 different countries? We have that problem here, too, but it presents an even greater challenge in the gulf.
Obesity is a huge problem … My enduring image of Dubai is the astonishing number of food outlets. Tempting food is everywhere. They may have brought in the Cleveland Clinic, but they also imported the Cheesecake Factory, Tim Horton's Donuts, Applebee's, California Pizza Kitchen and every global junk food brand. You can see it in the malls especially, with rich, sweet indulgences available every few paces (and there seems to be more eating than pacing going on).
As a result, the gulf has an alarming obesity problem that is reflected in extremely high rates of cardiovascular disease and diabetes. For example, World Health Organization data show that obesity rates in the UAE are twice as high as that of the Middle East as a whole; in most gulf states, more than half of deaths in the 30-to-70-year age range are attributable to cardiovascular disease and diabetes, compared with just 30 percent in the United States.
… made worse by no walking. I get it; jogging in 130-degree temperatures is not healthy. Indeed, that's why you see buff ex-pats jogging in the air-conditioned malls, darting past Louis Vuitton and running a long loop back to Chanel. But when I asked the hotel concierge if it was OK for me to walk the 2 kilometers to the Dubai Mall outside in perfect 70-degree weather, he looked at me astonished and hailed me a cab. (The cabs are cheap, plentiful and efficient.) So, you can't walk even if you want to, and guess what? It raises the classic public health equation: Cheesecake Factory + sitting on your ass = diabetes.
Expansion of coverage. The sheikhs could just sit on their money, but the leaders in the gulf seem determined to do the right thing for their citizenry and, increasingly, for the expats. While citizens of most gulf states have free health care paid by the government, many of the gulf states have expanded or are planning to expand coverage to all their citizens through employment-based mandates to provide coverage (paid by both employer and employee) analogous to systems in Switzerland or Germany.
For example, Kuwait and Saudi Arabia have had such a plan for some time. Abu Dhabi started its plan in 2006. And the gulf newspapers were all abuzz when I was there that Dubai's plan started on Jan. 1, and will be phased in for all residents including guest workers by 2016. Comprehensive coverage costs between $150 and $300 per year!
Health care as economic base. Throughout the gulf, but particularly in Dubai, Abu Dhabi and Qatar, health care is seen as a potential economic base for the future. In regional economic terms, it is a form of import substitution where the Cleveland Clinic comes to you rather than paying your citizens to fly to Cleveland (which most of the gulf countries will do for their citizens, by the way, few or no questions asked). Increasingly, though, gulf countries see health care as an economic base by attracting wealthy patients from elsewhere in the Arab world and beyond, as well as serving a large and growing domestic population.
For example, Dubai has an area known as Dubai Health Care City, where international standard health care facilities are being built, including assisted-living facilities and high-end retirement centers. (Actually, this might be a better option for U.S. citizens with modest retirements rather than spending down your assets to qualify for Medicaid and to get a bed in a long-term care facility in Arkansas.)
Leapfrog opportunities. Gulf countries are extremely wired (rather, wireless). They have huge Internet penetration, they have double the number of cellphone subscribers per capita as has the United States, and they are extremely heavy users of social media (as documented in a wonderful 2013 study by Northwestern University and Harris Interactive for the government of Qatar). This platform is an opportunity for the gulf to leapfrog over all our steam-driven, legacy-based, meaningless-use health IT systems to social, mobile and big data enablement of health care.
Indeed, Deborah DiSanzo, CEO of Philips Healthcare (my host in Dubai) believes the gulf states can be pioneers in this area. And she should know; in addition to her day job and outside board responsibilities like Project Hope, she is the steering board chair of the World Economic Forum's project on Health Systems Leapfrogging in Emerging Economies. Watch as more affordable innovations from emerging markets such as India, China and the gulf get applied as solutions in expensive, mature markets like Europe and the United States.
Pete Seeger's Take on Dubai
I feel a special connection to Pete Seeger, because my beautiful, talented, epidemiologist daughter spent two months on the Clearwater (Pete Seeger's boat on the Hudson) cleaning up the Hudson and teaching kids about the environment. This was during a two-year period between college and grad school when she had what I called serial hippy-chick jobs including working in a pet store catering to the Silicon Valley elite and looking after injured rescue dogs in New Orleans.
She raved about and was inspired by Pete Seeger's energy, commitment, compassion and concern for the less fortunate. And she marveled at his ability to get everyone to sing along and get along (even when he was being investigated by repressive regimes).
Pete dropped out of Harvard as an undergrad. (Is it just me, or do Harvard dropouts go on to greater things than those who graduated?) Then he traveled this land making music and mischief in the Civil Rights movement, the antiwar movement, the environmental movement and even lent a hand to Bruce Springsteen and Occupy Wall Street.
I thought of him in Dubai the day he died as I talked on my iPhone to my daughter about my adventures in the gulf.
I think Pete would say that many rich countries share a lot of problems like obesity, indolence and diabetes because we don't take care of ourselves and each other, and we need to eat better food, but less of it.
He would be appalled by skiing on artificial snow in the desert, but inspired that leaders can learn to cover all their citizens and all their residents, including guest workers. And he would point to the irony that if the sheikhs in the gulf can do it, why can't the sheikhs in Washington and the state legislatures make it happen?
He would ask questions about what happens to the poorest folk — how are they being treated? Much in the way my friend and fellow futurist Joe Flower did in a recent column about the care for the poor in the United States in a post-reform world.
And finally, Pete would be inspired and amused by innovations like the smartphone holding the promise to change how we deliver care. As Pete once said, "Technology will save us if it doesn't wipe us out first."