Friday, September 18, 2009

Making The World Sick, One Country At A Time

(Warning: this is a long post.)

The predicament that marks the probable end of our industrialized society has two stages. The stage most easily visualized by many of the first thinkers on this subject has its roots in the Limits To Growth scenarios first analyzed by the Club of Rome. Its most popularized images look like scenes from a dystopian science-fiction movie starring Charleton Heston or Will Smith or Mel Gibson or Harrison Ford – famine and the failure of technology; poisoned landscapes and cities with zombies running in the streets; “World of Warcraft” meets “Survivor” – in short, a “hard crash.”

However, there is a prior stage to the effects of resource scarcity: economic upheaval and contraction. The images that fit this are found in Dorothea Lange Depression-era photography; scenes from John Steinbeck's Grapes of Wrath; the Dust Bowl; tent cities; people losing jobs as the economy contracts; people being priced out of oil-based “necessities” as prices continues to increase; and people being thrown out of their homes, having their things repossessed and living under bridges due to “lack of sufficient funds.”

The second stage may be coming shortly, but the first stage is where we are now. The response to the onset of this first stage on the part of leaders in government and commerce by and large is as follows (there are, of course, exceptions): 1. A refusal to rearrange the social/political/economic systems under their control to make them more resilient in the face of the disruptions of Stage Two; and 2. A manic attempt to sustain their existing systems, which are unsustainable, and for which the writing is already on the wall. The leaders in government and commerce are now diverting all available public resources to this attempt to sustain the unsustainable.

Preparing for industrial and economic collapse in all its stages is therefore up to individual citizens. The captains of finance, economics and government will not institute the necessary changes, because such changes would reduce their power, prestige and access to wealth. This is why it's up to citizens. Yet the very nature and policies of the existing systems and their masters actively hinder the efforts of ordinary people to become resilient in the face of collapse. This hindrance comes either through government policies and laws that make resilience difficult, or through economic arrangements that bleed ordinary people dry so that they have no resources left for building resilience.

Such is the case with health care in the United States, that act of formerly selfless service embodied by the family doctors of decades ago and television doctors such as Dr Kildare, Ben Casey and Marcus Welby. This “service” has metastasized into a money-sucking “industry” so expensive that whereas the normal delivery of a live baby cost less than $100 in 1950, it now costs anywhere from $6000 to over $12000 today. According to one source, American national health spending is expected to reach $2.5 trillion in 2009, accounting for 17.6 percent of gross domestic product (GDP). Health expenditures are expected to increase at a rate of 6.2 percent per year from now to the year 2018, which is faster than even the most optimistic estimates of growth in GDP for this period. Part of the expense of American health care is due to exploding administrative costs. But there are other contributors, such as costs for prescription drugs that are rising at over twice the rate of inflation, cost increases for medical equipment and consumables, and inflation in employer-sponsored health insurance premiums which have risen at four times the rate of inflation during the past decade.

There's been much controversy this year over the possibility of Federally mandated health care reform. I really don't expect the Democratic or Republican Parties at any level of government to craft genuine reform of the sort that would lighten the economic burden for the recipients of that care. Some of our expectations regarding American “health care” may also be unrealistic, including the expectation that the Government can afford to pick up the tab for health care as it is currently practiced in the U.S. for all residents of the U.S. My suspicion is based not only on the unjustifiable rate of rise in American health care costs, but also on the fact that most of the wealth we could have devoted to equitable Government-backed health care and other safety nets has been squandered on covering the monetary losses of the rich. Our remaining tax revenues will largely be dedicated to servicing our large public debt, and the ability of our government at all levels to borrow additional money will shortly be severely curtailed.

I think it is also unrealistic for the masters of the health care “industry” - the doctors, hospitals, HMO's, insurance providers, drug companies and providers of medical technology – to expect that the system they have created can survive unbroken and unchallenged once almost no one but the rich can afford to use it. Already that system has priced 86.7 million Americans out of health care from 2007 to 2008. In 2008, at least 46.3 million Americans were without health insurance for a full year, according to the U.S. Census Bureau. In 2009 these numbers will only increase, due to the explosion of job losses, exhaustion of workers' unemployment benefits and continued escalation of insurance costs.

In short, I expect the nature and experience of health care to change drastically in the United States over the next several years. Increasingly, it will resemble the care provided in many Third World countries. Hopefully we will witness the adoption of some of the more beneficial and fair systems now operating in the Third World. Yet before we all rush to the countries of the developing world for inspiration and guidance, we need to see how the architects of the present American system of health care have attempted over the years to wreck viable, low-cost Third World alternatives. These attempts at wreckage were intended to protect and increase the revenue streams from the world's poorest people to the First World providers of expensive medical intervention and treatment.

The History of Western Medicine in the Third World

In his paper, “The Life And Death Of Primary Health Care,” David Werner writes that from colonial times until recent decades, the providing of Western medical service to the Third World was not equitable. The most expensive services were directed to the privileged, whereas health services directed at the “natives” were few, and were designed mainly to keep them healthy enough to work for the rich. But in the post-World War II era, there was a dawning awareness of health and health care as fundamental human rights. This led to efforts by rich countries to make Western medical practice more widely available in Third World countries.

However, this approach to expanded health care proved to be unsustainable, since Western medicine was too expensive even then for most Third World governments to widely support, or for indigenous peoples to use. This was partly due to the influence of budding multinational pharmaceutical corporations whose advertising induced a dependence on expensive treatments while eroding traditional forms of self-care. By the late 1970's it was widely recognized that the standard Western model of health care was failing in the developing world. This realization led to an international health care conference hosted by the World Health Organization in Almaty (formerly Alma-Ata) in the former Soviet Union in 1978.

Alma-Ata And Its Aftermath

The Alma-Ata Declaration of 1978 defined health as “a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity...” This declaration set forth this health as a primary goal to which governments should strive, and deemed existing health inequalities to be unacceptable. In order to achieve the goal of universal health, the declaration proposed a “Primary Health Care” which was defined as “...essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford ...”

The implementation of this Primary Health Care was to involve all major elements of community life, such as sanitation, the provision of safe and healthy food, access to clean drinking water, housing and other basic needs. Very importantly, this implementation was to be community-based, “...requiring and promoting maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and...developing through appropriate education the ability of communities to participate ...”

The Alma Ata Declaration was revolutionary its emphasis on addressing the root factors of health and giving ordinary people more control over their health and lives. It proved to be too revolutionary for the heads of the governments of the First World, who systematically transformed Primary Health Care into merely another program for extending conventional Western, top-down health services into the Third World. This was accomplished by the promotion of “selective” Primary Health Care by donor countries; by the increased shifting of costs of Western medicine onto end users (ordinary poor people) via “Cost Recovery”; and the takeover of health and social policies of Third World governments by the World Bank and the International Monetary Fund (IMF), which enticed many countries into taking loans with ruinous repayment terms, then forced those debtor countries to dismantle their social safety nets as part of their repayment.

One word on “selective” Primary Health Care: one of its initiatives was the so-called “Child Survival Revolution” that focused on growth monitoring, oral rehydration therapy (ORT) (for diarrhea), breast-feeding and immunization. The approaches implemented in this “Revolution” favored expensive treatments sold by pharmaceutical corporations – especially the pre-mixed ORT packets that were pushed instead of homemade foods and liquids.

The gutting of Primary Health Care as a viable option, combined with the World Bank's forcing debtor countries to dismantle government-sponsored social safety nets, led to a deterioration of health in the developing world. In addition, the World Bank has insisted on privatization of services formerly provided by governments, and has been an active agent in expanding the role of private health insurance in Third World health care.

American-Style Health Insurance – Coming To A Country Near You

Private health insurance is a very fast-growing worldwide market. The insurance “industry” is especially interested in the developing world, where it grew more than twice as fast as in the First World from 1994 to 2004. The promotion of private health insurance is especially attractive to the Organisation for Economic Co-Operation and Development (OECD), an association of thirty nations, most of whom are the richest in the world, and whose member countries are home to the largest multinational insurance and investment firms. One OECD study notes the extensive penetration of private health insurance in Latin America, while discussing strategies such as subsidized coverage in order to boost penetration in East Asia. However, even the authors of that study admit that the introduction of private health insurance “...might also lead to cost escalation, a deterioration of public services, a reduction of the provision of preventive health care and a widening of the rich-poor divide in a country's medical system.”

Private health insurance is threatening to displace other options, partly through advertising that seeks to induce dissatisfaction with public health care, and partly through the promotion by the World Bank of so-called “free market” policies and privatization of social services in Third World countries. In fact, since 1993 the World Bank has pushed a view of Third World health care as simply a means of enhancing worker productivity for economic growth – a view that is very similar to the colonial view of the purpose of medicine in the Third World: to keep the natives healthy so they can work for the rich.


Because of the power held by the medical and insurance industries in the United States, I expect that the present attempts by our leaders to “reform” our health care system will turn out as badly as the attempt by the WHO to implement the Alma Ata Declaration. As that declaration was thwarted by the rich, I expect that our health care “reform” will also wind up as simply another means of moving money from the pockets of poor people into the coffers of the rich. Ah, but that's what our health care system is already...


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