A Safety Net Of Alternative Systems - Providing Community Doctors

Medical care in the United States is insanely expensive. According to several sources, medical bankruptcies account for 60 percent of all personal bankruptcies in America (even though most of those driven into medical bankruptcy have insurance). Moreover, American health care is very technology and drug-driven. This is by design, as American health care has become a capitalist growth “industry” whose masters demand continually increasing profits every quarter. As the global economy continues to shrink, and as the economy of the U.S. in particular continues its collapse, an increasing number of people and communities are being cut off from standard American health care. This trend will only worsen as the industrial economy continues to contract due to the depletion of natural resources such as oil.

Today's post consists of a transcript of a recording I made a couple of weeks ago of an interview with Rachel True, MPH, Academic Program Director for the Medical Education Cooperation With Cuba organization, also known as MEDICC. We discussed the work of the Latin American School of Medicine (ELAM in Spanish) in training primary health care physicians to labor in poor countries and communities, and how disadvantaged American communities could benefit from the initiatives of ELAM. ELAM is now offering scholarships to students from disadvantaged communities in the U.S., for the purpose of training these students as doctors, with the condition that these newly trained doctors be willing to go back to their home communities to help their neighbors. ELAM is a Cuban school which trains Cuban doctors – doctors who have earned a very high reputation for competence and skill. ELAM is therefore an important avenue for communities in the U.S. who want to build their own health care systems.

In the following transcript, my questions and comments are in bold type. If you wan to listen to the interview, you can find it here: “Internet Archive: Free Download: Interview with Rachel True of MEDICC”.

Rachel, what I'd like to ask first is the history and motivation behind the setting up of ELAM. Why did Cuba decide to set up this school? What are their goals? What are they accomplishing?

Cuba has had a very long history of international cooperation in the area of health and human resources for health. For many years they have sent their own trained doctors abroad to countries, mostly in Latin America, but also in Africa and other parts of the world, where they have collaborative and cooperative agreements in solidarity with those countries as they work toward addressing health disparities and the inequities in their own health systems, and addressing the shortage of health care workers in their own countries.

ELAM began as a response to the hurricanes Mitch and George, which devastated much of Central America in the late 1990's. As is often the case, Cuba sent a large number of doctors to the affected areas to address the disaster-related health care concerns of affected communities. Many of those doctors came back from those areas feeling that they had done the best they could, but knowing that when they left, there was no one to take over. They had been manning health posts in remote communities and marginalized areas in Central America where there was no doctor when they arrived and no doctor to take over when they left. So they brought that message back to the leadership in Cuba, saying, “We really need to develop a more sustainable response...we need to bring these countries further along in addressing the shortage of their own health care workers.” So the Cuban government decided to open ELAM as a school to train students from those countries, from Latin America and Africa and Asia to become the kinds of doctors that are needed to work in these remote areas.

The curriculum is offered for free. It is a six-year curriculum. They recruit from marginalized and poor communities with the understanding that those are the students most likely to return to the communities where they're needed most. The curriculum focuses heavily on primary health care, public health and prevention, which have been shown to have the largest impact, especially in communities with large infectious disease burdens.

Regarding primary health care, how does the training of Cuban general practitioners compare and contrast with the training of U.S. general practitioners?

I think that the training offered at ELAM is scientifically very similar to the training offered at U.S medical schools. However, at ELAM, family medicine, which is their basic primary care discipline, is offered as a seven-week block – or rotation – in five of the six years of medical school at ELAM. In the U.S., it is not nearly as well emphasized or encouraged. So in the U.S. the system tends to incentivize sub-specialty and specialized care, and the discipline of family medicine is actually having a very difficult time filling residency slots. I believe last year only 42 percent of residency positions for family medicine were filled by U.S. graduates. The remainder were filled by doctors of osteopathy and by international medical graduates.

So there's a real difference between the two countries in the way primary care is seen and prioritized and encouraged as a prestigious and worthwhile career path. I think that also, integrated into the Cuban model of care and medical education is the idea of prevention and public health. In the United States, clinical medicine and public health are very different disciplines, and there are only a few medical schools that I'm aware of that are trying to bring those two together. In Cuba, it's seamless, it's one and the same; you can't be a doctor without understanding epidemiology and population-based health, or without really understanding and promoting the basic ideas of preventative health.

It sounds like the Cuban system focuses on preventing problems from arising, as much as possible, and the American system focuses on fixing problems after they happen.

Correct. I think that's a pretty good summary. And I think that some of that's out of necessity; I mean, Cuba has very few resources compared with the U.S., and they have decided to put a lot of their resources toward preventative health so that they don't have the exorbitant costs that go with trying to treat things they can't afford to treat at a complicated stage.

That brings up the doctors' response to disasters. I know that Cuban doctors have been very much in the news because of the response of Cuba to the recent earthquake in Haiti. From what I'm reading, it seems that Cuban doctors are extremely well-versed and capable in dealing with disaster medicine. Is that true and is that an emphasis?

Yes, it certainly is true. Disaster medicine is taken very seriously in Cuba; and the Henry Reeve Brigade, which has been around for many years, is a group of first responders from Cuba that have responded to many high-profile disasters. With many of these disasters, especially in Haiti, they [the Brigade] were able to hook up with a large group of Cuban doctors that were already on the ground and who had been working within the public health care infrastructure that already existed. They were thus able to hit the ground running; there wasn't a lot of start-up time, and they already knew the community and knew what was really needed most. They were able to triage well, right off the bat.

It seems that Cuban doctors are able to do a lot with a little. How much do they rely on expensive tests and equipment compared to doctors in the United States?

Very little. I can tell the story from the perspective of a medical student since that's who I have the most contact with at ELAM and in the Cuban medical education system. Students are very regularly asked to make a differential diagnosis based largely on history and physical. They do a much longer and more thorough history and physical than they would do here in the United States, and they are able to make a diagnosis and do testing just to confirm their diagnosis. So they would use radiological or blood testing just to confirm their diagnosis.

When students round with attending physicians in Cuba, they'll be asked to present patients of theirs, and to describe their history and physical work-up – what they did – and then will be asked how they arrived at their diagnoses, as well as the tests they ran to confirm the diagnosis. Then the professors will often ask students, “Now what would you do if you were in a rural village in West Africa? How would you then treat your patients? How would you diagnose them and confirm the diagnosis?” So they're constantly being asked to think about how to best use the resources available to them in Cuba, and then to take it a step further and think, “Now how would you do that if you were in a really remote place?” That's really useful for students who are planning to go back to such places. It's also useful for U.S. students who are planning to come back here and practice in underserved areas, because many of their patients won't have insurance, and won't have ways to pay for diagnostic testing – and they may have to take that into consideration. Others will want to do international work where that may be a consideration.

That leads me to ELAM and its outreach to other countries. How is ELAM funded, since the school is free?

It's a decision that was made by the Cuban government to put resources into this program. Like all things in Cuba, it's funded by the government. Therefore, it's funded in part by the Cuban people. The Cuban people are really proud of this program. They're excited about it and feel that it's the right thing to do.

So the Cubans take pride in exporting this knowledge to the rest of the world?

Yes, that's a nice way to put it.

As far as the outreach to the U.S. students, you mentioned that it was free – I like that price! What are the requirements for U.S. students who want to go? Let's say that someone from an underserved or disadvantaged community in the United States was interested in being a doctor, or someone reached out to them and told them that there was this option; what would be the requirements and what would they have to do to qualify?

The prerequisites are that you have to have at least one year of college-level biology, chemistry, organic chemistry, and physics, which is the basic requirement for medical school here. Many students at ELAM have done an undergraduate degree; it's not a requirement, but you do have to have at least one year of those basic science courses. You have to be under 30 years old. That's a requirement that the Cuban government has, which I think is aimed at trying to get people who will have the longest possible impact in their career.

The way a person would apply is by going through another organization based here in the United States, which has been involved since the very beginning of the ELAM project in terms of the U.S. students. That organization is IFCO – Pastors for Peace. They would go to their [IFCO's] website which is www.ifconews.org, and they could download applications there and get in touch with IFCO personnel to answer any questions and start the interview process.

MEDICC, the organization I work for, is also very much involved, but we're involved on the other end in terms of trying to make sure students have all the resources they need to re-enter the U.S. medical system after they graduate successfully. So we work with students as soon as they get to ELAM to connect them to mentor physicians in the U.S. We have a fellowship program that helps to defray the costs of their board exams, which are a requirement if you want to do a residency in the United States. For this, they need to pass a series of three exams, two of which cost about $750.00. The third costs nearly $1300.00. That can be a real barrier to students who are coming to medical school in Cuba largely because they can't afford the application process or tuition for medical schools in the United States. We have a set of programs to help make sure these students are getting the right support and resources they need in order to be competitive candidates for residency programs and get into the communities they want to work in and really start practicing.

As far as student satisfaction with the program, are U.S. students generally highly satisfied, moderately satisfied, really gung-ho? What's their reaction once they get through it?

I think the students are very excited about their education, and feel that they've gotten an excellent medical education. There is an attrition rate similar to that of U.S. medical schools; there are some students that get there and find that it's not quite for them, and that tends to be in the first one or two years. By the time they're into their more clinical years, which are years three through six, they're really excited, and they've settled in and they feel that it's an excellent opportunity and they have received an excellent education. And like you said, the price is right!

Oh yes, if I was under thirty, I'd be signing up right now! As far as student experiences after graduation, I know that ELAM really prefers that students from disadvantaged communities make a commitment to return to those communities after graduation. What is the general experience of a graduate after returning to the United States?

The first cohort of U.S. students graduated in 2007, and all residency programs are three years long. So we haven't actually seen graduates finish residency and enter practice. The lag is too long, so far. So it's going to take a little while to get enough numbers built up to see how effective this is in terms of being a model and pipeline for disadvantaged and under-represented students to go to medical school for free, as well as whether or not the alleviation of that debt burden [from attending U.S. medical schools] and the elimination of those financial and cultural barriers really are effective in leading toward a high rate of service in underserved communities. I think it will be successful, largely because these students have self-selected to participate in a program that is very geared toward the idea of committing to social service, an ideal that is reinforced throughout their education. The debt burden is really a motivator. People say that family medicine isn't a viable career path because you only make $150,000 a year. But to these students, that is a huge amount of money, and it would be a very comfortable life to live in their communities and do the work they want to do, and have the kind of impact they're looking for.

It seems that if a disadvantaged community in the United States were motivated and aware and doing research on options for taking care of themselves in a time of economic contraction and difficulty, such as this time, what they would be looking at in terms of providing primary health care would involve a long-term commitment...

Right. If they wanted to send one or two of their best and brightest to Cuba, they would be looking at a return ten years down the line. Those students would go through a six year program, then they would need to return to the United States and do a three year residency, and then be able to come back and really practice in their community. But it is an investment that has the potential to pay off in a very deep and sustainable way.

Have communities contacted you in the United States and said, “We want to put some of our students through this program?”

They haven't contacted MEDICC, because, like I said, we're not really involved in the recruitment and application process. They may have done that with IFCO. And I know that many students are supported by their churches – you know, you do need a little bit of money to pay for the plane travel back and forth if you want to come home for the summer, and like I said, there are the exam costs. So there are some incidental expenses that come up. I know that many students are supported by their community-based organizations or religious organizations. So I think there are people making that kind of commitment and investment.

Are there tutoring programs to help U.S. students to get the requisite first-year chemistry and physics requirements down?

You know, I don't know that there is a pipeline program just to get students ready to go to ELAM in particular. There are many pipeline programs to encourage under-represented minority students and students from low-income communities to get into the health profession. MEDICC is beginning to work with these programs and to explore ways that those programs and ELAM can be mutually beneficial and can learn from each other. So I think that's a great idea; I don't know that it's being done yet.

My last question is this: are there any passport or visa or legal issues that students need to know about before they get involved in a program like this?

No. Students who are enrolled in ELAM are able to travel legally and to be in Cuba legally – both from the U.S. and from the Cuban perspective. They get visas to study in Cuba, and they are able to travel freely and legally.

I've been talking with Rachel True of the Medical Education Cooperation with Cuba organization, which partners with the Latin American School of Medicine, known as ELAM. Thank you.

[Note: in the immediate aftermath of Hurricane Katrina, Cuba offered to send over 1500 doctors to New Orleans, along with badly-needed medical supplies. The United States Government under President George W. Bush refused the offer, along with an initial refusal of an offer of aid from France. Instead, the residents of New Orleans were treated to a round of infectious diseases. As President Bush said, “Heckuva job, Brownie!”]

Primary Health Care in the U.S. and Partnership With the Latin American School of Medicine (ELAM) - An Interview with MEDICC

This week, President Obama is hosting a “health care summit” with leaders of the Republican Party in order to facilitate passage of a national health care plan. The President's proposals are basically a copy of the Senate health reform bill recently passed. That bill would require all Americans to purchase a health insurance policy, with the Federal Government providing subsidies for people with low incomes to purchase health insurance. However, the bill would do nothing to rein in health care costs arising from explosive growth of health insurance fees, as well as excessive growth in pharmaceutical and medical technology costs. This is not surprising, as the fundamental problem with health care in the U.S. is that it is a for-profit “industry,” and the leaders of this industry seek continual profit growth. These leaders are controlling the present health care “debate” in this country.

However, there are resources for implementing alternative models of health care for communities in the U.S. that are interested in setting up their own systems of effective, truly affordable care. One such resource is the medical outreach program of the Latin American School of Medicine (ELAM) in Cuba. ELAM is a renowned medical school that produces top-notch doctors skilled in disaster medicine and promotion of community health with limited resources. (In fact, Cuba itself has become a renowned source of medical expertise.) ELAM has an outreach program in which students from disadvantaged countries as well as disadvantaged communities in the U.S. are invited to study medicine at the ELAM campus in Cuba, free of charge. Afterward, these students become board-certified primary care physicians. All that is asked of them in return is that they make a commitment to return to their communities to provide low-cost, high-quality health care to their fellow citizens.

I recently had the privilege of interviewing Rachel True, MPH, Academic Program Director for the Medical Education Cooperation with Cuba (MEDICC), a non-profit organization that facilitates Cuba's medical outreach to other countries. We discussed the work of ELAM, the unique competencies and emphasis of Cuban medicine and the doctors trained at ELAM, and lessons that could be applied to the United States. We also talked about how disadvantaged communities in the United States could sponsor their own young people to become students at ELAM, in order to build a network of primary health care providers in American communities. This is very important for the times we are now facing, in which the profit-driven U.S. model of health care (and education of health care professionals) is becoming ever more unsustainable. ELAM offers an exceptional education free of charge, and produces doctors who can deliver effective health care solutions at low cost.

I was able to save an audio file of my interview, which can be found at http://www.archive.org/details/InterviewWithRachelTrueOfMedicc. It should be accessible to computers running on either Windows or Linux operating systems. I will also be creating a transcript of the interview for a future blog post. And I am planning on interviewing a student who is currently enrolled at ELAM. God willing, I hope to post that interview in the next few weeks. Stay tuned!

A Fight Among Cannibals

We live and function in an “official” economy which is run by a very small group of very rich people. Their goal is continued economic “growth”, yet what that really means is continued growth of their profits. In the days before the present limits on the resource base of the global industrial economy, this growth could be achieved by industrial expansion. But now that our natural resource base has become constrained, the growth of the profits of the rich increasingly comes only by the robbing of the poor.

A prime example of this is the big ongoing Congressional song-and-dance over health care “reform.” It should be fairly obvious that universal health care is not the same as universal health “insurance.” The Congress could have aimed for universal health care for all Americans, regardless of income. The money spent on bailing out the banks and Wall Street could easily have covered the cost of universal health care. The money spent on the Iraq war could easily have covered universal health care. Even under our present arrangement, there would have been lots of change left over. And the elimination of the private insurance “industry”, combined with Federal prohibitions on unjust medical price inflation by pharmaceutical companies and hospitals would have made our care just that much more affordable.

That sort of genuine reform was never seriously attempted by anyone in Congress or the Executive Branch. The medical industry was too strong, having grown to 1/8^th of the total U.S. economy, according to this source: Health Care Reform: Problems for Human Health. The best our leaders could come up with was a proposal for a Government-run insurance plan that would have competed with private insurance companies. Private insurers are at present hideously expensive, with rates that rose at an annual rate of up to 13 percent in 2002 and 2003, and are rising at a rate of five percent per year now. The private insurers were deathly afraid of the mere possibility of Government-backed insurance, let alone genuine health care reform, and worked hard to kill this option, in a Senate Finance Committee vote which took place last week.

The Senate Finance Committee has therefore settled on a “reform” plan that would force all Americans to buy private health insurance by 2013. This plan is a “compromise” worked out by Democrats in order to appeal to Republicans who were afraid of the “Government spending taxpayer money to support socialism!!!” However, under this plan, ordinary Americans would be forced to spend:

• up to 13 percent of yearly (pre-tax) income for a family of four making up to $88,000 a year;

• over $700 a month for a family of four making $66,000 a year;

• and a tax penalty of up to $1500 a year for those who refuse to buy health insurance and whose earnings are less than 300 percent of the poverty level, and $3800 a year for those who refuse to buy health insurance and whose earnings are greater than 300 percent of the poverty level. (Source: “Reform Bill Will Address GOP Fears,” Washington Post, 15 September 2009)

And our leaders call this “fixing health care”?!

I wonder now...so many families are now heavily indebted, having been tricked into buying overpriced houses and overpriced cars, having had to make ends meet with stagnant or declining real wages while the prices of basics like food, gasoline and utilities continue to rise. So many students have been drawn heavily into debt to attend colleges whose tuition continues to rise at a rate far outpacing general inflation. So many people are now either laid off or are on involuntary part-time schedules. So many small business owners have been given the business by this present “recession” that has put them out of business. The only green shoots one sees in the vicinity of many empty and boarded-up strip mall lease spaces are the shoots of weeds rising through the cracks in the pavement. And I do see a lot more people in raggedy clothes next to freeway off-ramps, holding up signs saying something like “Please give. Anything helps. God bless!”

Is the Government going to force these people to spend $700 a month on private health insurance? Is the Government going to hit these people with a $1500 or $3800 a year tax burden if they don't buy insurance? And what kind of insurance would they buy? The insurance lobby and their Republican sock puppets would propose making insurance “affordable” by offering plans with high deductibles in order to “keep costs down.” So that means that Americans are forced to give money to private insurers, and that they get almost nothing in return? If you buy one of these plans, does that mean that eighty or ninety percent of the cost of a doctor's visit is not covered by insurance? That's like getting into an airplane and being handed a parachute the size of a handkerchief. It won't slow you down much, will it?!

Now people like Glenn Beck and the Tea Party organizers claim to be fighting for the American taxpayer. Why are they not protesting this plan to force Americans to buy private health insurance? Why isn't Fox News protesting this? Why isn't Sarah Palin outraged over this? Are the Tea Partyers all “partied-out”? Or are they on the side of the enemy, after all? And why are both Democrats and Republicans helping the insurance “industry” to rape ordinary Americans?

For a rape it is, or to use another metaphor, it is a cannibal feast. Ordinary Americans have now been reduced to little more than a pile of body parts and limbs, some of which have already been picked clean. The cannibals comprise a small group, yet among them are competing interests. Each representative of these interests wants as big a share as possible of the pile of body parts and limbs, because each competing interest wants to grow as fat as possible.

So we have the private prison lobby, which wants to grow rich locking up as many Americans as possible. But wait – if they do that, that will hurt the growth prospects of the real estate “industry,” who will not have anyone to buy their excessive housing inventory. But if people buy houses, and their wages don't rise, they won't be able to afford consumer electronics and cheap Chinese-made goods, and this would hurt Wal-Mart and other big chain stores. Now the medical/insurance complex wants its share of the cannibal feast – “hey, let's extort $700 a month from every American family to fatten ourselves!” But that will mean that people don't have money anymore to go to Starbucks or to keep their cable TV subscriptions, or to buy new cars, or to buy stocks, etc.

What to do, what to do? How will the competing cannibals sort it all out? I don't know. Perhaps they will all get into a fight with each other, killing each other off and leaving the rest of us alone. I have to confess that I would enjoy seeing such an outcome. Lord, forgive me.

Meanwhile, if you want to see an example of genuine citizen rage and not some store-bought Tea Party astroturf purchased by rich lobbyists, here's a link to a YouTube video of a woman delivering a few words to Bank of America. I must warn you that her language is not family-friendly. Yet I say “Amen” to her message. Here's the link: http://www.youtube.com/watch?v=jGC1mCS4OVo

Where There Is No Doctor (Because You Can't Afford One)

Much of this blog has focused on the ongoing economic collapse in the United States, and the warped economic arrangements that prevent ordinary people of small means from becoming resilient in the face of that collapse. American health care is just one aspect of these warped arrangements. Because health care in America is provided by a private “industry” that demands ever-increasing profits, the cost of American health care has become an ever-more-weighty and insupportable elephant on the backs of ordinary people.

Of course, this has led to the widespread suffering of ordinary people, and has generated much attention from politicians who have promised to “reform” the system. Genuine health care reform would consist of transforming American health care from a growth industry to the providing of an essential service, in all likelihood administered by the Government because of the proven untrustworthiness and selfishness of the private sector. Unfortunately, our leaders in government seem utterly unable to come to this conclusion. The best they can do is talk about providing universal health insurance (which is not the same as universal health care) to all American citizens. Their so-called “public option” would consist of a Government-run insurance program that would compete against private health insurance providers. This last week, the Finance Committee of the United States Senate voted twice to reject this “public option.” As things now stand, therefore, we ordinary people are about to be left once again at the mercy of the health care industry and its adjuncts, the pharmaceutical industry and the insurance “industry.”

But there is another option available. It is a “public” option, though it does not depend on the Government for its implementation. Who is responsible for implementing it? You are, dear reader. Today, let's talk again about citizens building a safety net of alternative systems for themselves. I must warn you that the steps of building a citizen-created health care safety net will be somewhat challenging. Some study and hard work will be required. But I have no doubt that many people will be sufficiently motivated for the task, once they find themselves thrown out of work by the present economic contraction. When their unemployment checks total less than $1300 a month and they are faced with COBRA payments of almost $1100 a month, that will be a real kick in the pants! (Source: COBRA Premiums for Family Health Coverage Consume 84 Percent of Unemployment Benefits)

By the way, health insurance payments have risen over 131 percent from 1999 to the present. COBRA payments in some states now exceed the size of mortgage payments on small to mid-sized houses. (Sources: Health Inflation Slows as Economy Tumbles, KFF Reports, and Insurance Premiums Still Rising Faster Than Inflation and Wages.) Thus, one other aim of my “public option” is that it would kill off the private health insurance “industry” in the U.S. if it were widely adopted. And that “industry” is ripe for the killing, if you ask me. (There is yet a third aim: to shut up all the "tea party" idiots now yelling about illegitimate birth certificates and "socialism!!!")

One caveat: I am not a doctor, but an engineer by training. I can't take someone's blood pressure or interpret what I would see if I stuck a tongue depressor into someone's mouth and told them to say “Ahh.” But I'd like to believe that I'm a somewhat competent systems thinker, and it seems to me that the health care problem is a systems problem with a systems solution. My proposed citizen-generated health care alternative therefore addresses three specific system concerns: preventive health care, infectious disease control and injury treatment.

Why these three concerns? What about degenerative diseases such as hypertension, Type 2 diabetes, osteoporosis, and so forth? I believe that a proper emphasis on preventive health care education and preventive health habits would greatly reduce the incidence of many degenerative diseases in the American population. If people took proper care of themselves and lived in unpolluted environments, the only threats to their health that they'd have to worry about would most likely be the threat of infectious illness and the threat of injury.

Preventive Health Care

Preventive health care consists of many elements that are already familiar to most of us, such as the development of healthy habits like eating right and exercise. If you see your body as a machine, it should be obvious that a properly maintained machine is less likely to break down in the first place. We need to learn to maintain ourselves.

Of course, part of that maintenance has to do with how we eat, and how much we eat. But another part of that maintenance consists of proper exercise. By this I don't mean the sort of “exercise” that's often sold at chain-store health clubs. I mean real, functional physical conditioning that enables people to do strenuous things without hurting themselves. My personal leanings are toward the Crossfit program (www.crossfit.com) and its teachers, although I don't agree with everything they say, and their classes are too expensive for me. (Also, I'm not quite as hardcore as they are.) But I like the fact that they encourage people to work hard, to develop functional capabilities that actually have some use, and that they are willing to train anyone for strength, from children to the elderly. By starting people off young and training them in a wide variety of fitness strategies, they help people build a solid foundation for maintained physical capability in later life, without worries about things like osteoporosis, injuries and other fractures, circulatory diseases, and diabetes.

Exercise should be a family affair. If you want strong, capable kids, you've got to work yourself to be strong and capable. I remember when I used to live in Southern California, that there was a horse/nature trail near my apartment. The trail head was right behind a County courthouse, and wound around past a medical office complex before ending again at a small man-made “lake” (a pond, really). Sometimes when I walked that trail, I would encounter a large family jogging past me. Usually their group consisted of several of the kids, the oldest of whom was in high school. But one time I think I saw the entire family – Dad, Mom and all the kids (they had many) running along in shorts and jogging shoes, with the youngest (who seemed to be around nine or ten years old) pounding along at the rear. That family was an inspiration and an example to me. May they be so to you also. So get off the couch, put out the cigarette, put down the sour-cream-and-chives potato chips, turn off the TV and start modeling some good behavior.

Dealing With Illness and Injuries

Last week's post, Communities of Healing Hands - The Hesperian Example, described the work of the Hesperian Foundation in developing simple, practical printed literature to teach untrained health care workers how to help sick and injured people. The writers of this literature strove to provide health care workers with tools that are uncomplicated, widely available, inexpensive, and easy to implement.

Ordinary Americans who want to free themselves from worry over possible medical emergencies should master this literature. As many people a hundred years ago knew how to treat a fracture, how to clear a boil, and how to deliver a baby, I think it's going to be necessary for many of us to re-learn skills like these if we don't want to be bankrupted by the medical “industry.” We are also going to have to learn to make our own medicines, and how to deal with infectious diseases. And we are going to have to learn to identify environmental factors that make people sick, and learn what to do about these.

As the Introduction to Where There Is No Doctor says, “...even where there are doctors, people can and should take the lead in their own health care...Health care is not only everyone's right, but everyone's responsibility...Informed self-care should be the main goal of any health program or activity...”

Educate, Practice and Agitate

It's time to educate ourselves, and to practice the techniques we learn through this education. Our goal should be to create community-based health care systems that work so well that we no longer need health “insurance” or special access to the overpriced products of the present health care “industry.”

If this goal appeals to you, then consider buying the Hesperian literature (or downloading it for free from their website). Start a reading/discussion circle to study this literature with friends, neighbors or co-workers. (At my job, we're going to kick off a study group for Where There Is No Doctor. Our first meeting is a week and a half from now.)

If you want an opportunity to practice what you learn, consider volunteering to provide basic health care services for the homeless, or at a local rescue mission. Document your efforts, along with any lessons learned, in a form such as a blog that allows a large audience to learn from what your doing. Try to analyze and measure the effectiveness of your efforts, and compare them to the results that would be provided by the standard American health care system.

As I have said, the Hesperian literature is written at a very basic level. But for those who want a more advanced theoretical background knowledge of health care, the Massachusetts Institute of Technology has provided online study materials for its Health Sciences and Technology curriculum under its Creative Commons-licensed OpenCourseWare. There are also many other sources of open-source or Creative Commons-licensed health care and health education information on the Web.

Lastly, we need to agitate. Where there are institutional, legal or political barriers to community-created health care, these must be publicized and those who create these barriers must be shamed. This is especially true where available cheap generic drugs are blocked from the market by powerful pharmaceutical interests and their political hired guns. I think of the way in which cheap Canadian generic drugs have been blocked from being imported to the U.S. by means of Congressional legislation. This legislation was especially ridiculous in 2006, when Republican congressmen argued that by banning the entry of cheap Canadian generics they were helping to protect the U.S. from terrorists! I wonder what drugs those Republicans had been taking...

Communities of Healing Hands - The Hesperian Example

In my last post, Making The World Sick, One Country At A Time, I stated some key facts to illustrate how the American health care system prevents ordinary citizens from achieving economic resilience and self-sufficiency by bleeding them dry. I also said that I don't really expect the U.S. Federal government to enact any serious health care reform of the kind that would lighten the financial burden on the backs of ordinary users of American health care. I then stated my opinion that over the next several years, American health care will probably come to resemble the care provided in many Third World countries. (By the way, there are signs that this is happening now.)

My post then explored the sort of care that is now provided in the Third World, as well as explaining the philosophy behind much of that care as embodied in the 1978 Alma Ata Declaration of the World Health Organization. I cited the concept of Primary Health Care (PHC) embodied in that Declaration, 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...”

I then described how rich First World entities such as the World Bank and International Monetary Fund have worked to weaken Primary Health Care in the developing world, how they have forced the governments of Third World countries to dismantle their government-provided social services, and how they have worked instead to force an American-style privatized system of health insurance coverage on the poor citizens of the developing world. This failure to achieve a universal good for the world's people has occurred because the attempt to achieve this good relied on national governments that were beholden to selfish, rich corporations and other holders of concentrated wealth.

Yet there are good examples of individuals and volunteer organizations banding together to create social safety nets, including basic affordable health care, in the Third World and in the poorer parts of the First World. These groups are often quite innovative, due to the limits on the resources at their disposal, and the work they do is worthy of high praise. In his paper, “The Life and Death of Primary Health Care,” David Werner makes mention of the good work of non-government, community-based health programs and the groups that administer them.

One such group deserves particular mention. The Hesperian Foundation (http://www.hesperian.org/), based in Berkeley, California, is a non-profit publisher of books and newsletters for community-based health care, as stated in the “About Us” section of their website. Their published information is developed in collaboration with formally-trained doctors, citizens of poor communities in the developing world, and untrained or informally trained health care workers in these communities. Their literature is very simply written and is designed for people without any formal medical training, and it not only covers the treatment of disease, but also covers the underlying social factors in building healthy communities. Their most well-known book is Where There Is No Doctor, a book that has almost become the Bible of primary health care in the developing world. Hesperian has also joined forces with the worldwide People's Health Movement to promote health for all and the widespread implementation of Primary Health Care as defined in the Alma Ata Declaration.

I recently had a chance to conduct an e-mail “interview” of the Hesperian staff, which I have included as part of this present post. My questions are written in bold type, and their answers to each question are shown immediately below that question. I would like to especially thank Hesperian staffer Ingrid Hawkinson for taking the time to reply to my e-mail inquiries and to collect all the answers to my questions. The approach set forth by the Hesperian Foundation could prove to be a vital part of the response by ordinary Americans to our present health care crisis.

In reading the “Our Philosophy” section of your website, it seems that you have incorporated all of the principles of the 1978 Alma Ata declaration of the World Health Organization. That declaration defined health as “...a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity...” and stated that health is a fundamental human right. It also went on to address the underlying societal factors that influence the health of a nation. Are you familiar with the Alma Ata Declaration, and was it an influence on your philosophy?

Yes, we are definitely familiar with the Alma Ata Declaration – we have spent the past 30 years building on the successful model of Where There Is No Doctor to create other resources that also help people discover not only the ways they can have equal access to health care, but to do so in a sustainable way that examines the social, economic, and political issues that not only block access, but make our communities unhealthy. In line with the Alma Ata Declaration, our mission is to achieve the right to health for all people.

If ordinary people put their heads together to examine their health problems, come up with solutions, and organize, so many issues will be addressed including the power balance, the state of the environment, our sense of wellbeing. . . The concept of “health” and the reasons behind poor health are woven into the fabric of our existence.

Your programs match the definition of “Primary Health Care” as stated in the Alma Ata Declaration. After that Declaration was issued, many rich First World nations protested that implementing this Primary Health Care would be too “expensive.” Yet you seem to be able to provide what rich First World governments could not. How do you do it?

What we do is very simple. We supply information that people can use in formats they can understand and easily share. Our books are developed collaboratively to ensure they make sense to the end user. Once this information is in people’s hands, they come up with solutions that work for them. So if, for instance, our readers don’t have money, our books help them figure out how to take care of their health using the resources available to them under the circumstances, and to prevent health problems before they become serious and costly.

One barrier to affordable health care is that there’s so much mysticism surrounding what doctors do. Yet the methods doctors use to diagnose and treat the most common and basic health problems are simple. In addition, the vast majority of medical information is available but not accessible. Typically, it is in dry, expensive textbooks full of elaborately constructed sentences; jargon confusing even to those studying medicine; and illustrations that depict illness rather than communicate ways for the viewer to visualize a concept or technique that will lead to its cure.

Another barrier is that many rich, first-world countries are run by governments supported by industries with a lot of money, such as the healthcare industry. And of course, if people could spend much less money on health care, they would. It’s not in the interests of governments to champion alternatives to the industries that supply their funding. Their argument -- that providing a single-payer program would be too expensive -- strikes those who are suffering right where it hurts: in their pocketbooks. The argument is illogical, yet it’s still somewhat effective because it weakens those who have the most potential to make change.

You have evolved a community-based, non-governmental approach to providing health and basic human services. Yet I am sure that you have interacted with governments in the nations where you work. Have you been able to collaborate easily with them? Are there any cases in which the relationship was strained or in which you faced opposition?

We are based in Berkeley, California, and we don’t provide health and human services – we produce materials to allow ordinary citizens to improve their health and organize for justice. We have an open copyright policy that encourages people to translate and adapt our books to suit their communities. Those who do adapt our materials negotiate with their own governments. We don’t normally work directly with other governments, though many large governmental health agencies use and distribute our materials.

Over the last two decades, the World Bank and International Monetary Fund have pushed many governments in the developing world to dismantle their social safety nets, including free health care. Have you ever encountered opposition or hindrances from the World Bank and IMF, or from First World governments, or from for-profit providers of Western medicine?

No, not that I know of.

What are some of your opinions about the present health-care reform debate in the United States?

Health care needs reforming, and as currently outlined in H.R. 676, with a single-payer system in which the government is the only health provider. In the United States, we could eliminate co-pays, deductibles, and employer contributions. At the same time, additional taxes would be added to individuals and employers (see the Healthcare-NOW website for a clear explanation of how H.R. 676 funding would work).

It is quite possible that the present recession will deepen, especially in the United States, while medical costs continue to escalate, and that there will be a sharp rise in the number of Americans without access to a doctor. If that happened, could individuals and communities in the U.S. implement the programs and approaches that the Hesperian Foundation has developed for the world's poorer countries? What would be the potential barriers and sources of opposition to such an approach?

Yes, absolutely, people in the United States could implement the approaches in our books, and some do already (people living on reservations, nurses, midwives, employees and volunteers at free clinics, travelers and sailors, professors of public health and environmental studies, ministers. . .). The only barrier is lack of knowledge and an unwillingness to change.

Is there anything you'd like to mention that I haven't covered?

• Most of our books are available for free download. We encourage you to print and share them.

• If anyone is willing to help us spread the word and spread health by posting a review, talking about our books on the radio, reviewing them in a magazine or newsletter, or by any other means, please contact Ingrid@hesperian.org.

• All profits from the sales of our books go towards printing, updating, revising, and creating more books, and also to our Gratis book program and Translations fund, both of which get health information into the hands of people around the world who might not otherwise have access to it.

• Give someone a present that really matters – send a gift of health to a poor community on behalf of a friend or loved one.

• We are currently working on a New Where There Is No Doctor for the 21^st Century, a new edition of HIV, Health and your Community, a Spanish translation of A Community Guide to Environmental Health, a Community Action for Women’s Health and Empowerment, and A Worker’s Guide to Health and Safety.

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.

Conclusion

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...

Sources:

• “Health Insurance Costs,” National Coalition on Health Care, http://www.nchc.org/facts/cost.shtml

• “Paying The Price: The High Cost of Prescription Drugs For Uninsured Americans,” Maryland Public Interest Research Group, http://www.marylandpirg.org/home/reports/report-archives/health-care/health-care/paying-the-price-the-high-cost-of-prescription-drugs-for-uninsured-americans

• “Employer-Sponsored Health Insurance Erosion Continues, Will Likely Accelerate Through 2009,” Elise Gould, Economic Policy Institute, September 2009, http://www.epi.org/publications/entry/jobspicture_20090306/

• “The Life And Death Of Primary Health Care,” David Werner, International People's Health Council Global Summit, 1995, www.healthwrights.org/.../Life_and_Death_of_PHC-Global_Summit_Sweden.pdf

• “Health for All Beyond 2000: The Demise of the Alma-Ata Declaration And Primary Health Care in Developing Countries,” John Hall and Richard Taylor, The Medical Journal of Australia, 7 November 2002, http://www.mja.com.au/public/issues/178_01_060103/hal10723_fm.html

• “Declaration of Alma-Ata,” International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978, World Health Organization, www.who.int/hpr/NPH/docs/declaration_almaata.pdf

• “Rich Countries and World Bank Must Stop Pushing Privatized Health In Poor Countries,” OXFAM International, 12 February 2009, http://www.oxfam.org/en/pressroom/pressrelease/2009-02-12/rich-countries-world-bank-must-stop-pushing-privatized-health-to-poor

• “The IMF And The No User Fees Policy In Health,” Sandra Graham, Jamaica Observer, 15 August 2009, http://www.jamaicaobserver.com/columns/html/20090814T200000-0500_157495_OBS_THE_IMF_AND_THE_NO_USER_FEES_POLICY_IN_HEALTH_.asp

• “Private Health Insurance for the Poor in Developing Countries?”, Denis Drechsler and Johannes Jütting, OECD, August 2005

• “Is there a role for private health insurance in developing countries?”, Denis Drechsler and Johannes Jütting, German Institute for Economic Research, October 2005