The Libertarian Lifeboat

I'm a bit tied up with an ongoing research project, so here's another repost from way back.  I think it's particularly relevant in light of some of the essays and comments I've seen circulating the blogosphere recently.  As I wrote in a recent post, American society has been unstable from the start, due to the emphasis by the Founding Fathers on "liberty" (as in the right to do whatever one pleases) without a counterbalancing emphasis laid on our duty to each other as members of a civil society.  Yet there are still credulous people pushing "libertarian" ideals and champions such as Lew Rockwell and Ron and Rand Paul.  I'd like to say to such people, "So...we got into our present fix because some people found out how to get filthy rich at the expense of all the rest of us by dirty, yet legal tricks.  Now they are making us all suffer.  And your solution is to keep promoting a supposed right to the very selfishness that got us into this mess.  Hmm...what's that saying about insanity consisting of doing the same thing over and over and expecting a different result?"

I'd like to take a break from considering alternatives to our present breaking corporatist economic and societal systems, in order to tell a couple of stories that need to be told. Also, I have taken a number of pictures of people over the last several weeks, promising those whom I photographed that I would post their pictures on future installments of The Well Run Dry. So, God willing, the next two posts will tell needful stories, and the following post will have pictures relating to bicycle transportation.

The story I am about to tell you is one I heard a few years ago. It is a very strange illustration of the potential for bizarre human behavior. It took place several years back, aboard a double-bottomed, Handy-sized sea-going bulk cargo ship whose name escapes me at the moment. The ship was old, and had seen many voyages, some through very severe weather, both in the Atlantic and Pacific oceans. Its crew was a volatile mix of quirky, memorable types and experienced, wise, level-headed men. One of the strangest and most quirky characters was the boatswain (or bos'un for the nautical initiates), a big-boned, burly, sandy-haired, square-jawed man of indeterminate age.

The bo'sun was a fearsome sight to the deck crew whom he supervised as he directed sharp glances all around, swiveling his large head on his bull neck while barking commands, muscular biceps flexed as he rested his large hands on his hips. Those who crossed him usually did it only once, as the punishment he dealt was swift and severe. Aside from giving orders, he almost never talked to any other shipmates. This was unusual, since the three licensed officers on board were quite friendly with all the crew, figuring that pleasant voyages contributed to crew effectiveness.

The bo'sun tended to keep to himself when not on duty or at meals, preferring to remain in his quarters rather than mix with the crew. Almost no one ever saw the inside of his quarters, but the one or two crewmen who were able to get a glimpse said that on one wall was a Confederate Rebel flag, and that there was a bookcase underneath containing books such as The Politician by Robert W. Welch; The Way Things Ought To Be and See, I Told You So, by Rush Limbaugh; and Robert Lewis Dabney: The Prophet Speaks by Doug Phillips, along with several copies of The New American, a magazine published by the John Birch Society. He also had a life-sized poster of Rush next to an old VCR with which he frequently played a battered copy of Birth of a Nation. (At times while on watch, other crew members could hear him muttering scenes of the movie from memory.) Somehow amid all the clutter, he had also managed to stash 250 pounds of cast iron free weights, a couple of dumbbell bars and a barbell bar, all of which he used religiously.

His physical training served him well on the particular voyage we are now considering – a voyage that took the ship from the tropics up into the North Pacific during the height of typhoon season. The ship was carrying a load of some grain – rice, I think – and its course carried it right into the path of a tropical depression that was also moving north. The loading of the rice had been supervised by a junior officer without much experience, and as a result, the cargo settled, then began to shift as the ship ran into increasingly rough weather. The depression strengthened into a storm that grew into a typhoon, and began to produce dangerous rogue waves. Most of the crew had experienced typhoons before, and they were therefore not terribly worried, until two rogue waves hit the ship within five minutes of each other and caused her to heel hard to port. This caused the cargo to shift dangerously, making the vessel list. Then a third rogue wave hit and downflooded the engine room, causing the ship to go dead in the water.

The vessel's situation was now serious. Yet even at this point she might have been saved if the engineer had been able to restore power quickly. But by this time the ship, which was old as has been mentioned before, began to suffer the effects of corrosion and metal fatigue as the pounding of the storm proved to be too much for her. Within thirty minutes of losing power the front hold began to flood, and the flooding quickly spread to hold number two. By the time the crew realized their peril it was too late for many to escape. Only one lifeboat could be launched in the minutes before the ship sank, and those who were lucky enough to be nearby piled into it in whatever condition they found themselves, with whatever possessions they happened to be carrying. It was night when she sank.

The dawn revealed that seven men had survived out of a crew of twenty-four. Amid somewhat calmer weather, they looked at each other with mostly frightened eyes. There were two able seamen, the second officer, an oiler, the steward's assistant, an ordinary seaman, and the bo'sun. The steward's assistant shivered in the wind and rain, as he hadn't had time even to put his clothes on before the sinking. One of the able seamen had been able to don a survival suit, as had the bo'sun. The second officer had a fractured leg. The ordinary seaman had suffered a concussion. All were badly shaken – except for the bo'sun.

He had managed to grab several items before getting into the lifeboat. His stash consisted of a number of blankets, some tins of meat, water and hardtack, several Army-style can openers, a solar still, an emergency fishing rod, a knife and a first aid kit. In all he must have carried over a hundred pounds of supplies with him into that boat. Of course, this was in addition to the supplies with which the lifeboat was normally stocked. The other survivors cheered up greatly when they saw the bo'sun's stash in addition to the lifeboat's regular supplies. But their cheer was short-lived.

The steward's assistant spoke first. “Hey there, bo'sun,” he said, “could you pass me one of those blankets? I was in bed when the ship started to sink.” One of the able seamen said, “Say, bo'sun, the second officer's in bad shape. Is there any Advil we could give him?” The oiler chimed in and said, “Oh, no! The launch of the lifeboat caused us to lose all of the can openers in the boat's survival kit. Hey, bo'sun, could you spare an extra?”

Their requests died away into silence as the bo'sun merely stared at them for several seconds. Then he spoke. “You're not expecting a handout, are you? That's socialism!” He spat derisively over the side of the boat. “I earned what I have by my own effort,” he continued. “I won't give handouts, but I will let you earn the privelege to use what I have. That's what our Founding Fathers believed in.”

Now the rest of the survivors were silent in their turn, staring with shocked faces at the bo'sun. Finally, the able seaman who had asked about the Advil spoke again. “But that's totally wacked out, bo'sun!” he shouted. “Look at the second officer! He's in no shape to earn anything! Why are you being a jerk?” An instant later, the bo'sun's fist crashed into his jaw and he crumpled to the bottom of the lifeboat.

“Now hear this,” said the bo'sun in a low, dangerous voice. “I don't give free rides to anybody. If you don't pull your own weight, you get nothing from me. Why, next you'll want me to socialize medical care! Ain't gonna happen. If the second officer is motivated enough, he'll do what it takes to get medicine. You who want the extra blanket!” he shouted, pointing at the steward's assistant. “If you want a blanket, get over here and grab this fishing rod. You gotta catch thirty pounds of fish. That's my price.”

Thus began the miserable journey of the survivors as ocean currents pushed them slowly northward. Needless to say, the second officer died within three days, and the others dumped his body overboard on the bo'sun's orders. The only epitaph the bo'sun spoke was to mutter about “freeloaders on society getting what they deserved.” He also muttered frequently that it was his manifest destiny to be the boss of that lifeboat.

Afterward, all the survivors were kept busy from sunup to sundown catching fish, cleaning fish, sun-drying fish and operating the solar still. In return for their labors they were allowed to eat just enough to stay alive. But the bo'sun ate his fill every day, and his stocky build began to grow chubby. By this time almost everyone in the boat was shirtless, since the weather had entirely cleared and had grown quite warm as the boat drifted out of the tropic zone into Northern Hemisphere summer conditions. The other survivors took notice of two large tattoos across the bo'sun's chest, one of which was an artist's rendition of Ayn Rand's face, and another which was a picture of a gnarled hand with the name “ADAM SMITH” written below.

The bo'sun himself noticed his increasing chubbiness, and began a two-hour regimen of calisthenics and body-weight strength-building exercises every day (although he never used his strength to do any actual work). Meanwhile the other survivors grew weaker and weaker, and one more man died. By now it was late July or early August, and though the boat had drifted north of the 35th parallel of latitude, it was still quite hot. The bo'sun was bothered by the heat, especially because it made him sweat a lot and grow thirsty during his workouts. But the solar still was slow in producing fresh water and the canned water was by now used up.

One day the bo'sun had a brilliant idea. “We're gonna do things a little different,” he said to the others. “We're all each gonna get his own space on this boat. However much space you get depends on how much you can fight for, and since I'm the strongest guy on this boat, I get the biggest space. Stay outta my space,” he said. Later that morning, he took most of the remaining blankets and made a shade covering over his newly created “space.” But still, he felt hot. Frustrated, he racked his brain for a solution. Then he smiled broadly as a new idea occurred to him. He found a hand drill and some large wood drill bits from the stash he had brought on board, and began to drill a hole in the bottom of the boat under his “space.”

The other survivors looked at him aghast. “Hey man, what are you doing??!” they all shouted at once. “I'm making a little fountain for my space, to cool my feet,” the bo'sun replied. “What's wrong, are you jealous?” “Dude,” they all shouted back, “you'll sink this boat and kill us all!” “What I do isn't gonna kill us or ruin this boat,” he growled, “and besides, what I do in my space is my business, so lay off!”

At this, the man telling the story broke off, overcome by emotion. “That dirty, selfish...” he finally said, then began coughing uncontrollably. The cough turned into a gag as our chief steward turned the man's body to the side and held a bucket up to his mouth. He retched up a last bit of swallowed seawater, then lay back on the steward's bunk, gasping. The steward noticed that the man was still shivering, ten hours after being pulled from the sea.  As the steward readjusted the man's blankets, we briefly glimpsed the sunburns and multiple salt water sores that covered his bony, emaciated body.  Under the blankets he was naked, for shortly after pulling him from the water, we had disposed of the tattered rags that had served as his clothing during his long months as a castaway.  At least he was no longer cyanotic.  Had we not spotted him at just the right moment, things would have turned out much worse for him. The ship's doctor gave the man an injection, told the cook to bring more hot water bottles, and told the rest of us to let the man have some rest.

P.S.: The story I have just told is entirely false. Anyone who has actually worked on a ship can probably tell that I haven't. But I told this story in order to prevent it from coming true, if you get my drift. As a very influential Man once said, “He who has ears to hear, let him hear.”

P.P.S.: The Bo'sun in this story is a caricature of a particular ideology. Yet there are many ideologies of selfishness in the world today, and they must all be guarded against if our society is to successfully navigate the downside of Hubbert's Peak.

Dreaming That We're Poor

This past week, the New York Times ran a front page piece titled, “Bleak Portrait of Poverty is Off the Mark, Experts Say.” It was basically a packaging of “expert” criticisms of a U.S. Census Bureau study titled, “Income, Poverty and Health Insurance Coverage in the United States: 2010.” The study stated that, among other things, the number of Americans living officially below the poverty line grew by 9.7 million between 2006 and 2010. (That figure is found in Table B-1, on page 62 of the report.) The report states that the number of Americans living in poverty has grown to 46.2 million, over four consecutive years of increasing poverty, and that the official poverty rate in 2010 was 15.1 percent. There are also now 49.9 million Americans without health insurance coverage.

The experts quoted by the Times (as well as the writers and editors at the Times) object to such a stark depiction of American poverty, saying that it does not take into account the availability of safety net programs for the poor as well as earned income tax credits. According to these talking heads, such things would cause “as much as half of the reported rise in poverty since 2006” to “disappear.” These talking heads grudgingly acknowledge a rise in the numbers of “near poor” people (what does that mean?!), who make too little to live comfortably and make too much to qualify for aid or tax breaks or reduced-cost medical care.

I find such talk to be very far from reality. It seems to me that the nation has become poorer. Social safety nets have been and are being gutted in every state in the Union while the rich continue to concentrate wealth. Access to social safety net programs is dwindling for most Americans. It's easy for so-called experts and their media mouthpieces to redefine “poverty” by fudging numbers. They have no idea what it is to experience life on $18,000 a year. But maybe I'm asleep, dreaming that most of us are poorer. If I just pinched myself hard enough, I'd wake up to find that most of us are rich.

Then again, maybe pinching myself wouldn't work. Maybe those of us who are tired of pinching ourselves should tell our stories to each other, lest the experts convince us that we're all crazy or dreaming. What if we bloggers mounted a campaign to contradict the Times and its talking heads by citing the Census Bureau study and posting our own stories of the poverty we're seeing?

By the way, if you want a copy of that Census Bureau study, you'd better download it fast. According to the Times, on Monday the 7^th of this month, the Census Bureau will publish a “long-promised alternate measure meant to do a better job of fudging the numbers counting the resources the needy have and the bills they have to pay.”

My Resilient Neighborhood, Part 1 - Laying The Foundation

As I promised in my post, “Adjusting My Own Oxygen Mask,” I want to write a bit about the steps I am taking to make my life and my neighborhood more resilient in the face of uncertain times. In this post, I will briefly state some of these steps.

The Personal: I see the need for a proper balance between the pursuit of money and the achievement of other life goals. This is especially true now that the money economy is fragile and my place in it is uncertain. My time goal now is to work between half time and ¾ time so that I can have the remainder of my week devoted to building a healthy lifestyle and a healthy neighborhood. My money goal is to be able to live on less than half of my salary so that the rest can be devoted to meeting personal and neighborhood needs. So far I am doing well on the money part of this goal, although the time part has lately been a bit harder to achieve.

Both the time and the money goal are important, and cannot be neglected. In this time in which many powerful politicians, rich people and media voices are promoting selfishness, in which many government social safety nets are being shredded, it is ever more important to prepare oneself to live a life of charity. As the Good Book says, “Let our people also learn to maintain good works for necessary uses, that they may not be unfruitful.” (Titus 3:14) I intend to use my spare time and money in some interesting ways. There'll be no room for certain right-wingers to howl “Socialism!!!”, because, after all, it's my time and money to do with as I please, isn't it?

I've been working part time as an engineer and teaching part time as an adjunct engineering instructor. I'm thinking of going back to school myself to get my master's degree. Such a move would make it easier to get a job teaching full time. If I decide to go back, I might study semiconductor fabrication with a view to learning more about organic semiconductors. It's not that I think organic semiconductors will enable us to live a high tech lifestyle, but rather, that I believe that in a low-energy future, the only semiconductor technology that will be available to society will be based on organic materials with performance that is not nearly as great as the silicon-based semiconductors we enjoy now. But a little bit of something is better than nothing at all.

I've almost finished building a chicken coop in my backyard. (I can hear people saying, “What?! You write a blog like the Well Run Dry and you don't have chickens yet?!!” Hey, I'm working on it...) One of my other projects is quite mundane: I need to clean out my garage this spring, so that I can start a workshop. I intend to explore home-based small-scale manufacturing and refurbishing. I am also continuing to study Russian, although my effort is confined to self-study right now. Once I become reasonably competent, I'll brush up on my Spanish.

The Neighborhood: As teaching has become an integral part of my strategy of personal resilience, so it has become the mainstay of my outreach to my neighborhood. In “My (Somewhat) Walkable, (Somewhat) Russian Neighborhood,” I wrote about the Russians and eastern Europeans I have met here where I live. One of them found out that I play guitar, and he asked me if I could teach some of his relatives. So over the last year I have had a handful of kids over at my house once or twice a week. It has been an experience, believe me! The kids are typical of kids everywhere: warm, sensitive souls one minute and crazed creatures the next. (The fact that I'm teaching them shows that the Almighty has a sublime sense of humor...)

I also may get to enjoy the privilege of being a learner in my neighborhood, as I have been talking to one of my Russian neighbors about having one of his relatives teach a beekeeping class to some of us. Hopefully that will happen this summer.

Teaching, both at a university and in my home, has gotten me thinking about many things – things such as pedagogy, the “diagonal economy” of Jeff Vail's writings, neighborhood-based solutions to neighborhood needs, and the process of developing a curriculum for the learning of skills appropriate for a post-Peak society. In future posts, I will explore these themes as I describe them through the lens of my weekly guitar class and my other neighborhood initiatives. My aim will be to show how a neighborhood composed of diverse cultures can come together in a calm and reasonable frame of mind to improve its quality of life even in the midst of a declining economy.

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!”]

Community-Managed Safety Nets, Food Security and Zenger Farm

It should be fairly obvious by now that the last few decades have seen the tearing apart of government-backed social safety nets in much of the world, and especially in the United States. While it is true that America now has a Democratic president and a Congress controlled by Democrats, their actions to date have not inspired overwhelming confidence that these safety nets might be repaired. (Just look at the present health-care “reform” debate and how our politicians and mainstream media define this in terms of health “insurance” reform. Forcing all Americans to buy private health insurance is not the same as providing universal health care at a cost that our rapidly expanding poor class can afford.)

It is therefore necessary for communities to create their own safety nets. Volunteers must arise to begin building community connections for meeting community needs, often without expecting much help from large government or corporate institutions (though there are cases where communities are pleasantly surprised by offers of government help). A key safety net is the provision of community food security, defined by the World Health Organization as “existing when all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life.” (Source: WHO | Food Security)

In the United States, as the standard of living of many people has been eroded over the years, community-based volunteer organizations have arisen to address the growing lack of access to adequate food, and to build systems of community food security. There are the usual food pantries and canned-goods collection drives. But in recent years there have also arisen many urban farming/gardening organizations that promote and teach the growing of food and raising of suitable livestock within urban communities.

I knew nothing about such organizations when I was living in Southern California. But over the last couple of years I have enjoyed getting to know a few of the several community-based, nonprofit urban agriculture organizations here in Portland, and watching some of their extraordinary staff. Many of these people are young, either college students or recent college graduates who have chosen to spend two or more years of their lives as full-time volunteers in these organizations. There is a touch of the otherworldly about them – their education and career paths clearly show that they didn't go to school to get big bucks and a BMW, but they are concerned about larger issues and social justice.

I've interviewed some of these staffers in the past. You can read the interviews here: A Safety Net Of Alternative Systems - Places To Live, in which the Portland Fruit Tree Project was mentioned; and Volunteer Groups And Community Food Security, which featured Growing Gardens. This week's post is another interview, this time featuring Zenger Farm in outer southeast Portland.

Zenger Farm (www.zengerfarm.org) is a century-old working farm that was once owned by Ulrich Zenger, a Swiss dairy farmer, and later by his son, Ulrich Zenger Jr, who protected the farmland from commercial development. In 1994, after the death of Ulrich Jr., the City of Portland's Bureau of Environmental Services purchased the farm. In the years since then, the farm has been leased by concerned citizens who incorporated as Friends of Zenger Farm, a non-profit organization dedicated to preserving the farm as a public space and community resource for sustainable urban food production. Friends of Zenger Farm also works in partnership with the City to oversee a 10-acre wetland adjoining the farm.

On a pleasant, sunny October morning, I had the opportunity to meet with Prairie Hale, Community Involvement Coordinator for Zenger Farm. I was primarily interested in trying to quantify the impact of the farm in building local safety nets and contributing to a resilient community, although there were other things that I wanted to explore. Below are my questions (in bold type), and Prairie's answers.

Has anyone tried to measure or quantify the impact of Zenger Farm on the surrounding community? There has not been a lot of measurement. However, there are general observable impacts. Zenger Farm serves as a place for field trips and educational and volunteer opportunities to learn about the natural world and develop a connection to that world; and to learn about growing, cooking and preserving food, thus fostering self-sufficiency.

The farm is known as a positive place and a good neighbor in the community. The farm staff are aware of what is happening in the neighborhood and are contributing to neighborhood goals. Not only does the farm grow food for the neighborhood, but it forms partnerships with neighbors to run egg co-operatives and farmers markets with the goal of providing culturally appropriate, fresh affordable food for the community. (However, the egg co-op has not yet attracted many members from the surrounding neighborhoods.)

The farmers market is a joint venture with the Lents Food Group, and the market has an “international” flavor. The market has provisions for accepting WIC (Women, Infants and Children) coupons, food stamps and senior coupons, and has a food-stamp matching program.

Field trips to the farm are conducted by local schools and teachers from public, private and alternative schools in the Lents and Powellhurst-Gilbert neighborhoods. The farm also serves as a gathering place to build a sense of community among residents.

The farm is part of a larger urban agriculture “community of knowledge,” both in the Portland metro area and worldwide.

On a related note, what contribution does Zenger Farm make toward building a “resilient community”? (A resilient community is able to survive economic shocks without its members being dislocated by those shocks.) The farm contributes toward increasing food security – that is, a stable supply of affordable healthy food in the neighborhood, as well as generating increasing numbers of people with skills to grow, cook and eat on a tight budget. The farm has offered a very popular class in local schools, named “How to Buy Food On A Budget.” This class has been taught in both English and Spanish, and has attracted both children and their parents.

What are the demographics of the neighborhoods surrounding Zenger Farm? The farm is adjoined by the Lents and Powellhurst-Gilbert neighborhoods. Much of this area is poor, yet many of the residents are actively trying to better their neighborhoods. Twenty-five percent of the population can be classified as “food-insecure.” The area was ranked “last in livability” according to a recent survey. The poor population is also being squeezed by gentrification (the encroachment of wealthy buyers of real estate into the neighborhoods), resulting in rising rents and real estate prices.

For the majority of schoolchildren, English is a second language. Only 30 percent are native English speakers. Spanish is the first language for another thirty percent; then the remainder are from Russian, Vietnamese or Laotian backgrounds. Zenger Farm is actively seeking translators for its classes and workshops.

How would you rate the ability of non-profit groups to make up for the dismantling of social safety nets formerly provided by local governments? There is some uncertainty regarding that question. For residents under stress in a disadvantaged urban neighborhood, worries about personal and family needs might take away energy from community organizing. Also, there is a lot of anonymity in cities, whereas small rural communities tend to be much more tightly-knit, and much more willing to pull together in times of crisis.

However, there are good examples of urban and neighborhood groups meeting neighborhood needs. One example is “Generous Ventures” on southeast 111^th Street, a group that salvages food that might otherwise go to waste, and distributes it to the poor.

What sort of lifestyle adjustments are required of a member of a non-profit organization? (In other words, most of the people I've met from groups like Growing Gardens or the Portland Fruit Tree Project did not go to school in order to get rich!) If someone is going to commit himself or herself to this kind of service, what should their expectations be? Not surprisingly, don't expect to get rich. Seek to gain satisfaction from developing a strong social network so we can take care of one another and provide for our needs.

(At this point, Prairie told me more of the personal events that had led her down this path. She related her family's Quaker background and how she spent most of her life in a small rural Oregon farm community. But as a result of an injury of a family member and loss of income, she and her family found themselves in Ecuador for a year when she was around eleven. That experience, and seeing the drastic difference between American life and the standard of living of the Ecuadoran population, was the catalyst of her interest in social justice.

As a result of that experience, she went to Earlham College, a Quaker institution of higher learning, and obtained a degree in Peace and Global Studies, a field of study which teaches nonviolent ways of bringing peace and social justice where it is lacking. One lesson she remembers is summed up in this saying: “Create the change that the community is ready for.”)

Regarding “closing the loop”: farming tends to deplete soils unless all organic wastes are properly composted and returned to the soil. Zenger Farm does not do humanure composting at this time, but have you ever thought about it? If you tried it, would you do so as part of a larger study of the feasibilty of this sort of composting in an urban environment? Humanure composting is feasible, but it requires a level of expertise and management that Zenger Farm does not yet possess. It seems to be more feasible on the scale of individual homes. As far as composting in general, Zenger buys compost now, but is looking to cut expenses by recycling more of its own plant matter into compost.

Are there any other general research projects being undertaken by Zenger Farm? The farm has not traditionally been involved in research, although a new focus is starting this year, with two farmers who want to try experimental organic techniques. The farm would like to explore other areas of research, such as adding more rainwater catchment and measuring the decrease in use of City water for irrigation when stored rainwater is used. They also want to do more water testing and measurement of sedimentation in the adjacent wetland, and want to explore various furrow and plowing arrangements to limit sediment runoff and erosion.

Do you have any thoughts on remediating urban sites that have been contaminated by industrial pollutants, in order to prepare these sites for urban agriculture? Research has been done on the use of fungi and mushrooms to rehabilitate sites. One prominent worker in this field is Paul Stamitz, a mycologist.

That concluded my interview with Prairie. As I was leaving, I remarked that it was refreshing to see younger people looking for more than a life of materialism and creature comfort (as opposed to my generation, who went to school solely to acquire big houses and BMW's), and that maybe we were witnessing a revival of something that had not been seen in the U.S. since the 1960's. She agreed, and said that it's not just young people who are waking up. Many older people are seeing that the American dream doesn't work, and are starting to want something more meaningful. Maybe there's hope for us after all.

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.