Just Books
health care
08/04/10
In his new book -- Partner to the Poor: A Paul Farmer Reader -- Paul Farmer, acclaimed 'saint,' chronicles his true-life, world-saving adventures.
Dr. Farmer talks with Diana Silver, Ph.D., about his work and the new book.
DS: Let’s begin with Haiti. How is the relief effort going?
PF: A lot of energy and resources went into immediate rescue and relief efforts -- with predictable results: not many people could be rescued. This is not atypical of a disaster of this magnitude.
The reconstruction efforts are slower. There are fewer resources. It is taking a while to get things going. Though there has been enormous effort to coordinate a better response, we can’t give ourselves good marks yet on reconstruction. For one thing, the number of people in camps with displaced homes continues to grow, not to shrink. That’s the biggest problem: shelter and basic services for people who have lost their homes, or are afraid to return to them. We haven’t been able to help much in this regard.
DS: Is there -- anywhere in this difficult situation -- cause for hope?
PF: Reconstruction is slower than what I/we hoped. This was a catastrophe on a nearly unprecedented scale. Some think as many as 20% of all federal employees were killed; all federal buildings destroyed. So how quickly can we expect reconstruction? But there are glimmers of hope – including the creation of the Interim Committee for the Reconstruction of Haiti, which had its first meeting and is designed to green-light a broad range of solid projects.
DS: Let’s talk about your new book, which is a gift to professors, because it is so beautifully organized. It’s organized dramatically, rather than chronologically. Can you describe the dramatic, organizing themes and say a bit about why you structured the book in the way that you did?
PF: Some of the early pieces cover the anthropology of epidemic disease and focus on Haiti, where I’ve worked for the last 28 years. It moves more broadly to some of the issues that animated the first years of my work, but focuses more explicitly on basic social and economic rights for people living in poverty. By basic rights, I mean the rights to water, health care, education and shelter. The issue of
sexual violence runs through the book. It’s a very difficult issue for physicians. There’s a focus on social forces that put some people at risk for illness or other bad outcomes. Racism is an example -- as is gender inequality.
DS: Structural violence is a loaded term. I imagine you use it intentionally. Could you speak elaborate?
PF: It is not an original concept. Many have found it to be too loaded. I began using the term to convey the sentiments and the experience of people I worked with in Haiti, in Peru, later in Africa. These people experienced every day life as violent and used loaded terms to describe their experience.
Let me give you an example. A woman in rural Haiti has many children and spends every waking hour in a struggle for food, for wood to cook with, and for water; she experiences this as a kind of violence done to her. I think it’s better for those in my position to echo her view, not just her anger, but also the sense of injustice with which she regards her experience I’m not wedded to the concept, but it is useful.
DS: In the section on structural violence in the book, you introduce the idea that health is a human right. And, you critique human rights groups that adopt political neutral positions or focus on civil rights, rather than human rights. Is this a fair description?
PF: It is an insider-loyalist critique. A number of prominent rights groups advocate for political and civil rights. These are important struggles. But there are other rights: the right to health care, the right to clean water, the right to education. These are the rights I consistently heard about in places like Haiti. And very often these rights are not much discussed in mainstream health organizations. So, yes, mine is an insider loyalist critique of an overly narrow focus on civil- and political rights.
DS: You have been critical of neoliberalism and some of its solutions to some of these problems. Can you say a bit about this?
PF: There are broad economic policies that favor social safety nets and others that really don’t. If you look back over discussions on various economic disasters in the country -- like the Great Depression -- this was a very vibrant topic of discussion. FDR and his cabinet members were very explicit about the need to think hard about the ill fed, ill housed and unemployed.
This is something Americans ought to be proud of; it’s part of our history too, just as is the more unfettered growth period that can sometimes collapse as we’ve seen with the recent economic set backs. It is important to say that we need to fight more to make sure that everyone has a right to basic health care. We are not going to see this happen under a lot of these more neoliberal economic policies. Another way of putting this: we need to focus on social protection as it benefits our physical and emotional well being, and also strengthens the economic well being of the public.
DS: Some advocate for neo-liberalism on pragmatic grounds. But your critique of neo-liberalism is also made on pragmatic grounds, yes?
PF: If you find 10,000 NGOs, as you do in Haiti, then you know that they are filling a space left by others. The others, in this case, are the public sector, the state itself. I work at an NGO, as a volunteer for Partners of Health. And I work for a private University. (I’m a professor at Harvard, that’s what I do for a living.) So, this is not an attack on the private sector of NGO -- after all, I represent an NGO. But, as NGO’s and non-State actors, we must believe in some basic social safety net to strengthen the public sector’s ability to provide basic services. This is a perfectly fine primary goal for an organization like Partners In Health.
Some people think of Rwanda as a place in which a sort-of neo-liberal economic policy is in place. But, if you look at the Rwanda budget, it is pretty shrunken in health care and education. Yes, there is strong encouragement from the private sector, including direct foreign investment. We need this in Haiti. The question is, do we provide this at the expense of any basic right of the population? The answer is: No. This is not in the interests of pragmatists.
Before the earthquake there was very high unemployment in Haiti, and relentless migration to the cities resulted. There was little investment in public work, safety or education. And so there was a perfect, terrible storm, when something as awful as the January 12th quake hit. Haiti has been terribly vulnerable to natural disasters for many decades, because it has been deforested because people need charcoal. And there is no charcoal, because there has been no significant investment in alternative energy sources. Haiti is not alone in that regard. But, as the recent complex chain of events shows us, you can be absolutely pragmatic and still say, ‘hey, we can put in place some basic systems to protect people from the worst.’
Having a safety net for health care is the ultimate in pragmatism. It is not ideological to say that people need a basic safety net. Same for education. It has been shown again and again that a girl’s education is the best way to promote child survival. What could be more pragmatic than equitable education?
DS: Some of your work has challenged epidemiologists, and the public health community, to look at the impact of economic and political policies on health, and focus less narrowly on individual risks for disease. You've also challenged anthropologists to go beyond cultural factors in explaining behaviors that put people at risk, and to investigate the political and economic context. In these ways, you've been pushing both these disciplines to stretch beyond where they have focused much of their attention over the last fifty years. Was this your intent? And do you think you've had an impact on the disciplines as a whole?
PF: That was my intent. It is difficult to measure impact. For the public health community or epidemiologists, there is always some kind of blinder on any methodology or any kind of disciplinary approach. For anthropologists and public health specialists to be blinded in this way is particularly offensive because it is our job to re-socialize our understandings of phenomena.
Again, going back to Haiti, there is an earth quake at 4.33 on January 12th. It is a natural disaster and also a social disaster. It is the job of some disciplines to work hard to make all of this clear. Why? Because understanding claims of causality, how one thing causes the other, is important to any convention. Going back to medical language, to get both the prognosis and the prescription right, you need an accurate diagnosis. This emerges from a comprehensive examination of the history of the illness -- and all the data that we have is laboratory data and modern biomedicine. The underpinning of that critique of my colleagues in public health and anthropology is that we are not going to get the diagnosis correct if we don’t have an historically deep, geographically broad, view. By geographically broad, I mean that if you are looking at epidemic disease you can’t focus your attention on one administrative unit. Usually in the 20th century nation state, epidemics don’t remain local. There is a lot in the book about epidemics. They never stay local. They always get out of prisons and hospitals, and out of one state and into another.
Parochialism about place, just like parochialism about time, is detrimental if we want a full understanding of big social medical questions presented in Haiti and elsewhere around the world.
Paul Farmer is Professor of Social Medicine and the Chair of the Global Health and Social Medicine at Harvard Medical School.
Diana Silver is an assistant professor of public health at New York University's Steinhardt School of Culture, Education and Human Development
Tags: Diana Silver, health care, JB, Author Talk, Paul Farmer
05/12/10
by Dick Morris and Eileen McGann
Reviewed by Naomi Wolf
In `2010: Take Back America: The Battle Plan,’ Dick Morris and his wife and coauthor Eileen McGann, present a game plan for Republican victory in the upcoming Congressional elections, and, a putative libertarian manifesto against an alleged plan by Obama to take over the United States of America with a devious Socialist agenda.
The book is fascinating and troubling. Fascinating because Morris and McGann are brilliant political analysts. And they are adept at reading Americans’ true anxieties and crafting policy proposals and language that resonate emotionally and intellectually with them. (Disclosure: I worked informally on policy and message ideas with Morris during Bill Clinton’s 1996 Presidential campaign.) Such smart people, who write so clearly for a mass popular audience, could help Americans -- of all political parties -- better understand the core dynamics behind our moment in history.
But that is not Morris and McGann’s task. Their book is troubling because, in addition to providing important and well-documented insights into crucial issues such as the influence of lobbyists’ money on the voting records of representatives, the skyrocketing deficit and what it means for our economy, and the dangers of unchecked `bureaucratism’ (one of Morris and McGann’s less felicitous but still useful neologisms), `2010: Take Back America’ frames these trans-partisan issues in a fully partisan way and then intercuts its strong reasoning with heated sound-bites.
Take Back’s abiding idea is that America as we know it is ending under Obama’s stealth program to undermine everything that makes America healthy and free: `[T]hese elections will be the critical turning point for America’s future... On the one side is the America we know and love. On the other is a very different America: the dream of Barack Obama…His dream is our nightmare.’
Their overarching assertion is that Obama and a democratic-controlled Congress want to take over America and re-create it as a flat-out socialist system. And, to do this, so the story goes, Obama and co. have craftily deployed tactics such as excessive government intervention in medical care, Congressional Democrats’ enslavement to lobbyists, and increased governmental regulation of banks.
You don’t have to buy into the duo’s partisanship to grant that the issues they raise bear consideration. And the authors' track record for prescient observation reinforces their authority. Morris and McGann rightly note that, in their book, Fleeced, they forewarned readers of a stock market crash, and that, in Catastrophe, they cautioned that Obama would scale up the national debt. Many serious commentators agree with the team’s current predictions that inflation is likely to soar and the dollar will likely weaken -- forcing tax and interest rate hikes for all Americans.
The author’s substantive insights are marred by sloganeering. They skid quickly from serious warnings about unsustainable federal debt, to: `His strategic mantra is: REDISTRIBUTE! He plans to redistribute wealth, to redistribute access to health care, and to raise taxes until it no longer makes sense for productive people to keep working.’
The authors accuse Obama of having a `One World Strategy’ that seeks to subordinate US sovereignty to global intermediaries [`[H]e’ll try to place the entire US economy under the rule of the International Monetary Fund.’ Their analysis, which explores the effect on the US economy of IMF and the G-20 agreements proposed by Obama, is serious, but their rhetoric is extreme.
McGann and Morris range from a powerful discussion of the danger of losing doctors under Obama’s proposed medical care changes to demagoguery on the same issue: `Washington will set the standards of who gets lifesaving treatment or surgery…and who is left to die.’ They follow a sober assessment of the increase in the money supply, which people of all backgrounds are concerned about, with a footnote-less assertion that legislation the Administration proposed `would give the federal government the power to seize any business, fire its management, wipe out its investors, and run it as a government company for as long as it wanted, spending unlimited taxpayer money in the process…Fidel Castro and Hugo Chavez have no broader powers!’
The authors supply a beautiful assessment of the risks to the Constitution of some unchecked interventions; for this liberal, their summary of the Heritage Foundation’s argument that “nowhere in the Constitution is Congress given the power to mandate that an individual enter into a contract with a private party to purchase a good or service and…no decision or doctrine of the Supreme Court justifies such a claim of power’ is extremely suggestive and sparked an interest in greater depth of understanding.
But then the authors undertake an extreme about-face and undermine their own constitutionalist arguments: they worry, for example, that Guantanamo isn’t tough enough to keep its prisoners off the battlefield once released, which nicely ignores the fact that the prisoners are both held and released without due process of law required by the same Constitution, or that they have been tortured, also forbidden in the Constitution.
The `Obama-as-Socialist Dictator’ meme gets a workout in this book, sometimes on very persuasive arguments about a power grab and sometimes on evidence that is much slighter: `[E]ver since President Obama came to Washington, his near-hysterical criticism of Fox news and anyone else who doesn’t toe his line have us worrying that we may be in the first stages of an attempt to roll back our democracy and inhibit freedom of speech. Remember: all dictatorships begin with increasingly strident criticism of the news media.’ Rather, as Jefferson knew, all democracies begin amidst increasingly strident criticism of the news media. (Indeed Jefferson and Adams, when in Washington as Presidents themselves, spent a great deal of time criticizing, sometimes stridently, the contemporary news media.) Dictatorships begin with increasingly tough restrictions on the news media and penal or other actual punishments for critical speech. Big difference.
Despite my reservations, and, my efforts to read with eyes wide open, I came away from 2001: Take Back America with a valuable -- if dismaying -- understanding of how liberties might, theoretically be subverted from the left. And, horribly enough, I also came away with an unwelcome and rather appalling insight about liberty in America and how to protect it: if Bush modeled from the right, as I argued in The End of America, a ten-step program for taking excessive power – and, as I argued myself in my conclusion, future leaders of any party are likely to be tempted to replicate those tactics because power grabs work and serve anyone in office – why should I be surprised by a book that basically proves that my prediction has in some ways come true? This administration may have had a learning curve derived from the previous administration. They too may be making broad, possibly threatening assertions of unchecked power; they too have seen that doing so works.
Every book that warns America is at risk ought to include discussion of ordinary citizens and what they can do to protect our country. Let me write this so it can’t be taken our of context: I do not support most of Morris and McGann’s partisan agenda, they offer exciting, sound, energizing and practical ideas about how citizens can take the power of political change into their own hands. They offer good, useful suggestions about social media and how to use it to; these, and other tips for citizen action, are predicated on the idea that citizens need not leave matters to the elites or the experts but can use social media to raise political questions, start grassroots campaigns, and otherwise make change themselves. This is invaluable, as is the author’s populist message. It would have been even more valuable if aimed at energizing our democracy for any concerned citizen, whether of the left or the right.
McGann and Morris are Republican consultants. So perhaps it is naïve to wish their clear concern for country expressed in this book could be rephrased in trans-partisan terms. But, now more than ever, we need leaders and spokespeople willing to empower citizens to defend liberty in a trans-partisan context.
This may be the moment at which we most need to collapse the paradigms of the left and right in order to save liberties in ways on which Americans -- that those on Morris and McGann and my side of the spectrum – can agree.
How can a traditional liberal trust autonomous government to build a social safety net, when the government is no longer run by the people at all, but rather by corporate interests, and so government is actually enmeshed within business? And how can a traditional conservative trust a presumably autonomous free market, if free market autonomy has been compromised by the way big business has become enmeshed within government? The new, ungainly monster-merger of government and corporate interests arrayed against the people -- whether urban hippie activists or small-town businessmen and women. Getting rid of the usual labels might be a good way to begin to fight back.
In this fight, it truly is us, the people – of all political persuasions – against the government/corporate nexus that serves its own endlessly self-replicating agenda.
2010: Take Back America raises important points for a right wing critique of threats to liberty from the democratic `brand’ of this Leviathan. But it is incomplete because a dualistic left-right worldview, in this historical moment, is incomplete.
I hope McGann and Morris can be persuaded to make use of their next book, and their analytical and predictive powers, to craft a trans-partisan game plan for liberty that takes aim at oligarchs on both sides of the aisle, and by doing so addresses all of us.
There would have been a great value in this book as a critique of threats to liberty from a democratic administration – to bookend other works that analyze threats to liberty from the right -- if it had been written with a goal that transcended partisanship. For the truth is that there can be threats to liberty from excessive power grabs from the left or the right; from an unchecked, dictatorial representative of private sector interests, as I argued Bush sought to be, to interests that come from the left that seek overweening power through other tactics, such as excessive government controls of private life. And history shows that damage to liberty has come in both costumes and from both strategies.
Naomi Wolf is the author of seven books, including the New York Times bestsellers The Beauty Myth, The End of America and Give Me Liberty.
Tags: democracy, Dick Morris, health care, Naomi Wolf, the economy, Book Briefs
04/02/10
by Theodore Marmor
One of the most striking features of the American health care debate is how little attention was paid to the subject of justice. The idea of fundamental fairness, questions about solidarity and what it requires in the way of patient cost sharing, and the importance of equal access: all were central components of the public conversation about health care – in Canada and Britain and democracies elsewhere.
The specific tropes vary as do ideas about what, specifically, justice requires, but notions of justice were central to similiar public conversations about universal health care in Scandanavia and elswehere on the European continent.
What lessons might we have learned had the American debate been less provincial? And did ideas about justice solidify and stabilize the health reform efforts elsewhere?
Consider the the British National Health Service (NHS). From the outset, it celebrated the idea that medical care should be 'free at the point of service.' This is a core premise. The idea is that equally ill citizens should share equal access to care – regardless of their ability to pay, and that, were it otherwise, financial barriers at the point of service would disproportionately, effectively, allocate health resources to those who can afford to pay for them.
Interestingly, the English practice has never quite lived up to its egalitarian norm. For decades, the NHS allowed for 'pay beds' which accelerates access to care for those with private insurance for public hospitals. From the start, the British system permitted physicians to charge for 'private patients' even while they devoted the bulk of their time to NHS patients. So, the principled commitment to a more just distribution of medical care has, in practice, accomodated some limited privileges of English physicians and some patients. This form of a mixed market for medical care has been the subject of continuing controversy within the Labour Party. It has also provided a safety valve for discontented physicians or patients with means or private insurance. But the essential fact remains: in contemporary Britain, two seemingly conflicting ideas – guaranteed access according to medical need for most, and, some access according to ability and willingness to pay — coexist; and, this is so even though the NHS accounts for roughly 90% of expenditures and private insurance about 10%.
In practice, Canada is even more egalitarian. Consider Canada’s hospital and physicians' financial rules. The Hall Royal Commission report of 1964– the founding document in the Canadian medicare system – called for a universal, comprehensive, accessible, publicly administered, portable system of health insurance. This is designed to remove all financial barriers to hospital and physician care and thus ensures equal access for all citizens. Successful practice depends, however, on rules that require physicians – and hospitals – to participate fully or fully exempt themselves from the public insurance system. Doctors can’t charge patients who come to them under the Canadian Medicare Program. Indeed, except in very limited instances, the Program does not allow private health insurance for medical services that the Program covers. The obvious goal is to substitute medical need for financial clout as a criteran for access. Canada's system is remarkable in this regard. No other industrial democracy places such firm limits on private insurance purchase.
Similiarly, if one reviewed the health care programs in France, Japan, Holland, and Germany, a common pattern would emerge. Each country offers different, but limited, market options for those who want and can afford special treatment; each of these countries, as distinct from the U.S., created a universal health care program fundamentally based on the idea that medical care is a merit, not a market good. The equal access norm does not, of course, mean ideal practice, but care is more equally distributed. It is also true that more equal medical care does not necessarily mean that access to health care is equally distributed in these countries. Health care and health aren't the same thing, and making populations more equally healthy is much more difficult than making medical care more fairly distributed.
Enter the US debate -- and the relative omission of serious ethical justification for the health care overhaul, soon to be termed "Obamacare." During his long campaign for healthcare reform, Obama repeatedly and eloquently described the traumatic, destabilizing consequences under- and uninsured Americans face. Private health insurance, he said, presents for many Americans a nightmare of troubles -- recissions, denial of applications because of pre-existing conditions, misleading advertising, etc. Medical inflation and the problems it has caused were the focus of much public hand-wringing. Cost control, too, was the subject of great public interest. But, what makes the Obama reform package a 'just' one? Or a morally-compelling legislative effort towards what end? The expression "affordable health care for every American" was bandied about, but was not clearly defined. Instead, it was repeatedly invoked as a means to avoid the various personal horror stories told and re-told throughout the long debate. In fact, there was little talk about why affordable health care for all is a good, much less, important or democratic, idea.
The politics of reform, which produced legislative "victory," will continue. Indeed, in the last days before it passed, Obama campaigned for healthcare reform as if he had the elections of 2010 and 2012 in mind. The Obama reform rhetoric will provide the opportunity to reinforce why this overhaul made sense, why it should compel admiration rather than scorn, and why it might make a more just America. And, this campaign will be crucial to heading off weakening rather than strengthening Congressional adjustments while we wait for the bulk of the legislative reforms to be implemented between now and 2014.
Last summer T.R. Reid published a much lauded book about comparative health care reform experiences in leading democracies. In a review in Health Affairs, I contributed to critical acclaim surrounding The Healing of America and the compelling case it makes for unversal health care; in doing so, Reid invoked the moral arguments that animated reform efforts in France, Britain, Canada, Japan and Germany.
Yet, while rightly calling attention to the moral principles that undergirded reform efforts abroad, Reid conflates the idea that consensus is, on normative grounds, a necessary condition for reform and the notion that arguments for a more just distribution of care would help rally support. Reid’s treatment of Canadian development was, in fact, misleading. His coverage, for example, omitted mention of the long period between 1957 and 1971 when Quebec finally joined in the national medical insurance program. Reid implied that Canada arrived at a moral consensus, which resulted in the Medicare Program. In fact, the justice imperative underlying Canada's national insurance program was a more a product of the nation’s move to universal coverage, than it was the force that animated the move.
Impressed by the overall merit of Reid’s work, I did not want to detract from his argument, at least not last summer when it was far from certain Congress would pass any healthcare legislation. Now, however, it seems important to push those seeking to solidify and to improve reform legislation to consider, seriously and thoughtfully, the lessons of comparative experience abroad.
Theodore Marmor is the author of 13 books about health care and public policy, the most recent of which is The Politics of Medicare (Transaction Press); A professor Emeritus of Public Policy and Politics and Yale University, Marmor is editor of a recent collection of essays about healthcare policy, Fads, Fallacies and Foolishness in Medical Care Management and Policy (World Scientific Press, 2007).
Tags: democracy, health care, justice, Theodore Marmor, Book Briefs, Barack Obama
Permalink