Thursday, October 11, 2012

Fwd: qotd: Howard Waitzkin on commodification and the search for a universal health program

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Subject: qotd: Howard Waitzkin on commodification and the search for a
universal health program
Date: Thu, 11 Oct 2012 13:30:32 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

Robert Wood Johnson Foundation
Human Capital Blog
October 11, 2012
The Commodification of Health Care and the Search for a Universal Health
Program in the United States
By Howard Waitzkin, M.D.

For better or worse, we treat health care in the United States as a
commodity. We buy and sell it, and would-be patients who don't have
enough money to buy it must either rely on limited public assistance or
go without care. In very real terms, it's not just health care that we
have turned into a commodity, it's health itself, so it should come as
no surprise that poor Americans die sooner than affluent ones, by an
average of close to five years.

I observed this dynamic up close for the first time about 40 years ago,
while working as a primary care practitioner in the clinic system of the
United Farm Workers (UFW) Union in the 1970s (which, for a time, my
mentors in the RWJF Clinical Scholars Program viewed as my required
activity in clinical medicine). As I treated hard-working patients
living in unhealthy circumstances, it was easy to conclude that one does
not need to travel outside the United States to find the so-called
"Third World." As I observed with many of the patients I treated while
working with the UFW, the living conditions of the poor contribute to
ill health.

Shortly after the military coup in Chile that occurred on September 11,
1973, while researching an article on the health consequences of the
military dictatorship that later appeared in the New England Journal of
Medicine, I discovered the work that President Salvador Allende had
accomplished in the field of social medicine. In 1939, three decades
before he became Chile's democratically elected President, Allende wrote
"La Realidad Médico-Social Chilena" (The Chilean Medico-Social Reality),
in which he presented an analysis of the relationships among social
structure, disease and suffering. The book conceptualized illness as a
disturbance of the individual fostered by deprived social conditions.
Breaking new ground in Latin America at the time, Allende­—himself a
pathologist—described the "living conditions of the working classes"
that generated illness, with emphasis on the social conditions of
underdevelopment, international dependency, and the effects of foreign
debt and the work process. Growing out of those conditions, in his
description, were a number of specific health problems, including
maternal and infant mortality, tuberculosis, sexually transmitted and
other communicable diseases, emotional disturbances, and occupational

Making the case that improved living conditions exerted a more profound
impact on population health than medical advances, Allende described the
responsiveness of tuberculosis to economic advances rather than
treatment innovations, the role of housing density in the causation of
infectious diseases, and the adverse effects of the pharmaceutical
industry's financial practices (for instance, Allende offered the
earliest known account of the differences between generic and brand-name
pricing of essential medications). In this context, Allende also put his
finger on a dynamic that has come to trouble physicians, patients, and
policy makers worldwide during recent years, writing colorfully that a
"problem in relation to the pharmaceutical specialties is…the excessive
and charlatan propaganda attributing qualities and curative powers which
are far from their real ones."

After his election to Chile's presidency in 1970, Allende began to move
health care toward a universal model, while at the same time initiating
a variety of public health initiatives, such as establishing maternity
clinics in rural areas, imposing new health and safety requirements on
mining companies, improving sanitation and housing in low-income areas,
and more. But Allende's nationalization of several industries dominated
by North American interests, despite the compensation provided to those
corporations, earned him powerful enemies, and a U.S.-supported military
coup drove him from power three years into his administration, ending
his efforts to improve Chileans' health.

In Central and South America, the part of the world where I've focused
much of my research, the United States and various international
financial institutions have worked to support health care systems
structured along the for-profit model. The World Bank, for example,
worked to foster health care systems that served the objectives of
private capital accumulation in less developed nations, with the
inevitable result that health and health care became a commodity.
Commodification burdens poor people's health in many ways, and the
adverse impacts of corporatized health care have spread throughout the

One irony, however, is that some less developed countries have found
ways to uncouple health from wealth. But it hasn't come easily. In
recent years, the commodification of health in Latin America has receded
somewhat, particularly in the wake of the worldwide economic crisis and
widespread protests that have followed. Regimes that previously embraced
corporate interests have grown weak and largely have disappeared,
replaced by elected governments that have refused to accept the
historical patterns of economic empire that fostered exploitation and
poverty around the world. National and local leaders have entered into
novel coalitions that have given rise to a new era of social medicine in
Latin America.

In the 1990s, for example, El Salvador saw sustained efforts to resist
efforts by the World Bank and the ruling right-wing political party to
privatize public hospitals. Strikes by health care workers at affected
hospitals spread elsewhere, leading to a commitment from the government
that it would abandon the privatization push. When the government
subsequently began contracting out hospital services to private
entities, more strikes followed. Eventually, the World Bank flinched,
backing away from a privatization requirement in a loan it was extending
to the country, and efforts to expand public-sector health care are
again under way.

Popular efforts to accomplish similar objectives have taken root in a
number of Latin American nations, and the idea of universal health care
has even taken root right here in the United States. It was a key part
of the agenda on which Barack Obama rode to victory in the 2008
Democratic election. However, the principle of universal access to
health services through a strengthened public sector largely disappeared
from the health care reform bill he eventually signed into law.

As many critics have pointed out, Obamacare, the Patient Protection and
Affordable Care Act (PPACA), uses public-sector funds and mandatory
patient-generated premiums to buy insurance coverage from the private,
for-profit insurance industry. This approach ultimately will provide
coverage for only about half of the uninsured, with costs that will
continue to rise over time due to the administrative waste inherent in
private insurance. In addition, Obamacare will provide yet another
enormous public subsidy for the private insurance industry, despite its
dismal historical record. Ironically PPACA closely resembles the
"neoliberal" health reforms promoted previously by the World Bank in
Latin America and other regions, for instance the widely criticized
reform that began in Colombia during 1994.

This paradoxical situation becomes quite striking because Medicare
offered a model for a successful system. Medicare provides universal
access to publicly financed services with low levels of administrative
waste and more effective cost control than seen under private insurance.
Although Medicare retains various flaws, these flaws are far less
critical than the continued commodification of health as preserved under
Obamacare. The Obama administration could have proposed an expansion of
Medicare for the entire population of the United States. Obama himself
favored this type of "single payer" approach while he was a state
legislator in Illinois but later changed his views when he began to
accept large financial contributions from the private insurance industry.

Despite widespread support from professionals (see for instance
Physicians for a National Health Program) and the general public (see
for instance Health Care Now), "opinion leaders" like those who lead the
RWJF have declined to advocate for the particular model of universal
health care embodied in the Medicare for All approach. At the risk of
appearing to bite the hand that feeds (which actually feeds only to a
very minor extent), let me say that one of my major disappointments in
the RWJF during its more than 40 years of trying to improve access to
affordable health care is that its leaders consistently have declined to
advocate for a coherent, unified model for a national health program.

The simple truth is that the United States remains the only economically
advanced country without a viable national program that ensures access
to needed care for all. As a result health care—and health—remain a
commodity for sale. Until we in the United States decide to de-commodify
our health care and health by implementing a universal, single, publicly
financed, national health program such as Medicare for All, we will
remain in our current state of ethical underdevelopment.

Howard Waitzkin, MD, PhD, is senior fellow at the Robert Wood Johnson
Foundation (RWJF) Center for Health Policy at the University of New
Mexico, as well as distinguished professor emeritus in the Department of
Sociology, and clinical professor in the Department of Medicine. He is
an alumnus of the RWJF Clinical Scholars Program. Waitzkin recently
received the American Sociology Association Medical Sociology Section's
2012 Eliot Freidson Outstanding Publication Award for his new book,
"Medicine and Public Health at the End of Empire," from which this blog
post draws.

Comment: Howard Waitzkin's article is too important to edit it for
Quote of the Day. It is presented here in its entirety. No comment

1 comment:

  1. MD247 doctors and telemedicine program members are legitimately given the opportunity to connect, allowing a patient the chance to talk to a doctor without that doctor worrying about time and overhead.