Social Health Care

When Danny Boyle (Trainspotters, Slumdog Millionaire), the prestigious director chosen to conceptualise and stage the opening ceremony for the recent Olympic games in London sat down to decide how he was going to do it, he was soon faced with a problem. Not with the concept itself; he quickly came up with the idea of using the occasion to showcase the history of Britain. Moreover, most of the elements were clear; start with a bucolic vision of England’s “green and pleasant Land,” move on to the 18^th and 19^th Centuries and the Industrial Revolution – the forging of the Olympic rings against a “Satanic Mills” background was a nice touch, I thought – and the final section was easy, from the swinging sixties – Carnaby Street, the Beatles, etc. – into contemporary pop/mobile/internet culture. But what could he chose as the theme for the penultimate, connecting piece?

The basic problem lay in conventional historical British iconography and legend. Ask almost any Britain about the first sixty years of the last century and two themes will automatically come to mind; the Empire and, above all, the war – the Battle of Britain, Dunkirk, the Blitz, brave Britain standing alone against the Nazi juggernaut which had blitzkrieged its way through most of Europe. Yes… Well… Not exactly the most suitable themes for a global Olympic celebration.

Boyle came up with a marvellous concept. Taking the idea of illustrating various themes from Britain’s wonderful panoply of children’s literature (with Mike Oldfield providing the background music), he set this before the background of Britain’s National Health Service.  This portion of the show took its title from the legendary directions in J.M. Barry’s Peter Pan, “second to the right, and straight on till morning.”

The choice of the National Health Service, as the official programme put it, “the institution which more than any other unites our nation,” was inspired. And it sent a clear message to the world about what Britons regard to be the real enduring legacy for them of the epic struggle of the Second World War; the welfare state as embodied, above all, by the comprehensive right of every British resident (and visitor) to free health care. And it is an institution which, despite all the problems, all the complaints, all the shortcomings, bureaucracy, inefficiency and everything else, still enjoys overwhelming support in the British population at large. Even Margaret Thatcher, at the height of her crusade to privatise every aspect of British life except the military, never dared to try to seriously attack the National Health, much though I suspect she would have liked to.

The Olympic opening ceremony was, of course, designed as a spectacle; a playful and artistic presentation, designed to touch us on as many levels as possible, primarily the emotional ones. Were I in a mood to cavil, I would point out that most European countries have a more or less comprehensive public health system, the origins of quite a few of them older than those of Britain’s NHS. But such a criticism would indeed be small-minded, because Danny Boyle’s choice of the NHS as a fundamental icon in the British consciousness of the history of the 20^th Century, particularly as a replacement image for the war, makes a much more profound point.

Beyond the concrete territorial aggression of Nazi Germany, the war fought throughout the world in the middle of the last century was a conflict between two ideological systems; to use the title of Karl Popper’s seminal work, the struggle between the Open Society and its enemies. In that respect – and Churchill was the only allied leader who really recognised this while WWII was still going on – the war itself was only half ended in 1945; it took 45 years more for the second form of totalitarianism, Stalinist centrally controlled statism, to follow its dark fascist twin.

The point I am making here is that it seemed perfectly clear to Europeans that a major part of the values which were at stake in the life-and-death struggle with totalitarian ideologies was the right of every man, woman and child to a decent life. And a prerequisite for a decent life is basic health and the treatment of illness. Society cannot guarantee happiness, but one of its most fundamental functions is to make possible for every last member – in the words of the US Declaration of Independence – “the pursuit of happiness.” Illness and disease are a major cause for suffering and, as such, make the pursuit of happiness for those afflicted much more difficult, if not, in many cases, impossible.

Seen in this way, basic health is a fundamental human right, a necessary condition for securing human dignity. This was a widespread consensus among Europeans, faced with the challenge of building up their societies after the trauma of the war, and the defeat of an ideology which despised and rejected the fundamental liberal Enlightenment consensus of what it meant to be human. And so the concept of a right of all citizens to comprehensive health care became a corner-stone of social policy in most post-war western European societies.

Even the USA, reluctantly and in a very limited form, followed this development, this maturing of realisation of the wider consequences of the recognition of the rights ensuing in a society based on the recognition of the inalienable dignity of every human person. In 1965, in the middle of what can well be called the civil rights decade, Medicare and Medicaid were introduced. But in the wake of this, an ideological change started to gain force.

The story of the roots and development of what can be called neo-liberalism or neo-conservatism is beyond the scope of this essay. The very fact that it is vicariously named after two traditionally opposed ideological positions is an indication of the complexity of the subject. Suffice it to say that a combination of economic ideas (Hayek, Friedman, monetarism, etc.), deeper philosophical concepts (Randian Objectivism for example), the growth in size and power of corporations, moving beyond single nations to become transnational molochs, the determination of certain powerful individuals to roll back developments in societies word-wide which increasingly threatened their power and economical bases, and a dollop of fundamentalist evangelical Christianity tossed in to complicate the mix, led to an increasingly popularised basic idea that state/societal/communal acceptance of responsibility for any aspects of life was generally bad, always a curtailment of freedom and only to be accepted as a measure of last resort, to regulate areas of life which could not be regulated any other way. The eighties saw the first concrete political fruits of this new societal paradigm under Reagan in America and Thatcher (who famously stated that there was no such thing as society) in Britain.

A development of the basic concept of general health care as a basic human right became, within this context, almost impossible in the USA, as the Clintons were forced to accept in the early nineties. In Europe too, the public health systems came increasingly under attack from proponents of the political opinion that the state was the root of all evil and that, left to themselves, deregulated “markets” would provide a better world for all. As someone who has been working as a professional within the German social health system for more than twenty years now, I have experienced continually the stress induced by the ongoing war of thousands of attempted cuts and programmes to increase “efficiency.” They have nearly all been carried out at the expense of the weakest of those treated within the system and those who work in the front-line of actually delivering health care. What they have actually managed to save is debatable – the only certainty is that the profits of the most powerful involved in the system (the big pharmaceutical and insurance companies, for example) have been secured and grown.

Fortunately, in most of Europe – despite all the debates, half-truths, propaganda, and downright lies – the fundamental popular support for social health care has been too strong for the neo-libs to succeed in their goal of dismantling it. That is what Danny Boyle was celebrating in the Olympic opening ceremony; even in Britain, the European country most strongly seduced by neo-liberal chimeras, the NHS remains untouchable.

This is why Obamacare is so important. Despite all its considerable flaws, probably inevitable as something resulting from a complex process of political compromise and horse-trading, it represents an enormous step for the USA in a direction of communal moral development, one in which it had so long been behind most of the rest of the western world. And this is why its winding-up in the wake of a Republican victory at the end of this year can be seen as nothing less than a step backwards towards barbarism.

Yes, public health care is expensive. But so is any good health care, and the question remains as to how any society can look at itself in the mirror, knowing that thousands of its members are suffering and dying because they cannot pay for what they need to save their lives.

Moreover, the very question of the costs of comprehensive health-care in any society is more complex than liberal critics would have us believe. Money spent in this area is money which, to an overwhelming extent, remains in circulation in the local areas where the costs are actually produced (apart from the exorbitant sums frequently creamed off by, for example, big pharma), creating secure jobs for thousands of people at all sorts of skill and educational levels, and adding stability and economic life to many communities.

Then there is the oft cited problem of efficiency. It remains an unquestioned aphorism that the profit-driven private sector is always more capable than bureaucratic, over-regulated public enterprises. There is some truth in this. However, two points should be remembered. Quite a proportion of this bureaucratic regulation is occasioned by the need in a complex, publicly-run service to guarantee fairness and accountability. Secondly, it can be asked whether increased efficiency in a predominantly privately organised system actually profits the patients in the end, or whether the end result is not frequently the delivery of the most minimal service possible, for the highest price attainable – frequently at the cost of the weakest people working in the system, not to mention the many patients who are deprived of treatments because there is no money to be made on them, or because they weren’t able to afford an insurance package which would have covered a necessary complex treatment.

I have worked for over twenty years now within a health system which is predominantly publicly organised. There are many aspects of it which are ridiculous, frustrating, badly-organised and just stupid, something about which I tend to frequently rant, as friends and relatives will readily testify. But even in doing this, I realise that I am complaining from a position of relative luxury. In a structure as complex as modern health care, dealing with situations in which many of the people who actually need to avail of the service are in truly extreme situations, defined by pain, uncertainty and fear, there will always difficult issues, with no easy – and sometimes no good – answers.

And, given the fact that research and human ingenuity is always pushing the capability of what medicine can do, there will continually be the question of costs. But for any society which sincerely subscribes to basic values like respect and human dignity, the question must always be; “how much can we afford?” rather than, “how little can we get away with?”

When it comes to the basic question of human health, I am very glad to be living in Western Europe rather than in the USA.

Pictures retrieved from

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https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQw-LFiH7wjUWV75elShXZ1_YMSoCbCCljCaArLjSVRhF_ulhHR9X6gsRy_Xjhni9mRI7XGyQTB5Aj-FPwnOc0w15_eLnp6Z7EcghiDV-R8srwEEo-sRNo3j47BC6BScFYE79zsBunseU/s1600/neo_liberalism.jpg

http://www.creditnet.com/blog/wp-content/uploads/2008/09/medical-cost.jpg

Nursing

I’ve been in nursing, one way or another, for more than twenty years now. Given my somewhat complicated biography, it wasn’t my first choice of career and the decision to enter it at the end of my twenties was more a rational one, taken at a period of my life where (I felt) I had to put myself on some kind of steady job/career path – I found myself with a young family to support.

It’s a decision I’ve reflected on frequently since taking it, but one that I have never really regretted. However, I freely admit that I do not belong to that group of colleagues (who I really admire), who seem to have been born for the job and who never seriously considered doing anything else. In that sense, it has been more of a profession for me than a vocation. Not that there’s anything wrong with that; indeed, as the years have passed, I have found myself increasingly regarding the idea of professionalism as being very useful for the long haul in this kind of work, helping me to integrate it into my life in general, giving me the capacity to combine genuine empathy with the necessary distance to be able to carry on daily dealing with the (often shocking) human suffering, pain and misery with which nurses are confronted without burning out or going crazy.

That said, I want to sound off about the way people working in the nursing area are often regarded by and treated in what is frequently called the “health industry” and our society in general. Our high-octane, performance-driven, (selectively) cost-conscious culture has developed all sorts of mechanisms and instruments to increase efficiency, frequently given such titles as “quality assurance” or the increasingly ubiquitous “total quality management” (TQM). I don’t want to completely demonise such processes – they can be very useful in many ways – but we should remember their origins in assembly-line based production industries and be wary about giving them unquestioned supremacy in areas which have to do with people and relationships (and the nursing process is fundamentally about relationships), particularly when these have to do with people in extreme situations – and people who are in a position where they need nursing (of whatever sort) are generally in situations which can be described as extreme. You just can’t treat someone suffering from terminal cancer or dementia in the same way as you can a carburettor and then decide that the time a nurse should need to help such a person to wash themselves or go to the toilet can be computed in the same way as the time someone on the factory floor needs to connect the carburettor to the rest of the engine.

But this is, in fact, what is increasingly happening in the health care area. Some of it is understandable. In a world in which medical advances make more and more possible it is becoming increasingly clear to everyone that such progress is not cheap. The fact that a basic driving mentality in our modern culture is to see every difficult situation as a series of problems to be solved exacerbates this. The end result of all of this is that modern societies (particularly in the so-called “developed” world) are faced with continually increasing costs in the health area and the issues of how we are going to pay for all this and how we can be sure that we are really getting value for the billions we are spending already become ever more critical.

Nursing care is, by its very nature, labour intensive. And this is where the problems really begin. Faced with (frequently conflicting) demands for high quality and efficient costing, the easiest quick fix is to look at staffing levels and organisation. The easiest reaction for medical institutions of any kind coming under economic pressure is to try to reduce labour costs. For all sorts of obvious reasons, for example, a hospital confronted with a choice of not buying the latest sexy piece of diagnostic equipment or getting by with a couple of nurses less will almost always choose the second option. The basic view of those making the decisions seems to be that there is always some slack in the nursing care area; that more rational organisation will always lead to a situation where fewer people can do the same amount of work.

In the nursing/care area this kind of thinking is made easier by the fact that it usually brings results – in the short term. These has a lot to do with the fact that people who work in such jobs are generally conscientious, highly motivated and are driven by an ethos which makes them try to ensure that their patients don’t suffer as a result of such efficiency drives. So they work harder, put in more (frequently unpaid) overtime, etc. Often the pressure becomes too much, some become ill and have to take sick-leave. The resulting gaps are filled by their colleagues, who have to do even more as a result. And almost everything they do has to be done almost immediately, whether that’s at night or on Sunday afternoon. The pressure increases. This increased pressure can – and sometimes does – lead to mistakes being made. But there are ways around that too, you just have to make sure that every step of the work done is adequately documented so that in the case of a mistake being made it can be quickly identified and rectified. Of course, this obligation to document everything also increases the work-load further. In an iconoclastic mood, I sometimes ask fellow health professionals the question; what is worse, to do something and not document it, or to document something and not do it? Ethically, the answer is simple but, in terms of basic self-protection, it is often better to be sure that your documentation looks complete.

And, should an institution or a department do their job really well, then that’s a sign that there’s obviously more potential for savings there. And so the screw is turned a bit more …

So, the next time you’re in hospital, in pain, and you ring for a nurse, don’t be surprised if it takes her/him a quarter of an hour to answer your call. Chances are there are only two or three of them on the shift responsible for around forty patients. The next time you see a couple of nurses drinking a cup of coffee on duty, consider that they may just have finished changing the dressing on a stinking open tumour, or that a patient may just have died (probably when they weren’t there, because the amount to be done in every shift doesn’t allow them to simply spend twenty minutes just being there for someone who’s dying). Of course, it’s also possible that they may simply be a bit burnt out – too many night shifts, too much suffering and pain witnessed, a relationship failed because their partner couldn’t deal with them being frequently exhausted or stressed out during their irregular free time. And the next time you hear a discussion about the costs of health care, think about what the managers of health insurance or pharmaceutical companies earn compared with a nurse. Or consider what you paid the electrician per hour the last time you had to call him/her because your washing machine was broken. Nurses would be very glad to work for that kind of money

Health Care Reform

So, the US Congress has passed President Obama’s health reform legislation and around 32 million US Americans will finally get some kind of health insurance. Seen from a Western European perspective, the USA has finally joined the group of nations which officially sees health care as a basic human right.

I admit to finding the US debate strange. Manipulated by various vested interests and some frightening ideologues, many US Americans of a conservative bent genuinely seem to see the reform as an attack on the foundations of their society, ramming through dictatorial socialism in the land of the free and the home of the brave. A confirmation of their fear of what the election of a black president with Hussein as a middle name and a surname which contains only one letter’s difference to the first name of the fanatic mastermind behind 9/11 would bring. One evangelical preacher has been making headlines by starting a list to pray for the deaths of all those representatives who voted for the health bill. This kind of fanatic, hate-filled opposition is frightening. The ironic thing is that it was the regions with the highest proportion of people with no health insurance whose representatives voted most strongly against the bill. (Those interested in the statistics can view them here: http://www.tableausoftware.com/healthcare-bill-passed.)

It all suggests to me that a lot of the opposition to Obama’s health care proposals is of basic ideological nature, rather than actually about health coverage. It’s about complex issues of perception rather than the concrete issues on the table. There are deep roots in old American memes of mistrust in government and a frontier mentality of self-reliance. These join with conservative evangelical themes which have a deep distrust of secular liberal pluralism and a feeling of being threatened by a dangerous, unknown, possibly hostile world outside the glow of the camp-fires around which those of like-mind, those you trust and love, huddle. A world of outlaws, of people who look and think differently to you; a world where you can be cheated and robbed – either by those poorer and more desperate than you, or by those who are cleverer, more smooth-talking and educated than you, who will take your money and leave you with snake-oil. Against the poor and the desperate you can protect yourself with a gun, but what will protect you from self-secure, godless, liberal lawyers, who want to take your money and (having pocketed a good portion of it) give the rest to those too lazy and indigent to look after themselves? And, there in the back of your mind, there’s still that niggling worry, the fear that you too could loose your job, get sick; but if there’s one thing you’ve learned, it’s that in such situations, the only ones you can really rely on anyway are family and, sometimes, trusted friends, and, of course, God. In him you trust, the rest pay cash and you do too, when you need something and you have it.

There’s a kind of residual Calvinistic tinge to all of this; a feeling that, somehow, sickness is a judgement of God, a result of your own failings and that general health insurance will be “wasted” on those who have stuffed themselves to obesity and diabetes or fornicated themselves into sexually transmitted diseases or situations in which they consider terminating pregnancies. The factual grounds for obesity in poor, cheaper diets and lack of exercise, the genetic component in diabetes, that the treatment of stds (with the exception of the special HIV issue) is generally cheap and easy and that it’s a miniscule amount of the health budget in developed countries anyway disappear in the heat of emotional discussion. But, as I said, most of the discussion is about perceptions rather than facts.

Not that there aren’t enough facts to be discussed. Health care is expensive and will become more so, especially in the developed countries, with ageing populations and ever better, more complex treatments which mean that people are coping with and living much longer with chronic illness. Are there limits to what society can carry collectively in the area of health and, if so, what are they? How much do we want to spend on the basic right to health care, how do we allocate and manage the resources? Are there deeper questions which need to be asked about the moral vectors in society with regard to the major area of confluence between health care and the dynamic to maximise multi-national business profits by banking and insurance corporations and the pharmaceutical and medical-supplies industries?

These are questions hotly debated in Europe and Japan and there is enough stuff for bitter conflict. There are many issues which can only be tackled internationally. But progress on these issues is dependent on two basic premises: firstly, that basic, universal health care is a human right and, secondly, that illness cannot be fundamentally seen as self-inflicted or deserved. Hopefully now that the USA has legislated for general basic health care, they can now join the rest of the world in the discussions about the more important and difficult areas; how to go about providing it.