Sicko and the ecology of health care reform
Culture Change Editor Jan Lundberg writes:
Up against the broken U.S. health-care system, the nation's disease-ridden population thinks these are tough days because of the financial aspects of medical care. However, these are our salad days, compared to what is to come when the effects of peak oil and climate change devastate the economy.
In light of Western medicine's massive dependence on petroleum for cheap energy, materials such as plastics, drugs from petrochemicals, and the centralized, top-down structure of hospitals dependent on motor vehicles, the future of health care in a changing world should be discussed now. Growth of the economy and the stability of the petroleum-oriented infrastructure are dangerous assumptions, as we see oil moving toward $100 per barrel and beyond.
Co-author Dan Bednarz told Culture Change, "We ask what health reform possibilities peak oil opens up to the people." His concern is that reformers such as Michael Moore are "wedded to the notion that large insurance companies and hospital/medical complexes are the crux of the issue. In my view they are symptoms."
Can Michael Moore's Sicko catalyze health care reform? Despite widespread praise for this exposé we doubt that any message carried on the big screen can meet this high threshold. On the other hand, Internet Movie Database  has links to 124 reviews of Sicko with hundreds of impassioned readers' comments. Moore examines an institution that tangibly affects everyone -- in the quality and span of their lives and in their pocketbooks.
In this review we highlight Sicko's success as a modern day muckraking triumph. Also, it is critical to examine the shortcomings of Moore's views of health care reform in the context of energy, ecology and sustainability.
One of Sicko's feats is its ability to shame and throttle many apologists for the current health care system. Who wants to come right out and argue that it's good for our national character to force a man to decide which severed finger to discard? Such "choices" mock the American mythology of self-sufficiency and rugged individualism. Nonetheless, some critics of Moore are foolish enough to serve up innuendo, red herrings, and fear mongering about the horrors of universal coverage in other nations.
Sicko renders these charges indecent -- simply "busted" -- because there's no way to win a propaganda war with Michael Moore on this: If you live in Canada, England, France or Cuba you will never have to choose which digit to save, bear the mortification of moving into your adult child's spare room because you've gone bankrupt from medical bills, work during your "golden years" to afford medication, or be told you must transport your literally dying child to an "approved" hospital for treatment -- that's as sicko as it gets.
What flummoxes defenders of the status quo is their inability to deflate the emotional wallop of Sicko, especially when Moore concludes by asking "Who are we?" to crystallize the values underlying the business side of health care in America.
If any movie can motivate, this is the one. So let's imagine for the moment that Sicko energizes the health care reform movement. After all, most Americans favor universal coverage, although in the past they have been easily misled and frightened into preserving the present system.
In bare-bones, Moore wants to exclude insurance and pharmaceutical companies; he wants money out of the temple of medicine.
Fine, and imperative; but we have some questions. First, as urgent and humane as it is to make medical care a right regardless of one's of financial status, will this solve our healthcare problems? Second, how sustainable is the new medical system Moore envisions? Third, how do we overcome the behemoth structure now in place to institute genuine reform?
We depart from Moore and the vast majority of reform proposals we've seen by locating health care in its ecological context, and assert that all three questions have an ecological answer. Since this will sound odd to many, let us repeat this in slightly different language: the economy, of which medicine is a subsystem, exists within and is wholly dependent upon the natural environment (also known as the ecology or the biosphere, among other designations). The ecology is not ancillary or subservient to the market economy; ultimately, it supplies the energy and resources necessary for human economic activity.
This is obvious, a truism, but -- to our knowledge -- unappreciated by most of those seeking to overhaul medicine. Indeed, many reformers operate as if healthcare is fed with manna from heaven. We are not picking a fight with them; we ask them to ponder our point of view that current medical care problems go far beyond cost and coverage to our relationships with nature: how we extract and then use energy and resources from the earth and how we live several degrees removed from the natural environment. And, how what we do to the natural environment affects our health and nature's health.
Approximately four decades ago scholars began to consider the future of our species through the lens of how the economy affects the earth's ecology. We are referring to works such as Donella Meadows' et al, Limits to Growth (1971); E.F. Schumacher's Small Is Beautiful (1975); William Catton's Overshoot (1980); Nicholas Georgescu-Reogen's The Entropy Law and the Economic Process (1971); and more contemporaneously Reg Morrison's The Spirit in the Gene (1999). Many writers now adopt this perspective, which helped organize the ecological economics paradigm represented in the works of Kenneth Boulding, Herman Daly, C.S. Holling, H.T. Odum, Robert Costanza, and Robert Ayres.
Despite differences in style, emphasis and theoretical orientation, a central question they raise is: given that the earth is finite and that its resources make economic activity possible, how sustainable is the perpetual growth economy? Schumacher puts it succinctly,
The idea of unlimited economic growth ... needs to be seriously questioned on at least two counts: the availability of basic resources and, alternatively or additionally, the capacity of the environment to cope with the degree of interference implied (p28).
Now, in the first decade of the 21st century, as these authors anticipated, ecological bills are coming due, energy is becoming scarce -- peak oil -- and the planet is heating up -- global warming. The writings of Catton, Meadows, et al, Schumacher and the others can no longer be ignored, distorted or fobbed off as peripheral to understanding "the market." They are about its sustenance and future.
A pertinent illustration helps. Many readers of this site know that Meadows' et al, Limits to Growth has been excoriated, derided, and allegedly "proven false." Matt Simmons  writes that as an oil industry banker he witnessed ritualistic, probably anxiety-reducing and group-cohesion-building denunciations of Limits. He notes that after reading the book he is convinced no one he heard criticizing Limits had read it.
Now we offer one example of a health problem and its connection to the ecology. Our health care system has in some ways mirrored the suburban experiment that took limitless amounts of energy and land for granted: central-city hospitals built regional, suburban hospitals and clinics, which seemed sensible at the time but nonetheless made sub- and exurban populations virtually dependent upon cars and interjected a degree of alienation from nature. The concept of a "walkable community" was rarely realized -- and certainly not valued -- in the suburbs, be it to go to the store, get a hair cut, visit friends, or get to work. This reliance on the automobile reflects oil dependence and has health consequences .
Our nation and the world are experiencing an "obesity epidemic," with attendant maladies of high blood pressure, diabetes, heart disease, musculoskeletal problems, and social marginalization, among others. The classic public health approach calls for study of the problem; creation of academic "centers for obesity research;" and "interventions" to promote healthy food choices and exercise routines; this requires massive government resources. Overlooked is the implicit link between obesity and fossil-fuel-based, sedentary lifestyle and culture. Instead of having physical exercise "built-into" life, one has to consciously "intervene" to seek out exercise -- typically at the fitness center or health club. Pithily put, how many sidewalks are in the suburbs? How many readers know of shopping centers and malls that are literally (or dangerously) inaccessible to pedestrians or bicycles?
Some of the "smaller carbon footprints" achievable through conservation solutions to peak oil and climate change are the same for the obesity epidemic: walking to public transit stations, bicycling to work and for leisure, eating primarily vegetable foodstuffs, and growing some of our own. These practices -- which should be part of normal life -- are recommended by preventive medicine and public health for conditions like metabolic syndrome  and its attendant health effects. How many people do you know who have said, "The doctor told me to exercise"?
Our next point is critical. The present medical care system is simply too expensive and consumes too much energy and other resources, and universalizing coverage will not solve these problems. Improved population health would lead to lowered demand for traditional medical treatment, which is imperative given the era of scarcity of energy and other resources we are entering. This in turn contributes to reducing the need to travel to physicians' offices, clinics, and hospitals.
Traditional treatment-medicine will always be needed, but a "relocalization" of the system is in order. ( Sicko refers to the cost-control and health benefits of preventive health practices in other nations; this is an oblique acknowledgment of the ecology-health connection.) Not only should patient preference for physicians and treatment facilities be of importance in any national health plan, but we believe proximity to care should also be considered. The Archimedes Movement, which holds that "health is the product not just of health care, but also of education, housing, stable employment and a clean environment," offers a vision of how ecology and medicine can be synthesized.
Relocalization of food production, manufacturing, water distribution (as opposed to bottled water), shopping, and residential construction is a trend playing out across the country and soon will be mandated by peak oil. A realization of this in medicine and public health could further inspire the massive transition we must make. This is made all the more urgent by the aging of the baby boom generation.
Finally, how do you change the deeply entrenched status quo of the health care industry? It is relevant to note that Upton Sinclair's The Jungle riled up Congress as it was in the process of passing the Meat Inspection Act of 1906. However, that act and the Pure Food and Drug Act were in the main the result of large corporations lobbying for regulation to gain a competitive advantage and to standardize interstate commerce instead of dealing with the possibility of 48 states regulating businesses . That's right, commerce sought out regulation; Sinclair's polemic was of minor importance.
Since we laud Sicko's potency and Moore's championing of the common person, we submit that he incorporate a colossal point: the medical establishment, and the pharmaceutical and insurance industries are living on borrowed time and will not survive the energy downturn in anywhere near their current forms . They are complex and require steady, large streams of energy and resources. They are a manifestation of what Catton termed "The Age of Exuberance." Simply put, they are highly vulnerable.
Imagine the debate we would now be having if Moore had located Sicko in the context of the ecology and the driving forces of peak oil and global warming. He would be "connecting the dots," educating his audience about the fundamental issues confronting health and health care -- and our daunting and unprecedented future. He can still do so and we suggest that he does.
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1. Internet Movie Database: www.imdb.com/title/tt0386032/externalreviews.
3. See: Terry Tamminen, Lives per gallon: The true cost of our oil addiction, 2006. Island Press.
4. Wikipedia, "Metabolic Syndrome.".
5. The Archimedes Movement: archimedesmovement.org
6. Wood, D.J. 1986. Strategic uses of public policy. Marshfield, Ma: Pittman Publishing.
7. See Bednarz, Dan. 2007. "Medicine after Oil," Orion Magazine, July/August.
From the article: "The scale and subtlety of our country's dependency on oil and natural gas cannot be overstated. Nowhere is this truer than in our medical system." The article has numerous examples of this dependency.
"Peak Oil and the health care crisis in America", Culture Change article by Dan Bednarz, 2005.
The Right Medicine: How to Make Health Care Reform Work Today , by David Cundiff, MD, and Mary Ellen McCarthy, Humana Press (1994)
Money Driven Medicine - Tests and Treatments That Don't Work, by David Cundiff, MD, published by Cundiff (2006)
Fasting for healing and inner peace", by Jan Lundberg, Culture Change e-Letter #92.
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