Probably the most unlikely article in the most unlikely publication, making the most unlikely comparison, is the one in a recent New Yorker magazine that contrasts health care reform and the evolution of U.S. agriculture.
It’s worth reading.
Atul Gawande, a Boston surgeon and associate professor at Harvard Medical School, has written extensively on the need to improve the nation’s health care system, to obtain greater efficiencies, and achieve more consistent results.
In the New Yorker piece, Dr. Gawande notes that “at the start of the twentieth century, another indispensable but unmanageably costly sector was strangling the country: Agriculture … Only by improving the productivity of farming could we raise our standard of living and emerge as an industrial power … The agricultural system was fragmented and disorganized, and ignored evidence showing how things could be done better.”
Government was enlisted to help millions of farmers change the way they worked, he notes, and “The approach succeeded almost shockingly well. The resulting abundance of goods in our grocery stores and the leaps in our standard of living became the greatest argument for America around the world.”
And it all began with a pilot program on the farm of Walter C. Porter near Terrell, Texas — “just one farmer (willing to try some ‘scientific’ methods (on 70 acres) and see what happened.”
That year, 1903, “proved to be the most disastrous for cotton in a quarter century,” Gawande writes. “Nonetheless, at the end of the season, Porter reported a substantial increase in profit … and announced he would apply the lessons he had learned to his entire 800-acre property.”
The following year, the USDA got funding for 33 Extension agents to set up similar demonstration farms in Texas and Louisiana.
The expansion of the Extension program was widely denounced as government control of agriculture, but in 1914, after much opposition, Congress passed legislation establishing the USDA Cooperative Extension Service.
What started as a pilot program, Gawande writes, led to “the world’s greatest biological discovery machine of all time … What seemed like a hodgepodge eventually cohered into a whole. The government never took over agriculture, but the government didn’t leave it alone either … The results were beyond what anyone could have imagined.
“Productivity went way up, outpacing that of other western countries. Prices fell by half. By 1930, food absorbed just 24 percent of family spending and 20 percent of the work force. Today, food accounts for just 8 percent of household income and 2 percent of the labor force. It is produced on no more land than was devoted to it a century ago, and with far greater variety and abundance than ever before in history.”
The history of American agriculture, Gawande says, “suggests that you can have transformation without a master plan, without knowing all the answers up front.”
Similarly, government has a crucial role to play in health care, he says — “not in running the system, but guiding it, by looking for the best strategies and practices and finding ways to get them adopted, county by county. Transforming health care starts with transforming it somewhere … To figure out how to transform medical communities, with all their diversity and complexity, is going to involve trial and error. And this will require pilot programs — a lot of them.”
The Senate health care bill, he notes, is almost half devoted to programs that would test various ways to curb costs and increase quality. “The bill is a hodgepodge. And it should be … Which of these programs will work? We can’t know … But in the end, it contains a test of almost every approach that leading health care experts have suggested.
“None of this is as satisfying as a master plan. But there can’t be a master plan. That’s a crucial lesson of our agricultural experience.”
Cynicism about government “can seem ingrained in the American character,” Gawande writes. (But government assistance through agricultural Extension) “involves continual improvisation and education; problems keep changing and better methods of managing them keep emerging — as in medicine.”
In the U.S. today, he says, “The poverty of our health care information is an embarrassment … We have better information about crops and cows than we do about patients. If health care reform is to succeed, the final legislation must do something about this.”
The health care system “won’t fix itself,” Gawande says. “And there’s no piece of legislation that will have all the answers either. The task will require dedicated and talented people in government agencies and in communities who recognize that the country’s future depends on their sidestepping the ideological battles, encouraging local change, and following the results.”
You can find the article at http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande. And while you’re at the site, read his June 1 article, “Conundrum,” which contrasts high cost health care systems with more efficient, lower cost systems and their results in patient outcomes http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande.
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