First of all, we do have a crisis. And the witnesses of world leaders, our own leaders, and physicians in the system, testify to its extent:

1. While we have the world's most advanced health care, the World Health Organization ranked our system 37th in their Health Report 2001.

2. The Institute of Medicine tells us that between the health care we have and what we could have with the money we spend "lies not a gap but a chasm."

3. Doctors who deal with it, call our system perverse because it rewards poor care and punishes good care. 

Like the man in the picture we all need some help figuring out what to do for our own, our family's, our nation's, and even our world's health care. Common Sense Medicine provides some insights for all of us about how we got in this mess and how we can get out.

Overview:

Health care's most visible problems, cost and unequal access, are not as important as what caused them.

Health care is a complex system that can adapt creatively to regulation.

• The politics of health care.

• How we got in this mess—an historical approach.

• And where are we going with health care.

Personal Health—Many conditions are discussed in Featured Articles.

How we got our name—Common Sense Medicine.  

 

The common point of view is that the major problems are:

• it costs too much; and

• everyone doesn't have access, let alone equal access. 

These are the problems that we all see and our politicians try to resolve. Republicans tend to focus on the first while Democrats focus on the second. Someone needs to see the whole picture.

•  We all see these problems because they are like the leaves on the tree. There are so many of them that they block our view of the tree's structure. We can't easily see the branches and the trunk, and the roots are invisible. But they are there and the systemic illness that pervades our health care system involves them as well.

•  In the past we have relied on the approach of mandate, regulate, and litigate to deal with these problems—but they just got worse.

•  They got worse because the regulators were trying to deal with the leaves. They saw the system as if it was mechanical—simple, predictable and controllable—but it wasn't, and it isn't.

• It's what's called a complex-adaptive system. Such systems are organic in the way they deal with stresses. 

• In the face of regulation the system finds another area that is not as regulated to focus its efforts.

Sound bite: Pruning trees will never change the fruit.

Governmental efforts   tried to make this system more mechanical. They tried to prune the tree, but it just grew somewhere else. 

Like a tree, the roots of the problems are not as easy to see as all the leaves, but it is from them that our system has grown:   

• The top roots collect most of the moisture. They represent how the system is paid. The problem is that it only rains when we are sick;

• The deeper roots provide support and structure. They represent how the system is built. But deals between members of this family (doctors, hospitals, drug and insurance companies. . . including the regulating agencies) are incestuous and continued inbreeding weakens the system; 

• the tap root gives identity—it's why Doctors do what they do in providing health care. Mostly we deal with symptoms and try to reduce their severity. But when our health care system looks at the body as a simple machine, and at symptoms only as problems that need treating, it is often wrong.

  More on these topics is linked here:

  • more on payment problems, together with an available solution.

  • how to deal with inbred weaknesses.

  • How we are still bleeding people.

Lord Acton, the British historian, pointed out that institutions are eventually destroyed by an excess of their first principles. We believe that our health care system is an excellent example and that the "roots" noted above make up its first principles—and that recognizing them is the first step in healing our system. 

 

• Simply stated a complex-adaptive-system is one that can interact with its environment, can adapt to a changing environment and has an element of choice. 

  • They are characterized by the potential for self-organization.  

  • They evolve by random mutation, natural selection, and self-organization. 

  • Examples include living organisms, the nervous system, the immune system, the economy, societies, clusters such as the health care and defense industries, and even families.

• Like the tree in the example above their response to stress is not predictable. 

• Predictable and mechanical systems are like a thermostat or a car. A thermostat senses and controls the temperature and a car goes faster when you step on the gas pedal and slows down when you step on the brake. 

• The behavior of these mechanical systems is predictable. 

• CASs are not predictable in this sense. 

  • They are more organic in their response to input from outside because they have more choices. 

  • If a person, the ultimate CAS, gets cold, she can respond by closing down the blood vessels in her skin in order to maintain her core temperature, putting on a sweater, turning up the thermostat, or many other options. 

  • CASs can make more choices in how to respond to a specific input.

The best description of our health care system as a CAS is in Paul Plsek's Appendix B of Crossing the Quality Chasm or at the web page for the Institute for Healthcare Improvement. 

• Plsek points out that the mandate, regulate, litigate approach used by politicians always viewed the health care system as a mechanical system that could be predicted. 

• They ignored the fact that the system is able to adapt and make different choices and this, he says, is the reason all political attempts at controlling health care costs have failed.

However, while it is impossible to predict the choices of the system, the general behavior of some CAS have been modeled very effectively by following a few simple rules. 

• Flocks of birds and schools of fish are types of CAS that Craig Reynolds modeled with rules looking at alignment, separation, and cohesion. (He called them "boids" and clicking on his name takes you to his web page that show some simulated flocks.)

• Applying these rules to our health care system is revealing.

  • Alignment means they tend to go in the same direction. In health care we have schools, practice protocols, and state licensing agencies that work to keep us practicing 'in the box.'

  • The separation rule means that we don't compete with each other for the same space. The main competition in the health care system is in gaming it—in maximizing one's return from the payers.

  • The cohesion rule is what gives the system its identity. All western countries have health care similar to ours in diagnosis and treatment. What sets our apart, its identifying characteristic, is its expense.

    • This has been the focus for some time, but it was not always so. [More on this below when we introduce Sara Baker.]

    • For more about how the cohesion, alignment and separation rules apply to our health care system see "A "boids" eye view of health care."

   

• And there are enough people talking about CAS's that they should get some of that part as well.

• As long as the government is as involved as it is in its own incestuous problems (referred to above in the link about incest) it is not likely that they will see ways to resolve the incest in our health care system.

  • In a move pressured by government the pharmaceutical companies ("big Pharma") has agreed to disclosure of financial ties with all authors of medical articles and speakers at medical conventions. This amounts to taking the bedroom doors off.  

  • It does not equate to an understanding of the incestuous nature of these relationships nor of the problematic inbreeding that results from them.

Sound bite: Wendell Berry put it correctly when he stated, "If change is to come, then, it will have to come from the outside. It will come from the margins. . . . It was the desert, not the temple, that gave us the prophets. . . ."(The Unsettling of America, p.174) 

That means it's up to us on the margins to find ways to save our system.

At the turn of the 20th Century Dr. Sara "Jo" Baker worked at the New York City Department of Health.

• It was Dr. Baker who caught "Typhoid Mary" twice, and it is Dr. Baker who is ultimately responsible for the signs in our public restrooms reminding us to wash our hands before going back to work.

• Her department was trying to deal with the epidemics of typhoid and dysentery that were killing thousands of the city's children. 
• Dr. Baker helped solve these problems by first looking at how the children got sick because prevention is always better than treatment—it's a lot less expensive too. 
• Dr. Baker taught mothers proper hygiene, mostly more and better hand washing, when caring for their children. 
• She also taught other family members because mothers were often working and left the children in the care of their older siblings. 
• Her program saved the lives of thousands of the city's children and was copied, before she left her position, by every other state in the union.  
• In the midst of this success, however, thirty Brooklyn pediatricians petitioned the mayor to stop the program because it was hurting their practices. 
• In her autobiography, Fighting for Life, she calls this the best recommendation she could have received.  

The intervening century saw the rise of states that chose to provide government funded health care and with which we eventually went to war. We saw these states as hostile to our free enterprise system and reacted by choosing private sector solutions whenever the opportunity arose. 

Sound bite: We've fed the pediatricians and starved out the Dr.Bakers.

• His booklet, published in January, 1776, identified the colonist's problems and focused their attention on what he considered the best alternative— Independence. 

• Prior to Common Sense most viewed themselves as loyal subjects of the king and wanted to stay with England. 

• After Common Sense they viewed themselves in a new way, as an independent people, and we had a revolution. 

• They went from being passengers on the ship of state to being its crew and navigators. 

• They had a paradigm shift. 

• First we tried cost cutting.
• Then we tried managed care.
  • Managing chronic illness illness became part of this.
  • Chronic illnesses are education intensive and most doctors don't have, or take, the time to properly educate their patients.
• Scholars such as those at Case Western Reserve University in Cleveland looking at this problem see "community helpers" who are successfully living with a chronic illness becoming teachers for those ill with the condition in the community. (Clicking on the link will take you to the whole article.) We expand on this role to include anyone who helps maintain health.
  • Doulas, birthing helpers, or midwives would be part of this because most of the time pregnancy is not an illness.
  • Healthy diabetics can teach others the value of diet and exercise in balancing their illness.
  • Using the Internet to learn about and deal with the problems they have is one such way.

   

• We are here to help.
•  Empowering Public Health is the other.
  • The role of Public Health has always been to promote the health of the citizens.
  • There are lots of ways to do this; most of them have to do with education and helping people stay healthy.
  • These services should be free.
  • When people get sick they can go to the illness care system, but this system needs to be paid.
  • Effective changes to complex systems need to come from within the system and the only part of the system where the government plays a part within the system is Public Health. It is in this area that government should focus its attempts at reform.

   

Today we have a crisis with our health care system and the trends are not reversible without a revolution that addresses the roots of our problems. Common Sense Medicine, as did Common Sense, looks at these roots and applies common sense.   

But the revolution we need can be relatively painless. Complex adaptive systems, like our health care system, can be revolutionized by addressing the roots of the problems and by making small, but effective changes at these roots where they are most effective. 

For example, the three root sections listed above could be addressed by:   

1. Health savings accounts, with the catastrophic part under Social Security, would both make insurance universal and place it under the control of—and therefore the responsibility of—the individual. 

© 2002 CommonSenseMedicine.org