conflict in a democracy
“…physicians, as an ethical duty owed to society, must practice efficient, parsimonious, and cost-effective health care.” From The American College of Physicians Ethics Manual, 6th edition.
After 10 days on the Cape, at the Southwest corner of South Africa, 10 days driving thousands of klometers overland on the’wrong’ side of the road and 10 days in Kruger Park at the North East extreme of the country, I hated to leave. Similarities and contrasts between our two nations is evident everywhere: the clash of humanity with nature, cultural present with past, progress with preservation, power with weakness, national language with other languages; all were apparent, even in the relatively sheltered and civilized ‘rest camps’ of Kruger Park. Of course I was at Kruger for the wildlife; perhaps there is nowhere in the world where an English speaking stranger can be sheltered at night in ‘rest camps’- luxurious electric fenced two or five acre cages- yet be free roaming by day in a different sort of cage- a car- while being ignored by herds of wild animals a few feet away. At the same time the visitor is relatively sheltered from political and social conflicts.
Yet even the park exists within the margins of history. The newest and largest rest camp is named ‘Skukuza‘- a native term for broom– because the park founder, Kruger, swept the native peoples from this 19,633 square km area, creating 360 x 40 km park bordered by rivers and by a similar park in Swaziland to the East. The current president, Jacob Zuma, in contrast to Nelson Mandela, epitomizes racial and tribal values. He declares that South Africa is for all (black) Africans; therefore the nation’s borders are now open, by virtue of ethnicity. The park is more affected by poaching; rhinos are affected, though there are so many herds of elephants they must be thinned and exported to other preserves. The Zuma position on open borders is herd politics, supported by a clear majority, who find it justified by inequities or oppression. It was democratically imposed by government, leading to turmoil, as has our Affordable Care Act (ACA), sometimes fearfully referred to as Herd Medicine.
The veterinary medical term “Herd medicine”, when applied to human health care, is disturbing to those who see the ACA in terms of Huxley’s Brave New World , while others find our current “system” antiquated, inefficient, and as unfair as the sweat shops of the Industrial Revolution. I suggest both views are flawed; a dual system is required featuring individually focused care and herd focused care, both are complimentary and necessary in a sustainable national health program. Veterinary medical practice offers a model of such a dual care system where “Herd Medicine” is focused on the greatest benefit to the greatest number, and the economics of health care, while “Companion Animal Medicine” is focused on the benefit to individual animals.
The table below provides side-by-side comparisons between what I will call Herd-Vet ( large population medical care) , and Pet-Vet (Companion Animal) medicine.
•A major factor
•Economic viability/profit critical
•Herd owner pays
•Justified with societal oversight
•Individual pet well-being
determined by vet and pet owner
•Pet owner pays
•Limited/constrained by law
•Abuse is severely punished.
“Pet-vets” practice a type of fee-for-service medical care. The Affordable Care Act (ACA) attempts to retain that kind of care, but requires practicing herd medicine also. These two aspects of national of health care need not be mutually exclusive. Indeed, every nation that has an ongoing viable national health program allows or employs a dual system: one focused on large numbers, outcomes, and economics; and the other focused on outcomes and options for individuals. Both rest on ethical and practical considerations, which address different aspects of national health care.
Where does that leave us in the current medical perfect storm? I confess to optimism. Any objective look at human life on this earth makes clear that over the centuries, people in general have lived progressively longer, healthier, more comfortable lives. I expect our nation will develop a unique U S functional, ethical, and viable system of national health care consistent with both Hippocratic/Oslerian medicine and with the medicine of large numbers, as revealed by the most significant word in the ACA title.
That word is Affordable.
“Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care…The primary function of regulation in health care…is to constrain decentralized individualized decision-making.” From “New Rules” by Troyen A. Brennan and Donald M. Berwick,1995, ISBN-10: 0787901490.
“MDs do not think of…patients as (a) herd (but) future health care decision-makers will.” From “Obama’s Herd Health Program” by Heather McCauley, DVM.