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July 12, 2008
The Cost Cutters Called Suffering and Death
A quick post, this. I didn't make it to DC this week, as I'm plagued by what is either an infected leg or something quite different, a neural problem called Reflex Sympathetic Dystrophy. I wouldn't mention it, except that I know some of you folks out there are doctors, and might be able to give me some advice. The condition isn't very common, but it sure is painful -- or can be, if I let it get out of hand.
But I have had some experiences with the Canadian medical system because of it and a few other things over the years, and would like to post a couple of observations. The first is that it's pleasant, and probably delusively pleasant, to walk into a doctor's office and not to have to worry about the cost, even though I'm not covered by the national insurance. And Canadian doctors seem to be every bit as friendly and helpful as Canadian plumbers, carpenters, and electricians. I've liked all the ones I've met.
Not that there are a lot of doctors here, though. Price controls have driven many doctors to the States; and the generally lousy schools have done a poor job preparing young people (young men in particular) for careers in science. Most of the doctors I've met are not Canadian, and with that comes all the problems of transience, and sometimes uncertainty about the adequacy of their preparation. But even assuming that they have all been well-trained, there aren't enough of them, not by a long shot. The shortage shows up in personnel, and then it shows up in machines, available tests, even beds in hospitals. Let's say you live where we do in the summer, and you need a hysterectomy, or a gall bladder removed, or something that is not absolutely urgent, but that will cause you a good deal of pain. You wait. You may wait as long as a year; I've seen this happen. You wait for a bed to open up, sometimes in Halifax, 200 miles away. But you need to be ready on the day when the bed is available. So people are told when their number is about to come up, and if they're not there when it does, the bed goes to the next person in line. That means that people stay in motels in Halifax for a week or two when the date draws near. Folks around here will hold raffles or other fund raisers to help a neighbor defray the costs; it is a regular occurrence.
But then, you can't keep the bed, either, as long as you should. My sister, an infectious disease specialist in Pennsylvania, tells me that the argument in the States is over how long you should be without fever before you are discharged from the hospital for treatment for infection. My neighbor up here was discharged with a fever, and with intense pain in her surgical incisions (she was back in the hospital two weeks later; this woman waited nine months for her three operations, nine months of pain). Her husband, several years ago, was discharged from the same hospital after open heart surgery, though he had been complaining of shortness of breath. His wife was driving him home, 200 miles, and stopped at a different hospital to have him checked out at the emergency room. It was lucky she did, because had she gone home and put him to bed that night, he never would have woken again. His lungs were half full of fluid; he was almost drowning in pneumonia.
A friend of mine this year had a blood clot in his ankle, which traveled to his groin by the time they could perform an MRI on him. Shortly after that, a piece of the clot broke off and formed a pulmonary embolism. He is on blood thinners. That's all; a blood clot in the lung, periodic local monitoring of his blood thickness, and no follow up on the embolism. He will not know whether or not it has dissolved, or when. I suppose that if it jars loose and hits the vena cava, he will know, unless he's asleep when it happens. My sister tells me that in the States the standard procedure, for somebody with leg clots AND an embolism, is to insert a kind of porous umbrella into the vena cava, to let blood through but catch clots. Nothing of it, here. The man's legs continue to swell, and he's worried.
Please don't tell me that the average lifespan of a Canadian is thus and so, better than that of the American. Too many factors are folded into those statistics....
Posted by Anthony Esolen at 10:53 AM | Permalink
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Comments
I share your skepticism about single-payer care, but I'm also sympathetic to arguments that the employment-based system unfairly burdens US employers and therefore also the job market. Why can't we have a voucher system in which the government sets a floor below which it will pay for basic insurance, but above which any premiums are the responsibility of the beneficiary or those (such as employers) who contract with him for this purpose? I am eager to be enlightened by those more knowledgeable of this debate than I.
I am aware, of course, than some folks will not purchase insurance even if they get a voucher to that effect. But then, they won't take care of themselves, either, and might not seek medical care except ICE. You can lead a horse to water....
Posted by: DGP | Jul 12, 2008 1:00:15 PM
Could this be remedied by paying doctors more?
It is my understanding that all of the countries whose medical care we compare to ours (in the States) spend less per capita on health care. My argument has always been that it would be an improvement if we moved to unviversal care away from the employee-tied system we currently have, even if the net costs would be the same. So you you think that systems like they have in Canada, Japan, Thailand, etc. might work if they simply spent closer to US levels on medical care, or are these problems endemic to any socialized system?
My question is very specific, related to just one aspect of this debate. Even though I may be touching on some liberal cultural signifiers, I am not interested in advocating Universal Healthcare in this forum.
Posted by: Jason | Jul 12, 2008 7:44:46 PM
Just a comment on Mr. Esolen's sister's remark on the standard of care for blood clots in the leg (DVT -- deep vein thrombosis):
I have two family members who have had both DVT and pulmonary emboli (PE): My husband, who at 39 developed ideopathic DVT (he had none of the usual risk factors), twice; and my mother-in-law, who at 86 developed massive PEs and is now on blood thinners.
Neither of them has received the device mentioned by Mr. Esolen's sister. Both have done well on "just" a blood thinner and regular monitoring of the therapeutic levels of the drug in their systems. The second (!) time my husband developed a clot several years after the first, he didn't even need a trip to the hospital.
Their treatment came from Duke University Medical Center and some of the best doctors in the country, so it's not as if they are being treated by someone with little knowledge of the disease.
Perhaps the case mentioned in the post above isn't necessarily the best example of delayed or defective Canadian health care.
This is not to say the Canadian system isn't terribly inefficient and dangerous at times. I've heard other, worse stories.
I understand England isn't much better. My mother-in-law had a bridge partner who is a British subject, and who would rave about how wonderful the National Health was, as opposed to the terrible U. S. system. She even moved back there when she developed problems with her vision, in order to take advantage of that care.
However, she soon found out that since her life wasn't threatened, and since she was also elderly, she didn't qualify. She wound up moving back to the United States and going to Johns Hopkins, where a new procedure restored her sight to the point where she can now drive again.
Posted by: Cathleen Koenig | Jul 12, 2008 10:00:39 PM
Mr. Esolen compares the best of the American system to the average of the Canadian system. What does the typical American patient get as compared to the typical Canadian? What does the typical UNINSURED American patient get compared to the typical Canadian?
Posted by: Karen | Jul 13, 2008 11:31:54 AM
>>>What does the typical American patient get as compared to the typical Canadian?<<<
A lot more than the average Canadian.
>>>What does the typical UNINSURED American patient get compared to the typical Canadian?<<<
Abut the same. Every U.S. hospital is required to admit any patient with a pressing medical problem, regardless of insurance status. Every patient gets treated. Not every patient qualifies for the latest and greatest treatment, and sometimes has to wait in line. In other words, the uninsured American has to go through the same crap as an insured Canadian.
Posted by: Stuart Koehl | Jul 13, 2008 12:07:00 PM
If there is the possibility of RSD my advice is to see a specialist in pain management ASAP.
Posted by: Dr Hugh Comer | Jul 13, 2008 1:01:10 PM
I deal with DVT and PE frequently in my practice. IVC filter placement is only indicated for patients who fail anticoagulation (recurrent clots on Coumadin with documented theraptic levels on lab checks) or in patients who can't be anticoagulated for some reason (trauma, previous intracranial hemorrhage, blood disorders, etc.). The standard of care for DVT and/or PE is initiation of blood thinners with subcutaneous injections (there are several different drugs available) and oral Coumadin (generic is warfarin which is the active substance in rat poison). The reason for the injections is that Coumadin takes several days to take effect.
Posted by: Clyde | Jul 13, 2008 1:47:12 PM
Someone -- I think it was Milton Friedman -- noted that it is possible to have only two of these three things that single-payer systems promise:
1) unrestricted access
2) paid for by third party
3) controlled costs
What usually is sacrificed is unrestricted access. Once health care is "free," people object to paying anything, and the government can't pay all the costs that would result if access were unrestricted. So the result is long lines and horror stories like the ones Tony related. We have some of the same problems in the U.S. because the government controls so much of the health care.
Posted by: Judy K. Warner | Jul 13, 2008 2:15:40 PM
Judy is absolutely correct, and the key to giving people reasonable access to affordable health care, as well as capping the uncontrolled rise in the cost of health care is making individuals responsible for their own health care decisions. The most logical way to do this is making the cost of health insurance tax deductible and allowing individuals to establish personal health savings accounts which would be tax exempt. Each individual could put money into his personal health savings account, which could be matched by his employer (though this is not necessary). For those falling below the poverty threshold, the government could deposit an amount considered sufficient to buy a modest health insurance policy plus covering deductables. The accounts would be vested in the name of the holder, and would be completely portable. Amounts not expended in a given year could carry over into subsequent years, and ideally there would be no limit to the amount of money that might accrue in the account (which would bear interest). There could also be a ceiling on how much could be deposited, either as a dollar amount, or as a percentage of gross income, but this is also optional.
With the money, each person could buy the health insurance policy that best meets his needs. Young, healthy single people could buy low cost policies with relatively high deductibles, plus a catastrophic health policy ('cause you never know). People with children could buy policies with "well child" provisions; people with bad teeth could get dental policies' those with bad eyes could get vision plans.
Thing is, it's your money, and you get to keep what you don't spend, so now you being to care about the cost of health care. You start to look at those hospital bills, and when they charge you $20 for one Tylenol, you bitch about it. You begin to ask if tests are necessary, if surgical procedures can be replaced by drug therapy, if a particular brand name drug can be replaced by a generic and so forth. Price discipline is returned to a market that lacked it, because the neither the customer (patient) or provider (doctor) paid for the services delivered.
This is only one of several reforms necessary to revitalize and stabilize the American health care system. The second is tort reform, to minimize frivolous lawsuits and cap punitive damages that drive up malpractice premiums and cause doctors to practice expensive "precautionary" medicine to minimize the chance of being sued. The third is creating a single, national insurance market so that people can purchase the best possible coverage for the lowest possible cost, unhindered by variations in local insurance regulations (usually the product of shameless political pandering at the state level).
If all three of these very sensible reforms were implemented, all people in the U.S. who WANT health insurance (and a good portion of those who presently don't have it don't want it) can have it at a reasonable cost; the cost of health care will stabilize, and possibly even fall (in real terms); and more people will be attracted to the practice of medicine (because paperwork and lawsuits will be minimized, and doctors will be responsible for patient care once again).
This is an example of what George Bush unfortunately called "compassionate conservatism" back in 2000. A better name for it might be "the personal responsibility state", in which the government will establish reasonable conditions by which people are themselves responsible for making the choices that affect their lives, rather than having solutions dictated to them by government. Forced to be responsible, most people will act responsibly; those who choose not to do so thus will have no one to blame for their predicament but themselves. It is not the job of government to save people from their own fecklessness and stupidity.
Posted by: Stuart Koehl | Jul 13, 2008 3:16:01 PM
In India if you have some money ie you are middle-class then there is no waiting for Medical procedures at all (saving organ transplants). You can have a test report and schedule an operation tomorrow. You pay cash and so hospitals have no incentive to discharge sick patients.
Indeed people have opposite fear that the hospital will keep them in for more period than required (but in my experience I have found this fear to be groundless)
Posted by: Bisaal | Jul 14, 2008 12:25:50 AM
The one thing folks always seem to forget when they praise the nationalized systems of Canada and the UK is that those systems are benefitting from the state of the current US system - both in terms of using our innovations down the road and by us subsidizing their cheap drugs, etc. If we go down their road - all of that will change and the entire world will be the worse for it.
Stuart,
Do you think the foundations that are messing with healthcre insurance in states like Colorado are going to go quietly in the face of a nationalized market? Ha!
I'd also add a fourth reform - going after China and other countries that are flooding our drug and device markets with fakes.
Kamilla
Posted by: Kamilla | Jul 14, 2008 10:39:25 AM
>>>The one thing folks always seem to forget when they praise the nationalized systems of Canada and the UK is that those systems are benefitting from the state of the current US system - both in terms of using our innovations down the road and by us subsidizing their cheap drugs, etc. If we go down their road - all of that will change and the entire world will be the worse for it.<<<
It goes a bit beyond that. Canada, for instance, by effectively making it illegal for doctors in Canada to operate outside the single payer system, implicitly depend on the United States to handle their overflow and time critical cases. If you have money in Canada, you go to the United States for any ailment out of the ordinary.
The UK still allows for private practice, so in effect there is a two-tier system in which the well-to-do have private insurance and rely on private providers, while the not-so-well-to-do are dependent on the National Health, which, by the way, is in the process of collapse. On my first trip to the UK, more than two decades ago, I was told by my British hosts that, if you are in a car crash, it is good that the National Health will admit you and treat you free of charge--but as soon as possible you should check yourself into a private clinic, because your prospects of recovery in the National Health decline drastically the longer you are in the system.
>>> Do you think the foundations that are messing with healthcre insurance in states like Colorado are going to go quietly in the face of a nationalized market? Ha!<<<
There are two ways of dealing with problems. One is to address them in good time, with a rational, well-conceived plan. The other is to let things slide until you reach a crisis, and then doing what needs to be done in a hasty, inefficient way. We are at the crisis in health care, there is only one solution, and we will end up adopting it only after going down every other dead end. When that time comes, there will be a single national health insurance market.
Posted by: Stuart Koehl | Jul 14, 2008 11:31:53 AM
Anthony doesn't want the use of statistics (convenient...) but in that case we are left with stories, like the ones he told. In that case I have two stories to tell.
1) My parents were missionaries overseas for a few decades but are back living in Canada now. A couple of years ago my father woke with chest pains, and my mother rushed him into the emergency room. Before she had even parked her car they had my father connected to a whole host of machines. They ran a plethora of tests and kept him overnight for observation. Being a missionary is not exactly a lucrative career choice, and my parents are of limited means. Had they been living in the US they would likely either not have medical insurance, or have very limited medical insurance. While Stuart is right that hospitals in the US are obliged to treat everyone, it doesn't come free. My parents would likely have been facing a significant bill.
2) About ten years ago my aunt fell and broke her leg. They found that she had lung cancer which had spread to her bones, as well as to much of her body (she was only about fifty at the time, and had never smoked). She was given only a few months to live, and the doctors said that there was virtually no hope. Nonetheless several specialists consulted on the case, she was given expensive experimental treatments and she had in home care. They were not poor, but they certainly weren't wealthy either. My uncle might well have been faced with the prospect of going bankrupt paying for expensive treatment with little hope of success. Indeed my aunt did pass away after about six months, but she was treated with dignity. Decisions about her treatment were determined by her doctors and her family, not by an actuary. One could find many stories in the US where that is not the case.
In both of these stories neither my parents not my uncle ever received a bill. It's interesting to note that medical costs are a huge cause of bankruptcies in the US (link). This leads to people not seeking care, especially preventive care, which ultimately makes things worse, both in a health sense and an economic sense. The Canadian health care system is not perfect by any means. However, were you to ask people in Canada if they would swap their system for that of the US I guarantee you will get a resounding "NO!".
Two other points regarding what Anthony wrote.
1) "Price controls have driven many doctors to the States".
This is at best a gross exaggeration.
link
2) "generally lousy schools have done a poor job preparing young people for careers in science."
You have little ground to stand on here, as the educational system in the US consistently ranks lower.
link
Posted by: David R. | Jul 14, 2008 12:07:20 PM
Healthcare is not an unlimited commodity - it *will* be rationed. The only choice left to us is *how* that will be accomplished. For the reasons mentioned, I prefer our system (which I fear will not be allowed to last long).
Not all of us who work in healthcare are in it solely for the money. I choose to work in a Catholic hospital because I don't want to participate in even a peripheral and unrecognized way in the provision of abortion. If I didn't care about that - I could be earning 10-20% more with better benefits. Because there are others like me staffing this hospital, the poor of the city are NEVER turned away from our ER.
Kamilla
Kamilla
Posted by: Kamilla | Jul 14, 2008 12:39:07 PM
As I understand it, the chief reason for high medical costs in the US, are meretricious lawsuits. As a result, doctors have to pay -very- high premiums for malpractice insurance.
Of course, malpractice -does- happen, and the practitioners can get away with it, but there are enough lawsuits that are falsely-based, or where the reward is far higher than the damage incurred.
If it were possible to have some sort of system whereby awards for malpractice would fit the malpractice, rather than how expensive a lawyer one can hire, it might help matters.
The CDC has already decided that in times of pandemic, health care will be rationed. IIRC, no one over 85 will get anything. No one over 65 with a chronic condition will get anything.
For the poor today, the requirements are waiting many hours just to fill one perscription, which might be postponed for a week or more due to the lines. To see a doctor is even harder. Only the most minimal care is available. Not the latest and best, not preventative (except for smoking cessation). Teeth pulled instead of fixed, etc. And a good half of patients appear to illegals or enemy subjects.
Posted by: labrialumn | Jul 15, 2008 9:57:25 AM
>>Please don't tell me that the average lifespan of a Canadian is thus and so, better than that of the American. Too many factors are folded into those statistics.... <<
The plural of anecdote is not data. Attempting to ban statistics on infant mortality rates, average longevity, etc., from the discussion merely leaves us, as David R. pointed out above, with isolated stories. One could as well suggest that US health care is entirely described by people dying as they wait, occasionally dialing 911, for help in ERs.
Posted by: Francesca | Jul 15, 2008 11:30:02 AM
Stuart,
It is true that anyone can go to the ER in the US and get treatment. Chronic and complicated medical problems are different, though. I just took a young man to a rheumatology clinic for free care. He waited almost two years for his name to come up.
In a later comment, you outline a detailed plan, with provisions for government aid for those under the poverty threshold. Have you looked at the numbers? According to your plan, my friend could make as little as $12,000 a year and not be eligible. To get a diagnosis for my friend, I took him to a regular doctor. The first lab slip he wrote up--after he crossed out half the tests when he heard my friend was uninsured--generated a bill for $1000. Could you live on $12,000 a year and afford a bill like that?
I'm not in favor of socialized medicine. I'm just suggesting that you don't have much of a sense for how poor people live.
Posted by: Abigail | Jul 16, 2008 7:32:20 AM
>>>I just took a young man to a rheumatology clinic for free care. He waited almost two years for his name to come up.<<<
Sounds just like the National Health. So the main difference is, on the one hand, you have to wait to get into a private hospital, and on the other, you have to wait to get into a public one.
>>> According to your plan, my friend could make as little as $12,000 a year and not be eligible. <<<
Operative word is "could", Obviously, the system is opaque and Byzantine, but there are ways to work it.
>>>The first lab slip he wrote up--after he crossed out half the tests when he heard my friend was uninsured--generated a bill for $1000. Could you live on $12,000 a year and afford a bill like that?<<<
First, most lab tests are not to get the best diagnosis for the patient, but to cover the doctor's ass against malpractice suits. They order them because they know a third party will pay, in most cases. When the doctor knows that it's just the patient's resources on the line, he only orders necessary tests. If you go to a place like Canada, the UK or France, you will discover that they provide routine tests (e.g., mammograms, pap tests, etc.) much less often than is recommended in the United States. And, of course, there are very long lines to get them. And of course, because there are very few technicians interpreting the test results, you wait longer for them and have a higher probability of getting an erroneous result.
On the matter of billing, most hospitals and doctors are flexible. They know most patients cannot pay back in full, but they are quite correct in demanding some effort to pay. Anything that is free is worth what you pay for it; moreover, when people don't have to pay, they take things for granted--this is the tragedy of the commons. If your friend talked to the doctor, he could have made arrangements to pay over time, or even get a discount on the bill. On the cost of the tests, are you suggesting that prices set below cost? Do you think, as the old joke goes, the doctor "can make it up on volume"? If you want cheap medicine, I can direct you to several Eastern European countries that were renowned, in Soviet days, for offering free health care to all. As I said, it was worth what they paid for it. It's still not much better there, but at least, if you can afford it, you can escape the system.
>>>I'm not in favor of socialized medicine. I'm just suggesting that you don't have much of a sense for how poor people live.<<<
Presumptuous in the extreme. Some of us, me included, were poor at one time. Very poor, in fact, for several years after getting out of school. And not in a job featuring health insurance. So, uninsured as I was, I have some experience in dealing with the system under those circumstances, including treatment for a collapsed lung, a broken foot, and asthma. For all the trouble I went through, I did manage to pay most of my bills, and I was grateful for the quality of care I received. Having witnessed first hand the way in which various national health services operate in Europe, I think we do a pretty good job of caring for the most needy among us.
Posted by: Stuart Koehl | Jul 16, 2008 7:54:07 AM
As P.J. O'Rourke famously said, "If you think health care is expensive now, wait until you see what it costs when it's free."
Posted by: Judy K. Warner | Jul 16, 2008 10:00:54 AM
I'm also curious about people who would turn their health care over to an entity that combines the efficiency of the Post Office with the compassion of the IRS (I can say that, now that James isn't looking over my shoulder).
Posted by: Stuart Koehl | Jul 16, 2008 10:17:14 AM
The reason why longevity statistics are at best only suggestive and at worst misleading is that Canadians are not Americans. They work outdoors more often, eat fewer vegetables, eat more starches, abuse drugs less often, are less prone to criminal activity, etc.
If you want data, try these bits of information. Cape Breton Island has, I believe, a population of 200,000. There are two neurologists on the island, one per 100,000 persons. Seems low to me; otherwise the nearest neurologist is in Halifax, 200 miles away. There is also a severe shortage of nurses in the province, due to a government decision some years ago. They say they are several thousand nurses short; the number I had heard on television was 10,000, but that seems absurdly high. The government, you see, determines how many people go to nursing school...
Posted by: Tony Esolen | Jul 16, 2008 11:37:30 AM
I'm also curious about people who would turn their health care over to an entity that combines the efficiency of the Post Office with the compassion of the IRS (I can say that, now that James isn't looking over my shoulder).
It's quite the stretch to describe healthcare delivery in the US as efficient. Study after study has shown that the US spends approximately twice as much on healthcare as other western countries for lower results (link1, link2). The multitude of healthcare providers in the US has led to significant administrative inefficiencies (link3). It's somewhat ironic that the most efficient provider in the US is the VA, which is essentially a universal healthcare system for vets.
Stuart, you keep implying that healthcare in the US is great and awful in any country with nationalized healthcare, but I haven't seen anything to back it up, other than a few stories. Stuart, you say, "I think we do a pretty good job of caring for the most needy among us.", but how to you justify that when faced with the facts about bankruptcies related to healthcare bills? (link4)
(part 1/2)
Posted by: David R | Jul 16, 2008 12:44:05 PM
Anthony, you are right that there are justifiable concerns relating to access to healthcare in Canada. However, specifically related to neurologists I'll direct you here (this link also has comments about the care provided by the VA in the US). From what I've seen if you're in the US and have a decent job that provides health care, you likely have access to care which is equal or slightly better that what you'll get in Canada (or other countries with national health care). If you don't have a good job, or you've been laid off, you're in a delicate situation, to say the least. I'll tell one more story. Last year my sister had her second child. It was a difficult pregnancy, featuring a painful cyst, the irregular heartbeat of the baby (for which she received immediate access to a pediatric cardiologist) and a four week premature delivery. Previously her husband had been laid off from his job. He got a new job, however my sister was curious and did some research regarding costs. She figured that had they been in the US and her husband been unemployed the birth would have cost them somewhere around $100k. Needless to say, it cost them nothing.
I'll end with this thought. Everyone in Canada has a vested interest to see that the healthcare system works well, as everyone is in the same boat, from the Prime Minister to the homeless guy. I would submit that if you are among the privileged in the US with access to top-notch health care you likely don't have a pressing motivation to solve the problem of millions of people without healthcare, even thought the associated benefits of preventive care would likely be to the economic and social benefit of all.
(part 2/2) (this spam filter is ridiculous...)
Posted by: David R | Jul 16, 2008 12:44:46 PM
>>>I'll end with this thought. Everyone in Canada has a vested interest to see that the healthcare system works well, as everyone is in the same boat, from the Prime Minister to the homeless guy.<<<
Which is why a provincial Supreme Court had to rule that excessive waiting lists constituted a violation of human rights which allowed Canadian citizens to seek health care outside of the system?
Posted by: Stuart Koehl | Jul 16, 2008 3:07:13 PM
>>>I'll end with this thought. Everyone in Canada has a vested interest to see that the healthcare system works well, as everyone is in the same boat, from the Prime Minister to the homeless guy.<<<
Which is why a provincial Supreme Court had to rule that excessive waiting lists constituted a violation of human rights which allowed Canadian citizens to seek health care outside of the system?
Your answer makes no sense, the one does not follow from the other. In 2005 the Supreme Court did indeed rule that wait times in Quebec combined with the lack of access to private clinics violated the Quebec Charter of Human Rights and Freedoms (Chaoulli v. Quebec). You are incorrect though that this resulted in the right to seek access outside of the health care system. For one, this decision only affected Quebec, not Canada as a whole. Secondly, the decision was stayed, and then essentially swept under the rug. The fact is that most Canadians are uncomfortable with the idea of privitized health care. We'd rather fix the system we have, imperfect though it is. And in the past few years there have been numerous changes. The federal government has doled out more money, with the money tied to improvements in targeted metrics, especially wait times. The plan is to move towards guaranteed wait-times within the next few years (link). While my confidence in the government's abillity to accomplish this isn't exactly high, I believe they are moving in the right direction. And, I should note, they are moving in the right direction due to the pressure of the public, which wants to make the system work.
Stuart, instead of changing the topic at every stage, how about you actually address the issues. Explain to me how you can justify the claim that the US system treats the poor well, given that so many bankruptcies are caused by medical bills. Explain to me how you can claim that the US system is efficient given that the US spends far more per capita while simultaneously ranking lower on almost every health metric compared to most western nations.
Posted by: David R | Jul 16, 2008 3:46:41 PM
The U.S. system is horribly inefficient. This is not because it is private, but mostly because of so much government involvement. For just one example, state governments set mandates for what health insurance has to cover. So in Maryland, if you are an 83-year-old man you have to buy insurance that covers fertility treatments. If you're low-income you can't buy a basic policy -- you have to buy all the bells and whistles. That's one reason so many people are uninsured. Actually, if you're low-income you get government health care -- Medicaid. The old man I took care of for a while was on Medicaid and he never had to pay a dime for any medical service. If you're slightly above low-income you don't get government health care and it's hard for you to get coverage. This is a perverse incentive for people to remain poor.
Another thing that has been mentioned is the ridiculous awards in lawsuits, which drive up the cost of malpractice insurance so high that some doctors leave their practice and the rest have to raise their prices. Some individual states have reformed this by limiting awards. But attempts to do this on a federal level have been stymied by trial lawyer lobbies.
Yet another is the tax break given to businesses to provide health insurance for their employees, rather than giving the break to individuals. This puts the employee at two removes from caring what his health care costs, so there is little competition in costs or services. Contrast that with specialties that are not covered by insurance such as plastic surgery and laser eye treatment, where costs have dropped greatly over the years.
But a larger point in comparing Canada to the U.S. is that you can spend less per capita because we are doing almost all the investment in new medical technology, pharmaceuticals and practices. You and most of the other countries in the world are simply living off our advanced science, technology, higher education and creativity. Our best medical care is the best in the world. Americans don't go to Canada for care; plenty of Canadians come here. Our problem is to get rid of the warped incentives that rack up inefficiencies and make the whole enterprise far more expensive than it needs to be.
Posted by: Judy K. Warner | Jul 16, 2008 4:14:40 PM
The difference between public and private health care systems is characterized by this joke from the Soviet era:
A delegation of Russian doctors comes to the United States for a medical conference. At the conference, the head of a U.S. hospital explains his frustrations to the head of the Soviet delegation:
"The problem is, we successfully treat a man for cancer, but he dies of heart disease. We treat a man for heart disease, he dies of a stroke. I feel like I am swimming against the tide".
"Ha!", laughed the Soviet doctor. "In Soviet Union is no such problem. Man comes into hospital with cancer, he dies of cancer!"{
Posted by: Stuart Koehl | Jul 16, 2008 4:18:41 PM
>>>Yet another is the tax break given to businesses to provide health insurance for their employees, rather than giving the break to individuals. This puts the employee at two removes from caring what his health care costs, so there is little competition in costs or services.>>>
That is why putting responsibility for health care in the hands of patients themselves must be at the heart of every serious reform.
Posted by: Stuart Koehl | Jul 16, 2008 4:21:05 PM
The difference between public and private health care systems is characterized by this joke...
Yet again you don't address the issues. And that joke would work a lot better if the US didn't lag behind in heathcare metrics.
Posted by: David R. | Jul 16, 2008 4:44:09 PM
Actually, health care metrics are very squirrelly things. You can get the results you want by choosing the things you want to measure. In the case of the studies you posted, the metrics selected presuppose certain outcomes, which might not actually reflect how well health care is delivered. But if I chose different metrics, I could get the result I wanted. I suppose if we were to look at cancer five year survival rates, Canada would not be looking nearly as good as you think it does.
You also ignore the fact that the Canadian system presupposes the existence of the United States, and that the Canadian system, along with the systems in the UK, Germany and France--often held up as exemplars for us--are all in a state of impending or actual collapse because they are financially unviable. In Europe, almost every country is moving towards a private system backstopped by emergency catastrophic health care, because that's what works. Any talk about state operated or even state directed health care being able to deliver first class services in a timely and cost-effective manner is just a utopian pipe dream.
Go back and look at my suggestion for the United States. It is more, not less, private initiative, less not more government involvement, that will provide a solution by putting health care into the hands of the people most concerned with it--the patients and their doctors--thereby introducing some badly needed cost discipline and rational decision making into the process.
Posted by: Stuart Koehl | Jul 16, 2008 5:14:33 PM
if I chose different metrics ... Canada would not be looking nearly as good as you think it does.
Don't just talk, back up what you're saying, show me the data! You're correct that there are a few metrics where the US does better than the rest of the world (specifically breast cancer), but overall you are simply not correct. From the source of all knowledge (link1):
In 2007, Gordon H. Guyatt et al. conducted a meta-analysis, or systematic review, of all studies that compared health outcomes for similar conditions in Canada and the U.S., in Open Medicine, an open-access peer-reviewed Canadian medical journal. They concluded, "Available studies suggest that health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent." Guyatt identified 38 studies addressing conditions including cancer, coronary artery disease, chronic medical illnesses and surgical procedures. Of 10 studies with the strongest statistical validity, 5 favoured Canada, 2 favoured the United States, and 3 were equivalent or mixed. Of 28 weaker studies, 9 favoured Canada, 3 favoured the United States, and 16 were equivalent or mixed. Overall, results for mortality favoured Canada with a 5% advantage, but the results were weak and varied. The only consistent pattern was that Canadian patients fared better in kidney failure.[7]Canadians are, overall, statistically healthier than Americans and show lower rates of many diseases such as various forms of cancer. On the other hand, evidence suggests that with respect to some illnesses (such as breast cancer), those who do get sick have a higher rate of cure in the U.S. than in Canada.[84]
In terms of population health, life expectancy in 2006 was about two and a half years longer in Canada, with Canadians living to an average of 79.9 years and Americans 77.5 years.[85] Infant and child mortality rates are also higher in the U.S.[85]. Some comparisons suggest that the American system underperforms Canada's system as well as those of other industrialized nations with universal coverage.[86]
the Canadian system, along with the systems in the UK, Germany and France--often held up as exemplars for us--are all in a state of impending or actual collapse because they are financially unviable.
FUD. Also known as bull&*%^. (link2, link3, link4)
that will provide a solution by putting health care into the hands of the people most concerned with it--the patients and their doctors
Only if those patients can afford it.
Posted by: David R. | Jul 16, 2008 6:00:55 PM
Just a side note to the conversation: when people talk about "free" health care provided by the "government," it's like calling public school "free": somebody IS paying for it. Every time I pay my property tax, I get irritated at the huge amount of it that goes to the public schools from which my five children have never once received any benefit -- and at the school officials who despise us home educators because they don't get a little bit more of that money by having our children enrolled in their broken system. But my money goes somewhere into the system -- I don't get it back just because my children don't use it! Socialized health care IS paid for, and it's paid for by the citizens of the country who pay taxes. And we all know how efficient government bureaucracies are . . .
Posted by: Beth from TN | Jul 16, 2008 6:08:48 PM
>>>Also known as bull&*%^<<<
I'm sure Gordon Brown and Nicholas Sarkozy are relieved to hear this, considering how much of their political capital they have put on the line to reform their respective systems. As an aside, I've spent a good part of this year traveling throughout Europe on business, including several trips to France, Belgium, Sweden, Britain, Germany, Poland and Romania. Perhaps the people in those countries are deluded, but they seem to think they have a health care crisis on their hands.
Posted by: Stuart Koehl | Jul 16, 2008 6:18:49 PM
>>>that will provide a solution by putting health care into the hands of the people most concerned with it--the patients and their doctors
Only if those patients can afford it.<<<
You obviously didn't bother to read what I wrote. How . . . Canadian!
Posted by: Stuart Koehl | Jul 16, 2008 6:24:40 PM
Anyone who thinks the NHS doesn't have the most ghastly problems has never spent any amount of time in the UK or never spent any amount of time outside the UK.
Posted by: David Gray | Jul 16, 2008 6:46:37 PM
Perhaps the people in those countries are deluded, but they seem to think they have a health care crisis on their hands.
Everyone thinks they have a healthcare crisis! You think the US is any different? But show me the data. I've presented numerous articles to back my points up, but again all you do is talk. What's the point in arguing with you? All you ever do is evade.
Socialized health care IS paid for, and it's paid for by the citizens of the country who pay taxes.
Absolutely! And I do it willingly. Healthcare doesn't translate nicely to the free market. You can't say, "Ahh, I'm a little tight this month, I'm going to not get sick right now." or "I think I'll go for the Kia cancer treatment, as opposed to the Lexus cancer treatment." Personally, I'm healthy and have never had any major health issues. But my father did, and my sister did, and other I know have. So I pay, and do so gladly.
And we all know how efficient government bureaucracies are...
Of course the irony of this statement is that the US spends approximately twice as much as other western countries on health care, for poorer results. The data shows that the US healthcare system is much less efficient than all those "government bureaucracies".
How . . . Canadian!
Stuart Koehl dishing out compliments, I never thought I'd see the day! And I did read what you wrote, and my point stands. You, on the other hand, have a whole host of questions which you have evaded.
Posted by: David R. | Jul 16, 2008 6:47:44 PM
Well, I'm not really up for Canada right now. After all, according to one Canadian human rights commissioner, free speech is not a core Canadian value. Neither, apparently, is recognition of reality.
Posted by: Stuart Koehl | Jul 16, 2008 7:05:56 PM
>>>Anyone who thinks the NHS doesn't have the most ghastly problems has never spent any amount of time in the UK or never spent any amount of time outside the UK.<<<
I'll be back there in a week (on pleasure, not business, for a change, so I am NOT bringing my computer). I will endeavor, however, to pick up the latest statistical abstracts on the National Health. Her Majesty's Government's printing office is located in Westminster, right across from the Houses of Parliament. But I don't think things will have changed much in a couple of months, so I expect that the National Health is still busted, and that the Tories are riding high on their plans to open up and privatize much of it.
Posted by: Stuart Koehl | Jul 16, 2008 7:08:59 PM
Here is an article from the Fraser Institute, a free-market Canadian think tank:
Why are Canadians still waiting for health care? It reports a wait of 18.3 weeks averaged over 12 specialties, including 25 weeks for cataract surgery from the time of referral and 42 weeks for joint replacement. Canadians may live longer (though I'd like to see disaggregated data to make a valid comparison to the U.S.), but they seem to spend more of their long lives in pain and discomfort.
Than another article from the same source tells us that "more than one half of the personal income taxes Canadians pay in aggregate are required to cover the cost of taxpayer-funded health care programs." It compares Canadian waiting times to other universal access nations and finds Canada comes out badly. The Fraser Institute recommends that Canada institute a dual-system in which people can choose private medical care. This is not possible now in Canada.
Posted by: Judy K. Warner | Jul 16, 2008 8:37:39 PM
Heavens, no! Canadians do not care if they have lousy health care, as long as EVERYONE'S health care is equally lousy. And for those so patriotic as to not be willing to wait in line for chemo or a kidney, there is always the U.S. and A, where grubby commerce rules, but the lines are pleasingly short.
Iron rule of supply and demand: subsidize something, you get more of it. Price it too low, and you get shortages. Make health care "free", and you will find people lining up around the block for things they don't need. Worse, still, you won't be able to find enough doctors to provide it to them.
Posted by: Stuart Koehl | Jul 16, 2008 9:01:04 PM
Judy, I appreciate you citing those articles, as they make some valid points. As I have said before wait times in Canada are certainly a weak point. This issue is being addressed, however it will be several years before solid conclusions can be made as to whether the government's strategy is working. I will note that both articles you cite were written by the same author (Nadeem Esmail) and are opinion articles as opposed to journal articles where scientific studies have been done. While Esmail has every right to his opinion, I think the data I've previously referenced in regards to healthcare metrics and costs stand.
Stuart, you're proof that a very knowledgeable man can be a fool. Your arguments are pathetic in the face of the data, which happens not to fit your ideological position and so is pushed aside. I realize that you believe this website is actually named Koehl's Comments, where your opinion reigns supreme, so feel free to take the last word. Just don't think for a second that anyone reading this thread will think any more of you for it.
Posted by: David R. | Jul 17, 2008 12:15:02 AM
>>>Anyone who thinks the NHS doesn't have the most ghastly problems has never spent any amount of time in the UK or never spent any amount of time outside the UK.<<<
Not just wait times. Canada also engages in very overt rationing of treatment based on assessment of outcomes (which in turn is based on factors such as age, overall health, nature and cost of the treatment, etc.) and tends to skimp on state-of-the art drugs and medical technology. You also ignore the real cost of the Canadian health care system, which is gradually eating the entire government budget entitlements have a way of doing that, as is the case in both Europe and the United States as well).
Your faith in peer reviewed journals of social science is touching--and incredibly naiive. The articles cited by Judy are synopses of more meticulous studies conducted by Fraser Institute, and so stand on par with the articles you cited (which were also opinion pieces). All such work contains inherent ideological bias. And, as I said earlier, the biases of those you chose to cite are quite obvious. But that would be acceptable if they did not so completely overlook the facts. As I said, I've been to Europe a lot. I have talked with many European political officials, civil servants and common citizens. From them, I have gotten a good cross section of perspectives on the state of their health care systems. People all across the political spectrum are in agreement that their system is broken, that the overall quality of health care is declining. Even the left now agrees that throwing more money into the system will not work (because the money just isn't there), and the only answers involve some combination of strict rationing of care and increased privatization. I will go with privatization, because that is how most European countries are digging themselves out of their pension hole--and it's working.
So what you want me to do is choose between the studies you have cited, and my lying eyes. Studies come and go, but I've still got my eyes.
Posted by: Stuart Koehl | Jul 17, 2008 4:22:30 AM
>>So what you want me to do is choose between the studies you have cited, and my lying eyes. Studies come and go, but I've still got my eyes.<<
LOL! You're funny sometimes, Stupe. That's like saying, as Pauline Kael once did, "Nixon can't have won; no one I know voted for him." I know we've been asked not to confuse this discussion with facts, but the World Health Organization released figures in June, 2000, that ranked Canada 30th in the world and the US 37th in terms of health care -- fairly similar, although the US spends more per capita on health care than any other country and almost twice as much as Canada does. France and Italy were ranked first and second (anecdote alert: my Italian relatives are very happy with their health care and are horrified by the stories of people dying in ERs in the US.)
I don't know that any one model is best, but stats do give us the means to identify systemic problems and to test which health care innovations are succeeding and which are not.
Posted by: Francesca | Jul 17, 2008 9:00:24 AM
The WHO's preferences do not constitute statistics, either. The WHO prefers Canada's system, but I keep hearing about Canadians who prefer the US's.
Unfortunately, I think it likely the majority of Americans may decide they prefer a "pig in a poke" to the current system - EVEN after they hear about what the pigs in other nations' pokes turned out to look like. Stubborn, ignorant optimists.
Thus the failure of the American education system will enable the failure of the American health care system...
Posted by: Joe Long | Jul 17, 2008 9:56:33 AM
>>Thus the failure of the American education system will enable the failure of the American health care system...<<
If our school don't do a better job of teaching students to understand sound statistical practices and methodologies, many people will continue to live in ideology-based "reality" in this country. However, I'm cautiously optimistic that fact-based decision making is gaining some traction (which I daresay will displease the "stubborn and ignorant":-).)
Posted by: Francesca | Jul 17, 2008 10:34:53 AM
"If our school don't do a better job of teaching students to understand sound statistical practices and methodologies, many people will continue to live in ideology-based 'reality'in this country."
Oh, I don't think that's dependent on sound statistical practices, unfortunately; though for once, I so wish I could agree with you. Very Smart People - literate, numerate folks - are quite capable of constructing ideological cloud-castles, and living in them; perhaps MORE capable than the average fellow. (Both the Soviets and National Socialists provided dramatic non-current examples. I suspect we would disagree about 180 degrees on who the current examples would be, but you must recognize the truth of the observation itself...)
Meanwhile, the schools churn out the illiterate and innumerate in alarming numbers, as the advertisers (political commercial and even academic) get better and better at subverting "fact-based decision making" in the population at large. Hang onto that optimism...you can hold mine, too, in fact; I'm not using it for anything.
Posted by: Joe Long | Jul 17, 2008 12:45:37 PM
>>>The WHO's preferences do not constitute statistics, either. The WHO prefers Canada's system, but I keep hearing about Canadians who prefer the US's.<<<
This is true. The WHO, for instance, rejects Uganda's AIDS prevention program because it does not stress the primacy of condoms but instead places emphasis on abstinence (horror!). The fact that Uganda, of all the countries in central Africa, has had the most success in curtailing AIDS is irrelevant to the WHO's position or its agenda.
>>>Unfortunately, I think it likely the majority of Americans may decide they prefer a "pig in a poke" to the current system - EVEN after they hear about what the pigs in other nations' pokes turned out to look like. Stubborn, ignorant optimists.<<<
As is often the case, there is a dichotomy between what Americans think about our health system in general, and what they think of their own personal health care situation. We see this in many areas: Americans think the public schools in general are in the crapper, but THEIR public school is great; they think Congressmen in general suck dead rodents, but THEIR congressman is a great guy (and the reelection rates for incumbents prove it!); they think crime is soaring everywhere, but THEIR city or town is a safe place to live. It's called the Lake Woebegone Syndrome ("All our children are above average"), and it applies to health care, too: Americans in general think the health care system is busted, but they are very happy with the health care they receive. That's why you can't put much trust in surveys.
>>>If our school don't do a better job of teaching students to understand sound statistical practices and methodologies, many people will continue to live in ideology-based "reality" in this country. However, I'm cautiously optimistic that fact-based decision making is gaining some traction (which I daresay will displease the "stubborn and ignorant":-).)<<<
I'm sure its because half of all American make less than the median income. But I am also sure Obama will fix that, too.
Posted by: Stuart Koehl | Jul 17, 2008 1:25:50 PM
>>... folks - are quite capable of constructing ideological cloud-castles, and living in them<< (Joe Long)
So I've noticed:-) However, while we're all entitled to our own opinions, we're not entitled to our own facts. As an example of facts being hijacked in the service of ideology:
>>The WHO, for instance, rejects Uganda's AIDS prevention program because it does not stress the primacy of condoms but instead places emphasis on abstinence (horror!). The fact that Uganda, of all the countries in central Africa, has had the most success in curtailing AIDS is irrelevant to the WHO's position or its agenda.<< (Stuart Koehl)
Here Stuart uses false information to shore up an ideological position.
In reality, the WHO has praised Uganda's highly successful, multi-faceted "ABC" (Abstain, Be faithful, use Condoms) approach, which has included candid and pragmatic health education, free condom distribution through clinics and hospitals throughout the country, promotion of condom use within a culture that has traditionally been somewhat averse, and promotion of abstinence. The age of onset of sexual activity rose, monogamy increased, and the number of young men (15-19) who had ever used condoms rose from 20% in 1989 to about 60% in 1995. The results: from 1992 to 2004, the rate of infected adults in Uganda dropped from an estimated 15 percent to 6 percent.
All well and good. However, in 2004, President Museveni of Uganda began pushing for a more abstinence-based approach. Additionally, PEPFAR policy dictates that at least 1/3 of all prevention dollars must go to abstinence-only education. In Uganda, more than 1/2 of PEPFAR funds now go to abstinence-only education. It is this, and not the ABC program, that has health workers worried that Uganda will regress. Their concerns are shared by the GAO, which in April 2006 delivered a stinging indictment of abstinence-only education as a means of reducing infections. In Uganda, 30 million condoms were recalled in late 2004 (they were later found to be safe,) causing a serious condom shortage. Data from 2005 indicate a slight increase in infection rate. Obviously, there are many factors involved (e.g., the perception that AIDS is now fully treatable by ARVs,) but the situation is best understood in the light of accurate information.
Posted by: Francesca | Jul 17, 2008 4:14:36 PM
Your citation of the eminently biased GAO report is an excellent example of why such "scientific" studies ought to be ignored.
By the way, I've worked with GAO reports for close to three decades now, and I would say their batting average tends to be slightly less than what would get you on the All Star Team back before the Designated Hitter rule. The important thing to understand is the GAO typically finds the results its congressional sponsors want them to find; truth is generally a secondary consideration.
And before you tell me I don't know what I am saying, did I mention that I have actually worked with people from the GAO?
Posted by: Stuart Koehl | Jul 17, 2008 4:37:13 PM
Here is a nice counterpoint to Francesca's assertions:
World's Most Successful AIDS Prevention Programme in Uganda "Sabotaged" by Western "Experts"
Western advisors used their control of international funding to force a change in direction to condoms and casual sex
By Hilary White
KAMPALA, Uganda, July 11, 2008 (LifeSiteNews.com) - While the US Senate considers a proposal to allocate US$50 million more for AIDS prevention programmes, one Ugandan expert says it will be wasted money if the attitudes of the Western AIDS prevention community towards AIDS transmission do not change. In a column appearing in the Washington Post on June 30, one of Uganda's leading AIDS prevention experts called on the Western "experts" to "Let my people go."
And another one:
UN Anger Over Uganda's Successful Abstinence Program Fueled by Loss of Funds Says Researcher
UNITED NATIONS, October 13, 2005 (LifeSiteNews.com) - The United Nations' envoy to Africa, Canadian Stephen Lewis, is highly critical of an abstinence campaign that has downplayed the role of condoms but been hugely successful at reducing HIV transmission in Uganda. Population Researcher Institute's Joseph A. D'Agostino suggests that the success in combating AIDS in Uganda "isn't good enough for UN officials, whose love affair with condoms knows no bounds, and who are also angry with America for funding her own AIDS initiative in Africa instead of giving the money to them."
Uganda, whose abstinence campaign has been so successful as to be likened to a highly effective vaccine, has reduced HIV transmission rates from 18% to 5-7%. "No other nation in the world has achieved such success," writes D'Agostino. "Most sub-Saharan African nations, following the pro-condoms model, continue to suffer from rising HIV infection rates. Ugandan surveys show a reduction in premarital sexual activity among Ugandan youth and a reduction in extramarital activity among adults," D'Agostino added. "The result: less AIDS."
Lewis is highly critical of the US President's Emergency Plan for AIDS Relief (PEPFAR), which has drawn the focus of AIDS prevention away from condoms to the successful abstinence model adopted by Ugandan president Yoweri Museveni and his wife Janet. "There is no doubt in my mind that the condom crisis in Uganda is being driven by PEPFAR," Lewis said. "To impose a dogma-driven policy that is fundamentally flawed is doing damage to Africa."
"This is a bizarre inversion of the truth, and threatens to do grievous harm to the one HIV/AIDS prevention approach that has actually worked," writes D'Agostino. Even Ugandan Health Minister Jim Muhwezi denied there is no "shortage" of condoms. "There seems to be a coordinated smear campaign by those who do not want to use any other alternative simultaneously with condoms against AIDS," he said.
In 2003, the UN itself (United Nations AIDS agency - UNAIDS) admitted that condoms have a disconcerting failure rate. The study revealed that condoms are ineffective in protecting against HIV an estimated 10% of the time. The admission from the UN, which is far lower than some studies which have shown larger than 50% failure rates, is a blow to population control activists which have aggressively and misleadingly marketed condoms in the third world as 100% effective.
"The UN's approach has failed, and its own statistics show it," D'Agostino emphasized. "HIV rates keep rising, to over 30% in some countries. Two decades of pornographic sex education and massive shipments of condoms have sent millions of young Africans to an early grave."
"Apparently, achieving results isn't good enough for international grandees," D'Agostino concluded. "It's death by condom or nothing. But we think the Bush Administration will stay the course."
"We understand that casual sex is dear to you, but staying alive is dear to us. Listen to African wisdom, and we will show you how to prevent AIDS."
Sam L. Ruteikara wrote in the Washington Post that efforts to maintain the world's most successful AIDS prevention programme was "sabotaged" by precisely those Western "experts" who insisted that only condoms would work.
And a third:
U.N.'s Top AIDS Envoy Forgets Diplomacy in Demonizing U.S. Abstinence First Strategy
BANGKOK, July 16, 2004 (LifeSiteNews.com) - The International AIDS Conference in Bangkok is in an uproar. While overpopulated with pro-condom ideologues, it is hearing from Uganda, the only African nation that has dramatically reversed the epidemic, on why condom use is a very distant third add-on to their successful ABC program of promotion of abstinence before marriage and being faithful during marriage.
However, rather than slamming the Ugandan delegation at the conference which included the Ugandan President, the anger of the pro-condom activists has been directed at the United States which has taken Uganda as an example and adopted a push for abstinence and fidelity over condoms. The U.S. move has made leftist activists such as Canada's Stephen Lewis irate.
The high-profile Lewis, United Nations Secretary-General Kofi Annan's Special Envoy for HIV/AIDS in Africa, came unhinged at the conference Wednesday after U.S. envoy Randall Tobias presented the proposal of abstinence and fidelity first. Using language uncharacteristic of UN higher-ups for whom diplomacy reigns, Lewis spoke to reporters saying of the U.S. approach, "It's completely out of date... an ideological distortion." He also called it "foolhardy" and "destructive."
Dr Sam Okware, Uganda's first AIDS control programme director and Commissioner of Health Services informed conference participants of his country's unique and dramatic beating back of the deadly epidemic. Okware explained that while the fight against AIDS is centered on the condom in other countries, in Uganda, condoms come last, with morality playing the central role. At the outset of the conference, Ugandan President Yoweri Museveni set sparks flying saying AIDS is, "obviously a moral problem when one has sexual intercourse before marriage or outside marriage."
Nevertheless, Lewis, who has a long history of intense social liberalism and socialist political views, pontificated, "Tobias has an ideological agenda, and the ideological agenda is abstinence over condoms as a matter of public policy. But that ideological agenda, with respect, is wrong, and most of the experts and scientists understand that it's wrong."
And one more for good measure:
Uganda AIDS Prevention Success Being Undermined by Infuriated UN Condom-Pushers
KAMPALA, February 4, 2005 (LifeSiteNews.com) – Dr. Edward C. Green, PhD, an AIDS prevention worker and senior research scientist at the Harvard Center for Population and Development says that the success of Uganda’s AIDS prevention program has so infuriated Western AIDS prevention groups, they are willing to destroy it rather than change their condoms-only approach.
Writing in the January 31st edition of the Weekly Standard, Green says the Ugandan success, based as it is on sexual abstinence and marital fidelity, “directly challenges core values and attitudes enshrined by the Western sexual revolution.” Green writes, “How infuriating that an approach not funded by the big donors and scoffed at by foreign experts should prove to be the very thing that worked.”
Reasoning that AIDS is spread mainly through sexual contact, the Ugandan government decided in the early 1990’s that the best way to prevent that spread would be to convince its citizens to adopt sexual abstinence and fidelity within marriage. This inexpensive, indigenous program required little outside funding or support and the results are acknowledged to be astonishing. The Ugandan HIV/AIDS rate fell by half, from 15% in 1991 to 4% by 2004. Uganda’s program was starting to be emulated by other countries such as Kenya and Senegal.
Green says, “One would expect the (Ugandan) model to have been replicated around the world…Instead, even in its country of origin, the model has fallen into disrepair.”
Various NGO’s, meanwhile, including the UNICEF, the UNFPA, the World Health Organization and Centers for Disease Control were spreading the dogma of condoms first, last and always for AIDS prevention. With most of the AIDS prevention work being done in Africa by these organizations, it can come as little surprise that the rate of AIDS has done nothing but climb to current pandemic proportions. Green writes that “few AIDS experts wanted to accept the evidence from Uganda because people do not like to admit they might have been wrong, especially in a matter involving countless millions of dollars and the lives of millions of people.”
Green said by 2002, presentations from the USAID and Centers for Disease Control staff made no mention of abstinence or faithfulness in assessing the Ugandan situation. “They spoke exclusively about latex, drugs, vaccine research,” he said.
Green writes that foreign donors have been systematically undermining Uganda’s successful model. Now condom advertising is ‘ubiquitous’ in Uganda and there are currently no plans for interventions that promote fidelity or partner reduction. “Indeed,” Green says, “with rare exceptions, they have simply refused to pay for” such programs.
This shift has not been the work of Ugandans themselves. Senator Sam Brownback, after a trip to Uganda, said, “African leaders are growing resentful that U.S. dollars are contingent upon acceptance,” of condoms. Brownback said the Ugandan President, Yoweri Museveni, is “in a battle with Western donors,” to keep condom promotion out of his innovative AIDS program.
Green concludes, “It is by no means clear that empirical evidence can overcome ideological blinders or compete with the big business in pharmaceutical products that AIDS prevention has become.”
Ruteikara is the co-chair of Uganda's National AIDS-Prevention Committee. He wrote in a column in the Washington Post on June 30, "AIDS epidemics in Africa are driven by people having sex regularly with more than one person." The Western experts, dedicated to the exclusive promotion of condoms, were incensed when Ugandan AIDS rates plummeted with this "ABC" method that left condoms as a "last resort".
The success of the Ugandan programme, Ruteikara said, did not sit well with those international experts and advisors, sent to Uganda to oversee the spending of international relief funds, who are devoted to the condom as the first and last answer to the AIDS epidemic.
Despite the official line that Western "advisors" were to work within local programmes, these experts, Ruteikara asserted, actively stonewalled the Ugandan committee's recommendations. The Western advisors objected that the programme was an attempt "to limit people's sexual freedom" and they used their control of the international funding to force a change in direction.
"Repeatedly, our 25-member prevention committee put faithfulness and abstinence into the National Strategic Plan that guides how PEPFAR [President's Emergency Plan for HIV-AIDS Relief] money for our country will be spent. Repeatedly, foreign advisers erased our recommendations. When the document draft was published, fidelity and abstinence were missing."
More insidiously, Ruteikara says that a "suspicious" statistic appeared in reports that claimed a significant increase in rates of AIDS among married couples. The claim was that 42 per cent of married couples were infected, a rate twice that of prostitutes. Repeated requests for the origin of this statistic were ignored. Domestic surveys done by Ugandan health officials found that only 6.3 per cent of married couples are infected, lower even than rates among widowed and divorced Ugandans.
Since the Ugandans were forced to change their programmes, surveys have shown that the percentage of sexually active men with multiple partners has more than doubled, undoing earlier declines, and the AIDS rate has begun to climb again.
The Ugandan success story is one of the most impressive in the fight against AIDS. Between 1989 and 1995, the number of men having three or more sexual partners in a year dropped from 15 to three per cent and HIV rates plunged from 21 percent in 1991 to 6 percent in 2002. At the same time, Western nations brought more than 2 billion condoms on Africa and the epidemic continued in nations that went along with the condoms-only approach.
The motive for opposing the Ugandan initiative, Ruteikara said, was financial as well as ideological. "In the fight against AIDS, profiteering has trumped prevention," he said. "AIDS is no longer simply a disease; it has become a multibillion-dollar industry."
Ruteikara's assertions are supported by Dr. James Chin, a former top AIDS epidemiologist at the World Health Organization, who said, "Easily preventable diseases are still killing millions of children each year, while billions of dollars are being squandered annually by AIDS programs."
Robert England, head of the charity Health Systems Workshop said in the British Medical Journal, "Although HIV causes 3.7 per cent of [worldwide] mortality, it receives 25 per cent of international health care aid."
Ruteikara concluded, "Telling men and women to keep sex sacred -- to save sex for marriage and then remain faithful -- is telling them to love one another deeply with their whole hearts. Most HIV infections in Africa are spread by sex outside of marriage: casual sex and infidelity. The solution is faithful love."
"We, the poor of Africa, remain silenced in the global dialogue. Our wisdom about our own culture is ignored."
Posted by: Stuart Koehl | Jul 17, 2008 4:45:37 PM
