Can US agriculture reform inform the healthcare debate?

A rather shocking analysis by an otherwise astute observer of American history Athul Gawande, MD, in the New Yorker has sent me reeling from its short-sightedness. In his article Gawande argues that the Senate healthcare reform bill is on the right track by not demanding wholesale budget controls, but rather instituting small pilot programs to see what works best. Although pilot programs may not be a bad idea, Gawande's argument is deeply flawed. It relies on the theory that the changes in agriculture and food production in the beginning of the 20th century were also characterized by small pilot programs that eventually took over the nation, bringing our food budget under control and, by reducing drastically the proportion of population engaged in farming, provided a productive work force for manufacturing and growing the economy.

Indeed, the changes in the way we produce our food that took place in the first decades of the last century are remarkable, and one can stand breathless before this edifice of modern science with unabashed awe... but only if one truly believes that this movement has been a success. And clearly, Gawande subscribes to this opinion:

The history of American agriculture suggests that you can have transformation without a master plan...

I would beg to differ, and so would many who worry about our current agricultural practices. We raise corn and soy beans as monocultures, and douse them with petroleum-based fertilizer to make them grow. The humus that Gawande talks about in his article is not considered at all in today's industrial agriculture, and the level of the destruction of the topsoil in these gigantic swaths of potentially fertile land is unprecedented. Similarly, food animals are grown in inhumane, crowded, disease-laden conditions in so-called Concentrated Animal Feeding Operations, or CAFOs, where cows are fed corn and corn byproducts. Instead of grazing in pasture and putting their rich manure back as fertilizer, thus ensuring the sustainability of the humus, their effluent now contaminates water supplies. It was only a little over 20 years ago that the world was shocked by the revelation that these ruminants were in effect made into cannibals by being given parts of other cows in their feed, resulting in the emergence of the Mad Cow Disease. I doubt that I even need to mention that because of the unhealthy conditions of the CAFOs, animals are actually routinely given antibiotics to keep them from contracting infections, a practice that scientists agree is driving the evolution of a class of superbugs that are now threatening our species.

A couple of other effects of our wildly "successful" farming apparatus are the obesity epidemic, the combined contributions of deforestation for the sake of pasture and the exorbitant amount of methane gas produced on these farms to climate change. There are also the effects of the continuing fallout of the displacement of family farmers from their communities and their connection to ancestral ways to the impersonal and demoralizing widget-making in the cities. All in the name of the economy!

So, dear Dr. Gawande, forgive me if I disagree with you on each and every point about how industrialization of agriculture has been a wonderful thing for America. I believe you, much like most pundits, are confusing the almighty American Economy with the American citizens, who certainly fade in comparison to the riches derived on their backs.

I am not fundamentally opposed to pilot programs -- they may be the way to tweak incremental changes in how we do medicine. But to rely on them as the sole fundamental tool in the reform is a big mistake. In fact, the history of the American agricultural revolution is the strongest argument there is against a transformation without a master plan. It would be tragic to be lulled into the complacency of "act now think later" at this critical cross-roads of our time.