Monday, December 7, 2009

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.        


  1. (This may or may not come as a repeat comment. I tried to edit two previous comments and in the process they diappeared.)
    I think you may have misunderstood Gawunde's article. He was not talking about industrial agriculture or anything like it. He was describing changes at the beginning of the twentieth century which were, if anything, the opposite of what is done on industrial farms. He was discussing agricultural improvements which in fact were for the most part environmentally sound -- more so than what had existed -- and which made it possible for small farmers to make successful livings as small farmers.

    I think his point was that efforts to impose a national version of health care right away would probably result in something more like industrial agriculture (though he didn't say that) than in good medical care. He is obviously aware of local context, for instance, which pig factory owners are not. He actually mentioned that the Mayo Clinic, and similarly praised institutions grew organicaly and don't provide models that can be imposed in some uniform way. He wanted to figure out how one could take advantage of true advances in knowledge and methodology while maintaining the integrity of treatment. Perhaps it's unfortunate that he chose agriculture, given the current nature of its practice in the US. However, I'm sure he wouldn't think industrial agriculture was some kind of good place to be any more than he would think some kind of medical assembly line for the treatment of patients was.

  2. Thank you for your comment. I am not sure that I misunderstood, and if I did, so did a lot of people. It is impossible to divorce the early "progress" in the US agriculture from the debacle it is today. That is exactly my point: you cannot allow a complex system like that (or healthcare) to follow its own entropic trajectory without having at least a scaffolding of a vision to build upon. Otherwise, as I wrote previously, you are asking for "unintended" consequences.

  3. The current state of agriculture is not the result of a headlong rush down a single, inevitable trajectory from the changes wrought at the beginning of the twentieth century. History doesn’t happen that way. Technological innovation in agriculture, regardless of the ideology guiding it or the time when it occurred, has been the keystone in the development of human groups into more complicated organizations. Innovation leads to change but not inevitably to industrial agriculture.Agriculture today is the result of a deliberate shift in the policy framework in the late 1970s to a a model which put profits first. Thus, a single dominant vision and framework is not by itself good. It can harden into what we now have: food production determined by unrestrained free-market ideology (or on the other hand, fatal "scientific farms" of the Soviets).
    I am quite sure that Gawande would not disagree that there should be a framework, but he would be careful about what the framework consisted of. In fact, his use of agricultural history demonstrates that rather than wanting medical reform to proceed “helter skelter”, he sees his patchwork approach as very well suited to providing true improvement in treatment and costs savings. Gawande certainly isn’t advocating that medicine follow its “own entropic trajectory”, just as he did NOT suggest that that was how agriculture should progress. In fact, quite the opposite. He says, “The agricultural system [before 1903] was fragmented and disorganized, and ignored evidence showing how things could be done better….Laissez faire had not worked. “ What did work was indeed government intervention even in the face of traditional American hostility to it. “Private farms remained, along with the considerable advantages of individual initiative. [But] the government was enlisted to help millions of farmers change the way they worked. The approach succeeded almost shockingly well.” Government intervention did have a “scaffolding of a vision,” and it also demonstrated an understanding of how to work with human nature, influenced as it is by changing cultures, experiences and knowledge. Planks in the framework to support increased and improved agricultural production included NOT increased production at whatever cost as seems to be the case today, but a recognition of the importance of a scientific approach, according to the science available at the time. It was the “hodgepodge of successful USDA initiatives that began as pilots” which produced the good approaches. As Gawande says, "...[T]he straegy worked because United States agencies were allowed to proceed by trial and error, continually adjusting their policies over time in response not to ideology but to hard measurement of the results against societal goals."
    Gawande says there are two kinds of problems: “those which are amenable to a technical solution and those which are not.” He puts health care coverage in the first category and the health care system in the second. Experiments through pilot programs will, he believes encourage the development of a more rational and humane health care system. This is a scientific approach: the testing of hypotheses through pilot programs along with the acknowledgment that we don’t know the “answers” and that in fact there probably are no single, permanent answers. This approach in fact is built on a framework designed to shape medicine both to improve care and reduce costs through government partnership.