Let's Prehend
A Manual of Human Ecology and Culture Design

NOTAM, Notes On The Anthropology of Medicine

Anthropologists tell us that all cultures throughout history have healing arts and specialists who practice them. Ancient cultures in China and Egypt developed elaborate systems for the treatment of human ails, often without the protection of a patent system or easy access to corporate funding. Zoologists tell us that even animals, especially our cousin primates are seen to select special herbs to alleviate their particular distresses. Brain scientists study the extensive areas of the brain of animals and humans that subconsciously influence the selection of nutrients and behaviors, in coordination with the short and long term health effects.

Evaluation and diagnosis of medical systems must be broader that simply its adequacy and distribution in the community that it supposedly serves. Analysis might also consider the general health of the medical system itself, a D scale parameter. How well does it deal with those minor system dissociations inherent in any complex system, namely public and private health? How rationalistic vs. organic is the medical practice and its credo? How holistic, high Ai, is common practice? How distributed vs. centralized are the physical facilities and personnel? How cooperative vs. competitive, or humanistic vs. adversarial, are its economics? Let's briefly use the Evaluation and Diagnosis charts for a frame of reference, a tool to aid thought and discussion of current practices in among the health care professionals.

The history of western medicine is well documented and described in many sources, but consider these few issues in the conflict between abstract and organic components. A century ago, many doctors were part of their community, touchingly described in biography and fiction. They often knew their patients and their families and developed keen intuitions about each individual. Unfortunately, their knowledge and means were so limited that early outcome studies indicated a net zero in effectiveness - many better, many worse. This crisis in the medical profession was soon alleviated by scientific discoveries such as immunizations, antibiotics, and better surgery. But the CAL drive into MAC drove the profession into Modern Abstract Medicine, MAM. MAMs increasingly "treated the disease, not the patient". Clinical research become the guide, bolstered by threats of malpractice litigations, abstracting treatment from the doctor's intuition toward `accepted practice'.

ROSL will bring with it Reconstruction of Organic Medicine, ROM, as described later. Technology will greatly aid this process, not only with cancer cures, better preventive medicine and even replacement of worn out parts, but also by increasing communications as needed and computer access to all relevant detail. Thus the individuation of earlier practice can resume, but at a much higher technical level.

Medical science is growing by leaps and pounds. Research and Development funds pour into the field from government, academic, and corporate and even individual sources. This growth of medical science is a growth in Ei value, an E chart analysis. But all is not well in the healing professions.

Consider the doctor-patient relationship. At present, while family culture dies and the social support system disintegrates, the medical personnel are called upon to take quasi-family and tribal roles. Such a role is normal in organic cultures, but incongruous in the present `abstract' medical system. Yet, even in an impersonal system, the medical people continue to offer some warmth and support, along with their technical proficiency. Supportive behavior in such an impersonal context testifies to the vast reservoir of family feeling and human love that can survive even such an abstract system.

Modern Abstract Medicine, MAM, has evolved to handle the diseases of modern abstract life: war, auto accidents, tobacco poisoning, etc. But broader health and deeper well-being, which require an expanded world view, get little attention and even less financing. Transition from fee-for-service to managed care, motivated by the HMOs need to cut costs and increase profits, stimulates more preventive medicine and healthy living. But in MAM, the personnel are obliged to take the narrowest view, to use only those treatments which are legally proven. As a result the system is compulsively reductionist (p.20), reducing treatments to narrowly defined `diseases'. What is defined as a disease, what medicines and treatments are approved, and what procedures can allay malpractice suits, are determined by the legal, regulatory, and financial systems, less and less by the doctors. The conflicted doctors are reluctantly obliged to order more services than needed as `defensive medicine' for the sake of legal protection and financial gain, yet cut their service for HMO patients. Doctors must mute their impulse to serve and often deny the best interests of the patient and community. They must play by the rules and go for the money. (See ICE, p.236, 241) The burgeoning HMO system increasingly corrects such over-treatment, and gradually approaches austere rationing.

We seem to have an epidemic of iatrogenic diseases, diseases caused by the medical system itself. Much medical treatment is required, not because of the diseases of the human condition, but because of the damage of previous treatments. Often, pills are piled upon pills in an expensive and futile effort to deal with what was originally a simpler problem.

For example, the mind and body tends to heal itself. Homeopathic medicine is very effective in this mode because it provides medicine with almost no molecules, leaving this magnificent human organism to heal itself without abstract interventions. Whether homeopathic remedies have some other role, aside from protecting the patient from allopathic medicine, has yet to be demonstrated. On the bottom line, no-medicine is not expensive enough to take its place in the medical profession.

The drug patenting system compounds the problem by rejecting old and tested treatments for newly patented and marketed substitutes. To illustrate, grumpy old patients are often given phenothiazines, which make them even sicker, rather than the tried and true opiates, which would make them happier and save money, as explained in OVER SIXTY FIVE, p.217. Granted this statement oversimplifies and exaggerates the problem - under the circumstances of loneliness and expensive care, even the new drugs can offer some respite. Addiction to benzodiazapines and a plethora of other questionable drugs does damage comparable to the much maligned illegal drugs, as argued in DRUGS, p.195.

Medical research is largely drug research, in the United States system. Financed largely by the drug companies, as well as the military, scientists make analogues of various body chemicals and of older drugs with expired patents, in the hopes of making a killing - financial, that is. Research programs often go like this: In any particular disease, especially a wide-spread one that promises lots of customers, they seek out one of the molecules which are relevant to the disease process. Then they modify part of that molecule to synthesize similar molecules which interrupt the disease process at that point by blocking or enhancing its action. Success is achieved when the drug has plausible effect and is patentable. By the time long term side effects appear, the patent has expired and another similar molecule is marketed.

Another SAM disaster is described in PEDDLING PILLS, THE RISE OF DIRECT-TO-CONSUMER PRESCRIPTION DRUG ADVERTISING AND THE DANGERS TO CONSUMERS, by Larry Sasich.[ PEDDLING PILLS..., by Larry *Sasich, in *MULTINATIONAL MONITOR, January 1999.] Doctors seem responsive to patients wishes, as it should be, but patient education by advertising is less than an alternative SNAP. Legislators are unlikely to limit the free speech of pharmaceutical corporations.

One sorry example of the corruption of medical research is the case of Knoll Pharmaceutical's Synthroid, hypothyroid drugs being the third most common medication in the US. UCSF scientist Betty Dong was engaged for a quarter billion dollars for a blind randomized trial in the nineteen eighties. Unfortunately, Synthroid was found to be bioequivalent, no better three other cheaper thyroid pills. Knoll then proceeded to sabotage the study by suppression and distortion, delaying the original report until 1997, too late to do much harm.[ Reported, again, in David *Shenk's article, *MONEY + SCIENCE = ETHICS PROBLEMS ON CAMPUS, Academic-corporate cooperation may be affecting the integrity of research in NATION MAGAZINE, 3/22/99.]

Treatments such as some cancer therapies may prolong life a few extra months, but often with chemically induced misery exacerbated by insufficient opiates. Physicians and staff often apologize for stingy pain management, lest the patient become addicted. This is a truly malicious system, yet a benign image of the medical profession is promoted by stage and screen, and the majority of patients and staff play the obsequious victim, if they want to get along.

The aged are subject to the final solution. The medical and nursing home system operates to separate the elderly from their money, before it is left to their heirs. Rather than accepting death as a part of life, the dying are prodded, explored, poisoned, and isolated until their money is all gone. Any sign of protest, or even awareness, is treated with the repertoire of psychoactive drugs to remove the last vestiges of mental integrity or social meaning from their lives. The medical treatment of the elderly is the Compulsion to the Abstract Life achieving at its final solution.

Legalization of suicide with medical assistance, as practiced in the Netherlands, could save a great deal of pain, humiliation, and medical expense. But great danger lurks - since 70% of a lifetime's medical cost is expended on the terminal illness, the acceptance, even ceremonialization, of suicide could cut the U. S. medical bill from over 12% to under 6% of the GDP, throwing thousands out of work, collapsing the stock market and depressing the economy.

The medical culture gives lip service to a systems approach, but in contrast, tends to reduce its view to narrowly defined diseases and narrowly directed remedies. A deeper systems approach could be pursued, especially with the aid of modern testing and computer technology. But instead, medical research goes for the money, driving the medical enterprise further in the abstract direction.

An interesting contrast to MAM medicine: The Chinese have been integrating their ancient and modern medical traditions, making the best use of both under very austere circumstances. With First World resources, such an integrative approach could alleviate the damage and inefficiency of modern Western medicine. But resistance is rife: an applicant to an American medical school, who is presumed to have an interest in Oriental or other holistic medical traditions, triggers the taboo and is rarely admitted. Like the professions of law and education, the medical system becomes more abstract and ideological fragility compels increasing loyalty and conformity, FOC.

In the United States, financing the medical system approaches the military system in its lavish inefficiency. The medical system uses more of the GNP than in Canada and Europe, yet a large portion of the population is squeezed out of the system. Even the collection of Medicare, etc, fees is costly, over twice comparable systems. (Documentation of current facts and figures is readily available, and any librarian can help.)

The allocation of expensive medical resources is a problem in transition. The present fee-for-service sector over-treats and exploits the rich, while degrading and neglecting the poor. About seventy percent of a citizen's lifetime medical expenses are extracted to finance the terminal illness. While terminally ill elderly are kept alive in agony and degradation, many children are poorly cared for. In the Netherlands, a large percentage of deaths are physician assisted. United States has the lowest child inoculation rate of any First World nation, lower than many poor nations.

Most U. S. government interventions seem to transfer wealth from the taxpayer into the medical profession, inflating the costs even further. In the case of HMO contracts by U. S. Medicare, about $400 a month is paid to the HMO to ration the service and pocket the profits. This rationing is done by insurance company staff by phone and often requires and extra staff member at the doctors office. The medical reform of the early Clinton administration was poisoned by the campaign finance and lobby system - changes can only be made if they make money for the lobbied interests. AMA leads the list of big spenders with $17.1 million, followed by Philip Morris (a drug company) $15.8 m, with Pfizer fifth at $10 m.[ *PRICE OF PERSUASION IN WASHINGTON, $1.17 BILLION in the 7/8/98 SF Chronicle, from Associated Press 1997 analysis.] In 1996 Journalist Haynes Johnson explained that Republican House Majority Leader Newt Gingrich defeated health reform in order to avoid the Democrats getting credit for a better system. Perhaps the insurance lobby deserves most of the credit for the present system.

Improvements to health care need not wait for the reconstruction of extended family and village life - medical services, like education and production, woven into the fabric of a rich and sustaining community culture.

But first take a close look at the medical system and admit its nefarious malice, then apply the principles of culture design at any stage to increase the value and the health of this inadequate and sick system. Whose responsibility is that?

Historically , medical care followed the compulsion to the abstract life, CAL, as medical facilities and personnel moved farther from the patient and community, a move up left on the D chart. This PROBLEM OF THE STRANGER (p.73) exacerbates the stress of medical trauma. A healthier and more efficient system would be a network of small clinics dispersed where needed, with simple treatment immediately available, and referral to central hospitals when necessary. For example, following a British program, childbirth could be offered with a familiar and well trained midwife, accompanied by a `Welcome Wagon' parked outside the home in case the event becomes medical. Imagine how our contracted system would have to expand to allow this option.

Reform is possible, even in the degraded medical science itself. The system is its own straightjacket in many ways, but the influence of the drug companies makes matters much worse. Perhaps after organizational reforms that allow the personnel to practice medicine, after the insurance companies are forced out of the picture, after the drug companies lose their hold on the patent system, then various wholesome developments can take place. Even the medical schools can heal, given a wholesome cultural environment.

In recent decades medical care has shifted from `fee-for-service' to `managed care', with a variety of medical insurance programs, Health Maintenance Organizations, HMOs. These insurance corporations collect premiums from government, employer, and individual, then pay most medical expenses. They strive to maximize profits by rationing service through elaborate patterns - pressuring hospitals, doctors and staff, pharmaceutical firms and others to cut costs and take less.

The contrast between fee-for-service and managed-care is more intense than most people care to admit.

Contrasting fee-for-service with managed-care: "What's the prognosis, Doctor?" ... "He may live a month, sixty thousand at most." or "He may live a month, but not for four hundred."

Strangely, the Medicare program was designed for those over sixty five. Studies show that three quarters of medical expenses treat the terminal disease, most of it after age sixty five. The government gives the HMOs about $400 per month to provide this care for oldsters, and try to make a sizable profit.

How strange that the elders get such expensive care, yet the youngsters who need much less are too often deprived. The Medicaid programs for poor children help somewhat, but only for the very poor who know how to access it. The slightly poor are in a precarious medical financial position.

One simple reform would be to eliminate the `age sixty five' from the medicare program. It seems a miracle that medicare exists at all, and extremely unlikely that further collective medical support is forthcoming. In spite of the heroic if unsuccessful efforts of Hillary Clinton to reform the medical system, the power of the insurance industries succeed in `privatizing' it. Remember the ad with the homey couple slamming the idea of government bureaucrats making medical decisions. Now we are left with insurance clerks deciding medical matters, one step further removed from any democratic input.

Fortunately, many excellent journalists and other media sources disclose these ongoing problems. *Gordon and *McCall point out that the greatest cost-cutting comes from reducing hospital stays. Unfortunately, this puts a heavy strain on the patient and her family, often to the detriment of their survival. Germany, Britain and Canada with comparable health care quality not only spend less but have longer hospital stays.

Consider two contrasting E charts, similar to Fig 2-3,4, page.. The left chart, the more abstract configuration represents the large hospital, high i, with minimum staff but very little organization at lower levels. The right chart represents a more organic medical system with local centers nearer to the patients. The general approach to any abstract system, any abstract organization, is to construct transition organizations at intermediate levels.

The large central hospitals offer the latest in medical technology and skill, appropriate to handle advanced and complex medical problems. But most health matters are more mundane and benefit from easier local more modest health centers. The centralization of medical care, and neglect of lower level attention is driven by the Compulsion to the Abstract Life (CAL, p.61) by the Magic Of the Marketplace (MOM, p.239). In developing health care system, human values and judgements are displaced by corporate market values. Heroic medical service people strive to humanize this abstract system as best they can, but they gradually loose the struggle against the onslaught of corporate `managed care' medicine.

Making matters worse is the inhuman market forces that direct medical research. For example, the pharmaceutical companies make money from patented drugs. But by accidents of history, the patents expire. Therefore new drugs must replace old drugs, be marketed as superior and safer, criteria that benefit from long experience longer than the patent period. The new drugs may be better and safer, but health workers are obliged to convince themselves regardless of insufficient information, rather than endure the discomfort of normative conflict.

The wealth of world herbal medicine, much of it developed before MAC, cannot be advantaged because common herbs cannot be patented. Cannabis is a good example of an ancient and modern herb that is effective for many ailments as well as a safe and benign recreational drug - certainly better than alcohol. Yet even though the increasing demand for its legitimization permits serious clinical studies, there's no money in it. Most likely, the Canadians or Europeans can complete the task, if they can resist the pressures from corporations and their governments.

The needed reforms are obvious. The medical system is inherently a collective responsibility, therefore some community supported minimal service is appropriate. This means improving the present system with active outreach, especially in the distressed communities, as well as the decentralization of first-service clinics in local neighborhoods and schools and work places. The medical personnel should be well paid from collective funds, and should not be harassed and degraded by financial or legal pressures.

The medical system could be protected from the legal and insurance systems by simple liability reform. There are plenty of excellent reform suggestions, and competent people to implement them, if only these reforms were protected from the lobbyists. Properly designed reforms would result in less governmental and bureaucratic interference. Decentralized clinics would help to redistribute mature responsibility and skill to the lower personnel levels, even down to the lowly patients.

One might argue that large well staffed central hospitals are safer. But the central hospitals are not replaced, they are augmented and assisted. With a distributed `organic' system, low level medical needs are handled more easily and cheaply while the local staffs can quickly refer more serious cases up the medical facility ladder. The system would also relieve the large hospitals of the plague of emergency drop-ins and the expensive treatment of problems that should have been handled earlier.

A large scale redesign of the medical culture is in order. It would fit neatly into the Reconstruction of Organic Social Life (ROSL, p.74). Cohousing units in Ecovillages would develop their own health centers in the neighborhood. We cannot and need not predict the evolution of organic health services, but we can look forward to greater depth, diversity, and economy from the reconstruction of organic medicine. Imagine the superb and fortunate synthesis of modern scientific medicine and hi-tech equipment supporting a system that serves all the people.

Imagine a more modest medical reform program, applying the principles of human ecology to the culture design of medical reform. On the E Chart, this would be a broadening of the steep curve of medical facilities and services toward greater integration with the community, similar to Figs 2-3 & 2-4

Elementary schools are still somewhat small and close to the community. Reinvigoration and modernization of the School Nurse Program, SNaP, could be a convenient way to decentralize the medical system, from Fig 2-5 to 2-6, p.?. Since elementary schools are already distributed in small schools - though not small enough - in their neighborhoods, let's use these facilities as the basic service center, with modernized equipment and communications. Quality and safety control need not be more difficult than the present system, especially with quality guidelines from the *Deming tradition and excellent communication systems.

Immunization and other basic needs of children are the first priority. This can be done quickly and cheaply by simply reestablishing the `school nurse', by funding health workers in every elementary school, starting with the most needy. This modest investment would save much money and suffering. We could afford it during the 1930's Great Depression, why not now?

Outreach to every pregnant woman for prenatal, birth and postnatal care. Since present child birth practices are so deformed, law should be passed to exempt these local school clinics from current practices.[ See classics by Joseph Chilton *Pierce as well as more modern studies on the subject of prenatal to postnatal life.] Free and safe birth control and RU486 abortions will also save money and suffering, and lower the birth rate. Local flexible guidelines allow cultural diversity, less expensive treatments, and broader approaches for both individual and community.

The next priority is to make the SNaP program available to the men in the neighborhood - for first aid, treatment, referral and follow up. This would relieve the burden of drop-ins to Hospital Emergency Rooms. A menu of basic free and low cost services should be developed gradually for prevention and early treatment. Since current medical costs are so corruptly inflated, the clinics need protection from medical, legal and insurance establishments. Clinics and patients also need protection from the drug laws - offering sanctuary like the churches in medieval Europe, perhaps copying the U. K.'s Liverpool program for free drugs with medical supervision.

Outreach to the elderly, with emphasis on participation and reattachment to the local society, should be instituted soon after the children are cared for, and with the children's participation. The elderly also need protection from the medical establishment that typically escalates high tech care to extract maximum funds while making them isolated and uncomfortable.

As some medical facilities go bankrupt, a portion can be bought up at great discount for the SNaP program's referral network. As health care improves, thousands of insurance and some medical staff will be unemployed, available for other healthier tasks.

The wealthy need not suffer any deprivation of their current ample health care. Thousands of the remaining medical staff and facilities can operate to torture and overcharge the rich.

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