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If we view the health care delivery system as a social system, it becomes amenable to sociological analysis. Sociology deals basically with the behaviour of social groups, organizations and institutions. As well, it deals with the phenomenon of social process and social change. It is valuable in analysing the behaviour of a particular social group to identify the major actors and the nature and source of their behaviour. Where there are multiple actors cemented together tightly by common goals, a social complex emerges in which diverse actors participate, nevertheless creating a predictable pattern of behaviour.
In analysing social systems, whether simple or complex, it is very important to understand the world view or belief system (paradigm) that guides their behaviour and tends to determine roles, norms, status, hierarchy, rewards and values. Social systems are subject to radical change or paradigm shifts and we can discern the beginning of just such a shift in the current health system.
The existence of socio-political complexes is a natural consequence of groups and organizations (the actors), held together by strongly shared norms, roles, values and world views or paradigms. We are basing our analysis on the U.S.A., a dominant power in the world and one which strongly influences Canada. We can discern three distinct social complexes in the U.S.A. — the military-industrial, the automobile-petroleum-highway, and the medical-pharmaceutical-insurance complex. These terms identify the major social actors or members of the complex. It will be, in part, our task to identify the paradigm that guides the latter system.
It is important to describe the larger context in which the medical-pharmaceutical-insurance complex has evolved. This context is the current process of globalization which imprints its values and paradigms on all dominant social systems. This will permit us to understand the true anatomy of our current health system. It is no accident that the U.S.A. is the only country in the economically developed world which does not have a national universal health care plan. Moreover, examining a group of social indicators measuring the state of general health, public, environmental and nutritional health and health care delivery, the U.S.A. has the worst record among all industrialized countries. It has the highest infant mortality, lowest life expectancy, highest incidence of cancer, cancer among men and breast cancer, as well as the highest per capita consumption of beef and snack foods. It also has the highest per capita production of all major pollutants and toxic waste.
The Two Faces of Globalization
There are two faces to globalization. One, represented by the international non-governmental organizations concerned with peace, justice and ecology, presents a vision of global equality, global unity, the acceptance of cultural diversity, and above all, a high level of cooperation accompanied by a dedicated program of aid from North to South, guided by ecologically sustainable technologies. This, obviously, requires fundamental changes in the North, and above all, to cease imposing its version of “progress” on the South, supported by economic and political domination, both covert and overt.
The dark side of globalization is that it is a new form of neo-colonialism. The authority and power of the most powerful international institutions and their institutional support groups such as the International Monetary Fund, the World Bank, and the General Agreement on Tariffs & Trade (GATT) with their narrow focus on “structural adjustment policies” is attempting to impose a single dominant unified developmental model on the entire world, while crushing the identity of indigenous peoples, local communities and alternative cultures. In effect, what the North has imposed as the new globalism is a belief system of unrestricted economic expansion and unrestricted exploitation in pursuit of that economic imperative. If this world view were to truly pervade the entire planet, life would inevitably find itself on the precipice of extinction.
The condition of the world in the late 1990s is worse than Susan George’s judgement, How The Other Half Dies.1 We may now be talking about how the other three quarters die. Moreover, the North has restructured the South so that debt exceeds income, a counter-productive process that can only lead to the deepening of the multiple crises.
What the world is really facing is a gigantic crisis in values. The underlying value of the current globalization trend is to make economic values dominant, reducing all other social values to their economic net benefit. Socially valued services such as health and education are being reduced to the privatization of the business enterprise whose sole criteria is profitability. The tragedy is best expressed by F. Scott Fitzgerald, “The victor belongs to the spoils”. The loss is the best that was human — the spiritual, the creative and the humanistic. Health delivery has become a business thereby subverting the historically evolved right to health for everybody.
A new and powerful kingdom has emerged in the world, more powerful than government. This is the kingdom of the huge international cartels and multinationals. They are also a manifestation of the new globalism. Their operations are planetary.There are no genuine restrictions on their activities. They are mobile, never tied to place or time, but always moving to where profits can be maximized. They are totally indifferent to the real conditions of living for masses of people.
They have a vision of a world of Coca Cola and Corn Flakes, or McDonalds and Burger King. That this is no exaggeration is supported by the following statement by the President of Nabisco — “I am looking forward to one world of homogeneous consumption... to the day when Arabs and Americans, Latinos and Scandinavians, will be munching Ritz crackers as enthusiastically as they already drink Coca Cola and brush their teeth with Colgate.”2
The vision of the multinationals is coming true. They have created the final unsteady state. At present no counterforce of equal power exists. Creating such a counterforce is the task of the next revolution. The goal of the global business community is to create a homogeneous culture of mass consumption and to free the global marketplace of all encumbrances such as health, safety and environmental regulations, and standards or public investment in health and education. Their goal is to shred the social safety net. Deregulation and privatization of everything is their formula for creating a global free market. The freedom of enterprise is to be completed and the economic imperative, the power of the bottom line, is to become the exclusive measure of all values: material, spiritual, human and cultural. Even the value of human mortality and morbidity are to be reduced to economic values. It is a saving for a corporation when a low-wage worker dies or becomes ill from the company’s operations, rather than a worker in a high-wage area. In general, the death of women is valued less than that of men. These are the formulae of the multi-nationals as they export waste or manufacture toxic substances.
What propelled the globalization trend was the demise of the Soviet Union and the emergence of a unipolar world establishing the Americanization of the planet, the essence of which is that there are no other meaningful operational values in this world other than the economic. This globalization of the economic imperative exerts enormous pressures on all countries to conform to an economic treatment of health that represents the triumph of the marketplace. For those business and government leaders who subscribe to this world view, the social safety net and its components of government support of health, education and other important social services is a violation of free enterprise domination. A direct consequence of all this is that the medical-pharmaceutical-insurance complex serves a common goal of maximizing profits, thus reducing them to a business rather than a service.
Ancillary groups emerge and attach themselves to the above complex. Association of doctors, health institutes, lobbies, regulators, research institutes, university departments of medicine, all tend, with notable individual exceptions, to indulge in an elite accommodation of the major goals of the complex. This often takes the form of seizing on uncertainty to delay or deny the existence of serious health risk. In the end, they indulge in the art of biopolitics, which is an attempt to treat something which is biologically hazardous as if it were biologically acceptable. They employ universal tactics in order to avoid regulation. First denial, then delay and then to reluctant regulation, or in some major cases, permission to continue to release hazardous substances to the environment. The social dynamics of the complex and its ancillary groups is to create a monolith of collectivity of all the actors, guided by a dominant paradigm and various sets of roles and norms.
The Disease System
Underlying all of this, but also a consequence of the above evolution, is a more fundamental distortion of our health system, in that it is really a disease system The Sociology of Health
with an exclusive concern with treatment and cure, and a profound neglect of prevention. This follows naturally from the power of the economic imperative. Since the treatment of disease is a business venture, only those patients who can generate profit will tend to be treated or given preference in treatment. In fact, the insurance companies have a name for these patients —“revenue generators.” This, of course, leads to the neglect of health care for the majority of the poor, and many of the aged and disabled. These people are simply sacrificed at the altar of organized greed. This is a system of functional inhumanity which views social services generally as subversive of free enterprise, thus the focus of deregulation. The need for treatment remains valid as long as disease exists. Like hazardous waste, we must clean up the past even as we prevent the errors of its ways for the future.
Economics of Health Care
Deficit cutting and balancing the budget are the current dominant economic policies of the economically developed world. However, this entails a very biased set of instruments. The major target is to shred the social safety net — health care, child care and education being prime targets, while also cutting taxes, particularly for the richer people and the corporations. Thus there is an organized system of unfair taxation predicated on the notion of the validity of the “trickle-down” theory. At the same time, the military budget is able to escape these cuts even in the face of the end of the Cold War. This is rationalized by continually inventing new threats to security. And the ultimate irony, of course, is that this totally violates the principles of free enterprise. The external baggage of the post-Soviet world is the curse of a new world order prescribed by the U.S.A.
The prescription for this new global market economy is to rob federal governments of all legitimate roles in setting standards, whether for the health of the people or the environment. Deregulation and decentralization become dominant policy since all regulations are viewed as violations of the freedom of the market. Laws protecting wildlife, natural resources like forests, or for that matter, the quality of air, water and soil, or the integrity of biodiversity, are viewed as unacceptable obstacles in the part of the market’s role in mediating all matters. Still another aspect of the new global order is privatization. The private sector is to be trusted to apply the laws of the marketplace to all matters social and environmental. The test for response to toxins in our environment is to measure the harm of continued use against the alleged greater economic harm of a ban, even if the substance is a carcinogen, the benefits being easier to quantify than the harm, when it involves human pain and suffering.
It is a great irony that the universal compulsion to cut the debt is accompanied at the same time by the greatest growth in environmental debt the world has yet known. The cost of clean-up and safe disposal of the total wastes that have already accumulated, many of them a constant health hazard, dwarfs the positive number of the Gross National Product (GNP). In effect, gross national pollution exceeds GNP, yet we continue to defer payments to future generations, making it a cowardly lie to talk about cutting the debt in the interest of those future generations. The law of capital investment is to maximize the return of the investment by any means, none of which has ever been a concern for future generations. In fact, a prime means of maintaining these profits is to defer payment of environmental debt. Yet this debt could be managed simply by a fair taxation of the most wealthy. In 1992, 66,000 of Canada’s most profitable corporations paid no tax. We don’t have a debt problem, we have a revenue problem.
A very subtle and dangerous development is GATT’s support for the U.N.’s World Health Organization — “Codex Alimentarius Commission” of Rome. The ruling body is dominated by the world’s most powerful pharmaceutical cartels and allied multinational corporations. The latest tactic of this imperial alliance is to attack the entire field of dietary supplements, recognizing these as a threat to their hegemonic control of the medical field. Under the “Proposed Draft Guidelines for Dietary Supplements”:
If you wish to have a picture of what will happen in every country, the Norway experience is frightening. Fifty percent of all health food stores and supplement manufacturers have been forced out of business. No amino acids, minerals or trace minerals are permitted for sale. Vitamin C and vitamin E have been redefined as drugs. In other countries companies have been indicted for selling vitamin C. All this is ironical in the face of the avalanche of new research supporting preventive medicine and the rich harvest of new medicines from natural products. But this development is also predictable. The powerful insurance, health service and pharmaceutical companies will not tolerate any threat to their powerful position. This vicious action by the international trading community is on a par with the wanton destruction of indigenous peoples, local communities and entire cultures, not counting the vast ecoculture of nature.
However the status and power of the Codex Alimentarius Commission on Nutrition and Foods for Special Dietary Uses is being challenged. According to the May 1996 issue of the International Journal of Alternative and Complementary Medicine, Codex’s claim that the rules it makes on these matters is binding on all members of GATT has been challenged by the
U.S.F.D.A. According to F.D.A., nothing in GATT can restrict either the sale of dietary supplements or the type of information manufacturers provide to consumers. These are subject to U.S. law. Thus it appears that the original vote of 16 to two in 1995 on a draconian resolution, put by the German delegate, is being recognized as binding in the European Common Market but not by the U.S.A. The above Codex resolution would ban the sale of any dietary supplement sold for preventive or therapeutic use. Nor could any supplement exceed Codex-established levels. In fact, all supplements could be banned unless permitted by Codex. This is a case of the global multinational kingdom attempting to impose its rule on the entire field of alternative and complementary medicine, a classic example of the new global order. In the U.S., nevertheless, the F.D.A. is under siege by the Republican Congress. Despite this, new laws protect dietary supplements, having accomplished deregulation. This is both good and bad news, the latter being the shift to the total deregulation of the industry.
The Special Case of Cancer
This author has called cancer the plague of progress. The reason is that to a major extent cancer is the result of the millions of chemicals in our air, food and water, including known and suspected carcinogens, exposure to ionizing radiation, and exposure to sidestream tobacco smoke or even secondary smoke, all of these being environmental factors and subject to ban if the political will exists. In fact The Sociology of Health
sidestream smoke from burning cigarettes, clearly an environmental factor, is more toxic than inhaled or exhaled smoke. Thus cancer is not merely a biogenetic disease but a biopolitical disease. According to various sources, “there is now widespread agreement that roughly 85% of all cancers are caused by environmental factors.”3 This estimate is hotly disputed, predictably by industry and its captive advisors. Some apologists, such as Bruce Ames, have indulged in a dedicated campaign of elite accommodation and thus have become leading figures in the estimates game.4 Ames has suggested that natural products are far more carcinogenic than environmental pollution, on a par with Ronald Reagan’s assertion that it is trees that are the major cause of pollution. In the distribution of causes between lifestyle (e.g. diet and smoking), biogenetic and environmental, the exact numbers are still uncertain. But the downgrading of the latter is a perfect example of biopolitics, i.e. arguing that a biological hazard is of minimal significance. The environmental factor has been vigorously defended by such scientists as Dr. Samuel Epstein, a major figure in the dispute, whose analyses of the politics of “cancer wars” is incisive. However he has, in the past, possibly reduced the risk of lifestyle factors.5,6
A special class of cancer-causing chemicals are xenoestrogens, found in some pesticides, cosmetics and plastics, which can behave in our bodies like hormones, mimicking estrogen or blocking testosterone. These are all hormone-disrupting pollutants. There is little argument about their impact on various animal populations, destroying the ability to reproduce and reducting in immunity to disease. Some investigators are now arguing, with considerable scientific merit, that these same xenoestrogens can activate natural forms of estrogen in human females, increasing the risk to breast cancer .7
A leading epidemiologist and consultant to the Department of Health and Human Services, Dr. Devia Lee Davis, has argued effectively that xenoestrogens are related to increased risk of both prostate and breast cancer.8
Theoretically, all of the cancers induced by environmental factors are preventable by the exercise of political will. The basic reason they are permitted is patently obvious. In our social system, economic values supersede and transcend human values. In the U.S.A. alone there are some one million cases of cancer currently and the death rate is over 50%. In 1971, former President Nixon declared his ill-fated “war on cancer”. Current mortality and morbidity rates have continued to climb, bringing us closer to epidemic levels. Like the Vietnam War, the cancer war is a lost one, despite billions of dollars spent on treatment. In fact, if we compare the total social cost of some one million cases, it is clear that prevention would be far less costly. The trouble is that cancer treatment is a business and the private sector discounts social costs in favour of private profits. And this is done with government condonation and collusion. Surely we cannot avoid making the charge of corporate crime for those companies responsible for the release of carcinogens into our environment. Nor could we ever account for the human cost of suffering for patients and their loved ones. In fact, as we have earlier pointed out, modern economics sink to the very depths of inhumanity in that they use synthetic cost accounting methods to put a price on morbidity and mortality. The latter, for example, is the value of lost earnings between the time of death and retirement. The poor and un-employed thus have zero value, and women generally less than men. On the other hand, expensive treatment and diagnostic procedures produce billions of dollars of profits, yet in the case of cancer are not always effective.
Paradigm Shift–A Hope For Health
In Thomas Kuhn’s seminal work, The Structure of Scientific Revolutions, he describes the process whereby dominant paradigms, apparently firmly entrenched, eventually succumb to revealed contradictions, anomalies and a general failure at predictive capacity, and then give way to a new alternative group of practitioners armed with with an alternative paradigm. which proceeds to replace the old conceptual/theoretical change in the health field.9 However, the Kuhnian model is not merely appropriate to the advanced evolutionary stage of science, where there is much value resident in the old scheme that can be absorbed by the new.The paradigm shift here tends to be much more one of approach, of orientation, of strategy and tactics, than rejecting the valid supporting scientific fields, i.e. it is a social paradigm shift, accompanied by new practices.
There is probably no single or simple term, as yet, to describe the emerging paradigm shift in health. By definition, what is emergent and not yet fully evolved is in a dynamic state of evolution. Some of the tributaries of this new stream in the health field are preventive medicine, functional medicine and nutritional therapy, but no single term encompasses all the nuances. For want of a better term, and in full knowledge of residual ambiguity, we are calling this emerging health paradigm the “complementary health field.” It is important to distinguish, within this field, the differences between nutritional medicine, which is moving rapidly into the mainstream of the medical sciences, and what is officially called “alternative medicine”, comprising such techniques as acupuncture, hypnosis, music therapy, yoga and some of the ancient medicine schools of India and China. In fact, the U.S. National Institute of Health (NIH) has created an Office of Alternative Medicine, to fund research to assess the validity of these alternatives. And, even earlier, the World Health Organization had called for a New Medicine, which weds conventional medical science to the older, traditional, non-toxic, non-invasive practices. Nevertheless, treatment will always be required for those people who fall through the safety net of wellness. Therefore there will continue to be legitimate questions of what is appropriate treatment, giving consideration to both the extension of life and the quality of life.
An even more radical aspect of the paradigm shift in health is that even the conservative National Cancer Institute (NCI) has called for a redirection of policy towards prevention, early diagnosis, and the swift application of new treatments. Even further, NCI has recently undertaken three large trials on the use of vitamins and minerals in preventing cancer — in Linxian, China, utilizing 34,000 subjects related to oesophageal cancer; in Finland among 29,000 smokers related to lung cancer; and among 1,000 Americans attempting to prevent the reoccurrence of basal-cell skin cancer. They are also funding a world-wide study to search for natural plant substances that might fight cancer, and also have established a Cancer Nutrition Laboratory to study dietary factors associated with cancer.
This reappraisal of vitamins and re-discovery of natural medicines is also part of a more fundamental challenge to conventional medical practices. The focus of the new health paradigm is on health promotion and disease prevention through nutrition, and the application of natural products and vitamins with therapeutic value. In general, medical sciences have also tended to discount environmental factors, both external and internal, as causes of disease. The basic principle involved is that prevention is intrinsically less costly than cure. There is also another cost-saving principle, and that is community health care focusing on the promotion of health. It offers significant savings opportunities.
In Canada, provincial health authorities are searching for a more cost-effective The Sociology of Health
health care system. In 1992, the bill for health in Canada was $60 billion, yet up to 50% of all patients in acute care hospitals could have been much more economically treated in community health care facilities. One of the principles of community health care is to actively enlist patients in building their own good health or wellness on the principle of informed consent. In the ’90s, home has again become the global work place for increasing numbers. It is rational that it could also become the site of much of primary health care. Coupling this to the application of nutrition to strengthen the body’s own defences against cancer by enhancing immunity and destroying toxic agents and processes, we can begin to see the fulfilment of the paradigm shift in the health field. It is too early to assess how such a program would impact on cancer incidence, but in general the creation of a state of wellness should, in itself, reduce all diseases.
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