Thoughts On the Table

In last week’s New Yorker, an article entitled Testing, Testing, written by Atul Gawande, details the author’s optimistic perspective on the Senate’s new health care bill.  Gawande highlights and applauds the bill’s inclusion of pilot programs reminiscent of those responsible for transforming American agriculture in the early 20^th century.  “While we crave sweeping transformation,” he writes initially, “all the bill offers is [these] pilot programs, a battery of small-scale experiments.  The strategy seems hopelessly inadequate to solve a problem of [such] magnitude [as that of our health care system].  And yet…history suggests otherwise.” 

Gawande goes on to explain that agriculture was, like health care, a ridiculously expensive and yet crucial sector in the early 1900s, when “more than forty per cent of a family’s income went to paying for food…and farming was hugely labor-intensive, tying up almost half the American work-force.”  The author credits former “agricultural explorer” Seaman Knapp, hired by the USDA in 1903, with getting farmers to farm differently through efforts that started with a pilot program.  Knapp’s work began in Texas, where he encouraged a single farmer to test out a list of simple innovations, including “deeper plowing and better soil preparation, the use of only the best seed, the liberal application of fertilizer, and thorough cultivation to remove weeds and aerate the soil around the plants.”  The success of this initial program led other farmers to follow Knapp’s guidance, leading to similar “demonstration farms” across the country and to the establishment of the USDA Cooperative Extension Service, employing seven thousand extension agents nationwide by 1930.  Other USDA pilot programs led to comparative-effectiveness research, investment in providing farmers with weather forecasts, seasonal statistics, and tremendously helpful information broadcasting.  Gawande claims that the “hodgepodge” of pilot programs led to ultimately successful change, in that agricultural productivity increased dramatically, food prices fell by over fifty per cent, and farming came to employ only twenty per cent of the workforce by 1930.  “Today,” he goes on, “food accounts for just eight per cent of household income and two per cent of the labor force.  It is produced on no more land than was devoted to it a century ago, and with far greater variety and abundance than ever before in history.”

Testing, Testing makes several worthwhile, take-home points.   The author characterizes the reformation of the health care system (like the transformation of the agricultural system) as a problem which is not “amenable to a technical solution,” or a “one-time fix,” but rather one that requires a process of change.  He recognizes farming and medicine as both involving “hundreds of thousands of local entities across the country.”    And he encourages his readers to resist their cynical reaction to the government, writing that his solution is one in which the government “has a crucial role to play,” to guide the system, rather than running it.  He rather shockingly fails to mention, however, the failure of the agricultural transformation that is his model for modern day health care reform. 

The failure of the 20^th century agricultural transformation is made manifest in the one product that (appropriately enough) both farming and health care would ideally generate: human health.

Over the past century, food prices have indeed gone down, agricultural production has indeed gone up, and America has, on paper, been relieved of devoting to agriculture the significant force of labor formerly required by farming.  This was all considered a success for several decades, until obesity, diabetes, early sexual maturity, and E. coli food poisoning (along with dozens of other health problems) were recently recognized as the effects of industrial agriculture.  The modern American diet – of highly processed foods made with high fructose corn syrup, meat from animals injected with antibiotics and hormones, and genetically modified foods not quite approved for human consumption – is one of the main causes of our deteriorating health.  Not to mention that industrial agriculture has irreparably damaged our nation’s environmental health, has dangerously demolished biodiversity, and still employs a fantastically under-paid, under-represented workforce of undocumented immigrants.

Gawande perhaps deserves the benefit of the doubt, for his article is optimistic, and encourages the American people to see more in the new health care bill than 2,074 pages that do not “even meet the basic goal that [we] had in mind: to lower costs.”  But his comparison begs for the recognition of what went wrong in the transformation of agriculture, because of a lack of holistic thinking, of preventative solutions, of respect for resources.  This time around, unless we are careful, the price drop and the productivity increase will still not provide the one thing we all want more than a smaller bill.  It will not provide us with health.