Atul Gawande's Recent New Yorker Article on Health Care Reform

Boston surgeon Atul Gawande has become one of the most acclaimed mainstream media critics of American health care.  An elegant writer with first-hand hospital experience, he has pointed out, in many articles for The New Yorker and several books, a number of ways that patient care could be improved.  My major concern about his reporting has been its consistent failure to acknowledge the critical role that nurses and other non-physicians play in our health care system. For more details of this critique, see ” The Cure: Can Doctors Change How They Think?” (  I now have another.  In his December 14, 2009  New Yorker commentary, entitled “Testing, Testing,” ( Gawande discusses the fact that  Administration backed health care plan about to be enacted by Congress will fail to address medical cost inflation.  “Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality?,” he askss.  “It does not,” is the obvious reply.

The author points out that these fundamental flaws have drawn heavy flak from a right-wing determined to block “ObamaCare” in any form. Progressive economists and single-payer advocates have also sharply criticized both the House and Senate health care reform bills—that are currently awaiting joint-committee “reconciliation”–for their deeply flawed incrementalism.

Nevertheless, Gawande remains quite bullish about this emerging Capitol Hill mishmash because, despite its many troubled compromises, “what it offers is . . . pilot programs.” Gawande reassures New Yorker readers that a watered-down, piece-meal approach to governmental reorganization of private markets (in this case, for health insurance) may not be so bad, after all.  To make his case, he takes us down legislative memory lane and recounts the fitful 20th century evolution of public intervention in agriculture.

In the early 1900’s, the U. S. Department of Agriculture began to sort out—for better or worse, depending on your point of view—the problem of food in America. Like health care today, the crisis then involved a big disconnect between widespread social need and affordable private provision.Gawande recounts how a patchwork quilt of federal regulation and costly tax-payer subsidies ended up producing safer, cheaper, more plentiful food stuffs for the nation. Meanwhile,   farmers were forced or helped to “innovate,” just like doctors and hospitals must do now, as part of the “reform” process.

Gawande does acknowledge, in passing, that U.S. farm policy has had a few glitches of its own over the years. But that is a political understatement of massive proportions. Our special interest-driven reshaping of agriculture has placed the bulk of it firmly under the control of “agri-business.” Its first cousins include all the big drug and insurance companies now expecting to reap a very profitable harvest from federally-mandated private medical coverage.  Just as the medical industry has largely driven the solo physician practitioner out of business, federally supported agri-business driven the family farmer into near extinction. The overall result of what Gawande applauds, down on the farm, has already proved to be pretty disastrous, in different ways, for small family farmers, consumers, and the environment, it has also had disaterous medical side effects.   And there is a direct link between this public policy back-fire and one major contributor to rising health care costs—namely, obesity and its myriad medical side-effects. Has the obviously well-read Dr. Gawande never bothered to peruse Michael Pollan’s The Omnivore’s Dilemma , with its a well-documented indictment of the public health consequences of tax-supported industrial agriculture?

For decades, the heavily-subsidized production of corn, corn and more corn has unleashed a sugary flood of Katrina proportions that’s now nationwide in scope. As Pollan points out, our millions of overweight corn syrup, and corn fed meat and chicken (and now farm- fed fish) “survivors” face an epidemic of heart attacks, high-blood pressure, and diabetes—each condition a costly hospital stay waiting to happen. (see  Annual Medical Spending Attributed to Obesity.  Health Affairs And, speaking of “testing, testing,” that  list doesn’t even include the current and future casualties of USDA-approved meat eating!

Among the threats facing carnivores these days (and I’m one of them) is a stream of contaminated food items, from here and abroad.  On December 31, 2009, The New York Times ran a front-page story exposing the failure of federal inspectors to stop Beef Products Inc. from sending large quantities of tainted hamburger to the market. Officials at the United States Department of Agriculture endorsed the firm’s ammonia treatment process as a way of keeping deadly E. coli bacteria “to an undetectable level.” In 2007, they decided it was so effective that the firm should be exempted from routine USDA testing. Unfortunately, some Beef Product burgers turned out to be very unsafe to eat.  This article followed an even more horrific NYTimes front page story about E.coli tainted hamburgers produced by Cargill that crippled a 22 -year- old dance instructor.

Anyone concerned about the overall health and well-being of Americans   is faced with a tremendous dilemma when it comes to the current health care bills wending their way through Congress.  These bills promise to address the problem of the uninsured.  The problem is they do little to protect   the American public and American patients from the rapaciousness of the private, for-profit insurance and pharmaceutical industries.  That’s why people genuinely concerned about the fate of reform should be wary of  hyping the kind of  regulatory “reform” and industry restructuring process that helped many of us get heavier and sicker in the first place. But that’s exactly what Gawande does with his ahistorical cheerleading for the two-(or three?)headed calf that’s headed for birthing sometime this month on Capitol Hill.  As a lont-time advocate of  real health care restructuring, Gawande’s article, ironically, makes me even more worried about the future we face under ObamaCare.  If it’s going to be just a replay of America’s costly, century-long, and still out-of-control experiment with “market reform” in agriculture, then will things get better or worse?

Showing 8 comments
  • Carol Paris, MD

    Thank you so much for writing this; I hope it gets read far and wide. I was going to try to get Wendell Berry to weigh-in on just this very thing; agri-business has made us obese and unhealthy and is NOT a model I want to recreate in healthcare reform.

    • Suzanne

      thank you so much for writing in on this. I think we need to generate a debate about this kind of uncritical discussion. it is a shame because Gawande is generally so astute in his comments.

  • Stephanie Olson

    I am so glad you wrote this. I was also blown away by Gawande using US agricultural policy for his model of how well things can work! He is a good writer, but this seems to be a pattern for him. In another New Yorker article in 2006 he uses maternity care as a wonderful modern medical model, despite the fact that the c-section rate is three times higher than recommended by the World Health Organization and keeps rising and that it is the opposite of an evidenced-based model. Do you know if any responses to his most recent article were printed in the New Yorker?

    • Suzanne

      Thank you for writing this. I don’t know, but you should write to the New Yorker Letters to the Editor as should anyone who is concerned about this piece.

  • Andy Coates

    Gawande writes clearly and his anecdotes vivid – yet his conclusions remain dodgy, weak and often false. Your characterization of his views as “ahistorical cheerleading” for the terrible proposals in Congress accurately sums up his health policy positions.

    I agree that those concerned with the overall health and well-being of human beings in the United States – especially those who are also fans of Gawande – may be tempted by a dilemma when it comes to the present proposals. By calling out and adding a little flesh to the bones of Gawande’s analogy – how the government helped profiteering triumph over farming – you begin to solve that dilemma.

    Elected on the promises of hope and change, and further raising expectations for real reform sky high, so many expect and await deeds to follow President Obama’s words. But if success simply means passing and signing whatever the insurance and pharmaceutical industries will allow, we know how it will turn out for the rest of us – just like “agribusiness.”

    Just as we need safe and nourishing food, not “agribusiness,” we need comprehensive and appropriate healthcare – not insurance! Single payer would be a step in the right direction. The bills in Congress are not.

    Thanks for this post.

  • jeanne

    I have just finished this article and saw it as a source of hope. Yes there are problems with agricultural policy but no system is perfect. I am encouraged by baby steps…the only other solution i see is medicare for all and that will do nothing but raise costs.

    Health care costs will continue to rise as we live longer. Just look at Bill clinton this week…50 years ago he most likely would have died but in our advanced medical world he’s home in a day.
    Who among us will say…”no, no i’ve reached my limit of health care money…i’ll just wait to die”

    • Suzanne

      Dear Jeanne and all who share the views expressed here, while I am in sympathy with your concerns, it’s imperative that people in the US understand that having a version of Medicare for all, or adopting some version of the kind of system that other countries have — tax supported national health care — will not cost more and it will save more and provide better services to all of us, not just the Bill Clintons of the world.
      It’s also important to understand that Clinton would have gotten the same care in any one of the many tax supported health care systems in the industrialized world. Indeed, an ordinary person in his situation would not have gone home to die but would have gotten similar if not better care.
      I implore you Jeanne to read up on health care systems in other countries before you make up your mind about health care proposals being floated in this one. I reccommend TR Reid’s Healing America — please check out the archive on this blog and see my interview with him.
      But thanking you for sharing your views. And please let me know if you read more what you think.

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