In this interview, Didi Pershouse of the Center for Sustainable Medicine talks with Dan Bednarz of Health After Oil about the Cuban health care system, peak oil, free medical schools, community acupuncture, cholesterol myths, and how working-class values and owning-class values play out in different models of health care. The interview first appeared at www.healthafteroil.wordpress.com in July of 2009. (See Sustainable Medicine and Peak Oil Part 1, in which Didi Pershouse interview Dan Bednarz about his thoughts on the subject.)
Bednarz: Let’s just pick up our conversation from a few weeks ago. Why don’t you start off telling me a little bit about your training and background and how it is you came to be doing what you are doing.
Pershouse: I am the founder of the Center for Sustainable Medicine in Thetford Center in Vermont. I have been in the world of alternative health care for almost twenty years now, five years in school and fifteen more in practice in the small town where I live. I started off in my twenties as a writer and editor in New York City. I was working in a department called Creative Services at New York Magazine: my job was half way between editorial and advertising, so I saw both sides of the system there. Sitting at an ancient computer monitor with smokers all around me in an office where the windows didn’t open, I developed headaches and back pain and all the usual office-job illnesses, so I ended up going to a variety of alternatives—chiropractors, homeopaths, acupuncturists, and yoga classes—to try to get better. Eventually I started studying alternative therapies and got certified as a yoga teacher and shiatsu practitioner, and then I quit my job and moved to Seattle to go to graduate school in Acupuncture. I ran a multidisciplinary clinic for many years here in Vermont, and now am in private practice, living and working under one roof. I’m also focusing more on speaking and writing about issues of sustainability in health care.
I grew up in a family of innovative thinkers in medicine. My great-grandfather on my father’s side was Dr. Francis Carter Wood who was a radiation researcher at the College of Physicians and Surgeons at Columbia University in New York. He was a contemporary of Marie Curie. They corresponded across the Atlantic, and he helped her get radioactive materials to work with. His specialty was treating cancer with radiation. He was a big experimenter, and actually experimented on a number of family members. Some of them are still alive and dealing with the after effects of that.
Bednarz: Yeah, cause they didn’t really know, right?
Pershouse: They didn’t know. My mother’s father, Dr. William Beecher Scoville, whom I knew quite well, and actually worked with one summer, was a neurosurgeon who was also an innovator. He did a lot of work in psychosurgery, which, in its time was pretty miraculous, I guess, but in retrospect, like radiation, came with a lot of negatives. He was known for developing new techniques in brain surgery, such as certain types of lobotomies. He did one surgery that has now become famous: in which he removed part of an epileptic’s brain, and the man lost a huge portion of his memory, for the rest of his life. That became a great learning case for scientists, because it turned out that part of the brain was the seat of memory, but in that patient’s individual case it was a disaster. So, coming from that background I have a respect for innovative thinking, but the kind of respect that sees both the positive and the negative of it.
In my own work, I was an acupuncturist back in the days when, if you said you were an acupuncturist at a party, it was the joke around the dinner table for the rest of the evening. And, when that became “normal,” I started studying a more obscure form of acupuncture taught by blind acupuncturists in Japan, and when that became too normal, I studied to become a homeopath, which is still something that is very little understood and hard to explain to people.
So, my path has been one in which I am both following in the footsteps of these people in my family—in the sense of being interested in innovation and medicine—at the same time I am trying in an odd way to make up for the damage they did along the way. Like them, I want to be creative and make an impact in medicine, but with the understanding that change needs to be made carefully, by looking at the long term effects on society and on individual people.
Bednarz: So then how did you come to be doing what you are doing now, and what are you doing now?
Pershouse: A few years ago I wrote something called the Sustainable Medicine Manifesto. I wrote it the night before a conference on sustainability and alternative medicine. I was thinking about what the connections are between the two, and I came up with a draft statement, which since then I have tinkered with and passed around, and it is slowly turning into a book, from a single sheet of paper. My website, sustainablemedicine.org, also grew out of that manifesto.
Bednarz: Yes, this is where the energy issue has led me as well, wondering how is peak oil going to affect the population’s health, and the ability for health systems to function. Some people see peak oil as just an economic problem, and well, we’ll fix that, then we’ll just get back to business as usual. That never made sense to me. Then a year ago I thought “But what more is it connected to?” I met some people who said “It’s connected climate change, and if oil disappears it will be great.” And I said “No it won’t be great, because then we’ll just start burning coal like crazy.” But then it began to dawn on me that this was really about sustainability.
Pershouse: Right, it is, and that’s how my work on this evolved. First of all, being in Vermont there has always been a large population here that is off the grid and back to the land—what the hippies have evolved into. So a lot of the people I treat and a lot of my friends are living that lifestyle already. Which means that around here there is a lot of support for that type of thinking: about how to have a minimal impact. Secondly several years ago I met a man named Jim Merkel who wrote a book called “Radical Simplicity.” He moved to the area and gave a talk that I went to. His book was about changing your ecological footprint. He figured out that if we really wanted to share the earth’s resources and still have some left for the next generation we would each have about $2,000 to spend on everything. (And that number actually doesn’t even take into account all the other species that we need to share with.)
Now, I know Americans spend almost $7,000 apiece just on health-care. So, first of all, we are way, way off the charts in terms of our whole lifestyle, but particularly in terms of health care. That’s way above and beyond what people in any other country are spending. And that money isn’t just money. That money represents actual resources that are getting used up in the earth, and that’s what the term “ecological footprint” means.
Bednarz: Yes and that’s what people in health care and public health don’t understand, that money is just a lien or claim that allows you to go and get resources.
Pershouse: Right, so if all we were doing was spending on health care, each of us is already using up three and a half people’s complete resources. If we allot ourselves $2000 of that, that’s still two and half other people who can’t live on the earth. And of course that’s just health care. If we actually live on, say, $40,000 a year, that means nine other people can’t live on the earth. We are eating up their pieces of the pie. So, meeting Jim Merkel really opened my mind. I also saw a film around the same time called “The End of Suburbia” that is a really well done film on peak oil. And that got me thinking more about oil-based resources, and how quickly we are running out of them, and what that will mean in the near future. The most shocking piece to me in that film was learning how much oil is used in standard food production—in terms of petroleum based pesticides, herbicides and fertilizers.
And the third influence on my thinking is a trip I took to Cuba in 1999 to research their use of alternative medicine—they were using a lot of acupuncture and homeopathic medicine. It was also one of the last truly socialist countries still functioning. The Soviet Union had just collapsed and China was already turning towards a more capitalist model. So I was intrigued to just see what that was like. I took a trip there, and found a few great contacts to show me around. I was really, really struck by what I saw there. In some ways I wasn’t prepared for it. I learned a lot about how innovative—back to that word again—and how creative they had been when the Soviet Union collapsed and they no longer had access to oil. Because they stopped getting aid, it meant that they not only had no fuel for cars, but they also suddenly didn’t have any petroleum based fertilizers and pesticides, and they also couldn’t get medicines. Unlike many other countries that had been connected to the Soviet Union and found themselves stranded, Cuba was very creative. They converted all their agriculture to organic, sustainable farming methods. They started growing vegetables in troughs along city sidewalks so that food didn’t need to be trucked in from the countryside, and medically they started leaning even more heavily on alternative medicine and created a very localized health care model that really works.
Amazingly, their health care expenditures are $220 per person, yet their life expectancy exceeds the United States’ and their infant mortality rate is lower. (It is actually almost half the rate of African American babies in the US.) And they didn’t have great health markers to begin with. Before the Cuban revolution, in 1958, their life expectancy was 55 and it has gone up to 76. Their infant mortality rate was 80 per 1000 live births and it has gone down to 6.4. So they really did a huge amount of work. What I saw, and what struck me the most was how community-based their medicine was. That made a lot of sense to me in terms of the way that I am currently working, in a small clinic in a small town. My neighbors are my patients and a lot of the issues around boundaries, not being friends with patients, have to be thrown out the window.
But they have taken that model of treating one’s community and expanded it out not only to their own country, so that everyone has a doctor within walking distance who can see them any time of day or night, and who knows them in the context of their own lives, but on top of that they have also sent over 100,000 trained physicians to the poorest areas of the world, for free. In a single year,1987, Cuban doctors attended 856,000 patients in Nicaragua alone, and that was just one of 32 countries they were providing medical aid to. In 15 months in Iraq they attended over a million patients, including births and surgeries, and they stayed there during the Gulf War when all other medical aid teams had left. 10,000 children a year from Chernobyl are also treated for free in Cuba. They offered to come here to help out just hours after Hurricane Katrina hit, but the U.S. refused to let them in!
There is a great book called “Healing the Masses” by Julie Feinsilver as well as a new film called “Salud,” both of which document the work of Cuban doctors around the world and some of the issues they have come up against. In two years of their being in Gambia, cases of malaria went from 600,000 to 200,000, just by embedding doctors in the poorest areas and focusing on prevention, rather than treatment.
Bednarz: That’s wonderful. Speaking of that, how do you approach the issues of health in your clinic, is it primarily care and treatment, or prevention, or a mixture?
Pershouse: It’s a mix. I try to get a full health history from everyone who comes in, because that’s the only way to catch the pieces where prevention, or lifestyle counseling, is going to be the main treatment for what’s going on. So if I can catch that someone is in an abusive relationship or I can catch that someone has a drinking problem or I can catch that they don’t actually have enough money for food, then that piece has to be addressed along with the rest of it. And sometimes that means referring them onto other agencies or 12-step programs, or other things. Sometimes it’s just a matter of a little education. So that initial interview is from one to three hours long.
Bednarz: Wow that’s pretty thorough.
Pershouse: I’m not interested in just treating wealthy people who can afford long treatments at high prices. So I’ve always had some way of making it possible for anyone who wanted to, to come see me. I have experimented with various sliding scales. I do a huge amount of barter. Most of the food I eat is brought to me by patients who grow organic food, produce raw milk, or raise chickens who are free to run around the yard and that sort of thing. My rule has always been “don’t not come because you can’t afford it.”
But a couple of years ago I went to a talk by a woman named Lisa Rohleder out of Portland Oregon who started something called “Working Class Acupuncture,” or “Community Acupuncture,” which I have incorporated into my practice here. Rather than starting one person every hour for acupuncture, she started treating people in groups and charging much less. Typically acupuncture in the United States costs between $65 and $125 an hour. So there are very few people who can afford to come four to eight times a month, which is what is often necessary to get better. And that means that as practitioners we are also all fighting over the same wealthy 1% of the population as patients. So she said well, let’s try something different and do it more the way they do it in China, which is where acupuncture originated, and have a bunch of stations. It only takes 5-10 minutes to put the needles, so when you are done with that, let the person rest with their needles in and treat someone else. So she and her colleagues started treating more people in an hour and charging a sliding scale of $15 to $45. That way they were able to help a lot more people. Plus there was no longer any competition for patients among practitioners because everybody could afford to come. So they had expanded the market by 100-fold, and the acupuncturists were making essentially the same amount as they had been making when they were seeing just one person per hour.
Bednarz: And they didn’t feel overworked?
Pershouse: No, because actually the group dynamic, which is one of the things I saw in Cuba, has a healing quality in and of itself. That puts less pressure on the doctor or the healer. People get to hang out quietly together, or discuss things among themselves. A lot of education happens just from people hanging out together and talking and there is less of this issue of specialness, like “I need everything to be really private, cause that’s the only way to get enough attention.” It’s more like people giving each other attention and neighbors running into each other. It’s a very different feeling. And that has been shown in many, many research studies, that when people are treated in groups there is an additional benefit other than just the economic benefit of it costing less. Even the hospital here has started doing group appointments for some things, such as in the midwifery clinic.
Bednarz: Well primates are social, that’s what my mentor always used to say. The other thing is that as we go forward into this sustainability issue, and I’m sure you think about this a lot, you have to have people working in groups because of the hardships we are going to have economically, we’ll have to share that psychologically as well as materially.
Pershouse: I am in another group called the “co-counseling” community, that shares time counseling each other without payment. We talk a lot about different social issues including the patterning that happens depending on what class you grow up in. So I was really interested when I heard Lisa Rohleder point out that for working class people, one of their main values is sharing resources, which inspired her, as a working class woman, to start the community acupuncture model.
I am living on a very low income now, and one of my neighbors across the street was raised in a working class family. Last year she was letting me use her shower, and her stove, and her washing machine as I was in the process of moving into the village. My kids still go there to watch baseball games and we often cook together, or share leftovers, or borrow pots and pans. And this is completely normal to her. Whereas I don’t feel comfortable asking any of my other neighbors, who are more middle class, to do that for me.
Bednarz: I grew up working class, and a little bit below actually.
Pershouse: And I did not, I grew up in an upper-middle-class family of doctors and teachers, descended partly from owning-class people who imported silk from China and Japan and owned a big mill in Connecticut, with many workers. Those patterns got passed down and the values I grew up with were much more about specialness and uniqueness.
Bednarz: Personal space.
Pershouse: Right, and also about helping the needy, in a somewhat patronizing way. But in the film “Salud,” someone said the Cuban model was about transforming society from below, and working with the poor, not for the poor. I like that. So, having grown up without necessarily a lot of money, but with owning class values, and now living as a single mom, on what is essentially a working class income I have been really interested in “Okay, how do people do this?”
Doing this model of community acupuncture at my clinic has brought in a lot more patients from working class backgrounds, since they can afford to see me more easily. And I notice that they are the ones who shovel the walk while they are waiting for their appointment, or they bring a bag of groceries even if it isn’t a barter. They are very used to that mode of sharing and pitching in.
Even though we have a mix of incomes here, the United States is an owning class or upper class society, relative to the rest of the world, because we have more material goods than anybody else. So in general, people from the US have this idea that we need everything to be special and we need to have our own TV and our own washing machine. As a society, we need to learn the working class values of sharing. In health care, that means sharing resources in a very different way than we are now. In our current system we don’t share resources at all. You get what you pay for, if you can get it at all.
Bednarz: And that’s the model in insurance. What Obama rolled out the other night, showed that there would be three tiers in the “public” option. And so, to me—I’m a sociologist—that was just the embodiment of the class structure. Who would want to go for the lowest if they had a choice? Nobody!
Pershouse: Exactly, and there was a meeting here last year, one of those town meetings, for the Obama Biden transition. And they wanted to get input on the health care system. We had a group of 12 very interesting people, some were patients, some were doctors, and I was invited as the token alternative practitioner. And the questionnaire was asking what are the issues that each of you is struggling with, with the current system. And we put down a whole bunch of issues, and that took up a lot of the time. And then there were a whole bunch of options listed and the questionnaire said “Which of these do you think would help?” And we said to each other, “None of them.” (laughs)
Bednarz: Yeah right!
Pershouse: I looked at the long list we had written up on the board and I said “There is one thing that would solve everything we put up there.” And everybody said “What is that?”
I said “If you took the profit out of the system, all these problems would go away. The problem with doctors being rushed, the problem of misinformation from drug companies trying to sell things; the problem of multi-tiered insurance programs; the problem of doctors being paid off by pharmaceutical companies, and care only being accessible to certain people: all that would go away.”
I can say that because I have seen the model work in Cuba. If you want to call Cuba a dictatorship, you can do that, but for whatever reason, they got this opportunity to try something out, and guess what? It is working. So there may be other parts of what is going on in Cuba that you disagree with, but you cannot disagree with the model of health care that they are promoting. It is working so well that it is not just working for them. It is transforming health care in a whole bunch of other countries.
Speaking of tiers, one of the interesting things that Cuba has done, and is also being done in Venezuela which is modeling a lot of their development after Cuba, is that embedded in every community are these primary care doctor s, who is both living and working right there, one for every 100 to 200 people. That takes care of all the preventive care, getting to know people in context, and middle of the night questions like do they need to go to the hospital or not? Then, a little bit more regionally they have diagnostic centers. So you don’t have to travel that far to get an x-ray or an MRI, but there isn’t one in every neighborhood. But it is accessible. And then even more spread out are the high-tech centers, with the super duper machinery and high tech surgeons—for open-heart surgery and other things. So everybody has access to all of them, but you don’t need everything everywhere.
Bednarz: What you are describing, Didi, is this consolidation that will happen if medicine survives in this country. This is really what I have come to think about in the past year as I’ve thought more about peak oil’s effect on the practice of medicine rather than just public health. As peak oil affects our economy and our resources, there are going to be fewer hospitals in America. And we’re going to have problems transporting people. In a place like Pittsburgh, where I am, instead of there being 20 hospitals, in ten years there might only be five.
It’s also going to be very hard as we go forward for insurance companies to make money, because their risk pools will become smaller and smaller. And in this economy, where are they going to invest the premium money? They might be afraid of losing it altogether rather than making something.
On my darker days I think: you know what? It might be better if the medical system would just collapse, which it really might, and then re-form over the long term, because, then you sort of break the stranglehold.
One of the things that will happen with diminishing oil supplies is that all these specialties, which make people oodles of money (and I understand why they go into it, because it costs so much to get the degree, the MD degree, and they want to make money as fast as they can) a lot of these specializations which grew out of abundance and the age of abundant energy are going to be reabsorbed back into general practice
All these things are in the mix. But I’m glad you’ve seen, in action, in another country, something that works. Those are the kinds of practices that I think are going to be exported to us.
Pershouse: Exactly. And to me that is the good news: that we have models already as to how this could look, and how it could work. And we get to watch how those evolve and what works for them and what doesn’t. Hopefully we have a few years before we have a major collapse and hopefully a few more filmmakers and writers can go to Cuba and Venezuela and gather information about how they made the transition, so that we will have something to fall back on rather than things going directly into chaos.
Speaking of chaos, there is a group called “acupuncturists without borders” that has travelled around to hurricane areas, and the World Trade Center and other places, doing a very simple protocol of ear acupuncture that has been shown to significantly reduce the effect of trauma. It helps people to sleep better, it helps blood pressure to go down, it helps reduce nightmares, anxiety, all of that, because without sleep after about three days people get absolutely psychotic. So as peak oil hits, and economic crises, and the radical weather changes like flooding and hurricanes from global warming start to hit there are some baseline things that we need to know how to treat really cheaply and effectively.
There is a group called NADA that believes you shouldn’t have to go to three years of acupuncture school to be able to insert five needles into the same five points in people’s ears over and over again. It’s really pretty simple. So they have been training people to be able to go around and do this protocol at prisons and trauma sites in different parts of the world, and this is where you start getting into politics. You get acupuncturists saying “They are putting me out of business.” And I do understand that. There is a concern for those of us who have multi-year degrees that we are still paying off loans for, that we don’t want our business to get swept out from under us. But ultimately, when chaos hits, we do need to have models in which you can train people quickly and have enough care to go around.
I know very little about the actual “barefoot doctors” in China other than that after the revolution they suddenly realized they needed people who could take care of people in remote areas. They couldn’t afford to wait four or five years to turn out more doctors, they just suddenly needed more. And in the barefoot doctor model they were able to train paramedics in the “does this patient need to go to the hospital right now?” type of skills, as well as in traditional herbalism, in acupuncture, and in more standard medicine such as delivering babies and suturing wounds. That way not everybody needed to get transported 150 miles to a hospital.
The insanity is that in spite of all our super duper training, we actually have a shortage of doctors in the United States. Part of the problem is that medical school is a huge investment, and as you said, people are having to go into specialties they aren’t even necessarily interested in, just to pay off loans. And doctors are having to practice in a way that doesn’t really speak to the reason they went into medicine.
Bednarz: Well its assembly line. And I meet doctors who have daydreams about getting out. And a lot of people think “Gee if I could be a doctor I’d have it made.” But that’s not how a lot of these folks feel.
Pershouse: One of the really fascinating things that Cuba has done has been to start a free medical school. Their medical school for their own citizens has been free since the revolution, but they started an international one in 1999. They are training people from all over the world with the understanding that they will go back to their communities and provide low-cost care. We don’t bat an eye that elementary schools and high schools are free in the US. There is no reason that medical school and other professional programs couldn’t be free as well. Expensive medical schools are just something we accept without really thinking about it. And expensive medical schools create expensive doctors that not everyone can afford to see. The truth is that a single day’s worth of our military spending in Iraq could pay for four years of university level education for 35,000 people. So, we could easily have a free medical school in this country as well.
One of the models that is happening in Venezuela is what they call “Mini Medical Schools” where a Cuban doctor will come live in a Venezuelan neighborhood and take on one or two students. They do 2-3 days a week in the “classroom” in somebody’s house, and then they follow the doctor at the clinic for the rest of the week. It’s just a completely different way of looking at medical training.
Bednarz: The biggest thing I see is that this will be a cultural shock of enormous proportions for the medical profession. (laughs)
Pershouse: I was just going to say that. Not just cultural but economic. The problem is that while the old system still stands, who is going to pay the salary, even if it’s a very low salary, of these new neighborhood doctors, because we don’t actually have that funding built into the system for that now, the way Cuba does.
Bednarz: It is a house of cards, it really is. That becomes clearer to me. Ultimately dependent upon the largesse of the federal government to supply these loans and grants. You know a lot of these medical research studies are worthwhile, but let’s face it, a lot more of them are so esoteric, right? And the returns that they are giving to society are so minimal, that we are coming to the point where the question that will have to be asked is “Is it worth it? And that’s why I think there are three things that might happen in the system. You might have a purely elitist system where only the very wealthy can afford medical care, or you have something like what you have in Cuba, an egalitarian system. Or, the system collapses and after that it re-forms. And maybe it re-forms with just local practitioners. There is a lot of expertise and a lot of knowledge, and certain parts of it will be lost. We have been relying on the government to supply all these resources which really comes down to all this excess of energy that we have had for the last few years. That’s how medicine has split up into all these specialties. It’s all connected to oil The guy who predicted peak oil was MK Hubbard from Shell, and one of the things that really got him into trouble with his colleagues and other people was he said “The more oil we find, the more ways we’ll find to consume it.”
To follow up on all the things you have been saying the past few minutes, we need to completely rethink what medicine is, and how it fits into the community. That’s the way it’s going to have to go. I don’t know how we get there other than through a crisis, or a series of crises. That’s pessimistic, but I think that’s realistic. We live at such a high level, as a society, we are simply not willing as a society to voluntarily give that up.
Pershouse: There’s another piece here which is that our whole definition of what health is has been completely warped by the profit in the system. For example, one of the basic tests that everybody gets every year is having their cholesterol checked. Yet if you go out and look at the research and read a few books like “Good Calories Bad Calories” by Gary Taubes, you find that the link between cholesterol levels and heart disease was a nice idea, but it was a failed hypothesis. Yet the drug companies are still suggesting that everybody with high cholesterol should be on statin drugs. Not only are these drugs doing nothing positive, but they are actually doing a lot of harm. They have terrible side effects, which go away quickly if you get off the drugs.
Patients come see me and always tell me their most recent cholesterol numbers, as if that is an indicator of their health. In fact it means nothing at all. But it’s been so drilled into us, even on boxes of Cheerios.
Similarly, when I bring my children to their pediatrician, the first thing that happens is that my 8 and 13-year old boys get their blood pressure taken. Now I know that unless a child is really, really unhealthy in any number of obvious ways, a child does not need to be tested for high blood pressure. A friend of mine who is a physician said “Do you know why they do that? Because in Vermont the insurance companies won’t reimburse the visit unless you check three vital signs.”
Now, that blood pressure test takes up about two minutes of the 15 minutes allotted for the whole visit. And when we have these really slim margins of time for a doctor or nurse to talk to a patient, to use up part of that time for a completely unnecessary test: it’s outrageous. So here are two useless tests that are now considered essential to a patient’s visit. So who is defining health here? The pharmaceutical company in one instance, and the insurance company in another. If this is what a visit consists of, why are we even going to the doctor? It’s not a good use of the doctor’s training and knowledge.
Bednarz: Well it’s a whole system that has been constructed around consumption and generating profits, as you said earlier, and that’s why these things are done. So if you were to rethink that, and think about it in terms of healthy communities and healthy people, then what goes on in this physician-patient exchange becomes something very different, and also the physician-community exchange.
Pershouse: And the truth is, as we see in Cuba, that keeping people healthy doesn’t actually cost that much money. There’s not actually that much profit to be made in it! (laughs). The drug companies really only make money when the population is unhealthy. So that right there is a real problem. Nobody should be making money from people being unhealthy.
Bednarz: Maybe that’s where we should close it for this session! This has been fascinating. I want to thank you, Didi for speaking with me.
Pershouse: Thank you, Dan.