Small town doctors, it turns out, had a more complex understanding of "health" than scientific medicine acknowledged. Is it too late to bring back that kind of care?
I live on an old sheep farm, which was carved out of a hillside almost three hundred years ago. There isn’t really any arable land on this hill, where the rocky soil of old New England had a small mountain of shale dumped on it by the edge of a glacier eons ago. Native Americans hunted here, then spent their summers farming a few miles away, growing maize and beans on the bottom land next to the river that drains these rocky hills.
European settlers came three hundred years ago and logged the chestnut forests so they could put livestock on the hillsides and use the hilltops for hay. In the late 1700s, a man built a mill on a falls about twenty miles from here and brought woolen mills from England, which created a huge demand for wool. All the small holds on the hills turned into sheep farms, a boom that lasted almost 30 years, until Eli Whitney invented the cotton gin. Then the bottom fell out of the wool market, and the sheep farmers turned back into small holds, and farmers struggled again with this rocky soil, struggling for five or six generations, until refrigeration and cheap transportation pushed the small farmers out.
Then the rural infrastructure imploded and the land was abandoned, leaving maple and ash forests with stone walls running amongst the trees. Those walls are the only evidence that there ever were farmers here, evidence that only nature lovers and the wandering children who live in suburban houses, built into these hillsides, ever see.
New England country doctors are about to follow small farmers into obscurity, pushed out by changes in technology and markets, changes which seem to be more powerful than democracy in configuring our lives.A hundred years ago, doctors practiced out of their parlors, delivered babies at home, and knew the people they cared for as well as they knew their own families. Truth be told, there often wasn’t much they could do for people when someone got sick or something went wrong, short of sewing up lacerations and setting broken bones.
As cotton makes a more comfortable fabric than wool, scientific medicine, which came in just after 1910 and really got rolling in the 1940s — just after the discovery of penicillin — was more effective than country doctors were at saving lives and preventing disability, and at letting families bring up healthy children. Now medicine is practiced by groups of doctors, who work with nurse practitioners, physicians assistants, physical therapists, psychologists, social workers, nutritionists, physical therapists and pharmacists, and they help organize a person’s care, which is made impressively complex by the panoply of drugs and devices that the market offers people with money to spend.
But pendulums have a way of swinging. Lots of the scienctific medicine practiced by these teams, medicine that appeared to be such an improvement over the country doctors it replaced, has degenerated into wasteful and unnecessary products. Few of the new drugs and devices actually do much, other than create profit for the people selling them, but few of us have figured that out yet, and fewer yet are willing to fess up to it.
Though pretty wasteful, scientific medicine is still way more effective than the country doctors of a hundred years ago were — effective, at least, at letting people live longer, at helping people who are hurt or injured recover, and at having families see their children grow up healthy. But scientific medicine came at a price. It cost more – way more, in dollars and cents — and it came with a whole new economic and political environment, of health insurance companies, and pharmaceutical manufacturers and device manufacturers and medical school professors and government policy experts and government regulators, all of whom mixed in together and used their new-found political and economic power to feather their own nests, the way agribusiness, once it got going, used its political and economic power to enrich itself at the expense of local communities.
There is now evidence that countries that use country or neighborthoood doctors — old style but recently trained, who know the science but leverage the relationships that happen in small places — actually do better than scientific medicine at helping people live long and recover faster. It turns out that in other countries, countries as diverse as Holland, Spain and Cuba, the best health outcomes are achieved not by having lots of fancy hospitals or corporate practices that live in office building in shopping plazas but by having lots of country doctors, people who practice in their own homes and care for their friends and neighbors.Holland, Spain and Cuba spend half of what we spend on health care, or less, and their people live longer, recover faster from illness and injury, and have children who grow up just as healthy as our children, if not healthier. What’s going on here?
Well, look at how the downturn in the economy impacted the rural economy. As Bill Bishop has pointed out a number of times on the Daily Yonder, rural areas lost fewer jobs in the downturn, and stocks of rural companies rebounded faster. Strangely, I think what is going on in health care is very much like what is going on economically in rural America.
When we industrialize, when we focus our attention on making widgets instead of maintaining the relationships in communities, we are putting all our eggs into one basket. We may increase short-term profit but we quickly increase long-term risk, too, because circumstances change, competition is everywhere, and centralization and oversimplification attract those who put profits before people. (If you’re an egg-eating snake, you want to find the basket with all the eggs in it.)
Why do Holland and Spain and Cuba do better by relying on country doctors than we do with our medical industrial complex? Because there is little profit in the complexity of real people’s health problems and because lots of resilience is built into the interlacing of lives and ideas that one country doctor working with one community or neighborhood brings us.
Why did rural economies do better in the downturn than urban economies? Because rural economies are actually quite complex and interrelated; rarely are they entirely dependent on one product or industry, try as agribusiness might to push those economies to one product. Even in beef country, lots of folks raise chickens.
Twenty years ago, Wendell Berry defined community as “a neighborhood of humans in a place, plus the place itself: its soil, its water, its air, and all the families and tribes of the nonhuman creatures that belong to it.” Berry had it just right. If we are going to be able to survive, and succeed, as a place, as counties, as states, as regions and as a nation, we are going to have to learn to understand the resilience that comes from interdependence. You can lift a sheep (or an elephant, for that matter) with a net or with one strong rope. If you cut one strand of the net, the sheep will stay aloft. But if you cut the one strong rope…make sure you’re not standing below.
Only if we build our counties, our states, our regions and our nation as communities of communities, all tied together in many different ways, will the whole continue to be stronger and better than the sum of the parts. We’re going to have to balance our need for independence, our desire for privacy, and our rightful caution about big government, big corporations and even big ideas, so that we choose technologies and policies that promote the complex relationships of small places. That’s where our health begins.