Sunday, January 3, 2010

The elephant in the waiting room

I think I'll have to add one of my other favorite writers to the fantasy dinner guest list: Atul Gawande. I've loved his work for years. In fact, the chapter on flesh-eating bacteria at the end of his first book was the first thing that popped into my paranoid head when my arm started swelling a couple of weeks ago at two in the morning at the campsite. But that's not why I'd invite him, to tell him how he'd nurtured my hypochondriac nature. It's because he's brilliant. And I have a little bone to pick with him.

I'm just catching up on some back issues of The New Yorker -- the only magazine I read with any regularity these days since Gourmet went under -- and came across a fantastic piece the surgeon wrote for the Dec 14th issue defending what many, especially the left-leaners, are calling a failed attempt at health care reform. Wait, wait: this is about food, I promise. And I am one of those very leftists. I know I have lapsed into rants about the atrocious state of health care in our country a few times now on this blog I claim is devoted to sustainable food, but Gawande's is an article as much about farming as it is about health care. In it he reveals quite a bit about the historic overhaul of another industry in crisis in modern times: agriculture. What I think is ingenious is Gawande's mapping of parallels between the floundering current American health care system and our flailing agriculture system at the turn of the (20th) century. What worked then for agriculture is the very same thing the current health care bills propose: pilot programs. Opportunities to test out a large number of possible solutions to a gargantuan problem on a small scale.

The extended case study he relates is one which he champions as a huge success: the USDA's farm extension program, which he claims reformed farming practices to meet the country's dire needs in a way that no sudden, sweeping government mandate would have. Slowly, beginning with a single farmer's 70 acres in Texas, then through increasingly larger test plots, more interested farmers began to adopt new methods of soil preparation, planting, fertilizing, tilling. Crop yields increased dramatically as more and more farmers bought into the new practices.

"Productivity went way up, outpacing that of other Western countries. Prices fell by half. By 1930, food absorbed just twenty-four per cent of family spending and twenty per cent of the workforce. Today, 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. / This transformation, though critical to America's rise as a superpower, involved some painful dislocations: farms were consolidated; unproductive farmers were winnowed out."

Sure, painful. Like a dislocated shoulder. It's this last sentence that gets me. Oh, those unproductive farmers were such loafers.... I should qualify that while I love his writing, I don't always agree with Gawande. (There were a few points in his second book that I recall being rather perturbed about.) Actually, it's not that I disagree with his illustration in this case -- it is true, factually speaking -- but I am concerned that the parallel may be too close for comfort: I worry about the health care system taking a similar turn in the longer term as agriculture has done. (Okay, it's the phrasing bothers me: the squashing of farmers who didn't adopt the new farming techniques that traded in quality for quantity comes across as a mere uncomfortable detail rather than the large-scale tragedy it has proven to be. And that irks me.) The overhaul of farming early in the 20th Century was a success in that it was able to scale up production and provide more food for less money to a population that was poor and undernourished. It also, in intervening decades, has spun way out of control. Our current, scaled-up, conventional system may be feeding many of us but it is not nourishing most of us. Most "food" in our country is too cheap and full of junk -- largely corn syrup or fake sweeteners and preservatives -- and things like "portion control" are practically unheard of. Diabetes and obesity are rampant as a result. Thousands of farmers are growing commodity crops rather than actual food and going into debt buying chemicals and genetically-modified seeds and ever-larger pieces of equipment (to keep up with harvesting ever more of the chemical-laden, GM crops). Excess herbicides and pesticides and fertilizers that we don't ingest directly are leaking into the water systems. Most animals raised for meat live and die in nightmarish CAFOs, pumped up with growth hormones and antibiotics. Not exactly a pastoral vision, certainly not something we'd aspire to a parallel of with health care reform. [End of rant... for now.]

I get his point, though, that the success of small test programs ultimately yielded a wildly successful paradigm shift. His hope is that the same will prove to be true for health care; my hope is that successful small-scale models will reform not only health care but our food system as well, which is overdue for an overhaul. For among the many small and diverse programs around the country that are working on sustainable food production and distribution, on food justice, on agriculture policy, there is encouraging data. This is part of the reason I'm riding my bicycle all over the country: to gather and share this data.

Gawande's a heck of a writer. Wicked smart, thoughtful, and articulate -- I would not be at all surprised if he became the Michael Pollan of the medical world (and not just because the title his most recent book, The Checklist Manifesto, suggests he's been reading Pollan's penultimate work). Yep, I think I would invite him to dinner, probably put him right between Pollan and McKibben. And I'd ask him to expand on his health care/agriculture case over dessert.

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