Dr. med. Bernhard Stein
The Sick System
From A Disease-Oriented Economy to Caring For People A plea for a new access to health care
Table of Content
Prologue: Crash or New Start
Analysis of The Current State – Spirals into the Abyss
a. What Happened ?
b. Philosophical And Ethical Issues
c. Society, Democracy and Economy
d. Illogical and Overexpensive Structures of Health
e. Organization and Marketing of Diseases
f. Science and Doctrine: Publish or Perish
g. Juridification of Medicine
Change – From Head to Foot
a. Where Could This Journey Lead to
b. The Role of Science and Medical Mainstream
c. Sustainability, Subsidiarity and Sufficiency in Medicine
d. The Role of People/ Patients
e. A New Concept of Health Care
I. Prevention und Health Information
II. Centers of Excellence and University Clinics
III. Regional Care
A Vision – Epilogue
About the Author:
Bernhard Stein, M.D., born in Braunschweig (Germany) in 1956, is a specialist for anesthesia, intensive care and emergency medicine. He successfully completed his professional education in the field of medicine and research in Germany and France and has worked in Luxembourg in a managing position since 1992.
Apart from working as a doctor, he is also engaged in issues of organizing both hospitals and the health care system, after having successfully completed additional studies of health economics and Quality Management .
Prologue: Crash or New Start
Discussing the health system is delicate. It is a killer topic for political careers. Due to its complexity and political explosive force, it probably is too big to be optimized instead of too big to fail.1
This book is meant as a manifest, born from the critical reflection and the feeling that we are going in a wrong direction.
The initial point is a critical, provable analysis of the current state, questioning our well-shaped image and our make-believe truths in order to show alternatives for a different way in health care.
The subjectivity consists of interpreting the facts and the verbalized theses, definitely provocative but provable and percebtible. The consequences we draw from this depend on the level of maturity of our society and the wish for changes.
This is a complex system that is threatened to become a victim of its own success. Its economic and political penetration influences its protagonists as well as a lot of normal people. When we subsequently deal with three key terms that have been unknown in health care, mainly been connected with other areas up to now or have been lost during the last trente glorieuses 2 critical questions arise:
• Sustainability, meaning the three pillars ecological, economical and social sustainability, supplemented by inter-/and intragenerational justice. Our current approach of the diseaseoriented economy is not sustainable.
• Subsidiarity as a principle striving for the development of individual abilities, self-determination and personal responsibility. Jobs, actions and problems should be handled by each individual, the smallest group and the lowermost level of an organization. Only when the obstacles are irresolvable, higher instances should support or take on the jobs. For health politics, this means a bottom-up approach, from simplicity to complexity or from the inside to the outside. Personal responsibility is shriveling under the pledge of expertise and quality and cost management (ILLICH, 1995).
• Sufficiency, meaning the careful handling of resources – financial resources, people, energy, work time, routes of transport etc. The current waste of resources promotes unregulated and unjust growth (SACHS, 1993).
Every crisis provides the chance of making a virtue of necessity and creating new ways of health care that serve as model examples and are focused on caring for people. The top priority should be social, ecological and economical subsidiarity and inter-generational fairness, re-directing personal sovereignity on health, disease and death and health care focused on the people – and last but not least rethinking in favor of self-restraint on what people consider sensible and desired.
This would lay the foundation for a new start.
1.Thesis: Within a few generations only, the attitude of people toward ailments and disease and their treatments has created a condition that is neither economically bearable nor strongly satisfactory for the people in the long run. A holistic approach and helping the people to help themselves have been replaced by a disease-oriented economy driven by economics and technology, which is now threatening to make itself independent. Their superficial success in life extension, economic performance and progress orientation are throwing a smokescreen over the other side of the coin: the incapacitation of people and the development of a health care system serving its protagonists more than the people.
2.Thesis: If we seriously apply the terms sustainability, subsidiarity and sufficiency on the health care system and if we give the authority for health, disease and death back to ourselves, we can create a new start for another type of health care system.
There is a time for everything and a season for every activity under the heavens:
A time to be born and a time to die, a time to plant and a time to uproot, a time to kill and a time to heal, a time to tear down and a time to build.
Old Testament, Solomon, chapter 3, verses 1-3
Analysis of The Current State – Spirals into the Abyssa
a. What Happened?
Under the impulse of a strong economization and adjustment to industrial management, today's health care focuses on the acute disease and its speedy, technically and economically demanding treatment. All the more, a person's entire life and medical history is considered a sequence of acute diseases in which the social, psychological and individual dimension is put in the background.
The professions of doctor and nurse, based on human attention toward the patient and requiring trust and concern, become business models of the market-oriented barter trade of services (MAIO). They get devaluated and ripped by pseudo-evident instructions turning their work into cost efficient and success-oriented consumer goods with the help of an industry-adapted arsenal of processes and therapy modules (MAIO).
For 100 years, medicine has always claimed to be non-judgmental and academic but eventually, it has played the card of unconditional technical and pharmacological progress rather than social or societal, or even global development.
The sheer quantitative problems caused by medical progress and demographic development, such as more old and chronically ill people, lead into a spiral of triply pressing problems:
• The increasing gap between the claim of an equal and affordable health care system despite social and regional discrepancy and reality. If we have believed up to now that this only applies to South and Eastern Europe and the Third World, that are so far away, we will soon come to realize that the gap is right within our countries, France and Germany – regionally as well as socially.
• This development is on the account of chronic and age-related diseases. In the logic of acute diseases, they are medicinally and economically wrongly or excessively treated and neither benefit from consequent prevention nor alternative or less invasive concepts of treatment.
• This is accompanied and enforced by a development in science and medicine influencing large parts of the medical mainstream in terms of an ever-expanding health care market with expensive pseudo-innovations and new mental disorders implying pathological significance.
The consequences are:
• Wrong incentives, most of all, wrong investments in a still oversized, expensive acute care range unable to adjust adequately to the changed frame conditions,
• the development of a lifestyle health care, mainly privately funded yet lucrative,
• the negligence and insufficient development of care and treatment of chronic and age-related diseases as well as the outpatient sector,
• the monopolization of health care by presumed experts, for 20 years complemented and increasingly dominated by squadrons of specialized managers, economists and quality managers, resulting in a definitely efficient high-end health care but creating a multi-tier health care and the increasing incapacitation of non-experts and patients.
While politics, public but also professional associations often concentrate on high-end health care and the medical progress, it is forgotten that approx. 90 per cent of public medical care takes place in their region, right outside their door and off the the university centers.
The region in particular is the first to suffer from deficits in the supply chain but at the same time, it is of particular importance for the prevention and treatment of chronic diseases and age. It represents a key element of our future health care system.
If society is striving to turn away from a disease-oriented economy toward a stable and innovative concept of health care, this will only work with an overall philosophy and a master plan that can reach the hearts, heads and wallets of the people, the experts and the decision makers.
3.Thesis: A certain attitude toward medicine is monopolizing our lives under the impression of spectacular successes of acute medical care. Ailments, lives and disease are seen with regard to the acute disorder and its technological-pharmacological treatment with maximum financial and technical input. What's left behind is a socially balanced regional supply that will fully leave people in their life contexts and individual responsibility.
b. Philosophical and Ethical Issues
In review, indigenous peoples, ancient cultures as well as people up to the Middle Ages had one thing in common: disease, death and healing belonged to a higher picture, a general view of the world and were an expression of an imbalance in this system. Therefore, healing had the nature of reconciliation with a higher power (SCHIPPERGES).
In both the Medieval Christian and Arab world, healing was related to eternal salvation and health care to the care of souls. Health care was based on the principles of human care. In other words, medicine was an accompanying and framework program for the predestined fate. In this system, the human himself was on the one hand strongly responsible for his life and salvation, his contact person was the higher power that determined his belief-/and life system.
On the other hand, he was not just burdened with the responsibility for his destiny and his physical and spiritual health.
Enlightenment and the development of natural sciences helped medicine to gain unforeseen success and insights as well as a whole new view on life. All vital and thinking processes were fragmented in biological and biochemical procedures that can be understood and influenced, accompanied by the technological revolution of communication media and an ostensible availability of information and knowledge for anybody.
Secularization of societies goes hand in hand with these developments and now passes on this responsibility for the big picture to the modern human by proxy of the higher power. This means that every individual now has full responsibility for his life, his health, disease and death yet increasingly passes it on to the experts. Considering the complexity and verve of sciences, man quickly loses the connection to his body and tries to compensate for this deficit with three counteractions the new world has given us:
• The revolution of knowledge, or rather, half-truths of modern communication implying to the people they could catch up on things in real time now and figure all procedures out even as non-experts.
• The juridification of life in itself causing jurisprudence to provide for justice on earth as counterbalance to the higher power.
• The economization of disease, medicine and health care is the last and probably the most profound transformation in this development. As in all other areas of life, there is a process working with precision and vigor, sweeping over all zones of life and action like a gigantic flood, spurred by the technological development and globalization (LAFONTAINE, 2014) (MAIO).
The development on our planet follows a philosophy of unconditional growth as a motor of social and economic progress, using and consuming ecological and social resources without actual assessment of the consequences. Thanks to globalization and communicative networking, this is brought to every corner of the world yet often goes along with an intellectual dumbing-down and dominance of mediocrity, implying that there is no alternative to the development of our society.
This apparatus may work adamantly and precisely and reach all areas of life but there is no noticeable masterplan behind it (WELZER, 2013 KEMPF, 2013). This scenario lacks the a.m. terms sustainability, subsidiarity and sufficiency as well as intergenerational justice and compensation (SIDELSKY & SIDELSKY, 2013). Thus, we are able to efficiently spread this philosophy allover the world yet unable to comprehend, let alone master its consequences on the social, ecological and economic balance.
Another factor that has newly been discussed or rather re-invented, lies in the sociology of modern institutions and corporations, to be termed as stupidity-based theory of organizations (ALVESSON M.) (CIPOLLA) (CANTO), in other words the domination and hegemony of mediocrity.
Contrary to the outwardly declared goal of sponsoring the talents and excellent abilities of the staff of an organization in order to guarantee success, the development goes in the opposite direction; toward a pseudo-harmonic organization with a manipulated, positive image, described as self-reinforcing stupidity by Alvesson and Spicer, and perceived by many as a comfortable, low-conflict type of work.
Deliberately fading out the full intellectual and analytical abilities of the members, most of all the often intellectually brilliant mavericks, leads to a short-sighted decision-making without concepts and reasons and a wasting of valuable abilities.
Apart from a probable aberration of the organization, frustration and a deranged communication are generated. This phenomenon, very common in the world of finance (CANTO), contributes to the problems and faultings of this sector (FORRESTER), not least during the worldwide economic crisis of 2008 (GAYRAUD). As part of the all-encompassing economization and adaption of management technologies, it is gradually establishing itself in social and artistic domains, too.
Jürgen Habermas wrote about our generation:
We live in a normatively stripped down generation that allows an increasingly complex society to impose a short-winded way of dealing with the every-day problems.
(HABERMAS, 20 May 2010), (SCHULZ 2010)
Economization of Life And Disease
For quite some time, there have been warning voices regarding the development of technology (MUMFORD), atomic technology (WAGNER) and the cultural (WOLTON) (FROMM) and economic (ENGELHARD) consequences of globalization. Modern medicine has also been criticized by representatives of philosophy and theology (ILLICH), medicine itself (MEYER) (SKRABANEK) (LOWN) ...