Soc. Sci.& Med., Vol. IZ pp. 107 to 115.
0037-7856/78.'1M01-0107$02.00/0
© Pergamon Press Ltd. 1978. Printed in Great Britain.
MEDICAL SYSTEMS AS C H A N G I N G SOCIAL SYSTEMS RAY H. ELLING Department of Community Medicine, University of Connecticut Health Center, Farmington, CT 06032 Abstract--Medical systems are seen as dependent components of their political economic contexts. A set of ideals are identified for achieving a fully regionalized health service as a system offering equity of access and adequate services for all along with user control. The most supportive national political economic context for this kind of health service system is seen as democratic centralism directed toward achieving a socialist economy. With regard to how inequitous systems might move, or be moved, toward the ideal, some phases of human liberation are identified as found in the work of Fanon.
INTRODUCTION
In the body of this paper I will hope to turn the above, assigned title inside out. I have come to believe that medical systems change primarily as a result of or in conjunction with broad change in national and international political economic orders I l l . In offering this perspective, this paper shares a good deal with Jantzen's paper [2]. As he notes, studies of the micro level, i.e. health beliefs, practices and local groups can reflect changes, but to explain these one must move to the macro political economic level. For example, in explaining changing degrees of establishment (corporateness, recognition and acceptance) of two indigenous medical systems--the Bakongo and the "Profits"--he found it necessary to examine the support they received under the struggle against foreign colonial rule and subsequently under a national colonialist regime. Thus the title of my paper should probably be something like "Changing social systems entail changes in medical systems". Beyond this important general point, it seems desirable to recognize the vast disparities in general resources as well a s indicators of health status in the world and within countries so one can develop some sense of the long-term direction of change as determined by class-based struggles for equity and liberation. One can contrast the political economic structures aM health systems of the People's Republic of China with those of India or Iran or of Cuba with Guatemala or Brazil to understand better how the assumption of state power by the working and peasant masses in China and Cuba has led to vast improvements in such general health indicators as infant mortality [3]. This question of direction of change raises some meta-theoretical concerns (questions about types of theories and their appropriateness) which I take up in the first section of the paper. This theoretical effort, or more modestly and correctly framework, or perspective, is recognized as value-laden and directed toward achieving improved health for all people. I take up in the second and third sections of the paper the questions which flow from this concern: (1) What kind of health system is most likely to improve the health status of all the people of a country (here,
within the context of an adequate national health planning and resource re-allocation structure, I suggest the region as the primary unit of study, analysis and action)? and (2) What kind of social (political economic) change is necessary to support such an ideal health system? In the final section of the paper I recognize our limited knowledge as to how to bring about the desired social change, but find the work of Fanon [4] suggestive of some analytic phases of decolonization which seem to help in understanding anti-colonialist anti-imperialist struggles now underway in most of the capitalist world [5]. While these analytic phases of decolonization may help our understanding of these struggles, more adequate theory will only evolve out of praxis and will only offer general perspectives as each situation will have its own particular combination of ruling elites, dominant ideologies, including medical ideologies [6], and struggling worker-peasant classes. SOME META THEORETICAL CONCERNS
Perspectives of administrators of international bealth-population-food agencies and programs are not central here. But it is helpful to address the political-value stance of these agents, for they help create a climate within which scholars work at the business of conceiving of health and medical systems (I will generally speak of health systems to include personal medical services as well as preventive and health education efforts both modern and traditional). Faced with the ideology of national sovereignty, international agencies and programs attempt to gain acceptance from national ruling elites by adopting and supporting the supposed value-neutral stance of "systems theory" in which each element of a system is seen as functionally as important as any other element. In reality, acceptance appears greater on the parts of conservative and rightist regimes for whom a supposed value-free pursuit of science is more convenient in covering over the disparities and conflicts within their nations. Along with the value-free stance has gone a pseudoscience, a quantification of everything, whether it could be understood in relation to the broader socioeconomic context or not. Mills, Gouldner and others I07
108
RAY H. ELLING
have shown the impossibility of the value-free stance [7]. The human observer-actor is unavoidably involved in a meaning-value nexus with implications for the observed-acted-upon system. Those persons and "larger" social entities more directly involved in the observed-acted-upon system pursue values which arise out of primary conditions [8] of production and distribution of goods and class relations to these conditions [9]. While current values reflect the ruling class structure of a society and serve as part of the preserving ideology, new answers to the question, "What is to be done?" derive not only out of so-called objective conditions, they are given in the struggle to change inequitous conditions. Thus: "there is no doubt that the revolutionary distrusts values and refuses to recognize that he is trying to achieve a better organization of the human community. He fears that a return to values, even by an indirect path, may open the door to further chicanery. But on the other hand, the mere fact that he is ready to sacrifice his life to an order, the coming of which he never expects to see, implies that this future order, which justifies all his acts but which he will not enjoy, acts as a value for him. What is a value if not the call of something which does not yet exist?" [10, p. 414]. The value question for theorists is to answer which set of interests they will serve. In the statement offered here I adopt a broad definition of health for all the people as the desirable goal. O f course the conception of health itself requires specification, for, as Kelman has shown, the conception of health proferred by the governing powers of a nation reflects the political economic structure of that nation [11]. Taken in its fullest implications, the W H O definition will entail revolution in capitalist social systems for its attainment [12]. To have "complete physical, mental and social well being" for all--the W H O conception of health and the conception adopted here--will require turning inequitous, exploitative systems on their heads. This is the direction I want to impart to the framework offered here. In addition to their value orientation, theories of society obviously differ a s to content. There may be an infinite variety in this regard, but only one fundamental difference. To the question, " W h a t holds capitalist society together'." one approach, the consensuaL structural-functionalist, or diffusion theory [13] answers: " C o m m o n values". But as we have just seen, revolutionaries, dissatisfied with their position, see the current values as part of an ideology helping to maintain the status quo o n behalf of the ruling elite. In struggling to pursue their own values encompassed in their vision of a new order, they run UP against raw force. It is power in its many forms, but especially state power backed by military-police force, which conflict or dependency theorists see as holding capitalist society together. The relevance of this framework even for simple societies (simple in terms of division of labor) in underdeveloped countries is that the political economy of the world is capitalist dominated [14]. This is the position adopted here. Perhaps the clearest most concise statement of w h a t is involved is given in the following quote from Lenin who in turn quotes Engels: "Let us begin with the most widely read of Engels' works,
The Origin of the Family, Private Property and the State, the sixth edition of which was published in Stuttgart as far back as 1894". We shall have to translate the quotations from the German original, as the Russian translations, although very numerous, are for the most part either incomplete or very unsatisfactory. "Summing up his historical analysis, Engels says: ~The state is, therefore, by no means a power forced on society from without; just as little is it "the reality of the ethical idea", "'the image and reality of reason," as Hegel maintains. Rather, it is a product of society at a certain stage of development; it is the admission that this society has become entangled in an insoluble contradiction with itself, that it has split into irreconcilable opposites which it is powerless to conjure away. But in order that these opposites, classes with conflicting economic interests, might not consume themselves and society in fruitless struggle, it became necessary to have a power seemingly standing above society that would moderate the conflict and keep it within the bounds of "order"; and this power, arisen out of society but placing itself above it, and alienating itself more and more from it, is the state.' (pp. 177-178, sixth German edition.) "This expresses with perfect clarity the basic idea of Marxism concerning the historical role and the significance of the state. The state is a product and manifestation of the irreconcilability of class contradictions. The state arises where, when and to the extent that class contradictions objectively cannot be reconciled. And, conversely, the existence of the state proves that class contradictions are irreconcilable" [15]. In anthropology, the most common approach to explaining culture change has been the notion that ideas emanating from value-prestige centers spread "a beacon light" and are adopted in a process of accommodation involving folk logic and synchretism. Fundamental aspects of the economy and political structure have been ignored or treated incidentally. Some recent work in anthropology and other social sciences reflects a shift from consensual or diffusion theory toward conflict or dependency theory. Dependency theorists (e.g. Roseberry on rentals and expropriation from peasants) have begun to focus on changing political-economic relationships accompanied by a shift in beliefs [16]. In the health sphere, we see in a recent statement by Foster a recognition o f historical stages of awareness. But he ends his analysis with a focus on the importance of institutional arrangements of health services ar/d facilities [17]. He does not go far enough. He does not carry his analysis into the changing political-economic sphere. With respect to health and nutrition problems in rural Latin America, Bonfil has noted that many anthropological studies "...refer to subjects such as ideas and beliefs on health and illness; concepts and rationalizations about nutrition; stereotypes carried by the community about the personnel in charge of sanitation programs; communication problems derived from differences in cultural traditions, and other subjects. The need and value of such studies is unquestionable; but it is more important still to point out the fact that greater attention has been paid to these subjects than to the basic causes of public health and malnutrition problems in our countries. In general, the problems studied have secondary importance as causal elements; that is, they are not primary factors in the alarming state
Medical systems as changing social systems
of chronic malnutrition and poor health which .affects most of the people in Latin America" [18]. Starting from this point, D e W a l t studied changing health beliefs and practices in a Mexican Village and concluded:
109
cross-national students of health and medical care systems are left with such general indicators as infant mortality, childhood mortality, maternal mortality, and longevity. But even with these age- and/or sexcontrolled measures of mortality there are horrendous problems of data being fitted to images of national "In terms of the relationship between beliefs about the and other social entities [29] as well as numerous nature of health and illness, and behaviours connected with technical problems, particularly in underdeveloped health and illness, these data appear to support a model which views the readjustment of cognition as following a countries. Nevertheless, remarkable and probably shift in the emphasis given various paths of behavior. This valid differences can be noted among nations in these is essentially the situation for which Woods and Graves general measures of mortality. Generally these differ(1973), found support in the data from San Lueas. It is, ences correlate strongly with overall level of resources however, at variance with many of the models implicit or (as reflected, for example, by Gross National Product, explicit, which have been offered by anthropologists in the itself a less than perfect measure for some purposes). past... But remarkable differences can be noted also between "The general picture of health related behavior, then, is countries at similar levels of overall resources, The one which suggests considerably less conservatism with re- examples of the P.R.C. as contrasted with India and spect to new alternatives than has been usually reported. Within less than a generation, the people of Puerto de of Cuba contrasted with Guatemala or even much Ins Piedras have behaviorally chosen the western physician "richer" Brazil have already been noted. An exercise as a primary resource person in time of illness, and have in the identification of such contrasting cases has been begun to restructure the cognitive system surrounding reported elsewhere [30]. Although very crude and inadequate, such studies lead easily to a consideration health and illness to incorporate this change" [19]. of the distribution of resources within countries and In a study of the development and effectiveness of to concern for the way scarce resources are organized a health aide program in Jamaica, Marchione has to promote the physical, mental and social well being found political variables influencing recruitment and of all persons in a nation. placement of aides. The overall dependency of the While improved health status in this broad sense Jamaican economy on external capital, control and is the ultimate goal, there are important intermediate supply were found of central importance as regards or enabling goals related to the socio-economic politinutritional status which health aides were expected cal conditions and to the health services. These are to influence [20]. to improve: In a study of the health system of the Ivory Coast, (a) Environmental and life conditions bearing on Lasker found the extra health system goals of the health; ruling elite to be determinative of the structure and (b) The level of understanding of health problems functioning of the health system [21]. and what to do about them; Examples could be multiplied. The colonial left(c) Anticipated satisfaction with service; overs in an indigenous colonial regime have kept In(d) Timely entry into preventive, therapeutic and dia from developing a mixed modern-traditional rehabilitative service; health system to serve the village masses [22] while (e) The logic of the care process. revolutionary China [23] and Cuba [24] see to These cannot be discussed here in detail, but it is have succeeded in this. worth observing that certain of these enabling objecAs already noted (see [1]) W H O has shown an tives are more proximate than others to the function, awareness of the interweaving of the health system ing of health services systems (as normally conceived). with its political economic context. Also, The World That is, certain of these objectives may be rather diBank and its staff have discovered this interweaving. rectly affected by the health services. Probably this This is best expressed in a paper by Sharpston [25]. is evident for the logic of care. Once a person However, in the best traditions of value-free internabecomes a patient in the medical care system, the tionalism, neither W H O nor The Bank openly raise provision of correct services and the way these fit the questions of who is in charge and whose interests together is largely dependent upon the organization the ruling forces serve. Such mystical terms as "the of the services system, even though what the patient national will" are invoked as if any old government brings to the situation and the services personnel's could do what the P.R.C. has done were they only understanding of the person in his social environment to make their minds up to it. also affect the logic of care. Note should be made GOALS that a concern for the logic of care may seem to carry I have already discussed the general thrust of this with it a bias toward "developed" societies where framework toward improved health in a broad sense orientations to "scientific" medicine may be stronger. for all persons. Problems in measuring health out- I would argue against this impression by suggesting comes cross-nationally have been discussed else- that part of the problem of logical care may be to where [26]. A problem pertinent to this discussion is accomplish an appropriate melding of folk and scienthe lack of any adequate general measure of health. tific medicine. The usual measure is disease specific and the crossSatisfaction with care will also largely be detercultural variations in conceptions and indicators of mined by such service organization factors as cost, disease are well known and well covered in the an- accessibility, and affability of treatment personnel. Of thropological papers of this collection [27]. Some use- course, satisfaction will also be influenced by ideologiful work has been done on disability as a relatively cal and social factors determining the kind of care general, but negative measure of health [28]. Thus which is acceptable. We include satisfaction of pro~s.~.Z2/2e--o
110
RAY H. ELLING
viders in our understanding of this intermediate objective. Certainly the satisfaction of health personnel with the care they can render is proximate to the functioning of the services system. Timeliness of entry into care (neither too often, nor too seldom, nor too soon, nor too late) is probably de?endent upon anticipated satisfaction as well as accessibility of services and other factors. Improved understanding of illness and how to avoid it and promote health is a complex dimension made up of knowledge, awareness and concern. It is referrable both to the treating personnel (what do they know of their m6tier, of the patients and the communities they are dealing with, and the health service system with which they have to work) and to patients and potential patients. Clearly, the educational part of the health services system is or should be a major determiner of the sophistication of health personnel. In-service and on-the-job training as important themes of regionalization can play at least as important a part as pre-service training. But the population's sophistication as to health and health services may depend much more on such factors as general educational levels, local health beliefs, etc. than on efforts of the health and medical services, such as health education. Environment and life conditions are probably least proximate to (least determined by) the functioning of the medical services as usually conceived in marketoriented medical systems. Possibly, one of the major strategies to suggest in health services innovation is the design of systems which directly or indirectly gain more control (have more influence) on some of the major intermediate goals which are not proximate to medical services as they now function. For example, if the workload of the system is to be most economically and effectively distributed, the population must play its proper role in preventive and treatment efforts and make the best use of health and medical service as well as contribute to appropriate change in the health planning and services system. Thus, it is a matter of great im• portance that the health planning and services systems operate so as to increase the involvement and the level of sophistication of the population as regards health problems and what to do about them. Nutrition and sanitation are obvious areas of concern among many others. Improved public understanding of the health services system and its limitations and public involvement in correcting inadequacies is equally important. Again, there is probably no more important cluster of variables affecting health status than the level and distribution of wealth, level of education, sanitation, housing conditions and patterns of life. In a most stimulating and provocative article, Payne presented data suggesting that nearly all disease conditions vary together in their occurrence according to such pervasive lifeconditions as poverty versus wealth ['31]. The implication is clear. The problem of disease is largely resident in the society. Nevertheless, in the perspective offered here, there is a close interweaving between the nature of society and the health and medical services system and health levels. Thus it is important in the next section to consider an ideal health and medical care services system.
MEANS---A REGIONALIZED SYSTEM OF CARE
The above goals will be best achieved (in so far as a health system determines their achievement) through a fully regionalized system of services within a national health system. The national system plays a role in standard setting, redistribution of resources, information exchange, evaluation, reporting and planning. These functions also go on within the regions where the most essential, i.e. the local, determinations will be made. With a relatively complete health services delivery system in view, the regional unit is the smallest yet most encompassing or complete unit of organization within a national system. There is a rich body of experience and literature related to regionalization of health and medical care systems, beginning with the Dawson Report in 1920 [32]. This is not the place for a review of this experience and literature [33]. In offering the following set of interwoven ideals which I have abstracted from this literature and experience, I want to emphasize that the elements of local citizen involvement and thrust of the system toward preventive and ameliorative care at the periphery, as well as local service organization capable of developing a positive as well as curative and rehabilitative health plan for each member of each household, require for their attainment full recognition of local customs and ways of life. In short, the emphasis here is on power to the people. Concerns for financing, authority structure, and a graded hierarchy of service may seem to some to smack of "officialese". But if "serve the people" is to have real meaning, organizational elements affecting conservation of resources and effective application of valuable knowledge and technology cannot be ignored. TEN INTERWOVEN IDEALS OF REGIONAL HEALTH SERVICES (I) The region should, depending on density of population and ease of travel and communication, consist of 500,000 to 3,000,000 inhabitants, representing historical, ethnic and political continuity and identity. The region should be capable of supporting a full range of health facilities and services (taking into account conceptions of complete health Services and available resources in each country as well as the need to locate some very costly elements so as to serve more than one region). (2) A graded hierarchy of regional service should generally be made up of three levels: the most local unit for primary and personal preventive care; the intermediate unit with special care to back up the general care of the local unit; and the regional center offering more specialized care. Extremely expensive components may be located so as to serve more than one region. (3) An integrated authority structure should be established over regional planning, decision-making and fiscal management. This should not interfere with but should encourage local participation. (4) A two-way flow of coordinated exchanges should be realized between levels, including patients, informations, personnel, and technology. (5) A direction should be established for the regional
Medical systems as changing social systems system whereby primary health care at the local level--the point of initial entry--becomes the highest priority. Preventive and general care problems should be the primary thrust with expensive and specialized needs being filtered to the intermediate and regional levels. (6) Closed-ended financing should be managed at the regional level through prepayment on a percapita basis for total care of all persons in the region. Prebudgeted or closed-ended financing should motivate the system toward general, preventive care on the local level. Prepaid funds will form a natural limit to the region's total health costs and prevent unnecessary expensive treatment. (7) The least trained person and least complicated and expensive technology which can adequately perform a given task or set of tasks should be the one to perform it. Often citizens themselves can adequately perform a number of health tasks and so on up the hierarchy of health services skills and technologies. (8) Continued education should, in addition to on-thejob training, be effectively organized to respond to regional needs. This function allows up-dating and flexibility within the system. (9) Citizen involvement should be instituted to the fullest extent practicable within the framework of the region's geographic, social, cultural, political and economic setting. An involved citizenry will increase satisfaction and the timely entry into the health care system. Performance of health personnel will benefit from a better understanding of their patients. (10) Local goals should be coordinated for the total care of all persons in this area. The local unit should pursue a complete health plan (preventive, curative and rehabilitative) for each member of each household [34]. It is at the local level that health care will be the most effective within the context of the area's needs and limitations and in recognition of the patient as a social being in a particular environment. In transition to the next section, it can be noted that as a form of governance such a regionalizing structure and process shares the essentials of democratic centralism as developed in China and conceptualizedby Mao [35]. CONTEXTS What political-economic structures will be most supportive of the above ideals? We might suppose that the level of resources would be most important. Certainly resources are needed. But in a wealthy, yet highly stratified and fractionated system (as regards authority, streams of financing, political will), such as the U.S.A., the class-based interests of such an overstuffed medical environment (organizations, occupational groups, and ruling elites) make service to all the people through coordinated plans and services on a regional basis more of a dream than a reality [36]. PL 93-641, The National Health Planning and Resources Development Act is only the most recent in a long line (Hill-Burton, Comprehensive Health Planning, Regional Medical Programs, etc.) of failed attempts to achieve regionalization in the U.S.A. [37]. Thus it is not resources per se which matter for regionalization. The organization of authority in
111
society seems primary, the key question being whether the working and peasant classes have effectively taken state power. Without losing the centrality of social classes and their relations to state power and the means of production, it may be helpful to focus attention on the organization of authority per se. While avoiding such vague everyday designations as "parliamentary democracy", "absolute monarchy", "socialist democracy", "military dictatorship", and without taking account of resource levels (thus we find what may seen strange to some---India and U.S.A. in the same cell) [38] the following typology identifies two dimensions: centralization-decentralization of authority and concertedness-fractionation of authority. ORGANISATION OF AUTHORITY IN SOCIETIES
Concentration
Concertedness PluralisticDivided, Fractioned
Concerted"Got it Together"
Centralized
Chile Iran Franco Spain Argentina ?
U.S.S.R. ?+--G.D.R. and other East European
Decentralized
India_ U.S.A.
I
F.R.G.
?
Tanzania China Sweden
0037-7856/78.'1M01-0107$02.00/0
© Pergamon Press Ltd. 1978. Printed in Great Britain.
MEDICAL SYSTEMS AS C H A N G I N G SOCIAL SYSTEMS RAY H. ELLING Department of Community Medicine, University of Connecticut Health Center, Farmington, CT 06032 Abstract--Medical systems are seen as dependent components of their political economic contexts. A set of ideals are identified for achieving a fully regionalized health service as a system offering equity of access and adequate services for all along with user control. The most supportive national political economic context for this kind of health service system is seen as democratic centralism directed toward achieving a socialist economy. With regard to how inequitous systems might move, or be moved, toward the ideal, some phases of human liberation are identified as found in the work of Fanon.
INTRODUCTION
In the body of this paper I will hope to turn the above, assigned title inside out. I have come to believe that medical systems change primarily as a result of or in conjunction with broad change in national and international political economic orders I l l . In offering this perspective, this paper shares a good deal with Jantzen's paper [2]. As he notes, studies of the micro level, i.e. health beliefs, practices and local groups can reflect changes, but to explain these one must move to the macro political economic level. For example, in explaining changing degrees of establishment (corporateness, recognition and acceptance) of two indigenous medical systems--the Bakongo and the "Profits"--he found it necessary to examine the support they received under the struggle against foreign colonial rule and subsequently under a national colonialist regime. Thus the title of my paper should probably be something like "Changing social systems entail changes in medical systems". Beyond this important general point, it seems desirable to recognize the vast disparities in general resources as well a s indicators of health status in the world and within countries so one can develop some sense of the long-term direction of change as determined by class-based struggles for equity and liberation. One can contrast the political economic structures aM health systems of the People's Republic of China with those of India or Iran or of Cuba with Guatemala or Brazil to understand better how the assumption of state power by the working and peasant masses in China and Cuba has led to vast improvements in such general health indicators as infant mortality [3]. This question of direction of change raises some meta-theoretical concerns (questions about types of theories and their appropriateness) which I take up in the first section of the paper. This theoretical effort, or more modestly and correctly framework, or perspective, is recognized as value-laden and directed toward achieving improved health for all people. I take up in the second and third sections of the paper the questions which flow from this concern: (1) What kind of health system is most likely to improve the health status of all the people of a country (here,
within the context of an adequate national health planning and resource re-allocation structure, I suggest the region as the primary unit of study, analysis and action)? and (2) What kind of social (political economic) change is necessary to support such an ideal health system? In the final section of the paper I recognize our limited knowledge as to how to bring about the desired social change, but find the work of Fanon [4] suggestive of some analytic phases of decolonization which seem to help in understanding anti-colonialist anti-imperialist struggles now underway in most of the capitalist world [5]. While these analytic phases of decolonization may help our understanding of these struggles, more adequate theory will only evolve out of praxis and will only offer general perspectives as each situation will have its own particular combination of ruling elites, dominant ideologies, including medical ideologies [6], and struggling worker-peasant classes. SOME META THEORETICAL CONCERNS
Perspectives of administrators of international bealth-population-food agencies and programs are not central here. But it is helpful to address the political-value stance of these agents, for they help create a climate within which scholars work at the business of conceiving of health and medical systems (I will generally speak of health systems to include personal medical services as well as preventive and health education efforts both modern and traditional). Faced with the ideology of national sovereignty, international agencies and programs attempt to gain acceptance from national ruling elites by adopting and supporting the supposed value-neutral stance of "systems theory" in which each element of a system is seen as functionally as important as any other element. In reality, acceptance appears greater on the parts of conservative and rightist regimes for whom a supposed value-free pursuit of science is more convenient in covering over the disparities and conflicts within their nations. Along with the value-free stance has gone a pseudoscience, a quantification of everything, whether it could be understood in relation to the broader socioeconomic context or not. Mills, Gouldner and others I07
108
RAY H. ELLING
have shown the impossibility of the value-free stance [7]. The human observer-actor is unavoidably involved in a meaning-value nexus with implications for the observed-acted-upon system. Those persons and "larger" social entities more directly involved in the observed-acted-upon system pursue values which arise out of primary conditions [8] of production and distribution of goods and class relations to these conditions [9]. While current values reflect the ruling class structure of a society and serve as part of the preserving ideology, new answers to the question, "What is to be done?" derive not only out of so-called objective conditions, they are given in the struggle to change inequitous conditions. Thus: "there is no doubt that the revolutionary distrusts values and refuses to recognize that he is trying to achieve a better organization of the human community. He fears that a return to values, even by an indirect path, may open the door to further chicanery. But on the other hand, the mere fact that he is ready to sacrifice his life to an order, the coming of which he never expects to see, implies that this future order, which justifies all his acts but which he will not enjoy, acts as a value for him. What is a value if not the call of something which does not yet exist?" [10, p. 414]. The value question for theorists is to answer which set of interests they will serve. In the statement offered here I adopt a broad definition of health for all the people as the desirable goal. O f course the conception of health itself requires specification, for, as Kelman has shown, the conception of health proferred by the governing powers of a nation reflects the political economic structure of that nation [11]. Taken in its fullest implications, the W H O definition will entail revolution in capitalist social systems for its attainment [12]. To have "complete physical, mental and social well being" for all--the W H O conception of health and the conception adopted here--will require turning inequitous, exploitative systems on their heads. This is the direction I want to impart to the framework offered here. In addition to their value orientation, theories of society obviously differ a s to content. There may be an infinite variety in this regard, but only one fundamental difference. To the question, " W h a t holds capitalist society together'." one approach, the consensuaL structural-functionalist, or diffusion theory [13] answers: " C o m m o n values". But as we have just seen, revolutionaries, dissatisfied with their position, see the current values as part of an ideology helping to maintain the status quo o n behalf of the ruling elite. In struggling to pursue their own values encompassed in their vision of a new order, they run UP against raw force. It is power in its many forms, but especially state power backed by military-police force, which conflict or dependency theorists see as holding capitalist society together. The relevance of this framework even for simple societies (simple in terms of division of labor) in underdeveloped countries is that the political economy of the world is capitalist dominated [14]. This is the position adopted here. Perhaps the clearest most concise statement of w h a t is involved is given in the following quote from Lenin who in turn quotes Engels: "Let us begin with the most widely read of Engels' works,
The Origin of the Family, Private Property and the State, the sixth edition of which was published in Stuttgart as far back as 1894". We shall have to translate the quotations from the German original, as the Russian translations, although very numerous, are for the most part either incomplete or very unsatisfactory. "Summing up his historical analysis, Engels says: ~The state is, therefore, by no means a power forced on society from without; just as little is it "the reality of the ethical idea", "'the image and reality of reason," as Hegel maintains. Rather, it is a product of society at a certain stage of development; it is the admission that this society has become entangled in an insoluble contradiction with itself, that it has split into irreconcilable opposites which it is powerless to conjure away. But in order that these opposites, classes with conflicting economic interests, might not consume themselves and society in fruitless struggle, it became necessary to have a power seemingly standing above society that would moderate the conflict and keep it within the bounds of "order"; and this power, arisen out of society but placing itself above it, and alienating itself more and more from it, is the state.' (pp. 177-178, sixth German edition.) "This expresses with perfect clarity the basic idea of Marxism concerning the historical role and the significance of the state. The state is a product and manifestation of the irreconcilability of class contradictions. The state arises where, when and to the extent that class contradictions objectively cannot be reconciled. And, conversely, the existence of the state proves that class contradictions are irreconcilable" [15]. In anthropology, the most common approach to explaining culture change has been the notion that ideas emanating from value-prestige centers spread "a beacon light" and are adopted in a process of accommodation involving folk logic and synchretism. Fundamental aspects of the economy and political structure have been ignored or treated incidentally. Some recent work in anthropology and other social sciences reflects a shift from consensual or diffusion theory toward conflict or dependency theory. Dependency theorists (e.g. Roseberry on rentals and expropriation from peasants) have begun to focus on changing political-economic relationships accompanied by a shift in beliefs [16]. In the health sphere, we see in a recent statement by Foster a recognition o f historical stages of awareness. But he ends his analysis with a focus on the importance of institutional arrangements of health services ar/d facilities [17]. He does not go far enough. He does not carry his analysis into the changing political-economic sphere. With respect to health and nutrition problems in rural Latin America, Bonfil has noted that many anthropological studies "...refer to subjects such as ideas and beliefs on health and illness; concepts and rationalizations about nutrition; stereotypes carried by the community about the personnel in charge of sanitation programs; communication problems derived from differences in cultural traditions, and other subjects. The need and value of such studies is unquestionable; but it is more important still to point out the fact that greater attention has been paid to these subjects than to the basic causes of public health and malnutrition problems in our countries. In general, the problems studied have secondary importance as causal elements; that is, they are not primary factors in the alarming state
Medical systems as changing social systems
of chronic malnutrition and poor health which .affects most of the people in Latin America" [18]. Starting from this point, D e W a l t studied changing health beliefs and practices in a Mexican Village and concluded:
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cross-national students of health and medical care systems are left with such general indicators as infant mortality, childhood mortality, maternal mortality, and longevity. But even with these age- and/or sexcontrolled measures of mortality there are horrendous problems of data being fitted to images of national "In terms of the relationship between beliefs about the and other social entities [29] as well as numerous nature of health and illness, and behaviours connected with technical problems, particularly in underdeveloped health and illness, these data appear to support a model which views the readjustment of cognition as following a countries. Nevertheless, remarkable and probably shift in the emphasis given various paths of behavior. This valid differences can be noted among nations in these is essentially the situation for which Woods and Graves general measures of mortality. Generally these differ(1973), found support in the data from San Lueas. It is, ences correlate strongly with overall level of resources however, at variance with many of the models implicit or (as reflected, for example, by Gross National Product, explicit, which have been offered by anthropologists in the itself a less than perfect measure for some purposes). past... But remarkable differences can be noted also between "The general picture of health related behavior, then, is countries at similar levels of overall resources, The one which suggests considerably less conservatism with re- examples of the P.R.C. as contrasted with India and spect to new alternatives than has been usually reported. Within less than a generation, the people of Puerto de of Cuba contrasted with Guatemala or even much Ins Piedras have behaviorally chosen the western physician "richer" Brazil have already been noted. An exercise as a primary resource person in time of illness, and have in the identification of such contrasting cases has been begun to restructure the cognitive system surrounding reported elsewhere [30]. Although very crude and inadequate, such studies lead easily to a consideration health and illness to incorporate this change" [19]. of the distribution of resources within countries and In a study of the development and effectiveness of to concern for the way scarce resources are organized a health aide program in Jamaica, Marchione has to promote the physical, mental and social well being found political variables influencing recruitment and of all persons in a nation. placement of aides. The overall dependency of the While improved health status in this broad sense Jamaican economy on external capital, control and is the ultimate goal, there are important intermediate supply were found of central importance as regards or enabling goals related to the socio-economic politinutritional status which health aides were expected cal conditions and to the health services. These are to influence [20]. to improve: In a study of the health system of the Ivory Coast, (a) Environmental and life conditions bearing on Lasker found the extra health system goals of the health; ruling elite to be determinative of the structure and (b) The level of understanding of health problems functioning of the health system [21]. and what to do about them; Examples could be multiplied. The colonial left(c) Anticipated satisfaction with service; overs in an indigenous colonial regime have kept In(d) Timely entry into preventive, therapeutic and dia from developing a mixed modern-traditional rehabilitative service; health system to serve the village masses [22] while (e) The logic of the care process. revolutionary China [23] and Cuba [24] see to These cannot be discussed here in detail, but it is have succeeded in this. worth observing that certain of these enabling objecAs already noted (see [1]) W H O has shown an tives are more proximate than others to the function, awareness of the interweaving of the health system ing of health services systems (as normally conceived). with its political economic context. Also, The World That is, certain of these objectives may be rather diBank and its staff have discovered this interweaving. rectly affected by the health services. Probably this This is best expressed in a paper by Sharpston [25]. is evident for the logic of care. Once a person However, in the best traditions of value-free internabecomes a patient in the medical care system, the tionalism, neither W H O nor The Bank openly raise provision of correct services and the way these fit the questions of who is in charge and whose interests together is largely dependent upon the organization the ruling forces serve. Such mystical terms as "the of the services system, even though what the patient national will" are invoked as if any old government brings to the situation and the services personnel's could do what the P.R.C. has done were they only understanding of the person in his social environment to make their minds up to it. also affect the logic of care. Note should be made GOALS that a concern for the logic of care may seem to carry I have already discussed the general thrust of this with it a bias toward "developed" societies where framework toward improved health in a broad sense orientations to "scientific" medicine may be stronger. for all persons. Problems in measuring health out- I would argue against this impression by suggesting comes cross-nationally have been discussed else- that part of the problem of logical care may be to where [26]. A problem pertinent to this discussion is accomplish an appropriate melding of folk and scienthe lack of any adequate general measure of health. tific medicine. The usual measure is disease specific and the crossSatisfaction with care will also largely be detercultural variations in conceptions and indicators of mined by such service organization factors as cost, disease are well known and well covered in the an- accessibility, and affability of treatment personnel. Of thropological papers of this collection [27]. Some use- course, satisfaction will also be influenced by ideologiful work has been done on disability as a relatively cal and social factors determining the kind of care general, but negative measure of health [28]. Thus which is acceptable. We include satisfaction of pro~s.~.Z2/2e--o
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RAY H. ELLING
viders in our understanding of this intermediate objective. Certainly the satisfaction of health personnel with the care they can render is proximate to the functioning of the services system. Timeliness of entry into care (neither too often, nor too seldom, nor too soon, nor too late) is probably de?endent upon anticipated satisfaction as well as accessibility of services and other factors. Improved understanding of illness and how to avoid it and promote health is a complex dimension made up of knowledge, awareness and concern. It is referrable both to the treating personnel (what do they know of their m6tier, of the patients and the communities they are dealing with, and the health service system with which they have to work) and to patients and potential patients. Clearly, the educational part of the health services system is or should be a major determiner of the sophistication of health personnel. In-service and on-the-job training as important themes of regionalization can play at least as important a part as pre-service training. But the population's sophistication as to health and health services may depend much more on such factors as general educational levels, local health beliefs, etc. than on efforts of the health and medical services, such as health education. Environment and life conditions are probably least proximate to (least determined by) the functioning of the medical services as usually conceived in marketoriented medical systems. Possibly, one of the major strategies to suggest in health services innovation is the design of systems which directly or indirectly gain more control (have more influence) on some of the major intermediate goals which are not proximate to medical services as they now function. For example, if the workload of the system is to be most economically and effectively distributed, the population must play its proper role in preventive and treatment efforts and make the best use of health and medical service as well as contribute to appropriate change in the health planning and services system. Thus, it is a matter of great im• portance that the health planning and services systems operate so as to increase the involvement and the level of sophistication of the population as regards health problems and what to do about them. Nutrition and sanitation are obvious areas of concern among many others. Improved public understanding of the health services system and its limitations and public involvement in correcting inadequacies is equally important. Again, there is probably no more important cluster of variables affecting health status than the level and distribution of wealth, level of education, sanitation, housing conditions and patterns of life. In a most stimulating and provocative article, Payne presented data suggesting that nearly all disease conditions vary together in their occurrence according to such pervasive lifeconditions as poverty versus wealth ['31]. The implication is clear. The problem of disease is largely resident in the society. Nevertheless, in the perspective offered here, there is a close interweaving between the nature of society and the health and medical services system and health levels. Thus it is important in the next section to consider an ideal health and medical care services system.
MEANS---A REGIONALIZED SYSTEM OF CARE
The above goals will be best achieved (in so far as a health system determines their achievement) through a fully regionalized system of services within a national health system. The national system plays a role in standard setting, redistribution of resources, information exchange, evaluation, reporting and planning. These functions also go on within the regions where the most essential, i.e. the local, determinations will be made. With a relatively complete health services delivery system in view, the regional unit is the smallest yet most encompassing or complete unit of organization within a national system. There is a rich body of experience and literature related to regionalization of health and medical care systems, beginning with the Dawson Report in 1920 [32]. This is not the place for a review of this experience and literature [33]. In offering the following set of interwoven ideals which I have abstracted from this literature and experience, I want to emphasize that the elements of local citizen involvement and thrust of the system toward preventive and ameliorative care at the periphery, as well as local service organization capable of developing a positive as well as curative and rehabilitative health plan for each member of each household, require for their attainment full recognition of local customs and ways of life. In short, the emphasis here is on power to the people. Concerns for financing, authority structure, and a graded hierarchy of service may seem to some to smack of "officialese". But if "serve the people" is to have real meaning, organizational elements affecting conservation of resources and effective application of valuable knowledge and technology cannot be ignored. TEN INTERWOVEN IDEALS OF REGIONAL HEALTH SERVICES (I) The region should, depending on density of population and ease of travel and communication, consist of 500,000 to 3,000,000 inhabitants, representing historical, ethnic and political continuity and identity. The region should be capable of supporting a full range of health facilities and services (taking into account conceptions of complete health Services and available resources in each country as well as the need to locate some very costly elements so as to serve more than one region). (2) A graded hierarchy of regional service should generally be made up of three levels: the most local unit for primary and personal preventive care; the intermediate unit with special care to back up the general care of the local unit; and the regional center offering more specialized care. Extremely expensive components may be located so as to serve more than one region. (3) An integrated authority structure should be established over regional planning, decision-making and fiscal management. This should not interfere with but should encourage local participation. (4) A two-way flow of coordinated exchanges should be realized between levels, including patients, informations, personnel, and technology. (5) A direction should be established for the regional
Medical systems as changing social systems system whereby primary health care at the local level--the point of initial entry--becomes the highest priority. Preventive and general care problems should be the primary thrust with expensive and specialized needs being filtered to the intermediate and regional levels. (6) Closed-ended financing should be managed at the regional level through prepayment on a percapita basis for total care of all persons in the region. Prebudgeted or closed-ended financing should motivate the system toward general, preventive care on the local level. Prepaid funds will form a natural limit to the region's total health costs and prevent unnecessary expensive treatment. (7) The least trained person and least complicated and expensive technology which can adequately perform a given task or set of tasks should be the one to perform it. Often citizens themselves can adequately perform a number of health tasks and so on up the hierarchy of health services skills and technologies. (8) Continued education should, in addition to on-thejob training, be effectively organized to respond to regional needs. This function allows up-dating and flexibility within the system. (9) Citizen involvement should be instituted to the fullest extent practicable within the framework of the region's geographic, social, cultural, political and economic setting. An involved citizenry will increase satisfaction and the timely entry into the health care system. Performance of health personnel will benefit from a better understanding of their patients. (10) Local goals should be coordinated for the total care of all persons in this area. The local unit should pursue a complete health plan (preventive, curative and rehabilitative) for each member of each household [34]. It is at the local level that health care will be the most effective within the context of the area's needs and limitations and in recognition of the patient as a social being in a particular environment. In transition to the next section, it can be noted that as a form of governance such a regionalizing structure and process shares the essentials of democratic centralism as developed in China and conceptualizedby Mao [35]. CONTEXTS What political-economic structures will be most supportive of the above ideals? We might suppose that the level of resources would be most important. Certainly resources are needed. But in a wealthy, yet highly stratified and fractionated system (as regards authority, streams of financing, political will), such as the U.S.A., the class-based interests of such an overstuffed medical environment (organizations, occupational groups, and ruling elites) make service to all the people through coordinated plans and services on a regional basis more of a dream than a reality [36]. PL 93-641, The National Health Planning and Resources Development Act is only the most recent in a long line (Hill-Burton, Comprehensive Health Planning, Regional Medical Programs, etc.) of failed attempts to achieve regionalization in the U.S.A. [37]. Thus it is not resources per se which matter for regionalization. The organization of authority in
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society seems primary, the key question being whether the working and peasant classes have effectively taken state power. Without losing the centrality of social classes and their relations to state power and the means of production, it may be helpful to focus attention on the organization of authority per se. While avoiding such vague everyday designations as "parliamentary democracy", "absolute monarchy", "socialist democracy", "military dictatorship", and without taking account of resource levels (thus we find what may seen strange to some---India and U.S.A. in the same cell) [38] the following typology identifies two dimensions: centralization-decentralization of authority and concertedness-fractionation of authority. ORGANISATION OF AUTHORITY IN SOCIETIES
Concentration
Concertedness PluralisticDivided, Fractioned
Concerted"Got it Together"
Centralized
Chile Iran Franco Spain Argentina ?
U.S.S.R. ?+--G.D.R. and other East European
Decentralized
India_ U.S.A.
I
F.R.G.
?
Tanzania China Sweden
