Explore: The Journal of Science and Healing
Volume 8, Issue 1 , Pages 59-64, January 2012

The Case for Commons Health Care

Top of Form

  • JamieHarvie, PE

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Outline

  • Lessons from Green Healthcare
  • Failing Systems
  • Common Drivers
  • Agroecology and Healthy Food Systems
  • Commons Healthcare
  • Commons Healthcare Roadmap
  • Commons Healthcare Trusts
  • Bioregional and Megaregion Anchor Institutions
  • Our Community Commons
  • Integrative Health Care and New Healthcare Leadership
  • Regenerative Healthcare Design
  • Conclusion
  • References
  • Biography
  • Copyright

A “tragedy of the commons” occurs when the self-interest of certain individuals in a group overrides the collective interest of that group, ultimately to the detriment of all. We are all too familiar with examples of how the unnecessary overutilization of healthcare, the race for medical technology and the entrenched medical interests is ultimately bankrupting our entire healthcare system.

Currently we are facing this type of situation in three intersecting areas—healthcare, agriculture, and climate. Moreover, these three spheres are so intricately interconnected to one another that they collectively and strongly affect, either for better or worse, the quality of life for all Americans.

Yet, we have learned from the work by Elinor Ostrom, whose work on commons management was recognized by a Nobel prize,1 and healthcare examples from communities across the country,2 that the tragedy of the commons is not predestined. Moreover, that through a set of community-based rules and conditions, this tragedy can be averted. In light of the dire state of global ecological and financial health, the question becomes whether we have enough time and resources to alter course.

Clearly, we need a new model. The primary purpose of this paper is to offer a new lens on seemingly disparate issues, to accelerate the development of a community-driven, multibenefit framework—“Commons Healthcare”—to solve the problems in our health, food, and climate systems, and to demonstrate that such an approach to public health is imperative.

Lessons from Green Healthcare

Over the last decade, the environmental community has been working with those in healthcare, with considerable success, to address ecological health issues associated with the design, construction, and operations of healthcare buildings. For example, the sale and purchase of medical equipment containing mercury has been virtually phased out. This trend is now international, with mega cities such as Mexico City, Delhi, and Buenos Aires, as well as countries such as Argentina and the Philippines also eliminating the sale of medical equipment containing mercury.

Increasingly, U.S. healthcare facilities are being designed with the ecological health impacts to individuals, communities, and the planet in mind. This work has been extremely important in shifting healthcare operations toward more environmentally preferable purchasing practices, which has then resulted in a variety of changes in the supply chain. In fact, it is important to emphasize that the greening of healthcare has played an important role in deepening an understanding of the relationship between human health and the environment.

Additionally, the immediacy of environmental and climate problems—note stark warnings from the UN Millennium Assessment and the Intergovernmental Panel on Climate Change—has helped to expand the focus of healthcare/environmental issues from product toxicity, waste reduction, and green design to climate mitigation and adaptation as well.

Yet, these changes have only resulted in limited transformation in funding practices, reimbursement policies, and healthcare-driven primary prevention strategies. In fact, the business of healthcare has for the most part continued “business as usual.”

For example, the healthcare's climate footprint derives primarily from the treatment of an increasingly sick population. Only 20% of a hospitals climate footprint is related to building energy use.3 Yet the majority of mitigation efforts are focused on energy efficiency rather than the increasingly overburdened healthcare system. Even though it would not be in the economic interests of a healthcare administrator working to keep beds filled, a primary prevention strategy that keeps people out of the hospital might be the best healthcare climate mitigation strategy of all.

This is not to suggest, that “green” healthcare is unimportant, or that renewable energy and energy efficient healthcare buildings are unimportant to the future of a prevention-oriented, sustainable healthcare model. All prevention efforts have a role to play. What the green healthcare movement has helped us understand is that even the “greenest” healthcare system cannot be economically or ecologically sustainable if it is not accompanied by a reduced demand for services. Moreover, it also becomes evident that the healthcare community will not change itself, unless the systems in which it is based are also changed.

Failing Systems

Healthcare now represents 17% of the gross domestic product (GDP) and is on a trajectory that is clearly not sustainable. In addition, although the United States now spends more than 50% more per capita on healthcare than the next most expensive system in the developed world, the health of the U.S. population is demonstrably poorer by most measures.

The most important factor contributing to the growth in health care spending in recent decades has been the emergence, adoption, and widespread diffusion of new medical technologies and services. Although technological innovation can sometimes reduce spending, such advances in medicine and the resulting changes in clinical practice have generally increased spending.

We see similar patterns in agriculture, through the predominance of an industrial agriculture production-driven model. Agricultural trade is now organized in global chains, dominated by a few large transnational players whose interests are driven primarily by their shareholders financial stake. Consequently, we are experiencing a global transformation of how societies grow and access food. Transnational supermarket chains are replacing the local, community-based markets. Thus, food access is not strictly an issue of personal choice, but one of what choices are available and the policies that dictate these choices. This helps explain the emergence of food deserts, areas in both urban cities, and rural communities where there is limited access to fresh fruit and vegetables.

Through this industrial food and agriculture model, ecological health costs have been externalized. In parallel with a treatment-oriented rather than prevention-oriented healthcare system, the treadmill continues. Rather than investing in and supporting a food supply and agriculture model that preserves and regenerates ecological services and social health, the associated ecosystem decline from the use of fertilizer and pesticides and farmer dislocation from land and communities continues unabated.

Common Drivers

For good reason, the Centers for Disease Control has called obesity the nation's largest public health threat, and organizations such as the World Health Organization has warned about the global tide of chronic disease poised to overwhelm global health systems. WHO Director-General Dr. Margaret Chan said that, “For some countries, it is no exaggeration to describe the situation as an impending disaster; a disaster for health, for society, and most of all for national economies.”4

At the same time, the British Medical Journal warns that climate change could be the largest public health threat of the 21st century. The World Health Organization also warns that health impacts from climate change are predicted to overwhelm healthcare systems.

Our health is linked to our food and agriculture complexes. In turn, the global expansion of agriculture into natural ecosystems has had a significant climate impact,5 through land use changes such as deforestation.

The global contribution of agriculture to green house gas (GHG) emissions, including agriculture related deforestation, has a value of approximately 30%.6, 7 Moreover, food produced and promoted by this system increases the risk of a host of common, nutritionally related chronic disorders, including obesity, diabetes, cardiovascular disease, dementia, and various kinds of cancer, among others. A host of studies demonstrate the risk from unhealthy diets.8, 9, 10, 11, 12, 13

It is clear that healthcare systems will increasingly shoulder the burden of health impacts associated with both our industrial food system and climate change.

Because our current healthcare delivery and industrial food models are in similar feedback loops, driving them toward system failure, business as usual cannot continue for much longer. Hence, it is time to recognize not only the important linkages between food, climate, and healthcare but also the potential for common solutions.

Agroecology and Healthy Food Systems

In early 2011, the United Nations Human Right Council submitted a report to the United Nations on The Right to Food. The report was based, in large part, on the recommendations of the International Agriculture Assessment on Science, Technology, Knowledge and Development (IAASTD), an initiative funded by the World Bank, and the United Nations' Food and Agriculture Organization and Environmental Program. It recognized that:

Increasing food production to meet future needs, while necessary, is not sufficient. It will not allow significant progress in combating hunger and malnutrition if it is not combined with higher incomes and improved livelihoods for the poorest—particularly small-scale farmers in developing countries. And short-term gains will be offset by long term losses if it leads to further degradation of ecosystems, threatening future ability to maintain current levels of production.

The IAASTD report recognizes the interrelationship between hunger, society, and ecosystem services. Importantly, it proposes agroecology as a viable alternative to our industrial model, which is exacerbating hunger, food insecurity, health disparities, and the destruction of ecological services. Once again, we begin to see potential for the emergence of a commons healthcare solution—the bridging of food systems, communities, and healthcare.

Ultimately, it is communities that will need to take responsibility for bringing these once seemingly disparate issues together, requiring goal setting and metrics to arrive at a commons health care solution. To that end, let us explore what a commons health care framework might look like.

Current / Future
Health care as an institution led service / Health and social care as part of the community
Curative and fixing medical care / Early intervention and preventative care
Sickness / Health and well being
Professional / Personal
Isolated and segregated / Integrated and in partnership
Buildings / Healing environments
Decision making based on today's finances / Integrated value of the future which accounts for the impacts on society and nature
Single indicators and out of date measurements / Multiple score cards, and information and in real time
Sustainability as an add on / Integrations in culture, practice and training
Industrial food production / Agroecology—Local, nutritious food systems
Waste and overuse of resources / A balanced use of resources where waste becomes a resource
Nobody's business / Everybody's business

Commons Healthcare

Several evolving models provide a basis for hope and inspiration. Recently, the National Health System in the United Kingdom published their Route Map for Sustainable Health, which explicitly supports the need for paradigm shift. It describes the shift from a system that is institution led, to one in the community that provides for the future of society and the environment, and is informed and in partnership with patients and communities in a more open decision making system.

Commons Healthcare Roadmap

Adapted from the Route Map for Sustainable Health (NHS).14

Commons health care also requires changing the current rationale for a healthcare system. In fact, the community-centered philosophy inherent in agroecology and primary prevention approaches reinforce that a new model will necessarily be community informed and directed. No longer can healthcare institutions be rewarded by filling their beds and keeping their labs, operating rooms, and diagnostic and therapeutic machinery humming. The incentives need to change. Moreover, a commons healthcare system would recognize, promote, and preserve health-promoting activities and institutions such as farmers markets, community gardens, better food access, and increased farmland, clean air, and clean water.

The following are some concepts and approaches, that if appropriately articulated, supported, and connected, might help facilitate rapid systems change.

Commons Healthcare Trusts

One model that holds promise is a proposed Commons Healthcare Trust (CHCT), a community-based trust, which by definition is legally obligated to promote and improve the health of all citizens. A CHCT might develop key metrics from the standpoint of healthcare utilization, primary care physician ratios, in addition to key metrics and indicators of prevention resources. These might include community gardens, average age of farmers, quantity of schools with farm-to-school programs, fast food expenditures per capita, food access, and water access farmland, average age of farmers, etc. The intention behind a CHCT would be transparent metrics that provide communities with an understanding of how and where their community healthcare treatment and prevention resources are being spent and to provide a legal mechanism to allow community-based decision making on prevention allocations.

In Alaska, citizen dividend checks are distributed every year out of the interest payments to an oil royalties deposit account called the Alaska Permanent Fund (APF). The APF is a public trust fund that distributes the commons wealth of its resources to its citizens. The Solar Commons, a recent U.S. Green Building Council Innovation Award winner, uses rights of way to install solar panels. Revenues generated are directed to support low-income housing needs. What if we imagined something similar at the local level, where the benefits went to improve health equity?

Because of the relationship between obesity and sugar-sweetened beverages, many communities have explored the adoption of sugar-sweetened beverage (SSB) taxes. Proceeds from an SSB tax (or a disease fee) could be reallocated to a CHCT, which might be then directed to promote the community objectives of the CHCT, especially because it has been demonstrated that SSB taxes are cost effective at obesity prevention.15 A local ecological service fee applied to genetically engineered food sales (or purchase), or pesticide sales, could be adopted with proceeds directed to the local CHCT. Similarly, fees associated with the marketing/advertising of fast food to kids might also be another mechanism to support a local, nutritious, healthy food system.

Studies indicate that behavior and environment account for roughly 70% of our health outcomes, and medical care only about 10%. Yet 96% of our national health expenditures are focused on medical care, with only 4% dedicated to prevention.16 If we are concerned about the health and future of our communities, we must create institutions that reflect this role. With strong collective will and creativity, we can develop new institutional governance models that generate and implement agricultural and prevention oriented policies, prioritizing the small-scale farm sector, rural livelihoods, food security, nutrition, and a food and agriculture focused policy and practice prevention agenda.

Bioregional and Megaregion Anchor Institutions

Most hospitals are affiliated within large health systems that cover multiple states and numerous foodsheds. These health systems, in turn, purchase significant amounts of food and medical commodities such as medical equipment through large national buying groups called group purchasing organizations. Although aggregated purchases through system wide and national group purchasing contracts may achieve some economies of scale for health systems, this system of purchases perpetuates food as a commodity.

The role of anchor institutions—large community-based universities and healthcare institutions—and their relationship to their communities and the local food system needs to change. Rather than working independently, these entities need to work collaboratively to utilize their inherent market position and outreach potential to foster an active and vibrant social fabric. Although our current healthcare system promotes competition, we need to develop community-based models that support collaboration. It is increasingly likely that these will be bioregionally or megaregionally based.17 Ideally, we develop food distribution and procurement models that fit the local food shed and as a result reflect the cultural food values of those communities.

Anchor institutions are central the development of commons healthcare at the community level, but to support this agenda, their leadership must recommit resources, attention, and reengage with their community. It will require that our institutions decouple their food procurement from their current model of national contracting and that our educational systems help provide the research and knowledge to support such food system infrastructure development. In some communities this reengagement is already occurring as anchor institutions commit to the development of regional, cooperatively owned and managed food hubs. Health professionals, health and educational leaders are central change agents, especially at the local level, and can influence food, agriculture, and social policies and thereby strengthen community resilience inherent in commons healthcare.