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In Search of Care :: International Adventures in Public Health

Freelance journalist and veteran traveler Michael Fox has sought medical care in more than a dozen countries. One of them stands out as the most difficult place to get treatment: his native United States.

Hospital Escuela

In the Hospital Escuela in Tegucigalpa, Honduras, a doctor examines a patient's X-ray.

Photo by Tech. Sgt. Cohrs, U.S. Army

Five years ago, I broke my arm in a tractor-trailer accident while traveling in Honduras. I’d left my friends outside of Tegucigalpa and thumbed a ride with a Nicaraguan truck driver hauling tens of thousands of pounds of fabric to the Nicaraguan capital, Managua.

Just a few miles outside the city, the Pan-American Highway winds steeply down the hillsides into thick forest. On our first major descent, the driver and I both knew something was wrong. The aging 18-wheeler was speeding up. The brakes were gone. The driver flipped the wheel hard to stay on the road. Grinding metal screeched through the air and the whole rig came crashing down on my side of the truck. We skidded to a halt, halfway on the gravel shoulder.

Passersby quickly helped us out through the shattered windshield. We were covered in glass. My right arm was limp, and pulsated with pain.

A passing family offered to take me to the hospital in Tegucigalpa. Since I didn’t have insurance, it would have to be the Hospital Escuela, the major public hospital in the Honduran capital.

There was a long line ahead of me, but the nurses walked me right in to a bed in the emergency room, without question of insurance or payment. Within a few hours I was X-rayed and a nurse came to pick the pieces of glass out of my bloody hands. Thankfully, only my right arm was broken—an incomplete fracture so close to my shoulder it didn’t need a cast. There was no charge for the X-rays, the consultation, or the pain medication.

My friends would pick me the following day, but with few funds for a taxi or hotel, and with no extra beds available at the hospital, I spent the night on the hospital floor.

“The abandoned son of the United States,” laughed the janitor the next morning, when he greeted me there on the floor and I told him where I was from. He repeated the phrase again to himself and then walked down the hall to tell his coworkers the news that someone from the United States of America had spent the night on his floor.

The uninsured and underinsured in the United States have a harder and more expensive time receiving adequate medical care than in any other country I know.

But the truth is that I got far better care in Honduras than I would have been able to get had I been in the United States, where I’ve been uninsured since graduating from college a decade ago. In fact, a year after the truck accident, my nose was broken during a random attack in San Francisco’s Mission district. The firefighters who responded to my 9-1-1 call advised me to say I was homeless—there was a safety net in place for homeless people, but none for those who simply couldn’t afford care.

In the years since, San Francisco has solidified a system of hospitals and clinics that provide free health care for all its residents while they’re in the city, making it an exception to the simple truth I’ve learned after using the public health system in more than a dozen European and Latin American countries over the last decade: The uninsured and underinsured in the United States have a harder and more expensive time receiving adequate medical care than in any other country I know.

I’ve been following the debate about health care reform from my current home in Brazil, where health care is considered a right of citizenship and all Brazilians are covered by the Unified Health System. As a foreigner, I have private insurance through my wife’s plan, which costs about $25 each month.

As protests rocked town halls in the U.S., I was shocked that so many people wanted to protect the most expensive, least inclusive health care system in the industrialized world. Lobbyists and industry groups have led many people to fear any change to the system, broken though it so obviously is. What does universal coverage really mean, they wonder? Does it take away my choice of doctor? Will it provide adequate care? The answers they hear are mostly in the form of fear-mongering industry spin.

But as a U.S. citizen who’s been a patient in countries throughout Europe and Latin America, I’ve experienced firsthand what universal access to health care is like. And what I’ve learned is that, in failing to offer what every other developed nation has been providing for decades, the U.S. and its citizens are missing out—and suffering unnecessarily as a consequence.

Europe

Six years before my accident in Honduras, I was traveling with a pair of friends on the tiny Greek island of Santorini. This time, rather than the brakes going out, the accelerator got stuck, and the scooter I was driving spun out, landing on my foot. While private practitioners are common in Greece, the Greek Health System (ESY- Ethniko Systima Ygeias) was established in 1983, guaranteeing free health care for all residents of Greece. I visited Santorini’s tiny clinic, then a larger clinic on neighboring Ios, where doctors took X-rays and outfitted me with a cast and crutches—all for free.

A few days later I was in Germany, home to the world’s oldest universal health care system. My foot still looked bad, and I decided to have it checked out again.

Pirna hospital

A hosptial in Pirna, Germany

Photo by Norbert Kaiser

German health care has no deductibles, and all Germans get the same high quality of coverage. To keep payments proportional to income, Germans pay a percentage of their salary into general “sickness funds,” forms of nongovernmental insurance that are closely regulated by the government. While high-income people can opt out and buy private insurance, few do.

Within a few days of arriving to Munich, I was sitting in the operating room of one of the best orthopedic doctors in the city, his nurses quickly shuffling around me, preparing the fiberglass walking cast which they would put on my foot moments later. They held my leg up to a cylindrical 3-D X-ray machine, which immediately showed the image of my foot on a nearby television screen—technology I have not seen before or since in the United States.

There was no charge for the diagnosis or for the cast. The doctor waved away any discussion of it, saying quickly, “I like to help people.”

He told me to have my foot re-examined in six weeks. By then, I was in London.

England is considered to have one of the most socialized health care systems in the Western world. Like many European countries, the UK established a public health care system on the heels of World War II. The National Health Service (NHS) provides free universal care to all UK residents, although eight percent of the population has private insurance.

I decided to go to King's University College Hospital. After a new X-ray, the doctors said that the bone had healed enough that I would be fine to continue without a cast. The service was top-notch and—like everywhere else—free. They did ask me to sign a form stating my “intent” to pay for the service. They made it very clear that I was not obliged to pay, but they at least wanted to insure that I “intended” to pay. British residents receive such NHS care free-of-charge (or free-of-intent-to-charge).

Over the following years, close friends and I would also use the public health systems in neighboring France and Spain. Each system differs slightly. Everyone is covered under the French health care system, funded mainly by payroll and income taxes. Also created just after World War II, the French Social Security system provides public health care to 80 percent of French people. The rest of the population receives their care through additional public or private insurance companies.

Latin America

Cuba clinic

Cuba's health care system is based on the neighborhood doctor and nurse.

Photo by Sarah van Gelder

On the flip side is the tiny Caribbean island of Cuba, under embargo by the U.S. for more than 47 years. Despite their lack of resources, Cubans have developed an extensive and world-renowned system of universal health care based on prevention, rather than on expensive emergency and intensive care.

When I was in Cuba in 2006, I came down with 104-degree fever and a wicked case of food poisoning. I was quickly rushed to a local clinic and then to a larger hospital. While the resources were low, the care I received was as good, if not better, than anything in Europe. Cuba has begun to charge foreigners for health treatment; however the price was far cheaper than anything I would have received in the United States. Had I been a citizen, all my care would have been free.

Despite their lack of funds, the Cubans have also opened their doors to many sick individuals who would never find adequate treatment in their home countries. Since 2000, thousands of Venezuelans have been treated in the island nation through the Cuba-Venezuelan Agreement. In 2006, I spent a day at a beach near the La Pradera International Health Center just outside of Havana, bathing in the turquoise-blue waters alongside dozens of bald Ukrainian children (and their families) who were being treated in Cuba for the cancerous effects of the fallout of the Chernobyl disaster.

The Cubans are also quick to send their health professionals abroad. According to the North American Congress on Latin America (NACLA), “since the first Cuban medical mission in 1963 (to Algeria), more than 100,000 of the country’s health professionals have served in 103 countries.” At least 20,000 Cubans have worked in Venezuela’s poorest communities through Venezuela’s six-year-old Barrio Adentro Mission. Venezuelans are now being trained to take over the positions from the Cuban doctors. According to government statistics, the Barrio Adentro Mission has carried out 300 million consultations and is estimated to have saved 120,000 lives.

I don’t doubt it. In 2006 and 2007, I lived and worked in Venezuela as a journalist. Everyone I knew used the Barrio Adentro public health care system—for everything from broken bones to bladder infections, yearly checkups to dental care. It was, and still is, utterly accessible and completely free to all.

With one of the largest petroleum reserves on the planet, and an average production of just over three million barrels of oil per day, largely in the hands of the state, Venezuela has the oil income to bankroll its social and educational missions. According to Venezuelan government statistics, as of 2007, spending in public health had roughly doubled over the last decade, to 4.2% of the national budget.

But that number sounds cheap, when you compare it with the 16 percent of GDP that the United States spends yearly on health care. And the U.S. figure doesn’t even cover the entire population.

United States

According to the World Health Organizations’ (WHO) 2000 report on Health System Performance, France came in at number one; Spain, number seven; Greece, number 14; the UK, 18; and Germany, number 25. The United States was way down at number 37. And when it came to the WHO’s ranking of Fairness of Financial Contribution to the Health System, the U.S. was tied with Fiji for 54th place, just after the Republic of Korea, the Maldives and Bangladesh. For the country whose total per capita health expenditure is by far the largest on the planet, that is dismal.

The problem is not one of production, but of distribution. The same WHO report rated the U.S. health system number one in its Level of Responsiveness. That is to say, if you have the money, anything is possible. The service is there. It just isn’t getting to everyone who needs it.

sick george
YES! Magazine's special issue, Health Care for All

It’s that last part that really bothers me. Health is not an item to be privatized. It is not a pair of shoes or a new car. It is not something you can do without. It is a human right–Article 25, in fact, of the United Nations Universal Declaration of Human Rights. And, as I’ve learned from my experiences, it’s not an unattainable goal, but something that countries far poorer than ours are able to deliver.

The health care crisis in the United States is not an accident. It is a by-product of a system built to maximize profit for large health insurance and pharmaceutical companies. When concern for the health of the citizens comes after the bottom-line, it’s a sign that the system is broken. If left only to the private companies, the system will remain broken, no matter how many reforms or vouchers you hand out to the growing poor.

The health care plan President Obama laid out in his speech on September 9th is a step in the right direction. There should be regulation of the private insurance companies. A public component is vitally important—as a competitor to keep private plans in check, and as a safety net all Americans can rely on. But reform cannot stop there.

Public health systems across the developed world rely on government-run programs not for five percent of the population (the number that Obama said in his speech would probably benefit from his public option) but for everyone. If citizens want to look for coverage elsewhere, they can, as in all the aforementioned European countries, pay for private insurance, or keep their existing private plan.

Millions of U.S. citizens would likely receive better medical attention in a foreign country thousands of miles away than in their own back yard.

I’ve been lucky to need medical help in places where it was accessible to me, and I’m grateful for the professional treatment I received. It is sad to think that millions of uninsured and underinsured U.S. citizens would likely receive better medical attention in a foreign country thousands of miles away than in their own back yard. That is what has to change.

Polls consistently show that 60 percent of U.S. citizens support some sort of government-run universal health-care system. Politicians say our current system is too entrenched, but they are just delaying the inevitable. It is not a question of “if.” It is a question of “when.” Because like the end of segregation, like the right to vote for all citizens, like the forty-hour work week, the right to universal health care will also come.

But it will only come with the grassroots mobilization of U.S. residents—which, in turn, will only come when we realize that universal health care is not something to fear, but a way to vastly improve our health system.

So, to answer the questions: Would a single-payer program take away my choice of doctor? Would it lower the quality of care? Based on my experiences across the planet, the answer is “no.” Quality can only improve with either a public or single-payer option. As Obama said, “Consumers do better when there is choice and competition. That's how the market works.”

But all of the companies competing in that market, concerned primarily with their bottom line, are now using their considerable resources to protect it, funding a disinformation blitz against public health care. In response, I say simply this: Don’t knock it, if you’ve never tried it. And if you have tried it and you don’t like it, then you can still purchase private care. That’s your choice. That’s freedom. That’s democracy.


Michael FoxMichael Fox wrote this article for YES! Magazine. Michael is a journalist, a reporter, and a documentary filmmaker based in South America. He is correspondent for Free Speech Radio News, and a former staffwriter for Venezuelanalysis.com. He is co-director of the 2008 documentary Beyond Elections: Redefining Democracy in the Americas, and co-author of the upcoming book Venezuela Speaks!: Voices From The Grassroots.

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