Barbara Ehrenreich: Nickel and Dimed

In this book the author descends from the upper class to play class tourist for a few months. She waits tables, cleans hotel room and arranges clothing at a Wal-Mart. Kind of like The Simple Life for the Sex and the City gals.  Couldn’t help but hum the peppy Pulp song Common People while reading this, as it’s about a woman wants to live like a commoner because it seems “cool”….and of course to have sex with Jarvis Cocker.

Unsurprisingly the working poor in the United States have it terribly. They don’t earn enough to cover the basic necessities of life, even if they work like animals. They are treated with disdain in the culture (“trailer trash”) and face daily humiliations in the form of drug testing and supervisors bent on degrading them.

The author herself was depressing as she does care about the poor, but is so obliviously classist that she demeans and classifies the poor as the “other” constantly. She points out a million times that she has a PHD, as though this implies some kind of superpower. When she shares a laugh with a co-worker, she is quick to point out that she laughs from a “feminist” perspective while the co-worker laughs from a “Christian” perspective. She mentions that an African American friend is an “educated feminist,” as though she wouldn’t befriend your average African American, only special ones.

The sad part is that even on the supposed left these are all euphemisms meant to denote a higher standing of class, when the emphasis should be that we are all humans. When working at Wal-Mart she mocks the distinction between brands on offer (Jordache – eww) and wonders why her co-workers show respect to their equally dim-witted bosses. She’s totally oblivious to the fact that, for the actual poor, their jobs matter and they have to submit to their superiors, the same as Ehrenreich would probably submit to her editor at the NY Times. I’m sure Jordache and Wrangler are every bit as different and make as much sense as Prada and Gucci.

It gets worse and Ehrenreich begins to imagine during her time at Wal-Mart that she is far too intelligent to simply do her job, so she starts directing her energy towards whipping up pro-union sentiments. She acts as though any average Wal-Mart employee is too stupid to think of this as opposed to the reality, which is that they are too exhausted and probably worry rightfully about being fired or punished. It perpetuates the myth that the poor are stupid and lazy, which the book is supposedly trying to eliminate.

I suppose if you are entirely oblivious to the poor or can only understand their plight if Samatha Bradshaw goes to live with them then this book accomplishes something.

I’ll let Jarvis provide the last word:

” ‘Cause everybody hates a tourist,
Especially one who thinks it’s all such a laugh,
Yeah and the chip stain’s grease,
Will come out in the bath.

You will never understand
How it feels to live your life
With no meaning or control
And with nowhere left to go.
You are amazed that they exist
And they burn so bright,
Whilst you can only wonder why.”

Jeffrey Simpson: Chronic Condition

This entry is a bit late coming. Why? I hated this book!  You tend to not pick up a book when you aren’t enjoying it. I didn’t quit, I gutted out all 376 torturous pages.

Chronic Condition is a look at Canada’s health care system, written by Jeffrey Simpson. Full disclosure, I’ve never liked Simpson. I’ve always thought he is a Liberal party stooge that toes the media line and never says anything interesting. The main problem with this book is that Simpson is a political writer, not a policy wonk.  I never got the impression he understood the Canadian healthcare system or even how the bureaucracy works. A political affairs writer is essentially TMZ for something more important than Snooki. It covers people involved in public policy, but it doesn’t get into the ins and outs of government programs and policies.  As a result the book was scattershot, highly repetitive and dedicated 100 pages to a political history of Canadian health care, when it could have been 10.

I never gave too much thought to the ins and outs of our health system in my twenties, but over the past two years I’ve been chronically ill. My partner is also an MD and we talk a lot about her work. The system works well in some ways (making sure people at immediate risk of dying don’t die mainly), but the more I learn the more I realize that it is an inefficient and incoherent mess. And nobody seems to mind this. Like all  massive bureaucracies “that’s just the way it is” and good luck changing it. I don’t think that’s good enough when it accounts for 40% of our provincial taxes!

I was hoping this book would give me some real insights, but I knew there’d be little insight when, speaking on the matter of finding efficiencies in the system, Simpson just says “that never works.” True it is inordinately hard to change the way a large, complex and entrenched system functions, but the book should be about giving it a crack. The other glaring omission is that Simpson barely speaks at all about what technology can do to make health care cheaper, or to better serve patients.

The book confirms that if you have cancer or are in a horrible car accident, you’ll be treated first and receive excellent care. It is everything else where we fail: wait times for specialists; treating chronic conditions; access to primary care; mental health services; and overall navigability.

In 2017 our medical system still runs on paper, phones and fax machines. Doctors communicate and refer among each other based, in large part, on who they happen to know. This is beyond inefficient, it is wasteful.

The system also serves mainly the practitioner and not the patient. Horribly ill and have to move 500 kms away? No, the Doctor will not talk to you over the phone for even 5 seconds. You must travel 1000 kms.

For the patient there are no options, no evident triaging based on need, no knowledge of what records are sent where. My family Doctor is part of a family health team that operated an after hours walk-in for its patients. Great, it’ll keep people out of the emergency room. At some point the after hours clinic stopped operating, but nobody ever told me. They don’t email patients. They don’t have a website. They have no incentive to inform me of how the system works, so why would they bother?

In my own case I waited so long to see specialists, that I ended up in the hospital for a couple of weeks.  This is probably, without exaggeration, 1000 times more expensive to the state than the ten 15 minute appointments that never happened.

At my wife’s clinic, probably 10% of appointments are not kept. Perhaps an automated auto-dialer or e-mail reminder might help lower this number? Nope. No time to call people.  That’s 10% of the time for someone being paid, on average, $250,000. Might as well burn $25,000 for each Doctor at the clinic (there are about 6 so that’s $150,000, almost enough to hire a new Doctor or a couple of nurses).

There should be some obvious priorities to fix:

  • Mandatory electronic health records that are connected to all physicians and pharmacies and which the patient can access. We do this for our taxes, why not health care?
  • Referrals to specialists that are structured, not based on who a Doctor happens to know. If a patient is willing to travel 1000 kms if it saves three months wait, let them have the option. It frees up space and gets people healthy.
  • Electronic referral, based on your geographic location and your health problem, to the correct practitioner (hospital, family Dr, nurse practitioner, walk in clinic etc.).
    • Let’s say I have a cut that needs stitches. Where should I go? I know that the hospital will deal with this, albeit after about an 8 hour wait. This is by far the most expensive place to go for the system. Is there another option? How do I even go about figuring this out? I don’t know. I doubt others do either, so they go to the hospital.
      • It is assumed patients understand how the system works. They don’t. How would they?
    • Do we need a yearly check up? My wife gets people coming in for these appointments, but they are apparently unnecessary.  How would the patient know this?

I agree with Simpson on this: some private medicine is a good idea; pharmaceutical prices should be negotiated by the federal government (we pay the 2nd highest prices for drugs in the world); there should be nominal fees for access ($15); and funding should follow patients and performance.

All and all a dull read that only touches the surface of what’s wrong and likely what’s possible. It could have been fascinating and there is still an amazing book out there for the right author!