The '3.5% rule': How a small minority can change the world
by David Robson - BBC Future - May 13, 2019
Nonviolent protests are twice as likely to succeed as armed conflicts – and those engaging a threshold of 3.5% of the population have never failed to bring about change.
n 1986, millions of Filipinos took to the streets of Manila in peaceful protest and prayer in the People Power movement. The Marcos regime folded on the fourth day.
In 2003, the people of Georgia ousted Eduard Shevardnadze through the bloodless Rose Revolution, in which protestors stormed the parliament building holding the flowers in their hands. While in 2019, the presidents of Sudan and Algeria both announced they would step aside after decades in office, thanks to peaceful campaigns of resistance.
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In each case, civil resistance by ordinary members of the public trumped the political elite to achieve radical change.
There are, of course, many ethical reasons to use nonviolent strategies. But compelling research by Erica Chenoweth, a political scientist at Harvard University, confirms that civil disobedience is not only the moral choice; it is also the most powerful way of shaping world politics – by a long way.
Looking at hundreds of campaigns over the last century, Chenoweth found that nonviolent campaigns are twice as likely to achieve their goals as violent campaigns. And although the exact dynamics will depend on many factors, she has shown it takes around 3.5% of the population actively participating in the protests to ensure serious political change.
Chenoweth’s influence can be seen in the recent Extinction Rebellion protests, whose founders say they have been directly inspired by her findings. So just how did she come to these conclusions?
Needless to say, Chenoweth’s research builds on the philosophies of many influential figures throughout history. The African-American abolitionist Sojourner Truth, the suffrage campaigner Susan B Anthony, the Indian independence activist Mahatma Gandhi and the US civil rights campaigner Martin Luther King have all convincingly argued for the power of peaceful protest.
Yet Chenoweth admits that when she first began her research in the mid-2000s, she was initially rather cynical of the idea that nonviolent actions could be more powerful than armed conflict in most situations. As a PhD student at the University of Colorado, she had spent years studying the factors contributing to the rise of terrorism when she was asked to attend an academic workshop organised by the International Center of Nonviolent Conflict (ICNC), a non-profit organisation based in Washington DC. The workshop presented many compelling examples of peaceful protests bringing about lasting political change – including, for instance, the People Power protests in the Philippines.
But Chenoweth was surprised to find that no-one had comprehensively compared the success rates of nonviolent versus violent protests; perhaps the case studies were simply chosen through some kind of confirmation bias. “I was really motivated by some scepticism that nonviolent resistance could be an effective method for achieving major transformations in society,” she says
Working with Maria Stephan, a researcher at the ICNC, Chenoweth performed an extensive review of the literature on civil resistance and social movements from 1900 to 2006 – a data set then corroborated with other experts in the field. They primarily considered attempts to bring about regime change. A movement was considered a success if it fully achieved its goals both within a year of its peak engagement and as a direct result of its activities. A regime change resulting from foreign military intervention would not be considered a success, for instance. A campaign was considered violent, meanwhile, if it involved bombings, kidnappings, the destruction of infrastructure – or any other physical harm to people or property.
“We were trying to apply a pretty hard test to nonviolent resistance as a strategy,” Chenoweth says. (The criteria were so strict that India’s independence movement was not considered as evidence in favour of nonviolent protest in Chenoweth and Stephan’s analysis – since Britain’s dwindling military resources were considered to have been a deciding factor, even if the protests themselves were also a huge influence.)
By the end of this process, they had collected data from 323 violent and nonviolent campaigns. And their results – which were published in their book Why Civil Resistance Works: The Strategic Logic of Nonviolent Conflict – were striking.
Strength in numbers
Overall, nonviolent campaigns were twice as likely to succeed as violent campaigns: they led to political change 53% of the time compared to 26% for the violent protests.
This was partly the result of strength in numbers. Chenoweth argues that nonviolent campaigns are more likely to succeed because they can recruit many more participants from a much broader demographic, which can cause severe disruption that paralyses normal urban life and the functioning of society.
In fact, of the 25 largest campaigns that they studied, 20 were nonviolent, and 14 of these were outright successes. Overall, the nonviolent campaigns attracted around four times as many participants (200,000) as the average violent campaign (50,000).
The People Power campaign against the Marcos regime in the Philippines, for instance, attracted two million participants at its height, while the Brazilian uprising in 1984 and 1985 attracted one million, and the Velvet Revolution in Czechoslovakia in 1989 attracted 500,000 participants.
“Numbers really matter for building power in ways that can really pose a serious challenge or threat to entrenched authorities or occupations,” Chenoweth says – and nonviolent protest seems to be the best way to get that widespread support.
Once around 3.5% of the whole population has begun to participate actively, success appears to be inevitable.
Besides the People Power movement, the Singing Revolution in Estonia and the Rose Revolution in Georgia all reached the 3.5% threshold
“There weren’t any campaigns that had failed after they had achieved 3.5% participation during a peak event,” says Chenoweth – a phenomenon she has called the “3.5% rule”. Besides the People Power movement, that included the Singing Revolution in Estonia in the late 1980s and the Rose Revolution in Georgia in the early 2003.
Chenoweth admits that she was initially surprised by her results. But she now cites many reasons that nonviolent protests can garner such high levels of support. Perhaps most obviously, violent protests necessarily exclude people who abhor and fear bloodshed, whereas peaceful protesters maintain the moral high ground.
Chenoweth points out that nonviolent protests also have fewer physical barriers to participation. You do not need to be fit and healthy to engage in a strike, whereas violent campaigns tend to lean on the support of physically fit young men. And while many forms of nonviolent protests also carry serious risks – just think of China’s response in Tiananmen Square in 1989 – Chenoweth argues that nonviolent campaigns are generally easier to discuss openly, which means that news of their occurrence can reach a wider audience. Violent movements, on the other hand, require a supply of weapons, and tend to rely on more secretive underground operations that might struggle to reach the general population.
By engaging broad support across the population, nonviolent campaigns are also more likely to win support among the police and the military – the very groups that the government should be leaning on to bring about order.
During a peaceful street protest of millions of people, the members of the security forces may also be more likely to fear that their family members or friends are in the crowd – meaning that they fail to crack down on the movement. “Or when they’re looking at the [sheer] numbers of people involved, they may just come to the conclusion the ship has sailed, and they don’t want to go down with the ship,” Chenoweth says.
In terms of the specific strategies that are used, general strikes “are probably one of the most powerful, if not the most powerful, single method of nonviolent resistance”, Chenoweth says. But they do come at a personal cost, whereas other forms of protest can be completely anonymous. She points to the consumer boycotts in apartheid-era South Africa, in which many black citizens refused to buy products from companies with white owners. The result was an economic crisis among the country’s white elite that contributed to the end of segregation in the early 1990s.
“There are more options for engaging and nonviolent resistance that don’t place people in as much physical danger, particularly as the numbers grow, compared to armed activity,” Chenoweth says. “And the techniques of nonviolent resistance are often more visible, so that it's easier for people to find out how to participate directly, and how to coordinate their activities for maximum disruption.”
A magic number?
These are very general patterns, of course, and despite being twice as successful as the violent conflicts, peaceful resistance still failed 47% of the time. As Chenoweth and Stephan pointed out in their book, that’s sometimes because they never really gained enough support or momentum to “erode the power base of the adversary and maintain resilience in the face of repression”. But some relatively large nonviolent protests also failed, such as the protests against the communist party in East Germany in the 1950s, which attracted 400,000 members (around 2% of the population) at their peak, but still failed to bring about change.
In Chenoweth’s data set, it was only once the nonviolent protests had achieved that 3.5% threshold of active engagement that success seemed to be guaranteed – and raising even that level of support is no mean feat. In the UK it would amount to 2.3 million people actively engaging in a movement (roughly twice the size of Birmingham, the UK’s second largest city); in the US, it would involve 11 million citizens – more than the total population of New York City.
The fact remains, however, that nonviolent campaigns are the only reliable way of maintaining that kind of engagement.
Chenoweth and Stephan’s initial study was first published in 2011 and their findings have attracted a lot of attention since. “It’s hard to overstate how influential they have been to this body of research,” says Matthew Chandler, who researches civil resistance at the University of Notre Dame in Indiana.
Isabel Bramsen, who studies international conflict at the University of Copenhagen agrees that Chenoweth and Stephan’s results are compelling. “It’s [now] an established truth within the field that the nonviolent approaches are much more likely to succeed than violent ones,” she says.
Regarding the “3.5% rule”, she points out that while 3.5% is a small minority, such a level of active participation probably means many more people tacitly agree with the cause.
These researchers are now looking to further untangle the factors that may lead to a movement’s success or failure. Bramsen and Chandler, for instance, both emphasise the importance of unity among demonstrators.
As an example, Bramsen points to the failed uprising in Bahrain in 2011. The campaign initially engaged many protestors, but quickly split into competing factions. The resulting loss of cohesion, Bramsen thinks, ultimately prevented the movement from gaining enough momentum to bring about change.
Chenoweth’s interest has recently focused on protests closer to home – like the Black Lives Matter movement and the Women’s March in 2017. She is also interested in Extinction Rebellion, recently popularised by the involvement of the Swedish activist Greta Thunberg. “They are up against a lot of inertia,” she says. “But I think that they have an incredibly thoughtful and strategic core. And they seem to have all the right instincts about how to develop and teach through a nonviolent resistance campaigns.”
Ultimately, she would like our history books to pay greater attention to nonviolent campaigns rather than concentrating so heavily on warfare. “So many of the histories that we tell one another focus on violence – and even if it is a total disaster, we still find a way to find victories within it,” she says. Yet we tend to ignore the success of peaceful protest, she says.
“Ordinary people, all the time, are engaging in pretty heroic activities that are actually changing the way the world – and those deserve some notice and celebration as well.”
https://www.bbc.com/future/article/20190513-it-only-takes-35-of-people-to-change-the-world
Forgive Us Our Debts
Churches are doing what politicians have been unable to do, rescuing Americans from crushing medical bills.
by Elizabeth Breuning - NYT - November 27, 2020
Vanessa Matos couldn’t believe what she was reading. “I was like, OK, this is a scam,” she recalled of the letter she received in February. Her husband, she said, had the same reaction: “Yeah, this isn’t real.”
But it was. Ms. Matos’s medical debt — more than $900 owed because of complications from surgery at the Massachusetts hospital where she had worked as a nurse — had been forgiven by strangers at a church she had never been to.
Adam Mabry, the lead pastor of that congregation, Aletheia Church, a multiethnic, 1,400-member Boston-area Christian community, doesn’t know Ms. Matos, and she doesn’t know him; the two have never spoken. But he told me: “It doesn’t take a theologian to connect the dots. Jesus paid my debt at unbelievable cost to himself, so it probably makes sense for me to pay another person’s debt at some degree of cost to myself.”
Aletheia worked through RIP Medical Debt, a charitable organization founded in 2014 by two former debt collection executives, Craig Antico and Jerry Ashton. It uses donations to buy portfolios of medical debt at a fraction of their value — and then forgives it.
Debt is a particularly destructive consequence of an American health care system that treats medical care as a consumer good. A Kaiser Family Foundation survey in 2018 found that 67 percent of Americans worry about paying for unexpected medical bills. By way of comparison, only 43 percent expressed similar concern about paying monthly utility bills, and just 41 percent cited rent or mortgage payments.
In 2019, the foundation found that 26 percent of adults have either struggled to pay medical bills or live with someone who has. Unpaid medical bills become medical debt, which destroys credit ratings, attracts harassment from collections agencies and postpones or precludes important purchases, including additional care.
In just societies, these debts do not exist. But in our society, charity must stand in for justice so long as the latter is in short supply.
One of RIP Medical Debt’s early fund-raising partners was NBC Universal, which ran a segment about the company’s campaign on its Dallas station in February 2018. The story caught the attention of Covenant Church, an enormous network based in North Texas. That Easter, Covenant donated $100,000 to relieve local families’ medical debt. RIP Medical Debt said since then it has worked with 465 congregations and religious groups to relieve about $820 million in medical debt across the country.
Partners of RIP Medical Debt need not raise the actual amount of money they intend to relieve in debt, because the price of debt reflects what collectors could recover — far less than is owed. That means a buyer can eliminate the debt for much less money than the debtor could.
RIP Medical Debt estimates that just one dollar can purchase, and relieve, $100 in medical debt. So with a series of relatively moderate fund-raising efforts and donations from corporations, nonprofit and religious groups, and individuals, RIP Medical Debt said, it has been able to eliminate almost $2.7 billion in medical debt.
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Some religious congregations have donated money from cash reserves, and others from fund-raising drives. But all of them grasp what our legislators can’t: The cost of survival in this country is unconscionable, and we all share a moral obligation to do something about it.
And yet there is still something remarkable — almost miraculous — about this faith-driven debt relief. Although American Christianity is as malformed by the harsh tug of political poles as any other realm, forgiving medical debt has managed to ally very different Christians behind the same cause.
Mr. Mabry, for example, cheekily described his theological stance as “historically boring and orthodox,” even evangelical. Most people “would associate social concern with progressivism and maybe theological liberalism,” he said, but “the great majority of actual social programs are funded and executed by really frustratingly conservative, boring, historic, orthodox people, I think we would find.”
The Rev. Traci Blackmon is associate general minister of justice and local church ministries for the United Church of Christ, a fairly liberal denomination. “The U.C.C. has no rigid formulation of doctrine or attachment to creeds or structures,” the church’s website says. “Its overarching creed is love.”
A recent campaign led by the church abolished more than $26 million in medical debt throughout New England, and the church plans to expand efforts to include the entire country.
Ms. Blackmon, like her denomination, is committed to social justice, having organized protests in Ferguson, Mo., after the police killed Michael Brown, and led an interfaith worship service in Charlottesville, Va., to oppose the 2017 Unite the Right rally. She sees this work as a natural extension of the U.C.C.’s interest in justice. “We’re buying somewhere close to $100 worth of debt for a dollar,” she told me, “and when you think about how many people’s credit is being ruined, how much access is being denied people because they can’t pay that bill, and I can come and pay your $5,000 bill with $12 — that’s not just.”
Mr. Mabry said a similar thing in our conversation. But if Christians so different in creed can agree on the necessity of relieving medical debt, why can’t Democrats?
The trouble with medical debt is that it is a consequence of the way our health care system is structured, with individuals owing, even in the best case, some out-of-pocket costs for their care. Debt may be eliminated today, but more will begin accumulating tomorrow unless drastic changes are made.
Karen Pollitz, a senior fellow at the Kaiser Family Foundation, said that while 45 percent of the uninsured have medical bills they can’t pay, one in five people in employer-sponsored coverage do, too.
In 2018, Kaiser asked people with high-deductible employer-sponsored insurance plans how they would pay if a medical procedure cost as much as their full deductible. Only 33 percent felt confident they could pay in full; the rest mentioned credit cards, payment plans, borrowing money — incurring medical debt, in other words.
It’s a reality many may soon face. Covid-19 can be an expensive illness to survive. Health System Tracker, a partnership between Kaiser and the Peterson Center on Healthcare, estimates that out-of-pocket costs for patients with private health insurance hospitalized for Covid-19 treatment can average about $1,300; those who require ventilator support or particularly long hospital stays can face even higher costs.
During his 2020 presidential bid, Senator Bernie Sanders proposed eliminating medical debt and then instituting a universal health care system that would prevent similar costs from building up again.
But President-elect Joe Biden’s record on helping Americans survive crushing debt is not promising. As a senator, he declined to vote for or he voted against measures that would have offered some protection to people suffering from medical debt. And he enthusiastically championed the 2005 bankruptcy bill that made it more difficult for families deep in debt to seek relief through the courts, touching off a feud with Senator Elizabeth Warren.
So far, his health care plan consists of protecting the Affordable Care Act and expanding tax credits and insurance options — better than nothing, but far less than needed.
There is an apocryphal statement often attributed to Saint Augustine, who helped lay the foundations of modern Christian theology: “Charity is no substitute for justice withheld.” Augustine was a proponent of both justice and charity, each with its place in the order of things. It is unfortunate that in the United States — a country so rich, so suffuse with every possible luxury — so many people receive justice only in the form of charity, and only after they have lost so much.
https://www.nytimes.com/2020/11/27/opinion/covid-medical-debt-church-charity.html
Why nursing home aides exposed to COVID-19 aren’t taking sick leave
The Conversation - November 23, 2020
The COVID-19 pandemic has devastated America’s nursing homes, but the reasons aren’t as simple as people might think.
To understand how nursing homes became the source of over one-third of U.S. COVID-19 deaths, you have to look beyond just the vulnerability of the residents and examine how nursing homes pay and manage their employees.
The average nursing aide earns just $14.25 an hour, less than $30,000 a year. Many are women who work at multiple nursing homes to make ends meet. Partly as a result of that, the typical nursing home has staff connections to 15 other facilities – each an opportunity for the coronavirus to spread. That risk is magnified by a reluctance among many nursing aides to take sick days when they are ill, even though federal law currently requires employers to provide paid sick leave for coronavirus-related reasons.
An alarming number of infections in long-term care facilities – nearly half – have been traced to staff who work in multiple health care facilities and who engage in “presenteeism,” meaning they continue to work even after being exposed to or falling ill from COVID-19.
As law professors who specialize in employment, immigration and health law, we have spoken with many nursing home aides to try to understand why this is happening and find ways to avoid it. The story of one of them represents what many others have experienced. We’ll call her Salma rather than use her real name to protect her from retaliation.
Like about a third of nursing aides, Salma is an immigrant. She often spends 12 hours a day cooking, cleaning and caring for residents’ most intimate needs, such as bathing, dressing, feeding and providing medication.
When Salma fell ill earlier this year, she requested paid sick leave, but her employer refused to provide it. She tried to assert her rights under her state’s paid sick time law, but she said her employer responded by threatening to report her to immigration authorities. When she explained that she had legal status, Salma said, her employer changed tactics and threatened to report her to the Internal Revenue Service because no payroll taxes had been deducted from her wages, as she was paid off the books. Salma was afraid she would lose her job, so she continued to go to work.
Our research, drawing on interviews with nursing aides like Salma and emerging studies of other essential workers during COVID-19, shows how employee policies, particularly for low-paid aides, have sharply raised the risks, and how access to paid sick leave could lower them.
A long-running problem
Historical records from previous outbreaks in the U.S., including the 1918 influenza pandemic and the 2009 H1N1 epidemic, show that immigrants and people of color are more likely to contract and die of infectious diseases. While preexisting conditions account for the severity of illness, they do not explain why these segments of the population are more likely to become sick in the first place.
Data show this is due to large percentages of immigrants and people of color performing essential labor, such as nursing aide roles, that requires close contact with many other people.
Our research asks why nursing aides are more likely to spread the virus. To answer this question, we examined laws and policies that affect them, including paid sick time.
San Francisco became the first U.S. jurisdiction to require paid sick leave in 2006. Other cities, counties and states followed, and now there are approximately 40 of these laws nationwide.
Paid sick leave laws require employers to pay workers who take time off when they or any family members are sick, injured or seeking medical treatment. Some laws explicitly allow for paid sick leave during a public health emergency, such as COVID-19. Most are based on an accrual model. This means employees must earn paid sick time hours; typically one hour of paid sick leave is earned for every 30 hours worked. Local paid sick time laws apply to private-sector employees and, in some cases, state and local government employees.
In March 2020, Congress passed the nation’s first universal paid sick leave law. This emergency law, which expires at the end of the year, provides most employees in the country with up to 80 hours of paid leave if the worker has been exposed to, is ill from, or is caring for someone infected with COVID-19.
However, a large survey earlier this year showed that many essential, low-wage employees still could not access paid sick leave after the law went into effect. That survey and our research show that these employees tend to either believe they have no right to paid leave or that their employer will retaliate if they try to use it. Many fear they could lose their jobs.
Even a short period of lost income can be financially devastating for these individuals. Among Latina essential workers, 43% surveyed said that even while employed they didn’t earn enough to adequately provide food for their families.
How to make sick leave work as intended
So, can paid sick leave laws be made more accessible for essential workers like Salma?
Our research highlights both the inadequacies of existing laws and policies and what might be done to strengthen them.
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First, nearly all paid sick leave law violations require federal or state labor agency intervention or the employee loses out. These agencies, however, often lack adequate resources to investigate potential employer violations and hold employers accountable if they retaliate against workers.
Second, most of these agencies are highly centralized and do not conduct effective outreach to immigrant communities, so both employers and employees are often unaware of paid sick leave laws. A handful of states and local governments offer pioneering examples. Massachusetts, for example, posted guidance online in multiple languages about sick leave and other workers’ issues. Washington, D.C., conducted tele-town halls with strategies to help workers and employers understand their respective paid sick time rights and obligations during the pandemic.
An approach that both empowers employees while informing employers about the benefits of paying employees to stay at home when sick can help save lives.
Moral Virtue in the Time of Cholera
How an Epidemic Revealed the Gulf Between Britain and the United States
by David Rosner - Foreign Affairs - November 18, 2020
In April, British Prime Minister Boris Johnson became one of the first high-profile world leaders to contract the novel coronavirus. He was hospitalized for about a week, including several nervous days in an intensive care unit where, according to Johnson, “things could have gone either way.” The prime minister recovered and used the occasion of his eventual release from the hospital to praise the National Health Service—the United Kingdom’s government-run health-care system. “The NHS has saved my life, no question,” Johnson said. Although successive Conservative governments have sought to privatize parts of the NHS, the system has remained deeply popular and a source of national pride. Johnson piously insisted that the United Kingdom would fend off the COVID-19 pandemic “because our NHS is the beating heart of the country. It is the best of this country. It is unconquerable. It is powered by love.”
U.S. President Donald Trump struck a rather different note when he became sick with COVID-19. Unlike Johnson, his stint in the hospital did not fill him with great reverence for social institutions or public health infrastructure but rather an admiration for himself. “I think I would have done it fine without drugs,” he told Fox News after receiving a cocktail of sophisticated medications and steroids. “You don’t really need drugs.” The president reportedly told advisers that he wanted to emerge from the hospital wearing a Superman shirt to show Americans that he had, through the force of his own indomitable strength, conquered the disease.
Johnson’s and Trump’s opposite responses to recovering from COVID-19 are indicative of two different personalities, but they also reflect an ingrained difference between the United Kingdom and the United States. Johnson affirmed the notion that combating disease is the task of a whole society, while Trump viewed his fight with the coronavirus as an individual struggle. That difference manifests most powerfully today in the countries’ disparate modes of health care. British citizens enjoy universal health care mostly free at the point of service, whereas the United States predominantly has a byzantine system of private insurance pegged to employment. Johnson and Trump may both be right-wing populist leaders, but they rule countries with contrary understandings of the role of the state and the individual in health care.
The divide between the British and the U.S. approaches to public health was apparent as long ago as the nineteenth century, when another pandemic, cholera, ravaged urban populations around the world. British thinkers, journalists, and medical professionals connected the disease to troubling social conditions and came to the conclusion that curbing the pandemic required a broader societal response. Their American contemporaries, on the other hand, saw the disease in large part as a moral failing and the responsibility of individuals.
These different responses in the 1830s did not entirely determine either country’s system of health care or approach to public health, but they did trace the trajectories the two countries would take in delineating the responsibilities of the government and the individual regarding health care. Britons and Americans still live with the choices their countries made during that time.
CHOLERA AND THE SATANIC MILLS
In 1831, cholera moved quickly from Central Asia through Europe and then to the United States. Newspapers on both sides of the Atlantic followed its deadly course in grisly detail. The pandemic was truly horrific: people who were seemingly healthy in the daytime would be dead by nightfall. In the United Kingdom, cholera swept away thousands in just hours. Desiccated bodies—the disease causes severe dehydration—lay strewn in the streets.
The British public linked the appearance of cholera to other crises overtaking the country. Beginning in the 1780s, hundreds of thousands of people left the countryside for booming industrial textile towns, such as Leeds and Manchester, where they lived in slums and worked for near-starvation wages. While they suffered, their labor produced great wealth for some in the expanding British economy—the merchants, factory owners, importers, and bankers.
The development of factories displaced and shattered rural communities and funneled people into truly unsanitary environments. The “dark satanic mills” that William Blake described in the preface to his 1810 poem, “Milton,” loomed large in the British imagination in the years before the cholera pandemic. Throughout the nineteenth century, Conservative and Whig politicians, political philosophers such as Jeremy Bentham and John Stuart Mill, and writers such as Charles Dickens debated the merits of and the destruction wrought by Britain’s sprawling new landscape of power looms, cotton gins, and steam- and water-powered factories, all built on the backs of laborers who lived and died in horrendous conditions.
The health of the worker became a poignant symbol of the excesses of capitalism. As Frederich Engels, himself an heir to a Manchester textile factory, wrote in his classic 1845 book, The Condition of the Working Class in England, it was “self-evident that a social class which live under the conditions that we have described and is so poorly supplied with the most indispensable necessities of existence can enjoy neither good health nor a normal expectation of life.” The ravages of cholera in London, Manchester, and other industrial centers alerted the public to the depths of a social crisis in which the industrial economy and its malign distribution of wealth enabled the spread of disease.
Despite Engels’s outrage, the suffering of the poor did not result in the overthrow of capitalism—but it did lead to a discussion about the responsibilities of the state in shaping the environment in which people lived and the services they received. In the wake of the cholera epidemic in the 1830s, social reformers such as Edwin Chadwick took note of the disintegrating health and well-being of large swaths of Manchester’s working class and began pressing for new housing laws and major investments in sewer systems, street cleaning, and water supplies.
In 1842, Chadwick published a 536-page report called The Sanitary Condition of the Labouring Population of Great Britain, which would inspire enormous infrastructural investments in British cities in the coming decades. Chadwick refused the narrow definition of sanitation—sewers, water supply, and garbage collection—in favor of a broad survey of the underlying conditions affecting housing, nutrition, and labor. His report suggested that the factors contributing to the diseases that killed the urban poor included such things as the construction of homes, the conditions in factories, and air quality. “These many subjects,” he wrote, “cannot be . . . overlooked in any report on the sources of disease among the laboring classes.”
In linking disease, the environment, and social policy, Chadwick set the stage for rethinking the role of government and public health in people’s lives. By the middle of the nineteenth century, doctors such as John Snow would realize that changing the environment—for instance, by taking the handles off water pumps and disabling them in streets served by polluted stretches of the Thames River—was the most effective way to address disease. Chadwick’s efforts helped convince many Britons that matters of health were embedded in social conditions, leading in the twentieth century not only to the NHS but also to public health services that were integrated into a broader social welfare system.
MEETING CALAMITY WITH SERENITY
The cholera epidemic did not prompt a comparable meditation on the responsibilities of the state on the other side of the Atlantic. U.S. newspapers reported the progress of cholera across Europe, detailing the rising number of deaths in London, Paris, and other European cities, but Americans remained largely untroubled by the prospect of the disease’s arrival. “Whether pestilence assails us in its most appalling form or whether under the favor of the Almighty, we escape altogether, or if peradventure in should please Divine Providence to bring calamity home to our doors, we and our fellows citizens will meet it with serenity,” the New York City Board of Health, a temporary body established for but a few months in the summer of 1832, gently reassured the population.
The epidemic soon spread. Religious leaders, state and local politicians, and even President Andrew Jackson called on the nation to observe “a day of fasting, humiliation, and prayer” and to go to church to ask God’s forgiveness as the means of ending the epidemic. As the weather grew colder, contemporaries believed their prayers were “answered” as the epidemic receded. Boards of health around the country told “their fellow citizens, that they consider the Health . . . so far re-established as to render the further continuance of their daily reports unnecessary.” Officials who were worried about the persistence of the disease generally took solace in the belief that it really affected only “the dissolute and intemperate” or that in smaller communities, such as Oyster Bay in Long Island, victims of cholera were “all Blacks.” Personal frailty and racism helped explain away the threat of the disease and assuage the fears of white citizens.
But by the middle decades of the nineteenth century, the toll of cholera and other epidemics in the United States had become undeniable. Cholera, typhoid, and yellow fever swept through cities along the East Coast and along the trade routes up and down Mississippi River towns from New Orleans to Minneapolis. As many as 48 people died for every 1,000 residents in New York City during these epidemics and thousands more, both infants and adults, Black and white, died in the rural South and Midwest. Scholars such as John Griscom in New York and Lemuel Shattuck in Boston surveyed their cities and found some of the same conditions that Chadwick identified across the ocean. Griscom wrote The Sanitary Condition of the Laboring Population of New York in 1844, two years after Chadwick produced the similarly titled report in the United Kingdom. Griscom celebrated Chadwick’s approach but gave it a special and telling American slant. He emphasized to his American readers that improving the social conditions of the poor would uplift their moral standing; the purpose of fighting disease, he argued, was in large part to make a more virtuous society. Would not education, for example, instruct the poor to avoid filthy habits and therefore disease? “Teach them how to live, so as to avoid diseases and be more comfortable,” he wrote. Although he recognized that social circumstances influenced health outcomes, Griscom still saw the poor and their habits as the root of the problem. Unlike in the United Kingdom, where disease was being cast as a social problem whose reach might extend across classes, in the United States, disease was still perceived as trouble for those deemed the “unworthy poor.” Those of high moral character and the wealthy were generally not thought to be at risk.
THE WORTH OF THE INDIVIDUAL
The United States adopted stratified systems of care informed, in part, by the notion that poor health signaled personal moral failing: private health insurance served the wealthy and the fully employed; Social Security and Medicare helped the aged and others who might have suffered through no fault of their own; and welfare and Medicaid tended to the so-called unworthy. Americans tied the provision of health care to the moral and social worth of the individual. Dwight Moody, perhaps the most popular and influential revivalist preacher in the United States in the 1870s, spoke to enormous, largely middle-class audiences in Boston, Chicago, and New York City and explained to them that there was so much “great misery and suffering” in their cities because “the sufferers have become lost from the Shepherd’s care”—not because millions were being squeezed into crowded tenements or because of the wider consequences of the inequalities of an emerging urban, industrialized society. In the following century, American charity workers, social policy experts, hospital administrators and trustees, and others in the middle-class professions and the political elites would distinguish between those people who had become dependent and sick because of circumstances beyond their control—the so-called worthy or deserving poor (or the “truly needy” in President Ronald Reagan’s words)—and those who brought suffering upon themselves through their own moral failings—the unworthy or undeserving. As a result, many American institutions, including hospitals and social services, tend to perceive suffering in highly individualized terms. In the United Kingdom, by contrast, from fierce debates among reformers, radicals, Conservatives, Whigs, and workers arose a new social welfare state that treats health and economic inequality as fundamentally linked and tasks the government with a major redistributive role.
The social and health crises of the nineteenth century thus created disparate futures for the United Kingdom and the United States. Today, as Trump and his acolytes dismiss the recommendations of public health officials as infringements on their personal liberties, they echo an earlier time, when Britons and Americans grappled with epidemics and came to very different conclusions. The United Kingdom’s success in reckoning with COVID-19 now depends on the marshaling of the resources and authority of the state to protect individuals—the collective enterprise that Johnson recognized after he left the hospital. In the United States, on the other hand, over 70 million Americans voted for a president who tried to convince them—in the face of all evidence—that his own virtuous conquest of the disease was proof that they had little to worry about.
https://www.foreignaffairs.com/articles/united-states/2020-11-18/moral-virtue-time-cholera
Vermont Medical Society endorses single-payer health care reform
VMS is the second state medical society to endorse single-payer health care, joins national medical groups American College of Physicians and Society of General Internal Medicine in supporting Medicare for All
The Vermont Medical Society (VMS) overwhelmingly endorsed a resolution supporting a single-payer national health program, also known as Medicare for All, at its annual meeting on Saturday, Nov. 7. The VMS, which represents 2,400 Vermont physicians and physician assistants, is only the second state medical society in the U.S. after Hawaii to formally endorse a national single-payer health care program.
The historic vote by VMS follows a year of rapid movement among physicians and other health professionals towards single-payer reform. In January 2020, the 159,000-member American College of Physicians announced its endorsement of Medicare for All, along with a “universal public choice” reform model. In August, the 3,300-member Society of General Internal Medicine endorsed a similar resolution. Meanwhile, more than 50 municipalities have passed resolutions endorsing Medicare for All, including major cities such as Philadelphia, Detroit, Seattle, San Francisco, Minneapolis, and Cook County, which includes Chicago. These resolutions reflect growing public support for a national health program: Last week, a Fox News election exit poll found that 72% of voters now favor Medicare for All reform.
The VMS resolution was introduced by Dr. Jane Katz Field, a pediatrician and vice president of the Vermont chapter of Physicians for a National Health Program (VTPNHP). “The need for universal single-payer health care has never been more urgent,” said Dr. Katz Field. “Thirty million Americans were already uninsured before the COVID-19 pandemic, and millions more continue to lose coverage as they lose their jobs. Today the Vermont Medical Society recognizes the need to move away from a broken health system that ties health care to employment, and towards a system of equitable and universal coverage.”
Dr. Katz Field added that the VMS also endorsed a second resolution reaffirming the group’s support “for universal access to comprehensive, affordable, high quality health care, centered on increased investment in primary care, reduced administrative burden and public health interventions that address the social determinants of health.” According to the resolution, any national health system would need to provide equitable access, minimal cost sharing, and fair reimbursement to practitioners.
Aside from funding the program through a publicly financed system, VMS developed a list of “core criteria” that a national health program would have to meet:
- Affordability, with no cost sharing for patients;
- Universal, equitable coverage for all U.S. residents;
- Comprehensive and high quality coverage for all medically necessary services;
- Fair reimbursement of physicians and other clinicians, particularly those in primary care;
- Collective participation by physicians and other practitioners in negotiating rates and policies;
- Global operating budgets for hospitals (similar to the way fire departments are funded);
- Elimination of for-profit health insurance companies in order to reduce administrative costs and burdens on clinicians.
The VMS’ endorsement comes at a pivotal time for health care reform in Vermont and nationally. Both of Vermont’s U.S. senators (Bernie Sanders and Patrick Leahy) support Medicare for All legislation in the Senate. Vermont’s U.S. representative, Peter Welch, is a sponsor of Medicare for All legislation in the House. Many single-payer advocates are also asking their members of Congress to pass emergency coverage for the duration of the COVID-19 pandemic.
https://pnhp.org/news/vermont-medical-society-endorses-single-payer-health-care-reform/
A Final Try by Trump to Cut Drug Prices May Stumble in Court
A new rule would base the price Medicare pays for certain drugs on the lowest price paid among similar countries. But a rushed process means legal challenges are likely.
by Margot Sanger-Katz and Noah Welland - NYT - November 20, 2020
Health officials on Friday finalized a policy that would base the price Medicare pays for certain drugs on the lowest price paid in some other developed nations. It is the most ambitious of several drug-pricing rules issued in the final months of President Trump’s term, but is likely to be vulnerable to legal challenges.
Mr. Trump has spoken for years about the idea, which he calls “most favored nation.” It would guarantee the United States the best price available among a group of developed countries for 50 expensive drugs it buys for Medicare beneficiaries. In a news conference Friday afternoon announcing the rule, he said it would “transform the way the U.S. government pays for drugs to end global freeloading on the backs of American citizens and American patients.”
The idea is anathema to the pharmaceutical industry, which has fought hard against any price controls on its products and has advertised heavily against the policy. And it runs counter to the policy preferences of lawmakers in Mr. Trump’s own party. Just last year, most Republicans on the Senate Finance Committee, which oversees Medicare, voted to prevent the administration from pursuing a weaker version of the same idea.
But Mr. Trump has always been an outlier in his party on drug prices, aligning himself more closely with ideas that are mainstream among Democrats. In his 2016 campaign, he said he wanted to let Medicare negotiate directly with drug companies on prices, an option that Republicans in Congress prohibited when they established Medicare’s prescription drug benefit in 2003.
The policy shares some features with a bill passed by House Democrats last year, which would also tie the prices paid for some drugs to those paid by other nations.
“His proposal is a break from the Republican orthodoxy,” said Rachel Sachs, an associate professor of law at Washington University in St. Louis, who called the regulation “an extremely big deal, rhetorically.” But she, like several drug policy experts, warned that a rushed regulatory process meant the proposal faced a high risk of being overturned in court after the industry inevitably sued.
Mr. Trump on Friday hinted at the possibility the rule may not survive. “I just hope they keep it,” he said. “I hope they have the courage to keep it, because the powerful drug lobby — big pharma — is putting pressure on people like you wouldn’t believe.” It was unclear whether Mr. Trump was referring to the courts or to the administration of President-elect Joe Biden. (The president at one point baselessly said he had won the election.)
On Politics with Lisa Lerer: A guiding hand through the political news cycle, telling you what you really need to know.
The proposal is possible under a provision of the Affordable Care Act that allows Medicare to test policy ideas that improve patient care and save money. But it is highly unusual because it would be established as a national, mandatory demonstration program. Most such projects have been set up as either voluntary or mandatory for only a random fraction of health providers, in order to study their effects. A few types of safety-net and cancer hospitals are exempted. The demonstration would last seven years, and feature a four-year phase-in of the price changes.
“This absolutely prevents the experiment from yielding results that could be interpreted,” said Dr. Peter Bach, the director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Hospital. “They’re not even pretending it’s an experiment.”
Though Mr. Trump described the policy as transformational, it may have very limited impact for most Medicare beneficiaries. The policy applies only to a category of drugs that patients get from doctors in an office or a hospital, not to drugs they buy themselves at the pharmacy counter. While some seniors do end up paying for a share of such drugs, the vast majority have special insurance that protects them from the cost. That means that the savings are likely to benefit the government more than individual patients. It will have no effect on the prices paid by people who get insurance through work or buy their own health plan.
But the plan, as written, would also change how medical providers are paid for administering those drugs, reducing their payment, too. An effort by Obama administration health officials to reduce those payments faced major opposition from the medical industry and was ultimately scuttled.
“America’s hospitals and health systems have very deep concerns about the substance and legality of today’s Most Favored Nation Model interim final rule,” said Tom Nickels, an executive vice president for the American Hospital Association, in a statement.
Mr. Trump announced two other major health policies. One would eliminate the rebates paid by drug companies to middlemen purchasers, a priority of Alex M. Azar II, the secretary of the Department of Health and Human Services. Another would loosen some anti-kickback rules on business relationships between doctors and other businesses, in an effort to improve cooperation between different players in managing patients’ health.
For years, Mr. Azar sought completion of the rebate rule, but faced opposition from the White House, including Joe Grogan, the former head of the Domestic Policy Council, who worked aggressively to kill the policy. Mark Meadows, the White House chief of staff, has worked with Mr. Azar this year to revive it as part of a package of drug pricing initiatives, senior administration officials said.
In a statement, a spokeswoman for PhRMA, the leading trade group for drugmakers, did not say whether the industry would bring lawsuits against the pricing rule. “It defies logic that the administration is blindly proceeding with a ‘most favored nation’ policy that gives foreign governments the upper hand in deciding the value of medicines in the United States,” said Nicole Longo, the group’s director of public affairs, who called the policy “unlawful.”
The statement was more supportive of the rebate rule, which drugmakers have tended to support.
Mr. Trump’s news conference was dotted with grievances against the pharmaceutical industry. He complained that he was the victim of “millions and millions of dollars in ads” targeting his drug pricing initiatives. He said Americans “have been abused by big pharma and their army of lawyers, lobbyists and bought-and-paid-for politicians.” White House officials are still upset about the collapse of an agreement with the pharmaceutical industry this summer to offer discounts to Medicare beneficiaries.
He also accused Pfizer of conspiring to deprive him of news of a successful coronavirus vaccine before the election, saying that his push to lower drug prices had prompted the company to hold off on announcing early clinical trial results.
“They were going to come out in October, but they decided to delay it because of what I’m doing,” he said. “They waited and waited and waited.”
There is no evidence of such a scheme. Though Pfizer had teased an early readout of data in late October, the company decided against it, waiting to gather a larger sample of Covid-19 cases that would offer a better indication of the vaccine’s effectiveness. Its analysis was announced on Nov. 9.
https://www.nytimes.com/2020/11/20/upshot/trump-drug-prices.html?
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