Above photo: Kiyoshi Tanno/ Getty Images.
Applying James C. Scott’s theory to current events.
In his brilliant book, Seeing Like a State: How Certain Schemes to Improve the Human Condition Have Failed, James C. Scott, warned of projects “driven by utopian plans and authoritarian disregard for the values, desires, and objections of their subjects.” Although the Yale Professor of Political Science and Anthropology, who died last year, wrote Seeing Like a State in 1998, his message is more important than ever as Donald Trump and his allies try to destroy and privatize the VA healthcare system and other government services.
Like the other authoritarian schemers that Scott analyzes, Trump, Elon Musk and their faithful servant, VA Secretary Doug Collins view the world through a narrow lens that ignores the “far more complex and unwieldly reality” in which human beings live their lives and, in the case of the VA, experience health and illness. Because they totally dismiss “local knowledge and know-how,” these privatizers are unable to even perceive, much less value the benefits of a comprehensive, integrated system that has developed expertise in the problems of a very specific population – veterans.
In his first chapter, Scott vividly describes the limits of this kind of narrow vision by introducing us to the work of the fiscal foresters employed by 17th and 18th century monarchs to calculate the worth of royal lands. Since Trump aspires to kingly status, and his minions are required to manifest the kind of obsequious deference due to a monarch, the example Scott deploys is particularly apt.
In Europe in the 17th and 18th century, monarchs sent out a version of the modern accountant to assay their vast forested domains. These fiscal foresters contemplated the royal forest and reduced its complex landscape “to a single number: the revenue yield of the timber that might be extracted annually.” These fiscal foresters (who were later followed by “scientific” forestry) acknowledged that the king’s timber could be used for construction and shipbuilding, and oh yes, maybe for fuel for the king’s subjects. The real value of the forest was not, however, how it served the people but how it served the revenue needs of the king. (You begin to see the relevance here?) “In state fiscal forestry,” Scott explains, “the actual tree with its vast number of possible uses was replaced by the abstract tree representing a volume of lumber or firewood.”
What was missing from this narrow perspective? A lot. Indeed, almost everything.
Missing from this myopic vision was, ”the flora: grasses, lichens, ferns, mosses, shrubs, and vines. Gone, too, were reptiles, birds, amphibians, and innumerable species of insects.” Missing was the human interaction with, and social uses, of the forest – “hunting and gathering, pasturage, fishing, charcoal making, trapping and collecting valuable food and minerals as well as the forest’s significance for magic, worship, refuge and so on.“
There was, of course, one human or social use of the forest to which the king and his sylvan accountants paid great attention — poaching, which was severely punished. But the “forest as habitat disappears and is replaced by the forest as an economic resource to be managed efficiently and profitably.”
This is precisely how Trump/Musk/Collins view the VA and the private sector providers with whom they are so enamored. The VA, like the king’s forest, is not a a real- life healthcare habitat or ecosystem but rather a collection of abstractions. Its value is measured only in the number of and cost of personnel, buildings, exam rooms, medical equipment, number and cost of medical appointments, procedures, and medications. Concerns expressed about delays in getting appointments or procedures, or about where care is located are simply a pretext to justify redirecting revenue from the pockets of the tax-payers (or commoners) and into the bank accounts of our modern- day kings.
When it comes to the current batch of would- be monarchs and their fiscal accountants, neither the patient nor caregiver experience – the human interactions that occur in the healthcare habitat – are visible. Invisible also the broader ecosystem in which the patient thrives or dies.
In his testimony to the Senate during his confirmation hearing, Doug Collins opined that the VA is hardly unique. “Health care is done in this country everyday outside of the VA.”
Indeed, it is. But what kind of care do veterans get outside the complex ecosystem of the VA in the world of profit -driven healthcare? Let’s look at cancer care. Studies show that veterans get more invasive procedures. Their oncologists mark up the chemotherapy drugs they receive – and thus have an incentive to prescribe round after round of chemotherapy even when the patient has no hope of a meaningful recovery. As I wrote in my book Wounds of War, “According to one recent study, “52% of older Americans with cancer were admitted to an acute care hospital, 27% had at least 1 admission to an intensive care unit, and 10% received chemotherapy.” In 2009 about 28 percent of older Americans—49 percent of them with dementia—died in nursing homes, where they received poor symptom management, with too many admissions to hospitals, as well as invasive treatments like mechanical ventilation, tube feeding, IV fluids, and antibiotics.
“The VHA, on the other hand, offers a system-wide alternative to medicine’s costly fix-it/fight-it model of treatment for the seriously ill, aging, and dying, as well as a model of full-throttle, team-based collaborative practice. The focus of this work is on symptom control; pain management; helping patients cope with depression, denial, despair, or anger; and figuring out patients’ goals so that they can have better quality of life during whatever time—be it years, months, or days—they may have. The palliative care teams work with patients who may not be actively dying but who nevertheless will eventually die of their disease. Through the VHA’s hospice services, they also work with patients whose lives are near an end.”
When I observed the interactions between oncologists and palliative care teams in the VA I was stunned. In the private sector, cancer doctors often put off referring a patient to palliative or hospice care because that will impact their bottom line. Stop treating and you stop billing. In the VA, patients aren’t viewed as generators of revenue (and neither are physicians) but as people in need of care. When medical treatment is no longer useful, oncologists will actively call the palliative care team and collaborate with them to help the patient die without pain and with dignity.
Or consider a story that illustrates the power of VA ecosystem in caring for patients with mental illness that a VA psychologist told me several years ago (when VA employees weren’t risking their job to tell the public how well the system works). The psychologist was treating an Iraq vet with severe PTSD. The patient needed a gallbladder operation and freaked out when he got to the surgical ward before his scheduled operation. Because the surgeon and psychologist worked in the same system, the surgeon immediately went to the shared VA electronic health record and found the name of the patient’s psychologist. Because the surgeon was on salary and worked in a system that highly prizes collaboration and teamwork, he immediately called the psychologist, described the situation, and asked for advice.
Given the patient’s history with PTSD, the psychologist wasn’t surprised to hear that he was having a hard time and advised the surgeon about how to handle the situation. The psychologist then walked over to the hospital and visited the patient to help calm him down. He the surgery and it all went well.
This would be an outcome that would be difficult, if not impossible, to be replicated in the private sector or through the VCCP. In a fee-for-service system, which the VCCP is, few surgeons would take the time to try to ferret out the name and contact information for a patient’s psychologist. Even fewer, if any, would have access to a shared medical record in which this information would be easily available. And what private sector psychologist – without the ability to bill for the activity – would get into a car and drive over to a hospital to visit a patient and calm him down. In the human habitat of the VA, this is not uncommon. In the private sector, it’s almost unheard of.
Collins, Musk, and other VA privatizers know absolutely nothing about healthcare in general and are utterly incurious about the intricacies of a system devoted veteran’s complex health conditions. In this, they echo their boss, who in 2017, when trying to dismantle Obamacare, announced with great surprise “Now, I have to tell you, it’s an unbelievably complex subject,” “Nobody knew health care could be so complicated.”
In his book, Scott warns of the “The dangers of dismembering an exceptionally complex and poorly understood set of relations and processes in order to isolate a single element of instrumental value.” Fortunately, many people do see — and even more are becoming aware of, the value of the VA healthcare system and other government programs. We can, I believe, fend off the attacks on our complex institutions but only by making the intricate and interconnected strands of their tapestry of care visible not only to the individuals those systems serve but to the nation as a whole.