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Maywood, IL
Dr. Goldberg is Professor of Pediatrics, Stritch School of Medicine, Loyola University Chicago.
Correspondence to: Allen I. Goldberg, MD, MBA, FCCP, Department of Pediatrics, Loyola University Medical Center, 2160 South First Ave, Maywood, IL 60153; e-mail: agoldbe{at}lumc.edu
Can we study the experiences of one nation and adapt them to another? Can a solution for one population be expanded to meet needs of others? Are there universal principles that may be applied? What kind of understanding is required to do so?
In the current issue of CHEST (see page 695), Stuart and Weinrich challenge readers to reflect on these questions and compare France and America. The authors describe the long-term care crisis we face in America and argue why we have an opportunity now to "fix it" due to the US Supreme Court Olmstead decision (judicial mandate) and the President’s "New Freedom Initiative" (political support). The authors have sought international best practices as models for development of integrated community health systems for high-cost patients in the United States. They have described the background, evolution, and successes in the French regional approach to chronic respiratory insufficiency, and suggest France may provide lessons for a more global chronic care model for America.
A historical tradition exists for comparing France and the United States to answer these questions. In 1830, Alexis de Tocqueville officially visited America to learn about our new evolving democracy.1 He sought lessons that might apply to France where the 1789 revolution had created the possibility for "liberty, equality, and fraternity." Democracy in America1 sought to determine if the American experience could be translated into models for France and other evolving European democracies. His footsteps have since been retraced and observations re-evaluated.2
Like de Tocqueville, I traveled abroad to learn from another nation. Since 1967, I have visited France on several occasions to observe patients who need long-term mechanical ventilation and get community-based support not available in America. I interviewed many people representing a diversity of perspectives: government officials, professionals, patients/families, health-care and social service providers, and health industry representatives. I gained insights about social, economic, political, and cultural factors that must be understood. I learned why their system works and how it evolved over 40 years.3 4 5 6 7 8 9 10 11 12
The long-term care crisis in America is severe and will only get worse unless addressed by long-term care policy. The 2001 Fred Friendly Seminar, "Chronic Care in America ... Who Cares?" dramatized situations of victims who related personal stories describing the impact of chronic care on their lives.13 Web site data put the crisis in global perspective: three of every four US health-care dollars are spent on chronic diseases; 125 million Americans have some chronic health problem (60 million have multiple conditions); this will increase to 157 million in 2020 at an estimated annual cost of $1 trillion; 26% of American adults (mainly working women) currently serve as informal personal caregivers; many also making significant out-of-pocket financial contributions to the well-being of loved family members or friends; and 89% of Americans find it difficult to get insurance for chronic health needs.13 Situations and statistics like these should outrage all Americans!
The need to address population-based chronic care is not limited just to the United States. A health-care crisis challenges many other nations due to growing demands for long-term care. Existing health and social service delivery systems are not prepared for these new demands. A 1990 Max-Plank-Institut health-care summit of social scientists and experts in health-care policy was convened to address the growing need for chronic care due to demographic, social, and political changes in a unified Germany.14 Participants analyzed alternative delivery models suitable for the elderly and persons with chronic health needs. They reviewed the evolution of different community-based models in countries with national health systems, national health insurance, and evolving market/regulatory approaches. In addition to the analysis of finance systems, transnational analysis was undertaken to evaluate differences between nations’ health-care delivery models based on the same financial approach (France/Germany). German authorities wanted to know the following: (1) What are suitable models for persons with long-term requirements for health care and medical technology? (2) What can other nations’ experiences tell us about optimal economic and finance systems to avoid limited access to care?
Conclusions reached were fundamental to understanding the future of global health. No matter what organizational model was described (traditional hospital, home care, community centers, nursing homes, or other long-term care alternatives), what happens in each nation is based on two factors: (1) funding— the finance system does not matter; what matters is that funding is made available to provide an incentive to develop an organizational system; and (2) culture—variations between nations with the same health-care finance system are best understood in context of cultural differences between nations and at regional and local levels. National policy does make a major difference. However, the community is where people work together to design a variety of innovative local solutions that work, encouraged by (or despite) national health-care policy. These conclusions validated my own after much reading and reflection about my experiences in France and the United States on the impact of culture on medicine.15 16 17 18 19
Why focus on chronic respiratory insufficiency as a model for the solution for all chronic care? There is already a precedent in the United States for this suggestion by the authors. C. Everett Koop, MD, FCCP (Hon), knew about ventilator-assisted children for whom he cared as Surgeon-in-Chief at The Children’s Hospital of Philadelphia.20 As US Surgeon General, Dr. Koop used the ventilator-dependent child as a "case-example" to analyze needs and recommend solutions that would be applicable to all children with chronic diseases and/or disabilities. The "tipping point" was his 1982 Surgeon General’s Workshop: a very carefully designed change management intervention inviting and engaging specially chosen people.21 The process involved many components: demonstration projects, regional conferences, health research evaluation, and government agencysponsored initiatives.22 23 24 25 The ultimate result was change in public policy (Title V), which led to funding community-based services for all "children with special health needs" and development of concepts, programs, and services meeting their needs. This was done with sensitivity to political, economic, social, and cultural realities and an understanding of how to get things get done in America.
What lessons from France are universally applicable to other nations?
The "Communications in Healthcare" project with Dr. Koop is a series of public dialogues under the auspices of the ACCP/CHEST Foundation.27 In these communications, which began at CHEST 1999,28 Dr. Koop attempted to address concerns about chronic care and to provide solutions that will work in the 21st century. As Dr. Koop mentioned in his Honor Lecture at CHEST 2000,29 global health must be our number one priority in the new millennium. The 2003 Surgeons’ General Conference at Howard University Medical Center focused on health-care disparity and cultural diversity.30 Surgeon General David Satcher and Dr. Koop noted that we must develop cultural understanding and address global health community by community. If we do not address the long-term care needs of our nation, we will neither have success in the global economy nor develop a secure, safe world.
Footnotes
Dr. Goldberg was supported in his original research by a 1983 World Rehabilitation Fund–Experts and Information in Rehabilitation Research Fellowship, and a 1986 World Health Organization Fellowship.
References
This article has been cited by other articles:
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  O. R. d'Orbcastel, A. I. Goldberg, and M. Stuart French Health System: More Work Is Needed Chest, November 1, 2004; 126(5): 1710 - 1712. [Full Text] [PDF]
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