Sunday, September 15, 2013

Campesino Medicine



Of my patients


I am a physician.  Most of my patients are Mexican.

Of course, we stop and scrutinize everything that mentions another culture or country, and parse the phrases for their political correctness, so let’s, for a second.  It is politically alright to call my patients Mexicans, I’d say, for they are from Mexico.  Most are not in any sense not Mexican-Americans; excepting a brief continuation of their stay in the United States, they are here illegally, awaiting deportation to Mexico.  The few I see who have lived since childhood in the US are a whole different sort.  I treat them in English; they are completely from a different universe.  My patients are from Sonora, and Durango; from Baja California Norte, and Oaxaca.  Mostly, their “business enterprises” have brought them here; I do not discuss their “business” background.

They come from a broad range of cultures, abilities, education and origins.  Here, in the US bubble, we sketch our pictures of Mexicans with the broadest strokes.  Our image of Mexicans is really a cartoon; our amigo bueno, Gustavo Arellano will tell you that in “Ask a Mexican®” in the Orange County Register, and in the local Alibi.   For those bothered by the logo on his column (right), one can click on it and take it up with Mr. Arellano and Mark Dancey.

I shall not dwell overmuch on political correctness in terms.  Political correctness is often called upon to fill up time in the absence of real thought, and to generate purposeless dispute and bickering, in the empty echo-chamber of modern thought.

We think of the campesino – the fieldworker – most of the time when we speak of Mexicans.  We do not think of the Museo Soumaya, a museum which contains a preponderance of the works of Rodin and other Impressionist artists in a boldly modernistic structure in Mexico City.  The picture is an actual photograph of the museum, although it appears so crisp and stylized as to seem like an artist’s sketch.

This amazing building was constructed by Mr. Carlos Slim, a Lebanese-Mexican businessman, in memory of his wife, Soumaya, who collected many of the artworks in her personal holdings that now reside in the museum.  She was a Mexican, like her husband.  Those artworks, like the museum, were paid for by the family out of their personal wealth.

Lest anyone cringe at the term “Mexican Businessman,” and consider the PRI and institutionalized corruption, this family’s wealth largely derived from introducing the digital age to Mexico and beyond.  One could call him the “Bill Gates of Mexico.”  However, his wealth exceeds that of Mr. Gates, so really Microsoft was founded by the “Carlos Slim of America.”

Of Campesinos that I have met


What we see here in America is largely the campesinos – the rural fieldworkers, who are simply the Okies of the Dust Bowl from a different place, from a different time.

America struggles to understand and handle the presence of illegal Mexicans.  I do not understand why, as they are the model residence in the eyes of government.  They work in an economic paradise, from the government’s perspective.  They often pay Social Security taxes through withholding, using bogus numbers; but they do not collect Social Security earnings, nor Medicare nor Medicaid.  They pay millions, but are not entitled to any benefits – any government’s ideal citizen.

In America, the campesinos do not annoy the government with entitled demands and expectations; they usually hide from any contact with authorities.  They flee.  They cannot argue for their Fourth Amendment rights, or other Bill-of-Rights stuff; that is not their America.

Unlike the farm and orchard, the Mexicans I see come from a broader swath of background and culture than the pickers and stoopers of the Central Valley in California. 

My interest is not in what makes pickers pick – our civilization has spent many millennia gathering food from the earth, and it is not a valuable enterprise, regarding wealth and prosperity.  It will keep you alive; the gleanings of windfall can be eaten from the orchards, the bruised apples and wormy pears.

In actuality, the term “Mexican” can mean picker, or entrepreneur, when applied to the whole spectrum of the country’s people.  Here in the US, we simply mean campesinos, and for some reason fear and despise them.  What Mexicans do to us does not concern me as much as what we are doing to ourselves.

Campesino Medicine


Somehow, the recruiters have gotten my email address.  I am offered a position in Virginia.  “Are you available in December to pick up hospitalist work?  We have a new facility in Virginia looking to fill their schedule and need your help!” And in California: “CA Puzzle Piece Solutions 1Hr to Bay Area, California - $300,000+ Real Potential - 100% Outpatient - No Call.”  Or Las Vegas (NV) “See a show or try your luck in Las Vegas for 6 months!~ ANY State License Gets You Here” And East Coast: “we have an opportunity just minutes form Philly and the Jersey Shore in our rehab facility.”

This is depressing.  How does a former profession go from providing care, to eMigrant labor in the 21st century?  Of all the business models for healthcare in the future, why the campesino model?

I have no particular contempt for the campesinos from Mexico.  One side of my family came to the factory town of Lawrence, Massachusetts to work in the mills doing handwork; the other side fled north Texas to high water and survival in Magdalena, New Mexico.  I think no less of pieceworkers, or pickers and stoopers; I only ask why that means of producing things is still used beyond Neolithic agriculture.

Of ideas old and discarded.


Somehow, we have harvested the chaff in management planning, at least in medicine.  All of the terrible ideas in management that were energetically discarded years ago have gone underground, and survive still in the HR departments and general occupational consciousness in America.

Early in the Journal of the Harvard Business School, Whiting Williams criticized and scrutinized some of these terrible old ideas and suggested a reformation of them.


To-day the majority of us find ourselves in such contact with the general public that we are likely to accept as final for us-the measurement of the particular tape-line which that public, rather than any smaller and probably more discerning group, currently, employs.   Here in the United States, that is apt to mean the pursuit of one thing - wealth.  For, at the present time at least, the dollar furnishes ·the yardstick by which the great body our fellow citizens habitually endeavors to determine the exact degree of each member’s accomplishment.


Too long we have thought of work as a curse. The truth is that every one of us plays a part in making it whatever it is; it becomes a curse only when we withhold from the performer of any useful service our proportionate economic and social recognition. Because we have so long failed to see men's wish for worth through work, we have failed too often to keep our promises of reward. Indeed, we have too generally based our whole program of the management of our industrial personnel less upon the hope of reward than upon the fear of punishment. That fear is the fear of discharge the fear of joblessness and all of those attendant stigmas and miseries which not management but society has erected.[1]


No campesino would speak well of any of the current management ideas.  They would agree with Williams – for what other purpose would drive a family to uproot themselves in the old country and flee to a new land without any guarantee of success, other than the hopes that Williams writes about.

They may be proud of being campesinos – of working hard with dignity.  They are not proud to be campesinos.  Their children are intended to be Americans.  Every culture that has come to America has hoped to make their children Americans, not second-class Americans.  Although they may derive honor for feeding their children, they would be embarrassed if their children only follow in their footsteps.

The awful idea remaining is that if a certain enterprise is considered too expensive, one should fracture it into constituent elements, rote behavior and piecework; and measure the productivity of the “pieces” scientifically, in order to maximize profit and throughput.  Then one can offer “best practices” that maximize the productivity of the workers’ hands.

Nowadays, Williams sounds uncomfortably Euro-socialist, and Frederick Taylor more familiar, at least in the concepts currently used for management in medicine, in his assertion:

As has been pointed out, however, the underlying principles of the management of "initiative and incentive," that is, the underlying philosophy of this management, necessarily leaves the solution of all of these problems in the hands of each individual workman, while the philosophy of scientific management places their solution in the hands of the management… Under scientific management, on the other hand, it becomes the duty and also the pleasure of those who are engaged in the management not only to develop laws to replace rule of thumb, but also to teach impartially all of the workmen who are under them the quickest ways of working.

All that is needed is to include the assumption, in medicine, that management is the thing learned in a business school with an MBA, and that MBA’s should direct the business of medicine, and there you have it – the history of medicine over the last few decades.  Taylor long ago invented “management” as a class of people, as well as a duty; he implicitly accepts the division of the “management” class from the “proletariat,” as Marx sketched out decades before.  The inherent assumption is that those who ‘do’ cannot possibly see the forest for the trees, and it takes a special, remote class to govern the strategic interests of the enterprise.

We have decided that we no longer have the money to pay for medicine, and our response is to revert to Taylorism.  To make it work in America, we must denigrate the status of the ‘do-ers’ to pieceworkers, and the ‘leaders’ as the management class – a concept credible only to Marxists and scientific managers.

In order to dissolve the old model of healthcare, we have needed to disparage the professions, which we have done so admirably with nursing.  Now, it is the doctor’s profession that is being reconstructed as the shifting, migrant pieceworker, here in the Central California valley for a few months, then up to Oregon for a few more – the locum tenens and the campesino as all but the same principle.  As picking strawberries is easily measured and paid, why not the provision of medical care?  From a management perspective, they are all the same.

Where are we going?


 So, we continue to stagnate with management ideas that are a hundred years old and obsolete.  Meanwhile, Latin America is becoming digital.  The Mexican GDP exceeds that of Canada; it rivals and may soon exceed that of the UK and France.  Mexico did not really have a firm foundation for stability until 1929, when it became a stable autarchy of the PRI; it has only recently had a credible multi-party government in this millennium.  Within a much shorter time period of stability, Mexico is rapidly flourishing.

Like the Ottoman Empire and Roman Egypt, America might become the Amusing Old Man of the New World over the next few decades.

Do-ers and leaders.


Somehow, after starting with a powerful contempt towards nobility and class, we have settled into a culture riven with class and status; while Latin America struggles to jettison its old racism and discrimination.  They, like the Americans of old, are becoming more interested in those that can do, make and build, over the old aristocratic days of color and family. Perhaps the legacy of Jefferson and the founders has spread; it has not taken permanent root at home.  We persist in our Puritan certainty of this land as Divinely Chosen even after nothing recognizable persists from those days.






[1] A Theory of Industrial Conduct and Leadership, Whiting Williams, Harvard Business Review April 1923
Ref:  See also Chomsky interview on Taylorism, Here.

No comments:

Post a Comment