A Parallel Polis for Medicine
How new, small-scale, decentralized initiatives can address our ills and reform a broken healthcare system.
As I explored in two recent posts (The Managerialist Revolution in Medicine and Why We Are Sick), our medical institutions—from hospitals and licensing boards to medical schools and professional societies—are failing us. The complex of problems in many of these institutions makes reform or repair, in the short term at least, impractical and perhaps impossible. Too many vested financial or other interests will not readily relinquish their territory.
Still, I want to suggest here a rough blueprint for a way forward. Any short-term hopes for the medical system’s fundamental reform or even moderation appear futile. I believe a better strategy involves, to the extent possible, ignoring the medical regime’s official structures and building new ones—small-scale initiatives where decentralized medical care can be restored and patients can be empowered to take responsibility for their own health. We need a what the Czech dissidents of the 1970s called a “parallel polis” for medical institutions.[i]
These would supplement the beneficial and necessary functions that are missing in the existing structures, and wherever possible, would use those existing structures, to humanize them. These initiatives need not lead to a direct conflict with mainstream medical institutions. At the same time, this strategy harbors no illusions that cosmetic changes to mainstream medicine can make any meaningful difference.
This involves occupying the spaces that medicine has temporarily abandoned or which it never occupied in the first place. These parallel institutions need not constitute a ghetto or an underground; they are not a black-market system hiding in the shadows. The purpose of these institutions is to eventually renew the entire healthcare system, not to retreat from it entirely.[ii]
Admittedly, every institution of the parallel polis will be a David facing the Goliath of a massively powerful and totalizing medical system. Any one or another of these institutions could be crushed by the state machinery, working as the enforcement arm of institutional and corporate medicine, if the state specifically targeted it for liquidation. Our task, therefore, is to create so many of these parallel structures and institutions that the captured state would finally be limited in its reach: while it could crush any one institution at any time, there would eventually be too many such institutions for the state to target them all simultaneously.
At the behest of governments, medical institutions during covid demanded we become disempowered and isolated. People globally ceded their sovereignty and abandoned social solidarity. By contrast, the new parallel institutions of medicine must return sovereignty to individuals, families, and communities and strengthen social solidarity. These institutions must help people take responsibility for their health and must always support the doctor-patient relationship, minimizing external intrusions on this relationship.
In these new medical models, physicians need to be able to exercise individualized clinical judgment and appropriate discretionary latitude. Doctors should work primarily for patients and only secondarily for institutions. During covid, governments weaponized fear to coerce individuals, families, and communities to cede their sovereignty and even make them forget they once had it. To help individuals, families, and small communities reclaim their ability to self-govern we must help people overcome their fear and find their courage.
Markets, communications, and governing structures within medicine have become increasingly centralized at a national and global level, robbing individuals, families, and local communities of legitimate authority, privacy, and medical freedom. Thus, the new medical institutions must be grounded in technologies and models of decentralized communications and information sharing, dispersed authority, and localized markets. To name just one example among many, subscription-based models of direct primary care, which bypass Medicare and other third-party payers, are springing up around the country and in many cases proving financially viable—delivering better health outcomes at lower costs by eliminating the expensive and superfluous bureaucratic middlemen.
Individuals, families, and local communities have been robbed of their legitimate authority. To rectify this, the new medical institutions must support the principle of subsidiarity and empower practical efforts at the local level. New cooperatives as an alternative to traditional health insurance are one example of recent creative thinking in the domain of healthcare reimbursements that respect this principle of subsidiarity and help individuals and families maintain legitimate authority over healthcare payments.
The Homeschooling Parallel
We need to plant seeds that might not fully germinate in our lifetimes, thinking in 50 to 100-year increments. Consider the homeschooling movement in the United States. In 1973, just over fifty years ago, there were 13,000 homeschoolers; today there are 5 million. A generation ago parents would get a visit from social services for not sending their children to “approved” public or private schools. It was considered déclassé, if not borderline criminal, to attempt to educate one’s children oneself.
Undeterred by suspicion and outright persecution, the homeschool movement created a parallel polis, reappropriating the idea of self-education and autonomous learning that had been monopolized by those with advanced degrees in education. While not every homeschooler succeeded, many thrived, demonstrating that their children could get a superior education—winning the spelling bees, acing standardized exams, and earning admission to prestigious universities—for a fraction of the cost of other schools. These pioneers formed co-ops, and often later founded private or charter schools, thereby influencing directly or indirectly the mainstream educational landscape. This movement eventually changed the face of institutional education. Homeschooling is now part of the mainstream and the resources to facilitate it have multiplied.
Medicine today needs its own equivalent of the homeschool movement. Ordinary people need to reappropriate the idea of self-care and autonomous healing that has been monopolized by physicians and other healthcare professionals. Just as homeschooling deinstitutionalized education so we need to demedicalize healthcare, at least to some extent. Medical professionals have our role—just as professional teachers continued to have a role, influencing and sometimes assisting the pioneers of homeschooling. But doctors and nurses need not be the only game in town. Over time, perhaps in fifty years, this decentralized health care movement will positively influence, directly and indirectly, the practice of institutionalized medicine.
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