Agricultural Extension: The Model for Health Reform?

Atul Gawande is a rare mix: A practicing surgeon who is also a wonderful writer. In thinking about our health care crisis and reform, he started looking for models in American history that have worked to transform systems. In a recent article in the New Yorker entitled “Testing, Testing,” he found his model in a surprising place: Agricultural Extension. His treatment of early success of the extension system makes for fascinating reading (and for those of us working in the system, a nice pat on the back!).

Gawande notes that our health care system lags behind other countries but costs an astronomical amount. He asks: What have we gained by paying more than twice as much for medical care as we did a decade ago? Not much, because the system is fragmented and disorganized. To control costs, the new health reform bill proposes to address many problems through pilot programs: basically, a number of small-scale experiments.

Lest this approach seem absurdly inadequate, Gawande shows that it has worked before – in agriculture. He takes us back to the beginning of the 20^th century, when agriculture looked a lot like the current health care system. About 40% of a family’s income was spent on food. Farming tied up half the U. S. workforce. To become an industrial power, policymakers realized that food costs had to be reduced so consumer spending could move to other economic sectors. And more of the workforce needed to move to other industries to build economic growth.

As Gawande sums it up,

The inefficiency of farms meant low crop yields, high prices, limited choice, and uneven quality. The agricultural system was fragmented and disorganized, and ignored evidence showing how things could be done better. Shallow plowing, no crop rotation, inadequate seedbeds, and other habits sustained by lore and tradition resulted in poor production and soil exhaustion. And lack of coordination led to local shortages of many crops and overproduction of others.

Unlike other countries, the U. S. didn’t pursue a top-down, national solution. But government didn’t stay uninvolved either. Gawande tells the intriguing story of Seaman Knapp, the original agricultural extension pioneer. Sent by USDA to Texas as an “agricultural explorer,” he persuaded farmers one-by-one to try scientific methods, using a set of simple innovations (e.g., deeper plowing, application of fertilizer). As other farmers saw the successes (and in particular, that the farmers using extension principles made more money), they bought into the new practices.

Extension agents began to set up demonstration farms in other states, and the program was off and running. In 1914, Congress passed the Smith-Lever Act, which established the Cooperative Extension Service. By 1930 there were more than 750,000 demonstration farms.

The rest is, as they say, history. Agricultural experiment stations were set up in every state that piloted new methods and disseminated them. Data were provided to farmers so they could make better informed planning decisions.

And it worked. Gawande sums up:

What seemed like a hodgepodge eventually cohered into a whole. The government never took over agriculture, but the government didn’t leave it alone, either. It shaped a feedback loop of experiment and learning and encouragement for farmers across the country. The results were beyond what anyone could have imagined.

Gawande profiles Athens, Ohio agricultural extension educator Rory Lewandowski, showing that the system performs the same vital functions it did a hundred years ago. Gawande suggests that the health care system can’t be fixed by one piece of legislation. It will take efforts at the local level that involve “sidestepping the ideological battles, encouraging local change, and following the results.” Impossible, people say? Not really, since it’s been done before – in agricultural extension.