Sanjeev Sabhlok's blog

By Franklin Parsons, 1913

[Download Word document]

The germ of the idea of hospital provision for infectious diseases, not merely for the relief of the sufferer but also for the protection of the com­munity, may be found in the leper houses and pest houses of bygone centuries; but it was only in the year 1866 that the power to provide hospital accom­modation was explicitly given to local authorities. Long prior to this date, however, local benevo­lence had provided fever hospitals or, as they were frequently termed, Houses of Recovery, in many large cities. According to Dr. Murchison, these were the outcome of the fatal typhus epidemics which committed such ravages at the close of the eighteenth century, and the earliest was opened at Chester by Dr. Haygarth. The London Small­pox Hospital had, however, been established in 1745, and the Lock Hospital for venereal diseases in 1746. The London Fever Hospital was estab­lished in 1802. Except for such hospitals the only accommodation for patients suffering from in­fectious diseases, elsewhere than in their own homes, was in the general hospitals or in the work­house infirmaries. In the workhouse infirmaries infectious cases were mixed with other patients, to the danger of the latter, and were nursed and attended to by pauper nurses, commonly feeble old men and women, ignorant of nursing, and too often vicious and neglectful. In the general hospitals also the infectious cases—largely typhus—were usually treated in the same wards with those of non-infectious diseases; and, indeed, many ex­perienced physicians deemed it better to distribute the fever cases among other patients in general wards, provided that the proportion of the former was kept low, and that sufficient space and ventila­tion were provided, than to^–treat them in special wards or buildings. This view, however, was controverted by Dr. C. Murchison.

It had already been recognised that small­pox cases could not be treated along with other patients without great danger, of the disease spreading; and as the provision of special isolation hospitals became more frequent, the practice of receiving other infectious cases into general hos­pitals gradually ceased. Enteric fever and diphtheria, however, long continued to be received into general hospitals, the infectious nature of these diseases not being so generally recognised formerly as it is now—indeed, it was only in 1889 that diphtheria became legally admissible into the hospitals of the Metropolitan Asylums Board—and a few cases of urgency, especially those requiring operation, still find their way into general hos­pitals. The Sanitary Act of 1866, and subse­quently the Public Health Act, 1875; empowered local authorities to provide “hospitals or temporary places for the reception of the sick.” The sick for whom this provision may be made are not limited to those suffering from infectious diseases, and, indeed, a few local authorities have, under special circumstances, made use of their powers to provide or contribute to hospitals for accident cases, or for those of other diseases. But public opinion in this country has generally favoured the view that the care of the non-infectious sick, in so far as it does not fall within the province of the Poor Law; is best left to private charity.

The earliest hospitals provided by the local authorities were emergency structures intended to combat some formidable epidemic disease, and were either temporary buildings hastily constructed of wood or similar material, or existing buildings converted for use as hospitals. Sometimes these were disused when the emergency had passed; but in other instances they were retained for the recep­tion of cases of the infectious diseases of ordinary occurrence in the district, and thus formed the germs from which permanent isolation hospitals sprung. It was found, however, that, as was pointed out by Sir R. Thorne in his Report to the Local Government Board in 1882; “On the Use and Influence of Hospitals for Infectious Dis­eases,” that hospitals thus hurriedly erected under the influence of panic had often not been ready for use until the immediate need for them was past; that they were commonly ill-planned and ill-con­structed, and that the accommodation which they provided failed, almost without exception, to meet the permanent requirements of the district, even when in amount it proved to be more than the district needed. In these respects they were in contrast to the hospitals which had been carefully planned and erected during non-epidemic periods, with a view of preventing epidemics by having in actual readiness means for the isolation of first cases of infectious disease.

Since the issue of Sir R. Thorne’s Report the provision of solation hospitals has become much more usual. In 1879 the replies to a circular letter issued by the Local Government Board showed that at that time, out of a total of 1,593 sanitary authorities in England and Wales, 296, or 18.6 per cent., possessed means of some sort or other for the isolation of infectious diseases; but the hospital provision was in many cases such in name only, being rarely or never used, or was available only for one disease, usually smallpox. At the end of 1892, according to a Parliamentary return issued in 1895, out of 1,653 sanitary authorities then existing in England and Wales, outside London, 631, or 38.2 per cent., had provided alone or jointly with other authorities some kind of hospital accommodation for infectious diseases.

During the seven years _.1893-1899 the Local Government Board sanctioned 334 loans for hospital purposes—not all, however, relating to newly established or to different hospitals—while many other authorities provided themselves with hospital accommodation without the aid of loans, either by the erection or adaptation of buildings of their own —the accommodation thus provided being indeed often of a more or less temporary or make-shift character—or by entering into agreements for the, use of hospitals for other districts.

The principle of combination of districts has re­ceived much extension since the date of Sir Richard Thorne’s Report. At the time when he wrote there were a few such combinations, some under a Joint Hospital Board, established by Provisional Orders confirmed by Parliament; others under joint com­mittees less formally constituted. Sir Richard Thorne, however, was of opinion that an isolation hospital should; if possible, be within the limits of the district for which it was erected, and that in order to be reasonably available it should, in the case of a town, be distant not much more than two miles, and in the case of a rural district, not more than four or five miles from the populous parts of the district. He did not, indeed, find that removal for a distance of some five, or even eight or ten, miles in a well-constructed ambulance over ordinarily good roads had appeared to do harm to the patients, provided their removal had been effected at an early stage of their illness, but he found that the relations and friends assented much more readily to their removal to a hospital within an easy distance than to a more distant one. But in respect to this question circumstances have much altered since Sir Richard Thorne wrote. With experience of the use of isolation hospitals, and increased public appreciation of the advantages of hospital treatment, the objection to removal of patients, even to a hospital at a distance from their homes, has in most parts of the country much diminished.

As a matter of fact it is found that the area which a hospital can serve is much larger than was formerly supposed. Again it has been found that as compared with the establishment of separate small hospitals for individual districts, the provision of a large hospital for a combined area pre­sents distinct advantages. There is only one site to be obtained, with a larger area for selection ; which is an important gain in view of the difficulty often met with in obtaining hospital sites. Then, again, the preparation of a site for hospital purposes involves expenditure on fencing, road-making, drainage, water-supply, and similar matters; these are neces­sary for a hospital, however small; but the work needed even for a small hospital will serve with comparatively small increase for a considerably larger one. The same remark applies also to administrative accommodation, such as quarters for nurses and other staff, laundry facilities, dis­infecting apparatus, etc.—matters in respect of which the earlier isolation hospitals were but poorly equipped. The provision of these on a scale, adequate for even a small hospital forms no in­considerable part of its cost; but the same provision will serve with but little increase for a hospital containing a considerably larger number of beds. In a larger hospital containing more wards there are greater facilities for the classification of patients with different diseases, and it is easier to maintain an efficient staff than in a small hospital serving a single district only, which may often be void of patients for long periods.

The number of Joint Hospital Boards, which was thirty-two in 1892, increased to fifty-one at the end of 1900, and eighty-three in 1910, while other districts combined in a less formal manner. In the case of small districts in the neighbour­hood of a large town it is usual for the former to make arrangements for the use of the hospital of the latter on terms agreed on.

Concurrent powers of hospital provision and combination of districts were given by the Isolation Hospitals Act, 1893, which placed in the hands of County Councils powers for the forma­tion of hospital districts and promotion of isolation hospitals. In some counties, as Wiltshire, Derbyshire, and the West Riding of York­shire, these powers have been freely exercised, and up to the end of 1909 some seventy hospital committees had been formed by Orders of County Councils.

Smallpox stands in a different category from the other infectious diseases commonly treated in^, isolation hospitals. It has been found by experi­ence that smallpox cannot be treated in the same hospital with other diseases, even in a different building, without risk of its spreading to the other patients; and it has also been found that smallpox tends to spread to persons living in the neighbour­hood of hospitals in which many acute cases are under treatment. There has been much controversy as to whether this spread takes place by the agency of aerial dissemination or of personal communication, but the fact that it has often taken place is beyond question; and it has become recognised as necessary that smallpox should be treated in separate hospitals, and that these should be at an ample distance from populous localities. The advantages which have been cited in favour of combination over the independent provision, of small hospitals for separate districts apply with especial force in the case of smallpox hospitals. Smallpox patients bear removal well, and people are commonly anxious to have them re­moved, so that with a proper ambulance it has been found practicable to convey them a distance of twenty miles. Hence a smallpox hospital may conveniently serve a larger area than one for other infectious diseases; and in some instances districts which had provided themselves with hospital accommodation for the ordinary infectious diseases separately or by smaller combinations have taken part in a larger combination for the provision of a smallpox hospital. A special advantage of com­bination in the case of smallpox is that as the disease is now comparatively infrequent a hos­pital provided for a single district would often be without patients for long periods, whereas a hospital serving many districts would be less often unoccupied, and the expense of its maintenance in readiness when empty would be shared between all the districts. In view also of its being fre­quently empty it is undesirable that the accommo­dation provided at a smallpox hospital should be on a large scale or comprise costly appliances; it may contain only a few permanent beds for the prompt isolation of the sporadic cases which occur from time to time, with space and facilities for rapid extension on the occasion of an epidemic.

This is an important speech. LKY makes a few mistakes (e.g. you DON’T need to actively pursue population control: economic development automatically reduces demand for children), but otherwise he is largely correct, and his advice is valuable to Third World countries like India that are struggling with corruption and incompetence even today.

DOWNLOAD PDF

===

OPERATIVE PORTION OF LKY’S ADVICE TO AFRICA (1993)

[Introductory comments removed. Source: https://www.nas.gov.sg/archivesonline/data/pdfdoc/lky19931108.pdf]

I offer these few principles which have been important in Singapore’s transformation.

Goal 1: Clean government, effective civil service

Our first goal in Singapore was to shape the government into an effective instrument of policy. This require strong, fair and just leaders, who would have the moral strength to command the respect of the people. Unity in the core group of leaders helped to send clear signals to the people thus avoiding confusion that would have arisen if the team had bickered and split. Leaders must have the sense of trusteeship, that they are only temporarily in charge of the destinies of their people and that their duty is not only to discharge this trust but also to pass it on to equally trustworthy and competent hands. Responsibility for the people under their care required that luxurious living whilst our people were mired in poverty and backwardness was out. We ensured complete accountability and open separateness between personal assets and public funds. Corruption which we regarded as a cancer must be eradicated as soon as detected.

A strong, political leadership needs a neutral, efficient, honest civil service. Officers must be recruited and promoted completely on merit. They have to share the same nation-building philosophy and development goals of the political leaders. They must be adequately paid so that temptations would not be difficult to resist. An impartial, capable Public Service Commission had to be shrewd at assessing character. Appointments, awards of scholarships must be made to the best candidates.

I need to emphasise this because of paragraph 42 of the InterAction Council report:

“It is not only in Africa that corruption exists. But in Africa it is dangerous because corruption is becoming ingrained culturally at all levels of society, both in government and in the private sector. As Africa glimpses the consumer society, a cleavage has arisen between desires and the ability to satisfy them locally. This provided fertile ground for corruption. Corruption must be curbed and weeded out as it is a real and serious obstacle to development and modernisation.”

Economist Survey on Nigeria, August 21, 1993, page 6:

“The cost of corruption to credibility reaches most of civil society. ‘The military government has distorted people’s values” says Beko Ransome  Kuti, a currently jailed civil rights leader and, like his younger brother, Fela (Nigeria’s wildly popular Afro-beat musician, who sings about thieving African politicians), a thorn in the flesh of the Babangida regime.

‘Politics is seen as a way of gaining access to fantastic wealth, and this government has carried it to an extreme.’ Nigeria has many fine lawyers, but the judiciary is tainted by trials settled with bribes. It has fine academics, but universities are tarnished by the trade in diplomas. It has respected chiefs, but the nobility has been mocked by the sale of chieftaincy titles. In many ways, the institution that has suffered the most under this military government is the military itself. ‘Military men are not soldiers any more’, is a common Nigerian observation.”

In a report by Keith B Richburg, an Afro-American in the international Herald Tribune, 14 July 1992, the Organisation of African Unity (OAU) official, Mamadon Bah, said:

“What we need in Africa these days is mainly discipline, but discipline from the top.” “Still many other Africans agree with Mr Musevani, President of Uganda, and OAU official that cultural factors do play a role in development. They argue that lack of discipline among African leaders is a particular problem. For even the hardest-working African has difficulty building a solid life if his country’s political leadership is corrupt.”

The question is how to put things right in Africa when both the political leaders and the civil service have become inefficient and corrupt. This is a most difficult problem to which few countries have found solutions. Once a political system has been corrupted right from the very top leaders to the lowest rungs of the bureaucracy, the problem is very complicated. The cleansing and disinfecting has to start from top and go downwards in a thorough and systematic way. It is a long and labourious process that can be carried out only by a very strong group of leaders with the strength and moral authority derived from unquestioned integrity. We just managed it and stopped it before it got out of control. The South Korean President Kim Yong Sam is in the midst of such a process.[1]

Goal 2: National solidarity

The next basic goal is to maintain national solidarity and social cohesion despite many races or tribes. All successor governments of colonial regimes inherit this problem of multitribal, multilingual, multireligious, multicultural solidarity. If national solidarity is broken, problems become intractable. Without a united people, development is almost impossible. The InterAction Council report, para 6:

“For many African countries the concept of the state is very recent, not older than 30-40 years. Ethnicity, regionalism, religion, race and class interests are the causes of sharp divisions and conflicts in many countries. Countries which currently seem to be more successful economically, whether among the wealthy industrialised world or in Asia and Latin America among the developing countries, usually have a much longer history of integrity, often stretching back from hundreds of years.”

The Singapore solution to the problems arising from its young nationhood has been a policy of deliberate gradualism in all issues which involve race, language, culture and religion. We are 76 per cent Chinese, but of different clans speaking different dialects from different parts of China. We are 15 per cent Malay-Muslims from different parts of Malaysia and Indonesia. We are seven per cent Indians from different parts of India. The rest came from Europe and other parts of Asia. We need a common language. We solved this by making everybody learn not one but two languages, English and the mother tongue. English is not any group’s mother tongue, so no advantage is gained or lost by any one group. We have neither forced nor pressure-cooked a national identity. We have refrained from suppressing ethnic culture, languages, religions or sense of identity.

Goal 3: Family Planning

The third goal, to slow down population growth. By comprehensive methods of family planning, we brought down Singapore’s total fertility rate from six children per woman in 1960 to 1.9 in 1990 and 1.8 in 1992 i.e. below the replacement rate of 2.1. The enormous difference between the population growth of Asia and Africa is fearful.

InterAction Council report, para 1:

“Population doubles every 23 years, food production doubles only every 30 years. There are more uneducated people now than there were 30 years ago. In 1960, Africa produced 107 per cent of its food requirements as compared to 78 per cent today.”

InterAction Council report, para 70:

“In 1990, the population of sub-Saharan Africa totalled 526 million; projections – taking account of the impact of AIDS – envisage two billion by the year 2050 and a stabilisation at 2.9 billion.”

InterAction Council report, para 71:

“The population had grown at an explosive rate of 3.1 per cent, caused by a steep fall in the mortality rate and a continuously high fertility rate, approximately 6.5 children to every woman – much the same as 30 years ago and twice as high as in South Asia at present. This population surge has been a major factor in impeding the rate of social and economic advance, characterised by such indicators as 59 per cent illiteracy and infant mortality of 100 per 1,000 births.”

No economic growth can cope when each African woman produces 6.5 children. Unless you aim to bring it down to 2.5 or at the most three children per woman, your economic progress will be swallowed up by the new mouths to feed and educate and find jobs for. With contraceptives, like Norplant, which can be implanted in the woman once every five years, it should not be too difficult to bring population growth rates down. UNFPA (United Nations Fund for Population Activities) programmes can help finance this. There should also be universal education not only on family planning but also on the dangers of Aids. Condoms should be freely available. Again, the international health organisations can help. Otherwise, Africa faces a bleak health problem which will weaken its societies as strong and young people die of Aids leaving their children as orphans.

Goal 4: Pragmatism not dogma in economics

Fourth, economic policy must be pragmatic not dogmatic. Singapore consciously set out to maintain continuity with past policies. We accept our colonial heritage. Continuity with the past helps the evolution into new growth sectors. This is one of our secrets to growth. We encouraged all British, European, American, Japanese and Asian businesses to stay and expand their investments. We encouraged our own businessmen to enter trade and manufacturing and services not by displacing these foreign enterprises but by working as their suppliers or competitors.

In the 60s and 70s, we had considerable animal husbandry like the rearing of pigs, chickens and ducks, and vegetable gardening. We did not consciously set out to phase them out, but allowed economic developments to increase the value of rental of land until it became uneconomic to use land for rearing of pigs and the growing of vegetables. They were phased out by economic forces. We still have for domestic consumption, battery chickens, ducks without ponds, and for export we grow orchids and rear tropical fish, not for eating but for aquariums.

If I were an African in charge of a rural economy like Tanzania, I would concentrate on improving productivity in agriculture, by bringing in expertise to improve yields and to encourage investments in large scale plantations for palm oil, coffee, cocoa, etc diversifying into as many products as possible. I would also encourage high savings. You will see from the Financial Times table the high savings in Asia, which means high investments without foreign debt.

I would encourage cottage industries so that people will stay in their villages. I would do nothing to accelerate the drift into the large cities. This will happen in any case, the slower the better. I would spend the minimum on prestige projects, whether monuments, buildings, airlines or shipping lines. Grandeur in monuments and squares will not help economic growth or feed the people.

Goal 5: Let foreigners and local entrepreneurs get on with their business

The seductive trap to be avoided is the equalisation of wealth through nationalisation of commerce, industry, land or any other property. On the contrary, I would attract more foreign investment of multinational corporations (MNCs) whether American, European, or Japanese. I would protect and encourage more Indians and Lebanese small traders and shopkeepers. For they know when to lend to which farmer who will pay back at harvest time better than any branch of any agricultural bank that the state may set up.

International Herald Tribune, 14 July 1992:

“Tanzania in many ways is the saddest, since it has enjoyed 30 years of peace and considerable foreign assistance, but its economy has been ravaged by years of socialist mismanagement. Dar-es-Salaam, its capital, is in worse disrepair than Hanoi. The road system has collapsed, telephones do not work, electricity is sporadic and the store shelves are bare. Tanzania is [and] remains, by many estimates, the third-poorest place on earth.”

Financial Times Supplement on Africa, 1 Sep 1992, page II:

“At present growth rates – five per cent for gross domestic product (GDP), and three per cent for population – it would take 20 years for Ghana to join the ranks of lower middle income countries. The less successful have longer to wait: ‘With today’s poor policies it will be 40 years before the region returns to its per capita income of the mid-70s, says a World Bank official.”

“In the meantime, Africa is being left far behind by the countries which have made better use of their resources and compete more vigorously for capital. In 1965, Indonesia’s gross domestic product (GDP) per capita was lower then Nigeria’s. Today, it is three times higher. Thailand’s income per head in 1965 was lower than Ghana’s; now it is one of the fastest growing economies in the world.”

“Former ‘success’ stories and ‘role models’ in the 1970s have since become cautionary tales. Kenya struggles to implement economic reforms which erode the patronage on which the ruling Kanu party has been so dependent. Cote d’lvoire moves deeper into difficulties that cannot be addressed until the CFA franc is devalued, an obstacle that holds up effective economic reform in the 13-member CFA bloc.”

“Most disturbing of all, perhaps, is the concern that Africa no longer has the adequate institutional capacity to help itself. The technological gap between Africa and the world has widened, and the continent’s management is weak. Many schools and universities are without teaching materials. Civil services have been neglected or politicised. The integrity of the judiciary has been eroded.”

Goal 6: Educate everyone

Education is the key to the long term future of any people. Modern agriculture, modern industry and today’s information technology, require the whole population, including women, to be literate and knowledgeable in order to receive knowledge and to participate and to add value. In an African context this means universal literacy and basic knowledge of personal health, hygiene, of agriculture and basic mathematics and science.

InterAction Council report, para 77 said:

“They (women) are not recognised as having their own rights as human beings and citizens. Despite all declarations by Governments, in reality, women are marginalised essentially because of culture.”

InterAction Council report, para 78:

“Governments need to change their attitudes in the way they view women’s rights, incorporate them as a key element in the development of a society’s full potential, and offer real opportunities to all members of society. Affirmative actions must be undertaken in all fields: political, economic, social and cultural. Special programmes enhancing women’s productivity, especially in agriculture and environment, are recommended. Enhanced acesss to formal education, health and nutritional education, and credit is equally critical.”

I believe this will solve not only the waste in not using half the population’s resources but [also] solve the dangerous population growth. Singapore’s experience has been that once women are educated equally with men and given the same job opportunities, they do not see any point in having large families which drag down the standards of living of the family and of society and make their lives a drudgery.

Goal 7: Go for results not political correctness

Singapore rejected conventional wisdom when it did not accord with rational analysis and its own experience. For example, in the 60s and 70s, it was politically correct to be anti-American and anti-MNC. The theology expounded by Latin Americans like Raul Prebisch was that MNC would reduce them to “dependancia”. We did not accept this. Instead we assiduously courted MNCs. They had the technology, know-how, techniques, expertise and the markets. We decided it was a fast way of learning on the job working for them and with them. Indeed they have been a powerful factor in Singapore’s growth.

It will be equally mistaken to follow mindlessly the present politically correct and stridently advocated view that democracy is the precondition for economic development. Without democracy, Western ideologies argued, Russia could not develop a free market. This was not borne out by the experience of Taiwan and South Korea and post open-door China. What is necessary for growth and progress is good government, one that is honest and effective and works for the benefit of the people. What Africans should work for is good government. Fortunately, this is recognised in the report of the InterAction Council. First, they stated the general principle in paragraph 10:

“Democracy, representative government and the ability to change it by elections are the best safeguards for human liberty. Such a setting would engender stability and facilitate development as a self-sustaining process. Security, stability, development and cooperation are interlinked and Governments must take a wide range of measures to develop to a democratically constituted system.”

Then in the next section under culture-attitudes-values, they went on to say, paragraph 15:

“If democracy is going to be sustained in Africa, it has to be home-grown and owned by the people and the countries. It cannot be imposed from outside. Governments should take bold measures to accomplish a higher degree of popular participation in the economic and political transition process.”

And in paragraph 16:

“Democracy is a culture. It is not given nor is it attained overnight. Democracy grows at a speed which differs from country to country. The form of a country’s democracy must evolve out of the culture of the people it serves. There is no standard pattern of blueprint for societies which differs fundamentally from the West.

This was also recognised in the Financial Times survey, 1 September 1993, page two:

“Hopes that the emergence of multi-party politics would prove a simple stepping stone to good governance have proved premature. Opposition parties have turned out to be weak, fractious and susceptible to patronage, owing more to ethnicity than policy for their support.”

Good governance includes the pursuit of national interest regardless of theories or ideologies. Good government is pragmatic government. When Singapore was up against the wall in 1965, cut off from its hinterland in Peninsular Malaya and the Borneo territories, and confronted with economic boycott by Indonesia, we concluded that we had to make ourselves useful to the rest of the world if we wanted to survive. We could not change the world. We could adapt to it. So even though China was the largest exporter of revolution in the 60s and 70s, giving arms and succour to the Communist Party of Malaya to subvert and create revolution in Singapore and Malaysia in 1950 to 1970, we never broke off our economic links with China. Nor did we close down the Bank of China even at the height of China’s madness during the Cultural Revolution. We reaped the benefits in trade and investments when China stabilised after Mao. The existing links were in place to facilitate a blossoming of new trade and new investments, not only by China in Singapore but by Singaporeans in China.

Finally, let me add this caveat. You have to draw your own lessons from your own experiences and from observing that of other countries. As the Financial Times Supplement on Africa, 1 Sep 93, page II, said:

“From Africa must come a new generation of leaders, committed to reform, and tapping the same spirit that brought freedom 30 years ago. Angered by the failures of corrupt and autocratic leaders, frustrated by economic policies that did not deliver, impatient to recover their loss of civil rights, and worn out by wars, Africa’s people are striving for a fresh start.”

I have only guessed at what would interest you. It is better that I stop to allow you to raise your interests at question time.

[1] The speech in Singapore archives leaves out the words, “We just managed it and stopped it before it got out of control.”. However, these words are found in videos circulating on the internet, and these words are both important and meaningful, given Singapore’s extreme corruption before LKY began his reforms.

I was deeply impressed by this interview which taught me many  new things. I’ve therefore taken the transcript prepared by AI and physically sat through the audio for around 6 hours to thoroughly edit/ refine the AI transcript. This might be useful to others – but will definitely be useful to me. I’ll also annotate this as I find time, to made deductions that can be applied to my various books/ writings. [I must acknowledge that without AI’s preparatory work, I would never have attempted this transcription]

=== ON YOUTUBE  | PDF of the transcript.

==THE TRANSCRIPT==

Interviewer: Dr Randall Bock  |  Guest: Professor Sean Flynn. On YouTube.

Randall Bock: I’m honored today to have Professor Sean Flynn. He is economics professor at Scripps College which is one of the Claremont colleges in the eastern part of LA County, it’s a beautiful spot out there. And he’s talking about a amazingly important issue: our overpriced health care system, our bloated healthcare system.

There’s probably … no bigger domestic strategic issue for the USA today than the high cost of health care. The fact that the USA spends four times more than Singapore – which is something Professor Flynn has noticed – on health care in comparative terms, yet achieves four to five years fewer of life expectancy, is a sign that something is fundamentally wrong with our health policies.

I came across your work recently through Sanjeev Sabhlok – a friend of mine, health economist in Australia – and I’m delighted to have you explain why the USA performs so badly and how Singapore has managed such an effective and efficient system.

We know that Lee Kuan Yew … the late Singapore leader and president and frankly interesting thinker, consciously rejected both the British and the American system. Singapore thereafter designed its own system from scratch. Clearly they have the right incentives both for consumers and market participants, enabling a stupendous performance.

We don’t want to copy their system but surely there are some useful principles we can adopt. And to wit, you have an excellent book on this topic of which I’ve read a good part but not in full.

So that’s a kind of a long intro. Tell us a little about how you landed on Singapore and what are your interests both economically and in the healthcare system.

Sean Flynn: Thank you doctor. Great to be on. Just to jump right in.

I accidentally became maybe America’s biggest expert on Singapore’s healthcare system because a Rotary Club in Claremont asked me to do a presentation. It was about 6 months before Obamacare got passed, the Affordable Care Act. This would have been November of 2009 and I needed a topic because I was asked to do this on short notice. There happened to be an op-ed in the Wall Street Journal the day before the talk I was supposed to give and it argued that both political parties both the Democrats and the Republicans should look at Singapore as the optimal guidepost – you know thing we could learn from – rather than the normal suspects which are Canada and England.

Even today, if you go into a school of public health, if they’re teaching first year master students or even the undergrads they’ll only usually usually talk about Canada and the UK. Maybe a few words on Germany, or South Korea does something nice with billing, but this guy said Singapore. And he also said they were delivering the best care in the world at the lowest costs and of course that’s not a combination an economist normally believes, right?  You don’t get a Rolls-Royce at a Honda price, right? That’s not what you’re expecting – highest quality and lowest prices – but I went online. The World Health Organization has a huge huge database of comparison statistics for every country in the world and everything I could get online said that it was true.

Singapore really was running the most efficient, lowest cost and best outcome healthcare system in the world. Usually, and I’ve now seen 20 years – decades – of statistics, but usually in they’re in the top three in life expectancy, maternal mortality, infant mortality and they’re by far at the lowest cost.

So whereas – I’m sure your audience is aware of this – we’re spending about 18% of national income on healthcare, Canada, England, France – they’re usually in the 12-13% [range], sometimes 11, if they’re doing well. Singapore has been under 5% throughout its history and I think it’s at maybe 4.6% right now.

And what’s even more shocking about that, [is that] they have mandatory health savings accounts which means they’ve got so much money in their health savings accounts. They’re the only country in the world that will not have to unplug granny in 20 years because their, you know, Medicare system is going to run out of money like ours is, right? And so they’ve got both a secure system, a sustainable system, and the most efficient in the world.

And over the subsequent five or six years, Dr. Bock, I ended up, you know, even being a guest of Singapore’s government and having a three-hour talk with the Ministry of Health and seeing all their different levels of health care systems from the basic public health up to the top. And it all checked out.

I love Singapore’s healthcare system, they’re very honest. They send you experts out every year to go see best practice around the world. And so everything they’ve done there, they borrowed from somewhere else. And they’ll admit that they just put it together properly. And a lot of it was from the United States, whether it’s price tags because they’ve got really competitive healthcare.

An American invented price tags, you know, back in about 1850. You may have had John Goodman on, the economist – he invented health savings accounts. He’s still alive. He invented them in the early 70s. Basically, all the key components of Singapore’s system we have here, we’ve just never put them together properly.

And so that that makes it even more of a tragedy that we are spending so much to so little effect. As you pointed out, you know, our life expectancy is five, six years less than Singapore and Japan. We could do so much better. And we could free up about $3 trillion a year, every year, forever. That could pay down the federal debt, that could fix the deficit, that could [fund], you know, any public program you want to spend money on, whether you’re on the left or the right, or just lower taxes. Some people on the right just want to lower taxes. Yes, there’s money for it if we fix the health care system in ways that are known to actually work and which we invented, which is the really embarrassing part.

Randall Bock: So, in the green room we were like making a reference to the Beatles and as you were talking I was thinking not about the Beatles but the Rolling Stones and the great philosopher Mick Jagger in “Satisfaction” said you can’t always get what you want. You can try. Sometime, you just might find you get what you need.

It’s not quite apt, but obviously if Singapore is paying a quarter of what we are paying, they’re going to be fewer things purchased, I assume, on some level. What are the things – getting to the “Satisfaction” lyrics – you might “just can’t always get what you want, but you just might find you get what you need”. It sounds to me as if that is the general economic proposition we have for all kinds of other products. I might want to have, I don’t know, a coterie of five different cars, more sports cars, an SUV, I don’t know. But I have to pick up one because I only have a certain amount of economic bandwidth to do what I want to do. If Singapore is paying a quarter, what are the things that they’re not getting, or are they just getting everything at a more efficient price?

Sean Flynn: OK, so that’s the latter, or more so the latter than any of the things you said earlier.

Let me let me try and unpack that a little.

We normally think – and the following is true in a competitive system where things are competitive like the price of wheat. If you’re in a competitive system, then price will be almost identical to cost. And by cost, what you mean is how much does it take to actually get something done or to purchase something or to grow something or to build it.

But there’s often big gaps between price and cost. A monopoly is the closest thing, right?  Does it actually take $1,200 to make an iPhone? No. Apple has 40% margins, right? They can do this because they’ve got a great public brand and stuff, but the price of an iPhone is well above the cost. Now, flip that around to supermarkets.

A typical supermarket has a 1% margin, right? Their prices are only about 1% higher than their cost. So, there’s certain industries in which there are these big gaps between price and cost. And there are these other industries where there’s almost no gap. If all of healthcare were more like supermarkets where there’s these really thin margins, then you’d have to say, well, if you’re spending less at a supermarket – in one supermarket than in another – or in one country than another like, say, supermarkets in Singapore, supermarkets in the United States, then yes, the only way to spend less money – if the price equals cost and the costs are basically the same everywhere – is to actually buy less. You have fewer apples, right? You have fewer pounds of beef at  a supermarket. But if you’re going from Whole Foods to Walmart, you can actually – because the prices at Walmart are lower than the prices at Whole Foods, and you know, the quality is basically the same (nothing’s going to kill you, and you can get organic stuff at Walmart), but the markups are so much higher at Whole Foods that you could take your hundred bucks at Whole Foods, go over to Walmart, and actually come out with more food. Another thing you could do is only spend $50 instead of a 100 at Walmart and still maybe come out with almost as much food as you did at the Whole Foods.

So what Singapore has done basically is set up a highly competitive healthcare system where competition – like with supermarkets. The supermarkets – it’s not that they’re being nice by, you know, only having 1% markups: they’re forced to do that because there’s such intense competition between the supermarket chains. Singapore’s basically got that same level of intensity of competition in its health care system, so that the markups are very small. And so when you see the price lower over there, you really could take a bunch of money from the United States, go over to Singapore and buy more stuff than you can in the United States. It’s not that the only way to get the lower expenditures in Singapore is by cutting back on the actual number of surgeries and, you know, bottles of aspirin or something like that; because they’ve eliminated these massive up-markings; … they’ve got a system where the price and the cost are nearly identical, highly competitive, the prices are low down with the cost level rather than, you know, the cost being low and the price is high – like going to Whole Foods Market or something like that. And because of that, you really aren’t cutting back.

And … there are some places where they are more efficient in the sense that they’ve got fewer doctors per capita than the United States, they’ve got fewer nurses per capita, they’ve got slightly fewer dentists per capita. But it’s not like… , you know, people there are can’t find a doctor. Actually, the wait times are shorter in Singapore than they are in the United States for all those things. There is no nurse shortage or something.

It’s just they’ve got a system that works really efficiently. So, for instance, doctor [Bock], my mother retired from Kaiser Permanente as an eye surgeon. One of the things that drove her out – I don’t know it’s been 16, 17 years – but they got “Epic”, right which is this coding billing system. And when they first got it in, there were like 140 pull down menus so anytime she saw a patient – and you know these are routine patients – they’re just coming in nothing’s actually wrong, she would have to fill out 140 different things, including for the men whether they were pregnant or not, right? So within six months Kaiser had to hire what are called scribes which are people whose only job is to … do the pull down forms while the doctor talks to the patient, right? Massively inefficient. And yet when all these electronic data systems were rolled out, it was claimed by the advocates, “Oh, with all this information science and data informatics, the healthcare system will save a huge amount of money”, right? That wasn’t true – because you had to hire all these other people just to do the pull-down menus.

And so we’ve managed to run; and here’s the key part – largely because we’ve created a system where the prices are so far above the cost – a system where nearly every hospital administrator, government public health person, you know, someone running Indian medicine for the Department of Interior, everyone can be massively inefficient, because they’ve got don’t have the pressure of actual competition, and having to keep prices down. And so I would argue the exact flip of what you set up there, doctor [Bock], … which is that we have created a system where we are so inefficient, right, in spending money, … and we’ve so forgotten that the prices are way above the cost – that we think as a public policy thing whenever, you know, say (it’s usually the Republicans), we’re going to, instead of having 4% per year Medicare growth, we’re only going to have 3; everyone starts screaming because they think, well, the only way to reduce the expenditure is to actually reduce the number of surgeries and the number of doctor visits and this and that: the actual quantity of stuff purchased. But that’s not true when you have a vastly inefficient system like ours.

And quite frankly, if you take Singapore as the comparison point rather than Canada or England, we’re spending about three times as much as we should be on nearly everything in the system: just massive waste, fraud, and abuse – incredible, like 10,000% markups on generic drugs, because … we’ve set up a monopoly system for distributing the drugs.

So it is not the case – and I want to be very emphatic about this – it is not the case that you would have to cut back on services 75% if you cut back on expenditures. If you cut out the 10,000% markups on certain drugs and all these other things where we’ve gotten really inefficient, you could have both lower expenditures and just as much and perhaps even slightly more actual medical services being delivered, especially to the poor.

You know, if we have time later, Singapore has created the world’s greatest social safety net for health care. And no wait times for the poor. Same access, same doctors. It’s absolutely amazing. But they could afford to do that because they created a competitive system where the prices were driven down to the cost level. Here in the United States, when Medicare or Medicaid goes in to pay for … an indigent person, they pay the almost identical outrageous “market prices” – these chargemaster prices that we have in our system, these bloated prices.

[In] Singapore, since all prices, both public and private are kept low by competition, the government goes in and can buy stuff for indigent people really, really cheap without the 10,000% markup on the generic drugs and things like that. And so that’s how you do it. You actually need the intense competition. But – and the real trick here with Singapore – they also built the world’s greatest safety net. They didn’t create a two-tiered system where the rich get stuff for cheap and they can afford it and the poor get nothing. It’s not like that at all. everyone gets the same level of service. The government steps in. There’s actually ombuds people hired by the government with like sociology degrees at every hospital to actually guide people through all their benefits and make sure they get everything and that the government will pick up the bill. [Clarification: In his book, Sean notes: “At the entrance, there are greeters as well as medical social workers. The medical social workers act as ombudsmen and advisors, making sure that each person knows which government benefits he is eligible for and how to apply for them”.] It’s absolutely amazing.

Randall Bock: So, there’s a lot there. I’m going to have to relisten to this video later because there’s so much to unpack. But obviously, the book is there as well. We’re going to get into the book and how people can find it and find you and so forth. On a personal note, I mean obviously I’m a physician and I’ve had some thoughts about this stuff. I substack away and I write and YouTube and all that kind of stuff.

There was a point about a decade ago I was at a healthcare conference sponsored by a law firm in town in Boston. And it’s ironic and or interesting maybe, or coincidental, that Boston’s sort of the medical mecca. People come here, you know – there’s a you know famous book by Samuel Samuel Shem [pseudonym of psychiatrist Stephen Bergman] that labels MGH [Massachusetts General Hospital] as man’s greatest hospital [Man’s Best Hospital (MBH)—a satirical name for it] – it’s tongue and cheek. but they often feel that way here. And so, all those hospitals – you know, all the Harvard hospitals – are basically annealed into one system.

And so you basically got this huge thing it’s mass general bighgam da da da, and so you know they have kind of a monopsony. I don’t know if they have a monopoly – I mean they have a monopoly to a certain extent for a lot of the tertiary care that filters through, and they probably get some monopsony aspect where they can be a single big purchaser of items and get some benefit on the on the short end. But the prices keep marching up because I don’t think we have that much competition within our own systems. We’re not free individual kind of atomized purchasers as we are for shoes or raincoats or pencils or whatever it happens to be which can come in and out of. I would probably short the pencil market these days because people don’t – I mean I have a pen in hand right now – but I don’t really buy pens very much anymore. I might get one here and there at the bank but I used to buy pens. I don’t really do that anymore because I got computers and dictation – all kind of stuff. So the markets changed … and we see some of that in medicine. So anyway, getting back to this conference I was at, I was probably one of the few physicians there, mostly lawyers and they were talking kind of how to game the system in a sense – not game it, but you know, be aware of what are the regulations, all the kind heavily regulated place.

We’ll get to that later, but I got up and I said, you know, what’s really amazing and great about the American health care system is the way, you know, things have gotten so much better this last decade and provided so much better care at so much … lower cost, more efficient and all that kind of stuff. And everybody just kind of looked at me puzzled like what planet is this guy from? You’re saying, … everything got better and cheaper and more efficient at the same time.

I said, “Oh, … I forgot to mention. I’m talking about LASIK surgery, dental implants, hair transplants, and veterinary orthopedics. OK, so if your dog needs a new hip (I swear I’ve looked in these things – somebody brought a startup to my angel group). You know, they they’ve just gotten so enormously better. They’re willing to experiment. There’s a huge market. Everyone pays with cash for their dog because … we don’t have doggy Medicare. We don’t have doggy Medicaid. All that kind of stuff. So, people want something for their dog, they have to go buy it. Or they can conversely not buy it and let you know – Rover – go around on one bad hip or whatever. So you know –ditto with all these other things which are elective items – plastic surgery and dental implants whatever. At some point they might be incorporated in the general … kind of medical pharmacopeia whatever, but at that point. So, … my point was that things that are … freely marketed … wind up finding their own equilibrium and people compete. And even you know, with hair transplants for instance, you know [it’s] not just here you’re competing. People are going on these medical vacations to Turkey and whatnot and they’re getting their hair transfer and they probably can get certain things like you … certain surgeries in … Mexico or wherever, … cosmetic surgeries in the Caribbean, Armenia blah blah blah. So, they can … travel. So it winds up having a marketplace for those elective things.

Anyway, there are certain kind of innate inefficiencies we have in our system. … So, what would it take to redesign, Professor Flynn, the American system in terms of time and effort. Obviously, there would be resistance from insurers, hospitals, pharmaceutical companies, and medical device manufacturers. Is there any way by which stakeholders could also win during the reform process? So, I don’t know if you want to tackle that one or anything I mentioned earlier.

Sean Flynn:  OK. Now, is the stakeholders everyone? Does that include like the big pharmacy benefit managers and United Health and things or do you mean the American people sort of the primary stakeholders?

Randall Bock: Well, we just had a barbecue the other day. My in-laws came over so we were holding some steaks ourselves. They were quite delicious.

Sean Flynn: [laughter] I like that joke.

Randall Bock: The American stakeholder could … you know somebody with high cholesterol and winds up getting cardiac issues. No, … I would say those stakeholders in that case would be the ones listed – the insurers, the hospitals so forth, who have their … GDP of their own individual companies are at stake by any kind of regulatory aspect. Because so this big lobbying. I mean I’ve been following the RFK Jr. MAHA story in DC and it’s been hard to just kind of peel off a couple of the less necessary vaccines from that schedule. There’s the NCVIA which is kind of a nice rent seeking blanket for companies to make vaccines instead of medications.

So I’ve spoken and followed all that stuff, but obviously there are going to be stakeholders who make it very difficult and put the feet to the fire of anybody who wants to think differently. So I’ve had on Robert Malone on my show maybe three or four times and you know physician and he was head of the ACIP temporarily, and he got out of it because it was ranker, too much pressure and whatnot. So anyway so those are the stakeholders I’d say but obviously the stakeholders are the recipients as well. So the people who would prefer to hold a stake than to listen to any of these things.

Sean Flynn: OK, and thank you for that clarification that makes it clear to me how I should approach this. So let’s start from top down and get more micro.

Top down the biggest problems are philosophical in that 30-40% of the country and maybe 70-80-90% of academics of any discipline – not just medicine-related or economics – have a fondness in their heart for the English and Canadian systems. They don’t seem to read the news and know that the wait times have been skyrocketing in both countries, they don’t realize that there’s a private sector safe valve in both countries. Yes, England has a national health service but anyone can afford to buys private health insurance and goes to private hospitals. They don’t realize that 80% of the Canadian population lives within 50% of the US border and so that the safety valve there is people driving south to the US to pay cash for things. But that being said, though, their allegiance to that system call it national medicine, socialized medicine, you give it whatever you name you want, government-controlled medicine, government funded single-payer.

Actually single-payer is sort of the neutral term which actually hides some of the defects. But let’s call it single-payer. Single-payer is a disaster for quality of care, drug development, innovation, you could go on and on.

I remember back in the 1990s, I haven’t seen the new statistics, but at the time the US had 3,000 MR machines and Canada had three. They should have at least 300 because their population is only a tenth the size. They had 1%. Right?

So these systems also massively under-capitalized, by which I mean they make too few buildings, they have too few operating theaters. You will routinely, as a result, see articles in the British tabloids about women at public hospitals having to have their babies in the hallway because there weren’t enough delivery wards. You know, it’s very predictable when a baby’s going to be born, right? There’s no excuse for a system not having enough personnel and building space available to deliver a baby after nine months of waiting, right? Yet, they goof that up.

And so the biggest problem is that there’s probably 30-40% of Americans who think that single-payer is the solution to all our current problems?

It wouldn’t be for two reasons.

1. A) the best it could possibly be is to look like Canada, England – [with] massive wait times and lower quality of care. But the real problem – if we tried to transition politically through an act of Congress signed by the President into such a system – that legislation would be completely gamed by the current powerful special interests. You’d actually end up with something worse than Canada and England if you tried to do it through our democratic processes because the lobbyists would be in there for big pharma, big medicine, big insurance the whole way. You’d actually get a less efficient and more expensive system. So, that’s a that’s a big problem we have to deal with.

On the other hand though, the [other end of the] political spectrum – the Republicans, and you know, libertarians and anyone who’s not of the single-payer mindset – they don’t really have any proposals that I consider publicly attractive. They say that we’re going to wave – what looks to other people like this magic wand of free markets – and everything will just be fixed. And yes, it’s true, and the examples you gave are spot on. Anything like LASIK that was not covered by insurance, the cost has gone down, the quality’s gone up – just booming business. And actually, for those things very few people do medical tourism? … Because they can get it for cheap right here in the United States.

And there have been other people like Keith Smith at the Surgery Center of Oklahoma – I don’t know if you’ve had him on yet – but they’ve been posting prices since 1998. They do over 900 surgeries now and people fly in from Europe to go there. We have import medical tourism in this part of the healthcare sector where they decided not to take insurance because Keith Smith and his crew figured out how to do everything really efficiently, high quality and so on. They get lots of Canadians, they get lots of Europeans, they get people flying up from the Caribbean and stuff and Central and South America. So, we can do this stuff here.

But politically only one side – the single-payer side – has something that looks like an easy quick obvious solution. And you’re probably aware of that old HL Menken quote about for every complicated problem there’s a solution that is – what is it? like “simple, intuitive and wrong”, or something like that. [Actual quote: “there is always a well-known solution to every human problem — neat, plausible, and wrong”; but it is more commonly used in the general public as: “For every complex problem there is an answer that is clear, simple, and wrong”] So, single-payer is that HL Menken solution that’s simple, intuitive and wrong.

But the other side doesn’t have an attractive opposing thing to say, and many of them I think are too wedded to –you know, they read Atlas Shrugged at 19 and they just think if everyone read this book too, they’d fall in line, right? But that doesn’t … deal with people really being worried about, you know, “if I get into an accident or if I get cancer, if I roll my car, who’s going to help me? Am I just going to die? Or, are they going to help me and then I’m going to go bankrupt?”

I have a neighbor across the street here. He works in warehouse distribution facilities. He got a gash on a finger. It went to the bone. He needed, you know, eight stitches on his finger. But, you know, no permanent nerve damage, nothing like that. So, not they didn’t need like massive surgery or anything. He got an $18,000 bill from the local hospital? And I’m Catholic and – you know – it’s a local Catholic hospital. Wow! How charitable are these people? And that’s what he’s dealing with now, “how do I, as someone who makes $20 an hour, figure out how to pay for an $18,000 medical bill”? And so, people are terrified.

The political right and the libertarians have no good, no attractive-looking solution. And so, as I said, I really think if we did get single-payer, our version would be worse than Canada and England because the special interests here would make sure they could still get to a trough filled with lots of cash that they could feed at.

And so the only way forward I really think that could work here so that we don’t end up with single-payer and we don’t continue just down the road we’ve been going on here with giant corporate health and stuff, is the little guys like Keith Smith. It’s the direct primary care doctors who just checked out. They don’t take insurance but they’ll charge you a flat monthly fee for virtually unlimited … and I’ve got a direct-care doctor, and so is my wife. And then the fact that we are getting more and more cash-price surgeries, cash and carry specialists, imaging, lab stuff. And unfortunately, most people don’t know this.

And you know, obviously if you’re Tiger Woods and you just rolled your car for the third time, you need emergency care, you’re going to get medevac [medical evacuation], but the vast majority of healthcare spending, you actually have time to think about it ahead. Even things for like heart stents, right? Unless you’re really about to die, the cardiologist said, “Oh, you can get it done next month or in six weeks; we’ll just schedule you” There’s emergency surgeries and then there’s basically everything else.

And the vast majority of stuff is everything else – where there’s delay, where there’s time to shop around. And we’re finally getting an ecosystem in the United States where there are – you know, I could not just call Keith Smith and ask him for his price on a knee surgery, I can call around to local hospitals, there’s websites like MDsave.com where doctors [have] already pre-arranged bundled surgery prices, and you can just use their search bar and your zip code and they’ll find the ones near you – give you every doctor, and sometimes they’re not the same, because the competition isn’t that intense: sometimes some doctors are 10 or 15,000 more or less. But you can also look up [that] they’re all board certified. You can see if anyone’s been sued. You can find out if the quality is there, as well.

And so that to me is how we can creep towards actual authentic reform because entrepreneurs, business people – if they know they’re operating in a competitive environment, they just naturally figure out how to do things more efficiency – which in medicine is the combination of higher quality and lower costs: which, if it’s competitive, also means lower prices. Because there won’t be much of a gap between the price and the cost if it’s competitive. You’ve seen that with these surgery centers.

But let me let me just say one more anecdote here as an example of the push-back in the system – and I don’t even mean malevolent, intentional push back. I talked to Keith once and asked him, “Wow, how many other surgery centers are in the country? Are you going to stand up a bunch of franchises?” He’s like, “No, no, no. I think they should all be locally owned by local doctors.” And he said, he’d advised on a whole bunch. And I’m like, “Wow, why can’t I find them on the internet?” He’s like, “Oh, they don’t post their prices”.

I’m like, “Why is that?” He said, “Well, a lot of these surgeons. they also do surgeries at – like, a local big hospital – and those local big hospitals have non-compete agreements and also these things where they shouldn’t be undercutting anyone else’s prices, right? So, they they’ve got the hospitals-negotiated reimbursement rate for … stent implant or something. If anyone finds out that doctor is doing the stent implants at a lower price than the hospital charges, then the insurance company can get mad at the hospital because they’re not offering the lowest available price in the area. So, the hospitals actually don’t want the doctors out somewhere else in a different facility, doing them. So, we’ve actually created a system here where … the incentives in the system are such that everyone wants to keep it quiet if they’ve actually got lower price and higher quality. You kind of have to do it clandestinely, which is just completely ridiculous. [Sanjeev: The cost of price discovery – the transaction cost – must be lowered via regulation. To operate efficiently, markets need publicly available prices. Singapore’s great reform was to force this disclosure on everyone.]

But there are doctors who know they could make plenty of money setting up their own surgery centers where they control the rent, they control the cost, they don’t have to deal with the insane insurance company – in network, out of network, higher cost, lower cost. Like Dr. Smith told me … in his local area in that county there are five different Medicaid reimbursement rates, so depending on which hospital a Medicaid patient goes to, the government will get charged more or less even though it’s identical service. That’s our crazy system here, and … to defend that [everyone] has to keep all the prices and the costs completely opaque. Because someone would end up asking: “Well, why is the government spending twice as much at that hospital as at this hospital? Isn’t that unfair to the hospital? Isn’t that unfair to the patients? Could that be dangerous for private care?” And the private insurance do the same thing. Depending on what insurance you walk into a hospital provider with, that hospital provider will get paid more or less for doing the exact same thing.

And that gets back to that gap between price and cost. The cost is the same whether they treat you or someone else at the same facility, but the price they get paid varies all over because we don’t have competition and everything’s been game.

Randall Bock: I wrote down a few things as you were talking. , I’ll give you a couple of these words and I’ll try to string them together. I wrote down NATO (North Atlantic Treaty Organization), I wrote down detox, I wrote Milton Friedman, and I wrote college, I wrote NBA. I’ll see if I can make sense of those scribblings.

Basically, Milton Friedman at one point said: look before you had Medicaid, Medicare, … he said it’s not like people were just sitting on the streets – like, you know, the image of Kolkata whatever back in the day – starving and rolling around with tuberculosis or leprosy or whatever. There were charity hospitals. The greatest flowering of growth of hospitals was in the late 18th – the Belle Époque, he guilded age – and into the early 20th century. So right here we have the Deakins hospital, a catholic hospital. You can find any number of Saint “this and Saint that” we have St. Elizabeth, which recently closed. There’s Beth Israel. Anyway, there there’s no shortage of hospitals with, you know, some Catholic, Jewish whatever – the Shriner’s Hospitals here.

The charitable impulse is a huge part of our society. I recently saw The Odyssey – the movie – and, you know, they talk about Zeus’s rule. And it’s also the … kind of the golden rule …. people have had this kind of stipulation to care for each other one way or another because it’s in our long-term best interest as a society. Maybe not individually in any given moment. I only bring that up because you know that’s like … sort of prehistory bronze age or whatever. Anyway, so for a long time we’ve had this idea of looking out for each other. It’s probably in our best interest to take care of each other to some extent. So Milton Friedman points out that before we had … enforced charity through Medicaid, Medicare, disability insurance, whatever, we had charities. It’s not like people were starving.

So that’s number one.

I brought up NATO because a lot of our [healthcare[ pricing and our model, and the reason that the UK and a lot of places in Europe can get by with their unipayer system, is similar to the NATO: … just the way we provide defense for Europe, and they pay far less of their own personal budget towards defense: frankly, they can put a lot of that towards medical care and socialize this and that.

So, we kind of have an umbrella [for Europe]. We’ve had an umbrella on pharmaceutical prices because we have more of an open market, so we’ve been paying higher pharmaceutical prices. We get more innovation. The innovation is all coming out of the United States as [the] place where people want to make the new Viagra, make the new this and that, because we will pay for it at top dollar – at least under the patent realm, 7, 15, whatever, 11 years. Whereas, Europe has this monopsony aspect and they will … get lower prices by single payer (single purchaser) and all that kind of stuff.

I brought up detox for a couple different reasons. One is, I used to do some narcotic detox as an ancillary part of my practice with subox and outpatient whatnot. I ran into a lot of people who had been through literally – not even not joking – 20 detoxes within that calendar year. And why did they do that? Well, they could do it because it’s like having a free ticket at Disney or a year pass at Disney. They could go in and out as many times they want and didn’t matter, so they had no personal repercussions. They’re on some form of public assistance and the detoxers are certainly happy to see the person come by again. They collect money every time the guy shows up and there’s no ramifications, no repercussions, no reformation. There’s no re- anything except rehab over and over again. So, the re- re- rehab.

But the other reason I wrote down detox is because the whole system in a sense is like a narcotic addict. The typical narcotic user needs to get his fix and so the system has to have its fix. It’s hard to get something [that’s] on a “system”, off.

And the reason I wrote college down is because I think the ancillary example is college. I think there has to be a college “fix”. There’s a lot of college being provided that’s unnecessary. I think it’s bloated. Everyone stays four years whether you want to become a French professor, work on HVAC or cure cancer – what everything needs the same kind of Turing machine answer of four years. Because college can get four years of payment through the grants and whatnot. They’ve managed to get that rent-seeking apparatus to get paid for four years – so the answer to everything is four years. And so how would you fix college?  How would you fix the healthcare system? These are probably similar things.

I mean, YouTube can fix college. Peter Theil wants to get people away from college and give them a certain amount of money to go get their ideas right out of high school, and go pursue it rather than waste four years in college. We could probably do something. You weren’t that fond of the electronic medical record and probably in initial permutations, not so great. But I think that there’s a lot of stuff that can happen with AI with medical records and portability of our own so that we can source our knowledge not necessarily through the physician through the hospital [but] through other means, leaving the hospitals for those places that are [for] the catastrophic aspect that has to happen somewhere down the line. So when you do have your massive stroke, you don’t necessarily go to Charles surgery center on the corner [but] need a hospital. [For] a massive aortic aneurysm … you go to the hospital because you’re going to need a lot of stuff going on – transfusions or transplant, who knows? So there probably a place for it, but probably it needs to be pared down.

Probably colleges are OK for certain things, but not necessarily for everyone to live in, have a four-year keg party and absorb the social milieu – while they’re getting a little bit of stuff that they’re not really paying attention to.  They get the AI notes they pass [with]. A lot of people pretending to teach, people pretending to learn, and people get these pretentious degrees after the fact. So, you know if you want to get rid of colleges, I don’t think you can like tell the college to stop doing that. They’re there for the long term and Harvard with it “Harvardiness” is able to sell that as a as an actual credential, and hospitals have that same kind of thing in people’s mind, at the very least. So, I think it’s a kind of a slog.

Anyway, so that’s a diatribe, not a question, but you can attack any of those things I’ve just said or we can go to do either one.

Sean Flynn: OK, well, I like diatribes. People being frank is something that we have a little bit of a problem here in America unless we’re actually doing an attack ad or something. So, let’s run with the college example, because I think that’s another great place here, where we need to point out that prices are set by demand and supply.

The supply – at any moment in time – you can’t control much of. It’s based on your current technologies – how many trained people you have, like in a hospital – or a college you could teach a physics class or something. But you could have very pernicious and very large effects on demand.

So, if supply is fixed and demand increases – if you’re thinking of a supply and demand graph, that would be supply curve not moving but the demand curve being shifted to the right or you could think of it being shifted up. You get higher prices, and if the supply curve is nearly vertical which it is in the United States, it’s hard to get a license to start a new college or anything. It’s nearly vertical, at least in a short period of time. Then any rightward shift of the demand curve or anything that increases the demand – and demand, remember, in economics is defined as both willingness and ability to pay for something. I am willing to pay for a Ferrari but I am not able to pay Ferrari. So, my willingness just shows up as zero movement in the Ferrari demand curve. But if someone gives me subsidized student loans, now my willingness to pay – because now I can spread it over the next 30 years – my willingness goes up.

There have been two major public policy goofs. which is why college now is not just this dumb ritual where no one gets educated – which is largely true: there’s tons of evidence for this objective evidence, a lot of students do not walk out any more educated, better thinkers, or even with technical knowledge in a field after four years, and they get their bachelor’s degree, [to] the one they went in. It’s a travesty.

The two big things. Accidentally a Supreme Court case – and forgive me, I can’t think of the name of the case around 1972 – where I think IBM got sued basically for racial discrimination or some kind of discrimination, might have been gender, because … maybe … whites were doing better on the exams, the IQ test that IBM gave to 18 year olds. IBM used to be perfectly willing not to insist on bachelor’s degrees. They took people out of high school. They’d test them and the really smart ones would be put on an electronic track where they learn all these electronics first as a workman, but then they’d actually be sent to college by IBM. IBM would pay for their college. They’d come back with master’s degrees, PhDs, and this and that. And if you didn’t test so well, they might put you on a track to be a janitor. Now, part of testing was, as an 18-year-old – is did you get to go to good schools? We have a legacy of bad schools for African-Americans in this country, especially around 1970. Clearly, you’re going to get a few or smaller portion of African-Americans being able to do well on those tests. Absolutely fine, disparate impact, I’m with you there.

But we ended up with a pernicious effect of the Supreme Court ruling that tried to fix that –  because they basically said it was illegal for any employer to use IQ tests or even tests of technical skill and ability to sort workers out into different career trajectories. Now, the US Army does this, right? They make everyone take the ASVAB test, the Armed Service was a vocational aptitude battery test. And yes, if you do really well, even if you wanted to be a trigger puller in a special forces, no, they send you to intelligence. They just put you someplace where you’re an “electronics” guy. And so, jokingly

within the military, and my friends who were in the military would joke about this: “Yeah, I ended up a grunt, I did bad on the test”. But they’re happy with that because they wanted to be a grunt.

But we switched to this system and here’s the weird thing. Businesses could no longer do their own testing. So, they basically outsourced it to colleges and universities. And this is when the SAT took up. So the schools could sort kids on ability. The schools could sort on. And so basically you now in order to get sorted into the career track at the high end of IBM, you needed to go through a bachelor’s degree. You needed to go to the big state school or MIT because then as a 22-year old, someone had done the sorting for IBM and all the other corporations hiring.

So that massively increased the demand for a bachelor’s degree. It became the official certification of elite success, especially, obviously, if you’ve gone to a highly ranked college and a lower ranked college. Also, you create this war among middle-class parents to suddenly make sure their kid goes to the high-ranked school rather than low-ranked school so they can get the job at Goldman Sachs. Goldman back in the ‘20s, they didn’t they actually hated people with bachelor’s degrees. They thought they were overeducated and would be terrible traders on Wall Street. They actually look poor kids with very bad formal training but who had street smarts. That’s who they wanted to train. We got completely away from that. By the end of the financial crisis 2008, 60% of Princeton’s graduating class was going to Wall Street. This is a complete misallocation of resources in the economy. And also, most of those kids probably didn’t even need to go to Princeton for four years. They would have been just as well at Goldman Sachs as 18-year olds. Total waste of resources for society.

The next thing, Randy, was in 1978 or 9, Jimmy Carter as payback for winning in ’76 – he barely, barely beat Ford. Anyone my age or younger can’t even remember that election. But he just squeaked it by, despite Watergate and despite Ford falling down the staircase and being mocked on Saturday Night Live every night. He barely won. And the only reason he won was because the teachers unions went out and knocked on doors for him. So, the payback was creating the federal department of education, which immediately massively expanded the student loan program. We’d had a teeny-tiny one only [for] engineers since Sputnik because we were freaked out by the Russians in the ‘50s and wanted more engineers, and the only student loans we gave were for technical things. The Carter administration opened it up to every major, every school in the country. And ever since then, we’ve had this massive increase in willingness and ability to pay because you could take out the loans for it.

And so, we screwed that up and it’s very similar to healthcare with Medicare and Medicaid stepping in, in 1965 with the Great Society. Suddenly there were all these billing codes and anyone who could game the billing code or set themselves up as the highly marked up middleman like United Health or CVS Caremark could make a ton of money, because another way to put this: the user and the payer are different people.

I have a textbook with McGraw Hill. It’s a good textbook but it is marketed to the faculty because the faculty choose the textbook and then the students pay for it, the users are different. And healthcare’s got a lot of those aspects: what gets purchased for whom is basically a government money, or a CVS caremark decision, or a committee at a state capital for “certificate of needs” to build a new hospital: “Oh, do we really need a new hospital? That might ruin the profits of the existing hospitals. Couldn’t allow that. We need them to keep their giant monopoly hospitals”. And so, we’ve set up all these dumb systems where we massively increase the demand for health care because there’s third party payers that really don’t care about the cost. Any private business – if 20% of your money was going to fraud like it is Medicare and Medicaid … (the higher-end figures). It’s at least 5%. It’s probably 10. It might be as high as 20. Any private sector company would figure that out and they call the police and get people arrested, fire employees. Medicare, Medicaid, no. everyone keeps their jobs. They’re all civil servants. It doesn’t matter. And so, we have this system where the demand is really, really excessive because we’ve set up a bunch of bad policies. And of course, the cost is high. And, of course, there’s this giant gap between the prices and the actual cost of service.

Randall Bock:  It’s incredible. I used to be a disability exam doctor. And for various parts of my life, I got the nickname Dr. No for the James Bond villain. (Some people, you know, called me “Dr. No it at all.” That’s separate. That’s with a K.) And so, the Dr. No aspect was actually for a lot of people in pursuit of narcotics before I started the detox thing the decade before that.

They’d come to me, you know, with a bunch of ailments, you know, theoretically, and they were explicitly allergic to every low-level narcotic. They only wanted the high-grade ones. I would sus that out. But I’d called a few pharmacies and you know … so I got this nickname, epithet, or whatever (compliment in my view, a curse in theirs) that I was Dr. No. But that that kind of carried over, because I told them to get detox or rehab or whatever. I didn’t not care about them, or not care for them. I cared for them a different way from what they came for. They were actually there, again – sort of to your point – they were there on somebody else’s dime to get something that they wanted, and you’re going to pay for it. But it’s so diffuse, you know, the hundreds of millions of taxpayers have no idea that this one guy is going to, you know, 13 doctors a day and getting prescriptions and selling them, having a whole separate business. [A] kind of a fraud-on-the-run. It’s like Door Dash you know, Drug Door Dash anyway. And it’s dashing to his own door for the most part.

But as a disability doctor, I worked both for the Commonwealth of Massachusetts and also for the VA and so, two separate channels of people complaining of disability. Frankly, the VA ones were a lot easier and nicer because they had been in the military and they endeavored to serve the country and their stuff was kind of fixed. The state one was for people who wanted to get on [a] kind of long-term disability and payments. So, they were aggrandized. If they had a bad pinky, it meant they couldn’t work at all. …Their view of what this really was, and mine, differed.

I tried to look everything objectively and I would write things up. I couldn’t out-and-out deny people but I’d say: “Professor Flynn has a bad pinky, has horrible gouty arthritis. We should fix that. But that’s not going to really interfere with his job, which is economics professor. So, he’s going to use either left or the right side of his brain or either one. Nothing to do with his pinky. I don’t think he’s disabled. He doesn’t need to be on our money for now. And so he can probably go back to work tomorrow”. I didn’t write it as explicitly as that but wrote things that were, if you could read through it, you’d say, “Oh, this guy’s pretty much OK.”

And people would come back to me. I thought they’d come back angry, but every now and then, repeatedly, people came back to me, “Thank you, Dr. Bock. I really appreciate you gave me that disability.” And I’d be like, “What happened?”

You know, the disability team, through UMass, university, they would approve everything. Their business model, working for the disability unit, was to keep themselves employed.  And how do they do that? By handing out more disabilities. So, their model is not the same as yours. You know, college administrators don’t have the same interest in keeping costs down as you and I might.

Sean Flynn: OK, one quick anecdote to follow up on that? So, in ancient China allegedly – I’ve never been able to verify this – it used to be the case that rich gentlemen of means would pay their medical doctor, but only when they were healthy. If they ever got sick, they cut off the money because that way the doctor would have an incentive to keep them healthy.

And let me bring this to something modern in America. There are these direct primary care doctors. They get paid a fixed amount per month, I think the national average is about $75 a month. Talking to one of them – maybe you should have him on your show – Dr. Josh Umbehr, Wichita, Kansas – runs an outfit called Atlas MD there.

He likes to joke that he loves getting some older fat guy as one of his patients, because Josh has the time as a direct primary care physician. They only have patient panels of maybe 600, to actually text the guy every day till he’s taking his metformin and he’s actually doing what he should, and then in Josh’s perspective – just like the Chinese doctor who got paid when someone’s healthy – Josh gets 75 bucks a month for doing nothing. Because that guy is healthy. Josh makes his profit when that guy’s healthy. And that’s the kind of health care system we need to set up.

Randall Bock: That’s a business model thing. Last couple questions, how would consumers be involved and engaged in demanding reform? If you were Trump’s health secretary, what would your elevator pitch be to the people of the USA to get them on board, and/or to Donald Trump, etc., to get him on board and wanting to do what you want to do?

Sean Flynn: Well, one thing you know – the idea of Trump RX – not the cheap drugs, but the government website with trusted information where you could find the lowest cost providers, that would be great. Singapore’s government does a similar thing with the hospitals and surgeons. You could look up which hospital has the lowest rate of complications on surgeries, and stuff like that. And so, there’s all this quality and price information out there. If there were a trusted national source – of course, everyone’s going to try and game this trusted national source – Randy, so I’m not naive here. But if there were something where consumers could actually just type in their own zip code, and ask: “Hey, where’s the lowest cost provided for X or Y or Z”, that would be amazing.

Similarly, letting doctors, you know, continue to practice across state borders.

There’s a lot that could be done to lower the cost of care because very often, you know, someone just needs to see you for two minutes because you’re such an expert. Doctors can figure out what’s wrong with you, make the right diagnosis. The treatment plan is usually very standard. If there’s a standard treatment plan for millions of people, with the same diagnosis, this is the country that invented the assembly line and the Model T Ford. That’s something we can do. But most people think of it as a bespoke thing. They got to go talk to a doctor, it’s things individual, the treatment’s going to be different.

But I think the starting point is the price comparisons. Price tags on everything and quality metrics that can be trusted.

Randall Bock: Well, I like that. So, if you could if you could get Congress to do one reform during this term of government, what would it be?

Sean Flynn: You’d switch all the ACA [Affordable Care Act ] subsidies and not just the tax subsidies to the individuals, but the whole darn system is subsidized. You just give people the money. It would look like what Milton Friedman wanted with school vouchers, which have turned out to work really well. Give people the money, put it into their health savings accounts. Then the government would just create a catastrophic backs stops. Have it administered in the private sector. When people are given the money themselves.

In Singapore, they’ve got health savings accounts and every baby gets $3,000 just for being born into a health savings account. People spend that money very carefully due to something called loss aversion which got a couple guys the Nobel Prize, Daniel Kahneman. So, give the people the money and then let them decide when and where to spend it rather than some bureaucrat who, as you said, thinks they need to shovel money out the door in order to keep their job.

Randall Bock: Well, thank you so much, Sean Flynn. So, give us the name of the book and how people can buy it and find you.

Sean Flynn: The name of the book is “The Cure That Works”, and the subtitle is “How we can have the world’s best healthcare for a quarter of the cost”. It’s on Amazon. If you need to remember my name, I also wrote Economics for Dummies, one of those yellow and black things. So, first look up Economics for Dummies, get my name and then get the Singapore health care book.

Randall Bock: I got to say I like the Dummies series. And I have not seen yours, but I probably will go buy a copy if you will venture to autograph it for me. I’ve been called worse myself and you know so I very much appreciate your being here on the show. Thank you so much, Professor Flynn.

We have a problem with the Bowring edition: it is full of error. However, in this case it is the best one has, in relation to education. That’s because the first volume of the Code published in Bentham’s time ( signed copy) stops before considering the functions of the Education Minister. I have therefore used the OLL version of Bowring’s work, below.

===

Section VIII.:

Education Minister.

Enactive.

Art. 1. To the Education Minister, under the Legislature and the Prime Minister, it belongs to give execution and effect to all institutions, ordinances, and arrangements, emaning from the Legislature, in relation to the subject of Education.

Enactive.

Art. 2. To this purpose, it belongs to him to exercise, under the direction of the Prime Minister,—as to all persons, in so far as employed under the direction, or at the expense, of Government in the business of Education, the locative, suppletive, directive, and dislocative functions;—as to his own office, the self-suppletive function;—as to things, in so far as thus employed in conjunction with the Finance Minister, the procurative, custoditive, applicative, reparative, transformative, and eliminative functions;—as to persons and things, the inspective;—as to persons, things, and occurrences, the statistic, recordative, publicative, and officially-informative;—as to states of things, ordinances, and arrangements, the melioration-suggestive.

[Sanjeev: Basically, Bentahm’s Education Minister has THREE main function: to inspect things, to record and report on the state of affairs, and to provide suggestive means to correct a situation]

Enactive. Expositive.

Art. 3. In the exercise of his directive function, to him it belongs to preside at all examinations, performed in public, for the purpose of ascertaining, and making manifest, the degree, absolute and comparative, of appropriate aptitude in all its branches, on the part of all aspirants to government offices. [Sanjeev: The Minister will hold an examination for all recruits to government]

Enactive. Expositive.

Art. 4. On this occasion, he has for assessors the Ministers, to whose subdepartments respectively belong the several branches of instruction, forming the subject matters of the several examinations. [Sanjeev: Relevant departements will send assessors for the public service exam]

Enactive.

Art. 5. To this Minister it belongs, moreover, to exercise, as to all such establishments within the territory of the state, as, having any branch of education for their object, are at any time on foot, or in progress, at the expense, or under the direction of sublegislatures, of individuals, or incorporated or otherwise associated bodies,—the inspective, the statistic, and melioration-suggestive functions. [Sanjeev: The functions apply to all institutions that are involved in education, including religious institutions]

Enactive. Instructional.

Art. 6. On this occasion, it belongs to him, with more particular care, to inquire, and from time to time to report, whether there be any and what institutions or establishments, in which application is made of the matter of punishment or of that of reward, in such manner as thereby to engage any persons to make profession of particular opinions as to any subject, more particularly as to government, morals, or religion. [Sanjeev: The Minister will examine whether institutions are giving rewards or punishments to influence POLITICAL or RELIGIOUS opinion]

Ratiocinative.

Art. 7. An establishment thus applied, is an establishment for the subornation of falsehood, by irresistible means; falsehood, the appropriate instrument of crime in all its shapes. By it, throughout the whole field of judicature,—domestic as well as public,—that which should be justice, is converted into injustice, and the judge, howsoever unwillingly, rendered the accomplice of the evil-doer. Of falsehood in this shape, discovery is impossible. Under this security, on what occasion soever, by the commission of it reward may be earned, or by the noncommission of it, punishment incurred, the commission of it follows of course. No opinion more absurd or more mischievous can be conceived, than are many of those, the profession of which is thus regularly obtained, at the hands of millions. Be the opinion what it may, the support thus given to it, is presumptive evidence of its being in itself false, and conclusive evidence of its being so in the eyes of such its supporters and their approvers. An establishment for the subornation of falsehood is an establishment for the propagation of immorality, and for the poisoning of the fountains of justice. Of no crime commissible by an individual, can the mischief be equal, in extent or magnitude, to that produced by every institution, of which, upon a national scale, corruption in this shape is the fruit.

Suppose that among the supporters of it, there be really any person in whose eyes, while he himself is exempt from pernicious error, all others are to such a degree prone to it, that a declaration of this sort, if prescribed or approved by himself, is more likely to prevent, than to produce mischievous error,—by no persuasion of his sincerity can Government be warranted in placing or leaving any such instrument of despotism in his hands. [Sanjeev: UNCLEAR. He seems to be suggesting that educational institutions should not be diverted into ulterior causes which lead to deception and fraud in public life]

Enactive. Instructional.

Art. 8. On the occasion of the inspection taken of Education Establishments maintained at the expense of the several sublegislatures, bodies corporate, and individuals respectively,—it will therefore be the especial care of the Education Minister not to exercise any coercive or unnecessary interference, with the view of producing uniformity, contrary to the opinions and wishes of the parties immediately concerned. [Sanjeev: Since coercive ways to impose opinions is not good, the Minister should not do so during his inspections]

Enactive. Instructional.

Art. 9. It will in a more especial manner be his care to avoid giving offence to any persons concerned, in respect of the opinions respectively professed by them on the subject of religion, to the end that no person may be debarred from maintaining and disseminating, in relation to that subject, any opinion whatsoever:—every individual being responsible for any offence into which he may have been led, by entertainment given to erroneous opinions. [Sanjeev: This also means that Minister won’t try to stop others from their opinions]

Enactive. Instructional.

Art. 10. In case any such opinions should present themselves to his observation as have, or are likely to have, the effect of producing mischief, by acts placed in the catalogue of offences,—he will report them to the Legislature, to the end that, in case of need and use, provision may be made of appropriate instruction and warning, holding up to view the erroneousness of the opinions, and the offences with which, as above, they present themselves to his view as being pregnant.

Enactive. Instructional.

Art. 11. In the exercise of the statistic, inspective, and melioration-suggestive functions,—to the Education Minister, in concert with the Indigence Relief Minister, it belongs to consider, and from time to time to report, whether, by any and what means, for relief against excess of population, at any time, in the whole or in any particular part of the territory of this State, the non-adult or junior portion of the relief-requiring class,—the orphan class in particular,—may, by appropriate preparatory education and instruction, be employed with advantage, in the way of colonization:^* relief being given in land unappropriated or unemployed, in this State or any friendly foreign State, near, adjacent, or in any degree remote: the employment in which they are brought up, being combined into a system, specially directed to this object. Ingrafted on this question may be another,—whether, from a colony, if thus established, any contribution in any shape towards the relief of the helpless class, to be administered here, or in any such colony, can be looked to, as obtainable.