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The American Healthcare System The world’s Best and Worst

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by Kumar David

Remember Dickens? “It was the best of times; it was the worst of times. It was the age of wisdom; it was the age of foolishness”. America has the finest medical technology, its operating theatres are superb (when you walk past one it looks like a NASA space control centre), the surgeons, doctors, support staff (anaesthetists, nurses) and rooms and toilets are excellent. At the same time American healthcare is the most expensive, and the universal grouse is that hospitals and doctors earn more than justified.

The diagram that I have displayed with this column shows the flow of funds in US healthcare. Households pay local State (say California) and Federal Income tax. The Federal Government (Washington) is the big paymaster into the healthcare system through what are known as Medicaid and Medicare payments to healthcare providers (hospitals for example) and top-up transfers to States. Households, or companies on behalf of their employees, also take insurance policies because government Medicaid and Medicare is insufficient to pay for surgery, drugs and specialist fees.

In the case of serious illness people may have to make out of pocket payments. I am not saying doctors knowingly cheat, overprescribe, make excessive consultation references to other doctors, or have deals with hospitals. The excesses are simply built into the way in which the system functions. Often the old and invariably the poor cannot afford payments and forego some services. Political pressures have brought about changes in recent decades. Now anyone can walk into a hospital in the US and cannot be denied emergency medical attention and provision of immediate medication – creeping social democracy you might say!

A recent book by Ed Down however asserts that “people must come to understand that the alleged healthcare providers are actually legal drug dealers who base their diagnosis and recommendations primarily on their profit potential. Not wilfully but at least that’s the model they have been taught and most follow”.

The countries with the eight highest per-capita annual healthcare costs in 2022 were as follows.

United States – $12,300

Germany- $7,400

Switzerland – $7, 200

Norway – $7,000

Austria – $6,400

Denmark – $6,400

Sweden – $6,300

Netherlands – $6,200

All these including the US have an ageing population and this pushes up per capita cost. All hire healthcare workers and professionals from other countries – the US from Mexico and the Philippines, Germany from Eastern Europe and the UK from Commonwealth and Eastern European countries. Still the nearly two-to-one cost ratio between the US and most others is difficult to explain except in terms of profiteering by hospitals and healthcare institutions and overcharging by doctors. Medical professionals and institutions take insurance against what is called malpractice where an accidental error may expose a professional or an institution to law suits of several millions of dollars. This adds a great deal to costs; America is a highly litigious society and there are law firms specialising in screwing doctors and hospitals.

Comparison with the UK

The UK is where well to do Sri Lankans still seek treatment. Costs are lower and the National Health Service (NUS) provides a good service at a lower price than the US. In 2022 compared to the eight high spenders I listed previously, UK healthcare spending on the NHS came nineteenth – below $4500 per annum. The biggest complaint is that the waiting time for non-essential surgery is very long. My friend and late comrade Prof. Sivaguru Ganesan had a complex open-heart procedure five years ago in the UK and never stopped lauding the NUS. “If not for the NUS I would be long dead!” was his constant refrain.

I have quoted above the most expensive per capital health budgets in the world. The US healthcare price tag of over $4 trillion is 55 times Sri Lanka’s entire GDP at the current exchange rate. There are those who say that despite a comparatively tiny budget Ceylon/Sri Lanka has a healthcare system that caters well to the needs of the population, like our education system. I have heard this often from Prof. Carlo Fonseka. I think there is truth in this though conditions here have been sliding downhill steeply in the last two decades.

The following is a summary of a write up prepared for me by Velupillai Kuhanendran, a political comrade of Ganesan and mine and an activist in the Global Tamil Forum and the Labour Party. Sri Lanka/Ceylon is much influenced by the British model. Since the affluent classes still travel there for medical care I am quoting at length (three paragraphs).

QUOTE:

“The post-war Bevan model was for a population aged 20 -50 years and not 70 – 90. The pension industry too was based on this assumption. Medical technology was low and health services dealt with general problems and people were kept in hospital until they were discharged as fully fit. Open heart or major surgery was rare and cancer issues infrequent. The situation has changed dramatically. The population has aged; medical technology has advanced, people live beyond 80, it is common for a man to have two or more surgical interventions, cancer treatments is common, hip and knee replacements very common, the need for beds is high. The demand on the health services has increased exponentially but unlike the US investment and infrastructure have not kept pace.

“General medical services can deal with demands from day-patients but the system has not been modernised. Due to the economic austerity of the last 12 years the government did not invest in building hospitals so there is a massive shortage of beds. The government reaction has been to arrange social-care services but adequate funds are not allocated for these services either. Patients brought by ambulances were kept there till a bed could be found. Ambulances were used as substitute beds and prevented from performing their function. The government promised to fix it by allocating more funds but it did not.

“Though the UK has not invested in the NHS the lower and middle classes who are a majority of the population rely on it. The older population which is now numerically (electorally) significant depends on it. No government (Tory or Labour) has the backbone to run it down; no political party can afford to alienate it. The NHS is here to stay. No one dares to abandon it. More immigration of doctors and nurses is part of the solution. Private medicine is no match for the NHS”.

END OF QUOTE From Kuhanendran.

While the US healthcare system is the most advanced in the world it is also the most expensive. It is paid for by the American taxpayer, meaning by the Federal and State government budgets and by households via insurance companies. I think it is not unfair to say that the principal beneficiaries are the medical institutions (hospitals etc) and doctors and medical personnel. The burden is carried by households via Federal and State taxes and Medicare payments, and by employers both small and large via payments to private Health Insurance companies. Though technically cutting-edge the US system is also the costliest. I think it is not unfair to say that the principal beneficiaries are the medical institutions (hospitals etc) and doctors and medical personnel. It is an arrangement that fits in with the ideology and practices of American market capitalism.

It will be challenged and overthrown as America moves in the direction of social democracy. (Some things like the defacto joint Israeli-US occupation of Arab lands will not change). Biden’s four-trillion-dollar economic package is putting more money into the hands of consumers, for example there are two vacancies for every job seeker, and folks are on a spending spree, despite sustained inflation. The social and political complexities of this period overlap in ways not seen before in a century. Everything points in the direction of significant change in the days ahead. I will return to these themes in the weeks and months to come because America changes its mind rather rapidly.



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Humanitarian leadership in a time of war

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Sri Lanka Navy rescuing survivors of the US torpedo attack on IRIS Dena last week

There has been a rare consensus of opinion in the country that the government’s humanitarian response to the sinking of Iran’s naval ship IRIS Dena was the correct one. The support has spanned the party political spectrum and different sections of society. Social media commentary, statements by political parties and discussion in mainstream media have all largely taken the position that Sri Lanka acted in accordance with humanitarian principles and international law. In a period when public debate in Sri Lanka is often sharply divided, the sense of agreement on this issue is noteworthy and reflects positively on the ethos and culture of a society that cares for those in distress. A similar phenomenon was to be witnessed in the rallying of people of all ethnicities and backgrounds to help those affected by the Ditwah Cyclone in December last year.

The events that led to this situation unfolded with dramatic speed. In the early hours before sunrise the Dina made a distress call. The ship was one of three Iranian naval vessels that had taken part in a naval gathering organised by India in which more than 70 countries had participated, including Sri Lanka. Naval gatherings of this nature are intended to foster professional exchange, confidence building and goodwill between navies. They are also governed by strict protocols regarding armaments and conduct.

When the exhibition ended open war between the United States and Iran had not yet broken out. The three Iranian ships that participated in the exhibition left the Indian port and headed into international waters on their journey back home. Under the protocol governing such gatherings ships may not be equipped with offensive armaments. This left them particularly vulnerable once the regional situation changed dramatically, though the US Indo-Pacific Command insists the ship was armed. The sudden outbreak of war between the United States and Iran would have alerted the Iranian ships that they were sailing into danger. According to reports, they sought safe harbour and requested docking in Sri Lanka’s ports but before the Sri Lankan government could respond the Dena was fatally hit by a torpedo.

International Law

The sinking of the Dena occurred just outside Sri Lanka’s territorial waters. Whatever decision the Sri Lankan government made at this time was bound to be fraught with consequence. The war that is currently being fought in the Middle East is a no-holds-barred one in which more than 15 countries have come under attack. Now the sinking of the Dena so close to Sri Lanka’s maritime boundary has meant that the war has come to the very shores of the country. In times of war emotions run high on all sides and perceptions of friend and enemy can easily become distorted. Parties involved in the conflict tend to gravitate to the position that “those who are not with us are against us.” Such a mindset leaves little room for neutrality or humanitarian discretion.

In such situations countries that are not directly involved in the conflict may wish to remain outside it by avoiding engagement. Foreign Minister Vijitha Herath informed the international media that Sri Lanka’s response to the present crisis was rooted in humanitarian principles, international law and the United Nations. The Convention on the Law of the Sea (UNCLOS) which was adopted 1982 provides the legal framework governing maritime conduct and obliges states to render assistance to persons in distress at sea. In terms of UNCLOS, countries are required to render help to anyone facing danger in maritime waters regardless of nationality or the circumstances that led to the emergency. Sri Lanka’s response to the distress call therefore reflects both humanitarianism and adherence to international law.

Within a short period of receiving the distress message from the stricken Iranian warship the Sri Lankan government sent its navy to the rescue. They rescued more than thirty Iranian sailors who had survived the attack and were struggling in the water. The rescue operation also brought to Sri Lanka the bodies of those who had perished when their ship sank. The scale of the humanitarian challenge is significant. Sri Lanka now has custody of more than eighty bodies of sailors who lost their lives in the sinking of the Dena. In addition, a second Iranian naval ship IRINS Bushehr with more than two hundred sailors has come under Sri Lanka’s protection. The government therefore finds itself responsible for survivors but also for the dignified treatment of the bodies of the dead Iranian sailors.

Sri Lanka’s decision to render aid based on humanitarian principles, not political allegiance, reinforces the importance of a rules-based international order for all countries. Reliance on international law is particularly important for small countries like Sri Lanka that lack the power to defend themselves against larger actors. For such countries a rules-based international order provides at least a measure of protection by ensuring that all states operate within a framework of agreed norms. Sri Lanka itself has played a notable role in promoting such norms. In 1971 the United Nations General Assembly adopted a resolution declaring the Indian Ocean a Zone of Peace. The initiative for this proposal came from Sri Lanka, which argued that the Indian Ocean should be protected from great power rivalry and militarisation.

Moral Beacon

Unfortunately, the current global climate suggests that the rules-based order is barely operative. Conflicts in different parts of the world have increasingly shown disregard for the norms and institutions that were created in the aftermath of the Second World War to regulate international behaviour. In such circumstances it becomes even more important for smaller countries to demonstrate their commitment to international law and to convert the bigger countries to adopt more humane and universal thinking. The humanitarian response to the Iranian sailors therefore needs to be seen in this wider context. By acting swiftly to rescue those in distress and by affirming that its actions are guided by international law, Sri Lanka has enhanced its reputation as a small country that values peace, humane values, cooperation and the rule of law. It would be a relief to the Sri Lankan government that earlier communications that the US government was urging Sri Lanka not to repatriate the Iranian sailors has been modified to the US publicly acknowledging the applicability of international law to what Sri Lanka does.

The country’s own experience of internal conflict has shaped public consciousness in important ways. Sri Lanka endured a violent internal war that lasted nearly three decades. During that period questions relating to the treatment of combatants, the protection of civilians, missing persons and accountability became central issues. As a result, Sri Lankans today are familiar with the provisions of international law that deal with war crimes, the treatment of wounded or disabled combatants and the fate of those who go missing in conflict. The country continues to host an international presence in the form of UN agencies and the ICRC that work with the government on humanitarian and post conflict issues. The government needs to apply the same principled commitment of humanitarianism and the rule of law to the unresolved issues from Sri Lanka’s own civil war, including accountability and reconciliation.

By affirming humanitarian principles and acting accordingly towards the Iranian sailors and their ship Sri Lanka has become a moral beacon for peace and goodwill in a world that often appears to be moving in the opposite direction. At a time when geopolitical rivalries are intensifying and humanitarian norms are frequently ignored, such actions carry symbolic significance. The credibility of Sri Lanka’s moral stance abroad will be further enhanced by its ability to uphold similar principles at home. Sri Lanka continues to grapple with unresolved issues arising from its own internal conflict including questions of accountability, justice, reparations and reconciliation. It has a duty not only to its own citizens, but also to suffering humanity everywhere. Addressing its own internal issues sincerely will strengthen Sri Lanka’s moral standing in the international community and help it to be a force for a new and better world.

BY Jehan Perera

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Language: The symbolic expression of thought

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It was Henry Sweet, the English phonetician and language scholar, who said, “Language may be defined as the expression of thought by means of speech sounds“. In today’s context, where language extends beyond spoken sounds to written text, and even into signs, it is best to generalise more and express that language is the “symbolic expression of thought“. The opposite is also true: without the ability to think, there will not be a proper development of the ability to express in a language, as seen in individuals with intellectual disability.

Viewing language as the symbolic expression of thought is a philosophical way to look at early childhood education. It suggests that language is not just about learning words; it is about a child learning that one thing, be it a sound, a scribble, or a gesture, can represent something else, such as an object, a feeling, or an idea. It facilitates the ever-so-important understanding of the given occurrence rather than committing it purely to memory. In the world of a 0–5-year-old, this “symbolic leap” of understanding is the single most important cognitive milestone.

Of course, learning a language or even more than one language is absolutely crucial for education. Here is how that viewpoint fits into early life education:

1. From Concrete to Abstract

Infants live in a “concrete” world: if they cannot see it or touch it, it does not exist. Early education helps them to move toward symbolic thought. When a toddler realises that the sound “ball” stands for that round, bouncy thing in the corner, they have decoded a symbol. Teachers and parents need to facilitate this by connecting physical objects to labels constantly. This is why “Show and Tell” is a staple of early education, as it gently compels the child to use symbols, words or actions to describe a tangible object to others, who might not even see it clearly.

2. The Multi-Modal Nature of Symbols

Because language is “symbolic,” it does not matter how exactly it is expressed. The human brain treats spoken words, written text, and sign language with similar neural machinery.

Many educators advocate the use of “Baby Signs” (simple gestures) before a child can speak. This is powerful because it proves the child has the thought (e.g., “I am hungry”) and can use a symbol like putting the hand to the mouth, before their vocal cords are physically ready to produce the word denoting hunger.

Writing is the most abstract symbol of all: it is a squiggle written on a page, representing a sound, which represents an idea or a thought. Early childhood education prepares children for this by encouraging “emergent writing” (scribbling), even where a child proudly points to a messy circle that the child has drawn and says, “This says ‘I love Mommy’.”

3. Symbolic Play (The Dress Rehearsal)

As recognised in many quarters, play is where this theory comes to life. Between ages 2 and 3, children enter the Symbolic Play stage. Often, there is object substitution, as when a child picks up a banana and holds it to his or her ear like a telephone. In effect, this is a massive intellectual achievement. The child is mentally “decoupling” the object from its physical reality and assigning it a symbolic meaning. In early education, we need to encourage this because if a child can use a block as a “car,” they are developing the mental flexibility required to later understand that the letter “C” stands for the sound of “K” as well.

4. Language as a Tool for “Internal Thought”

Perhaps the most fascinating fit is the work of psychologist Lev Vygotsky, who argued that language eventually turns inward to become private speech. Have you ever seen a 4-year-old talking to himself or herself while building a toy tower? “No, the big one goes here….. the red one goes here…. steady… there.” That is a form of self-regulation. Educators encourage this “thinking out loudly.” It is the way children use the symbol system of language to organise their own thoughts and solve problems. Eventually, this speech becomes silent as “inner thought.”

Finally, there is the charming thought of the feasibility of conversing with very young children in two or even three or more languages. In Sri Lanka, the three main languages are Sinhala, Tamil and English. There are questions asked as to whether it is OK to talk to little ones in all three languages or even in two, so that they would learn?

According to scientific authorities, the short, clear and unequivocal answer to that query is that not only is it “OK”, it is also a significant cognitive gift to a child.

In a trilingual environment like Sri Lanka, many parents worry that multiple languages will “confuse” a child or cause a “speech delay.” However, modern neuroscience has debunked these myths. The infant brain is perfectly capable of building three or even more separate “lexicons” (vocabularies) simultaneously.

Here is how the “symbolic expression of thought” works in a multilingual brain and how we can manage it effectively.

a). The “Multiple Labels” Phenomenon

In a monolingual home, a child learns one symbol for an object. For example, take the word “Apple.” In a Sri Lankan trilingual home, the child learns three symbols for that same thought:

* Apple (English)

* Apal

(Sinhala – ඇපල්)

* Appil

(Tamil – ஆப்பிள்)

Because the trilingual child learns that one “thought” can be expressed by multiple “symbols,” the child’s brain becomes more flexible. This is why bilingual and trilingual children often score higher on tasks involving “executive function”, meaning the ability to switch focus and solve complex problems.

b). Is there a “Delay”?

(The Common Myth)

One might notice that a child in a trilingual home may start to speak slightly later than a monolingual peer, or they might have a smaller vocabulary in each language at age two.

However, if one adds up the total number of words they know across all three languages, they are usually ahead of monolingual children. By age five, they typically catch up in all languages and possess a much more “plastic” and adaptable brain.

c). Strategies for Success: How to Do It?

To help the child’s brain organise these three symbol systems, it helps to have some “consistency.” Here are the two most effective methods:

* One Person, One Language (OPOL), the so-called “gold standard” for multilingual families.

Amma

speaks only Sinhala, while the Father speaks only English, and the Grandparents or Nanny speak only Tamil. The child learns to associate a specific language with a specific person. Their brain creates a “map”: “When I talk to Amma, I use these sounds; when I talk to Thaththa, I use those,” etc.

*

Situational/Contextual Learning. If the parents speak all three, one could divide languages by “environment”: English at the dinner table, Sinhala during play and bath time and Tamil when visiting relatives or at the market.

These, of course, need NOT be very rigid rules, but general guidance, applied judiciously and ever-so-kindly.

d). “Code-Mixing” is Normal

We need not be alarmed if a 3-year-old says something like: “Ammi, I want that palam (fruit).” This is called Code-Mixing. It is NOT a sign of confusion; it is a sign of efficiency. The child’s brain is searching for the quickest way to express a thought and grabs the most “available” word from their three language cupboards. As they get older, perhaps around age 4 or 5, they will naturally learn to separate them perfectly.

e). The “Sri Lankan Advantage”

Growing up trilingual in Sri Lanka provides a massive social and cognitive advantage.

For a start, there will be Cultural Empathy. Language actually carries culture. A child who speaks Sinhala, Tamil, and English can navigate all social spheres of the country quite effortlessly.

In addition, there are the benefits of a Phonetic Range. Sinhala and Tamil have many sounds that do not exist in English (and even vice versa). Learning these as a child wires the ears to hear and reproduce almost any human sound, making it much easier to learn more languages (like French or Japanese) later in life.

As an abiding thought, it is the considered opinion of the author that a trilingual Sri Lanka will go a long way towards the goals and display of racial harmony, respect for different ethnic groups, and unrivalled national coordination in our beautiful Motherland. Then it would become a utopian heaven, where all people, as just Sri Lankans, can live in admirable concordant synchrony, rather than as splintered clusters divided by ethnicity, language and culture.

A Helpful Summary Checklist for Parents

* Do Not Drop a Language:

If you stop speaking Tamil because you are worried about English, the child loses that “neural real estate.” Keep all three languages going.

* High-Quality Input:

Do not just use “commands” (Eat! Sleep!). Use the Parentese and Serve and Return methods (mentioned in an earlier article) in all the languages.

* Employ Patience:

If the little one mixes up some words, just model the right words and gently correct the sentence and present it to the child like a suggestion, without scolding or finding fault with him or her. The child will then learn effortlessly and without resentment or shame.

by Dr b. J. C. Perera

MBBS(Cey), DCH(Cey), DCH(Eng), MD(Paediatrics), MRCP(UK), FRCP(Edin), FRCP(Lond), FRCPCH(UK), FSLCPaed, FCCP, Hony.
FRCPCH(UK), Hony. FCGP(SL)

Specialist Consultant Paediatrician and Honorary Senior Fellow, Postgraduate Institute of Medicine, University of Colombo, Sri Lanka

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SIMPSON’S … set to carve a distinct sonic identity

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SIMPSON’S: Quite active in the scene here

It is, indeed, encouraging to see our local artistes working on new formats, where their music is concerned.

Variety is the spice of life, they say, and I do agree, especially when it comes to music.

Blending modern synth textures, ambient layers and soulful undertones, the group SIMPSON’S is set to carve a distinct sonic identity within Sri Lanka’s contemporary music landscape.

Their vision, they say, is not simply to produce songs, but to create emotional atmospheres – experiences that elevate, energise and resonate, both locally and beyond.

This four-piece outfit came into the scene, less than two years ago, and they are already making waves with their debut single ‘Balaporottuwak’ (Hope).

The song, I’m told, marks the beginning of a new sound, and at the forefront of ‘Balaporottuwak’ is the group’s lead vocalist and guitarist, Ryo Hera, who brings a rich cultural heritage to the stage.

As a professional Kandyan Wes dancer, Ryo’s commanding presence and textured vocals bring a distinct energy to the band’s sound.

‘Balaporottuwak’

Ryo Hera: Vocals for ‘Balaporottuwak’

is more than just a debut single – it’s a declaration of intent. The band is merging tradition and modernity, power and subtlety, to create a sound that’s both authentic and innovative.

With this song, SIMPSON’S is inviting listeners to join them on an evolving musical journey, one that’s built on vision and creativity.

The recording process for ‘Balaporottuwak’ was organic and instinctive, with the band shaping the song through live studio sessions.

Dileepa Liyanage, the keyboardist and composer, is the principal sound mind behind SIMPSON’S.

With experience spanning background scores, commercial projects, cinematic themes and jingles across multiple genres, Dileepa brings structural finesse and atmospheric depth to the band’s arrangements.

He described the recording process of ‘Balaporottuwak’ as organic and instinctive: “When Ryo Hera opens his voice, it becomes effortless to shape it into any musical colour. The tone naturally adapts.”

The band’s lineup includes Buddhima Chalanu on bass, and Savidya Yasaru on drums, and, together, they create a sound that’s not just a reflection of their individual talents, but a collective vision.

Dileepa Liyanage: Brings
structural finesse and
atmospheric depth to the
band’s arrangements

What sets SIMPSON’S apart is their decision to keep the production in-house – mixing and mastering the song themselves. This allows them to maintain their unique sound and artistic autonomy.

“We work as a family and each member is given the freedom to work out his music on the instruments he handles and then, in the studio, we put everything together,” said Dileepa, adding that their goal is to release an album, made up of Sinhala and English songs.

Steering this creative core is manager Mangala Samarajeewa, whose early career included managing various international artistes. His guidance has positioned SIMPSON’S not merely as a performing unit, but as a carefully envisioned project – one aimed at expanding Sri Lanka’s contemporary music vocabulary.

SIMPSON’S are quite active in the scene here, performing, on a regular basis, at popular venues in Colombo, and down south, as well.

They are also seen, and heard, on Spotify, TikTok, Apple Music, iTunes, and Deezer.

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