Sunday, August 26, 2007

Sicko (the movie)

Usually these blog entries are about books that Dubya obviously hasn't read and won't read, but this time it's about a movie he's unlikely to see. I suppose it's possible, but he wouldn't like it and it would probably bruise his bubble, since he appears a couple of times in predictably unfavorable lights. (However, none of those appearances actually made enough of an impression to make it into my review of the movie...)

Review of Sicko by Michael Moore

Not at all sure where to start with this one. There are so many perspectives I could write from. It's a movie that I'd been hearing quite a bit about for some months and I was even looking forward to seeing it. I've decided to start with particulars and move to the more general conclusions.

The first particulars regard the circumstances of seeing the movie. It arrived in Tokyo yesterday, quite a while after its release in America. Compared to the debut of Fahrenheit 9/11 several years ago, I felt the response was tepid. There was a long line to see Fahrenheit 9/11 when it arrived here, and my recollection is that many of the showings were sold out. However, Sicko is apparently not being widely promoted, and several of the theaters where I asked about it have no plans to show it. The theater where I saw it has about 140 seats, but I'd estimate that only about 100 seats were filled in my showing, the second showing on its first day in Japan. I don't think that's because of the effective blacklisting of Michael Moore in the States, but probably reflects a basic irrelevance of the theme to Japanese people. What's to discuss from the Japanese perspective? Japan has universal health coverage via mandated health insurance, and there just isn't much relevance here. Then again, perhaps the blacklisting is effective in keeping non-Japanese out of the theater? I spoke to two foreigners about Sicko later in the day, and the American immediately dismissed it, while the Canadian said he wasn't planning to see it any time soon. Serendipitously, a Japanese physician overheard one of those conversations, and did ask about it, but only briefly. It did make me curious how Japan deals with uninsured people such as transient foreigners, but basically it seems like a very minor problem here. The health care system in Japan works, and works well. Why should the Japanese be interested about those American problems?

As I turn to the actual topic, I feel like I need to back up a bit... Since this is such a personal issue, I feel like I should intrude with some of the particulars of my own medical experiences, because they have to color my perception of the issues here. I suppose it's an interesting point that every reviewer of the movie does have relevant personal experiences, one way or the other. Do they just ignore them? Anyway, in my own youth in the States I was mostly happy-go-lucky about it, and didn't worry about medical insurance. I do remember some fairly major medical incidents, but I managed to get by. Upon reflection, I think I may have been slid under the table a couple of times. For example, I had a fairly serious eye procedure that I now suspect was partly subsidized as research. When I was in boot camp, they wanted to pull my wisdom teeth, but I wanted a second opinion and my recollection is that I later wound up paying $165 for a civilian dentist to do that work. No insurance, but I'm surprised to see (via a bit of Web searching) that the price apparently hasn't changed that much. My last major medical incident in the States involved a motorcycle accident, and I remember that one of the first things they did when I arrived at the hospital was introduce me to a woman who was some sort of payment counselor. Her job was apparently to help make sure I would be able to pay for it all, and it turned out to be quite expensive, too. Fortunately, the other driver was clearly and obviously at fault, so I was sure he was going to pay for it. His insurance company almost immediately offered his coverage limit as a settlement, and since I thought that would cover my medical costs, I accepted. It turned out that it was enough money, but not by much, and it really didn't cover my losses if you considered things like lost income. (I was a contract programmer in those days, and I lost a lot of working time.) At the time, I knew I could have sued him and probably received a judgment for about double the settlement, but I didn't want to. After I saw all the bills and after they ate up the settlement, I wasn't so happy-go-lucky about medical costs, but a few years after that I came to Japan, and the problem went away. I've been sick a few times in Japan, but it just isn't an issue here. Trivial particular directly related to Sicko involves the woman whose insurance company bailed on covering her ambulance ride. I remember that as costing about $700 when I needed it in the States, but in Japan it's just a free service. For this part I can say that I've lived with and received medical care under both systems, and I prefer the Japanese approach. Enough prelude:

The movie started with a couple of stories about uninsured people. The footage of a fellow sewing up his own injury was rather shocking, actually, but he was very matter of fact about it. The other story was the widely publicized piece about the fellow who cut off two fingers and could only afford to reattach the cheaper one. Michael Moore noted that about 18,000 people die each year because of their lack of medical insurance, but said he wasn't going to say more about them. However, the film always skirted around the edge of the uninsured issue, because many of the cases included in the film involved various kinds of losses of medical insurance or fear of losing medical coverage. Also, the section about the charity cases being dumped on Skid Row was obviously about uninsured people...

Most of the first half was just sob stories, though Michael Moore didn't really try to jerk tears there. My feeling was that he was deliberately trying to keep it light, though there were still places where I felt close to tears. It seemed to me that he deliberately decided against the tearful approach, both in the stories he selected and in the way he handled them. He tried to focus on the upbeat and humorous side of people who wanted to keep fighting for their own better health. There was some fairly aggressive coverage of claims denials and policy rejections, but it still seemed like a relatively light touch. For example, I felt he could have gone much farther with specifics when he was interviewing the fellow who had worked as a investigator for the insurance companies.

The transition point away from problems in the American system involved a young woman whose insurance was canceled when she developed an age-inappropriate medical problem. (This was also where Michael Moore became more visible in the movie rather than just being a disembodied voice.) Her long-term solution was to commit fraud against the Canadian government by exploiting their free health care system. She did seem basically troubled by this unethical solution, but maybe she took the ethical way out and actually married her Canadian friend and accomplice. Michael Moore actually suggested as much, and the closing credits included a jovial plug to marry Canadians for their health coverage, along with a link to, a real website which currently includes a link back to Michael Moore's website.

Hereabouts Michael Moore inserted some footage of American criticisms of the Canadian health system, focusing on such things as quality problems and long waiting times, so he used that as an excuse to investigate the Canadian system. This was especially a place where I felt a more conventional and systematic approach would have been good, but Michael Moore just treated it very informally. He just walked around and talked to people. Okay, it's a valid sampling approach, but I felt like I wanted statistics more than essentially random samples. However, I'm not sure how he could have done it while maintaining the light tone. Perhaps a news ticker at the bottom of the screen with statistics in synchronization with the people he was interviewing? For example, the ticker could show average waiting times while he interviews someone who reports an actual waiting time.

I've already forgotten the transition rationale, but he had some excuse for continuing with the British system. Again there were lots of fairly random interviews with people who seemed basically satisfied not to worry about paying for their health. This section included a fairly long interview with a British doctor who seemed to be doing quite well even though he was involved in socialized medicine. Actually, the topic of 'socialized medicine' was an area where Michael Moore played a kind of interesting game. In several places he deliberately used propagandistic and polemical footage, but as a kind of humorous contrast, treating the demonization of universal health coverage as a kind of sick joke, which he then contrasted with the successful realities.

I felt the transition to France was actually rather abrupt and loose, but by now it was quite clear that Michael Moore did not want the movie to feel tightly structured (which also made the time feel like it was flying). This part of the movie actually had a number of complicated focuses that were jumped over rather quickly. Of course the primary focus was the French medical system, with a lot of the reporting coming from Americans living in France. That included an interesting segment where he rode around with a doctor who was making house calls. A lot of minor ailments are evidently handled at great convenience to the patients. A secondary focus was on the cost in terms of taxes paid, and Michael Moore's primary response there was just interviewing a middle class couple to show that they seemed to have a very nice lifestyle, taxes notwithstanding. The generous vacation laws in France got more coverage here. The final focus was on French democracy in action, with Michael Moore's theory being that the French government is much more afraid of the French voters than the American government vis a vis the American voters. That's a topic you could easily make an entire documentary on, but it was basically just a passing item here, though it was clear Michael Moore admired the vigor of French democracy.

Again there was a loose transition, this time back to America to consider some women who were dumped by hospitals. The impression I had here was that it was just a sad story that he felt was too powerful to cut. Or maybe he was moved by the coincidence of the second woman who was dumped just before he arrived to film the story about the first one. He did use this topic as the basis of one of the most structured transitions in the film. He considered the question of fair treatment for the least among us, taking these poor and elderly women as examples, before asking about fair treatment for the greatest among us, taking the heroes of 9/11 as his new examples.

In this part of the movie he focused on three of the 9/11 rescue workers who had gotten sick as a result of their 9/11-related work and who were now in need of medical treatment that they couldn't afford. I'm not sure where he got the idea of linking Guantanamo Bay into it. Something about the mixture of inhuman incarceration with frequent accusations of torture mixed with glowing descriptions of the medical treatment the prisoners received? Anyway, I don't feel like he even tried to establish a basis for expecting they could get any medical treatment there, but the real point all along was to make an excuse for comparing America's medical system to Cuba's. In a more classic documentary, I think the director would have made much more of the differences in national priorities and the results. Cuba is a very poor nation under intense pressure for many years, but because they give a very high priority to health care, they are able to provide care that on average is quite close to what America provides with a very low priority. He did mention how Cubans have longer life expectancies than Americans, but mostly this section felt like he was just trying to make America feel ashamed. I felt like he did a pretty good job of it, actually, though I suppose the cold-blooded documentary approach would have been to focus more heavily on the cost-effectiveness aspects, which he only touched in passing.

After that, the movie ended rather abruptly. Lightly structured to the end. However, there were a couple of interesting items in the credits. I already mentioned the Canadian website. However, the big item was a sharp dig at one of his critics, and this incident struck me fairly powerfully, which is enough justification for Michael Moore to have included it in the film. It was handled in a rather ironic way, but he got me curious enough to investigate the details and they were easily found. Turns out his critic had some financial problems related to the lack of universal medical coverage in America. Now this is not just some guy who dislikes Michael Moore, but (based on viewing his website) an angry lunatic who has dedicated a large part of his life to attacking him. It's not just an amusing hobby for this guy, but a major expense, and when his wife got sick he was reduced to begging for money to keep his anti-Michael-Moore website up. This already seems absurd to me, but maybe that's because I have this weird thing against begging. Me, I'd just say sorry, but I need the money for something more important. However, this guy made a public announcement about needing money so he could continue attacking Michael Moore for advocating a social policy that would eliminate his need for the money he was begging for. (I already said the guy struck me as a lunatic.) Anyway, Michael Moore slipped him the money anonymously, the guy accepted it, and now he's angry about it. (I already said he was angry, too.) So if that's how he feels, why doesn't he return the money? Oh yeah, he doesn't want to shut down his website that attacks the idea of eliminating his real need for the money. I visited the website in question, and he has a prominent blurb with links that are apparently supposed to explain why Michael Moore is still a terrible person, but he didn't manage to make anything very clear. Angry lunatics are like that, eh? Next I thought about looking for his substantive policy statements on universal health coverage, since that's supposed to be the issue at hand and he hadn't mentioned it anywhere I could find. Maybe in light of his own experiences he had reconsidered the issue? After all, that would be another ethical solution, and he could still continue to insist that Michael Moore is a terrible person. Unfortunately, his search engine just returns an error, which seems kind of a shame if he's spending all that money on the site... Perhaps he's a bit of a technical fool, as well?

I guess that's enough for the particulars, and now it's time to try and tackle the movie from a higher level perspective. I've decided to take a kind of backwards approach by focusing on the criticisms I've heard, though bear in mind that I mostly didn't read the reviews because I wanted to see it and make up my own mind.

I remember running across one review that liked the movie, but described it as a polemic rather than a documentary. Perhaps I've been spoiled by perfection, but when I think of a polemic, I think of one of Lenin's works. Now there's a polemicist! The point of a polemic is to be negative and to attack, and Lenin was a real polemicist. When you finish a polemic, there should be no doubt about who you hate and why. However, by that standard, the movie comes up quite short of being a "polemic". A polemic is supposed to be focused on the villains, and it's pretty clear that Kaiser Permanente is one of them, but overall they are barely mentioned. Where's the spotlight on the evil villains? My assessment would be that there were basically only three sections that had enough negative focus and energy to be regarded as polemical, and all of them were brief. One was the scene with the names of insurance companies featured, second was the taped discussion with Nixon about HMOs, and third was the list of pharmaceutical companies. Yes, there was lot of negative stuff in the film, but it was mostly leavened with positive stuff and humor, so I'm having trouble making the label stick.

The other dismissive label is of course "propaganda", but that's a word of such breadth that it's almost impossible to assign a substantive meaning to it. If you go by the common dictionary definitions, then anything that has any point of view would qualify as propaganda. What would you exclude? However, it's pretty clear that the critics who use that label intend to associate it with the most negative uses of the term, when it was applied to things like racist Nazi propaganda or the old South African propaganda in defense of apartheid. Well, I've studied quite a bit of that sort of thing, and again Michael Moore's work falls quite short.

The label that the critics of Michael Moore's works uniformly reject is "documentary". Not just the critics, but even many of the people who like and recommend Michael Moore's movies describe them with other labels, such as the "polemic" example mentioned earlier. I quickly pulled a list of 14 definitions, and there was only one entry (of a three-clause definition) that would seem to allow excluding Michael Moore's works on the grounds of bias. Many of the other definitions explicitly acknowledge viewpoints, and one of them even mentioned Triumph of the Will as an example of documentary as propaganda, with Why We Fight as the "propaganda counter-attack" (sic)... I would certainly agree that there are many styles of documentaries, but I would not agree that any of the many that I've seen are truly impartial and unbiased, though they often try to sound like they are coming from godlike perspectives. Actually, the most effective propaganda documentary is the one that does the best job of pretending to be unbiased. Michael Moore is certainly not making any secret of his beliefs, but... To me the biggest difference between his documentaries and others is that I come away from a Michael Moore movie with a fresh bunch of questions about the topic, feeling rather like I've been teased, whereas many other documentaries try to leave you with the sensation that you've become an authority on the topic.

Overall conclusion? I actually feel like this movie is about a relatively more important topic than any of his previous subjects, but that the movie is relatively less forceful than the others, and in particular has less impact than Fahrenheit 9/11. To date, it certainly seems to be eliciting less reaction, though I think some of that is due to a new kind of blacklisting targeted at Michael Moore. They can't stop him from making movies, but his critics can certainly repeat over and over again that his movies are not worth watching, regardless of the importance of the issues involved.