Jose Bollo, manager of the Barcelona hobby shop, RC Tecnic, lets shoppers test-fly toy helicopters like this one. He says most people leave with at least one chopper under their arms. Economists say small stores need to be creative to survive during this long economic downturn. (Photo: Gerry Hadden)

Spain’s new Prime Minister has announced spending cuts and labor reform as the country seeks to calm anxious lenders.

The conservative leader Mariano Rajoy was sworn in Tuesday, and inherits big problems. Unemployment is at 22 percent, the highest in the Euro-zone.

In Spain this holiday season all people seem to talk about is crisis, crisis, crisis. But as Christmas approaches, shops and restaurants seem to be mostly full.

In his inaugural address, Prime Minister Rajoy tried to be optimistic, but he also warned citizens that tough sacrifices lie ahead. His administration, he said, has no choice but to slash government spending – by more than $20 billion. He called it a thankless task.

“We’re like those families who find themselves having to feed four people,” he said, “with only enough money for two.”

The crisis is upon us, goes the mantra in Spain these days. 22% unemployment. A flat economy. Soaring interest rates on government debt. And yet, on the street, you can’t help but wonder if things are really that bad.

At a local mall in Barcelona, holiday shoppers are out en masse. Santiago and Lourdes, a young couple pushing a baby carriage, are sort of like the family to which Rajoy eluded in his speech. Lourdes has lost her job as a waitress, Santiago says, but he’s still got his, as a security guard.

“We’re subsisting on half of what we had,” he said, “and this year we’ve made sacrifices. But we’re still spending on the things that count.”

This holiday season what counts are presents. Shopping bags hung from Lourdes and Santiago’s hands, and from the handles of their baby carriage. So how exactly is this crisis affecting this young family?

“We go out to dinner less,” Santiago said. “Instead of going to restaurants, we now gather at friends’ houses.”

So there you have it. As world financial markets batter Spain with unsustainable interest rates, as the government slashes spending for healthcare and education, as the press reports that businesses are making contingency plans in case the euro currency collapse, this hard hit couple cuts out the occasional restaurant meal.

Spanish shoppers flock to local malls during the holiday season, undeterred by the economic crisis. They're probably spending a bit less, experts say, but they're still spending. (Photo: Gerry Hadden)

He said that what probably happens is that if you ask the shop owners they will immediately tell you well shopping is lower than last year, and this will go to the press.
“But if someone says for the year, has it been okay? They’ll say yes, we did a very good year. So they’re not closing down,” he said. “A lot of people are doing well.”

Oliver says that what’s often lost in the way we discuss this crisis is context. Spaniards may be spending less today, he says, but in recent years they’ve been spending – and earning – more than ever. He says that when stores report that sales are off, they may be very well be off – but from record highs.

That’s the case at Ulanka, a shoe store here in the mall.

“People are more concerned with prices this year compared to last,” said manager Asai Juan, “but that sales aren’t off by much.”

Big malls like this don’t tell the whole story, of course. Small independent shops have suffered more in this crisis than the retail chains. But economist Xavier Oliver said the crisis has given small businesses a much needed kick in the pants. The ones that survive, he said, must find ways to stand out.

We’ve been selling this idea in business schools for centuries,” he said, “and no one has believed us till today.”

A crisis, he said, is the time to recreate your operations.

“How can I help consumers, my clients, and do it in a way that they notice that you’re helping them?”

Oliver sited as a model the Apple store, where you can ask questions, take classes and most importantly, touch the products.

A decidedly smaller store in Barcelona uses that same technique. When you walk into the RC Tecnic hobby shop, you see stacks of remote control cars, planes and, set out on the counter, model helicopters. They let you fly them.

Manager Jose Bollo says sales this year are better than last.

“We’re bringing people in by offering sales prices before Christmas instead of afterwards, like most stores do,” Bollo said. “And we let people fly the birds.”

The new Spanish government hopes to help small businesses like RC Tecnic, by lowering taxes and making it easier to hire and fire employees. But those reforms won’t be in place until next holiday season.

Read tweets about Spain

With revenues shrinking, Spain has had to slash spending. One hard-hit sector is health care.

In Spain, health care is state-run and state-financed – and the state is spending less.

Now health providers and patients say they’re feeling the impact.

The World’s Gerry Hadden reports from Barcelona.

The protest banner reads, Vall d'Hebron fights back. Enough with the budget cuts. (Photo: Gerry Hadden)

“But it is Sunday,” said the nurse from behind the glass screen.

“Yes,” my friend said.

“The payment office is closed on Sundays.”

“We’re screwed,” my friend said to me anxiously.

“Why?” I asked.

“Because we can’t just leave without paying,” he said. “What are we supposed to do?”

I translated his concern to the nurse.

“Why can’t he just come back tomorrow,” she said, looking bewildered. “What’s the problem?”

I explained to my friend that he could pay the following morning, and we walked out of the hospital. He was shaking his head in disbelief.

“Come back tomorrow?” he said. “Try that in America. ‘Hey, I don’t have any insurance, or cash on me. I’ll come back to pay my $4,000 hospital bill tomorrow.’”

He was right. It hadn’t struck me how absurd that would have sounded back home. Yeah, the check’s in the mail. No problem. Except stateside that’d be a big problem. One that would likely end with your bank account getting embargoed.

The real shocker for my friend came the next morning. We got up early, drove back to the hospital, and found the payments office. I handed over the bill for the emergency room care and overnight stay. My friend pulled out a credit card.

The clerk looked at me. “Doesn’t he have cash? It’d be a lot easier.”

“He’s asking if you’ve got cash.”

“Yeah,” my friend said, “I’ve got a suitcase full of twenties in the trunk of my car.”

“How much is it?” I asked the clerk.

“30 euros,” he said.

“It’s 30 euros,” I told my friend. “I’ve got a 10. If you’ve got 20 euros on you we’re good.”

If my friend had been shaking his head the day before, now, as we walked to my car again, it was positively spinning.

“That would have been thousands of dollars back home!” he exclaimed. “How can they do it?”

“Well,” I said, “it’s not really so cheap. People pay for the healthcare system in part through a special healthcare tax. Like the medical version of our Social Security.”

“But I don’t pay that,” my friend said. “I’m just a tourist. And yet they only charged me 30 euros.”

“Yeah, well, it’s a pretty good system.”

My friend flew home, impressed.

I am too. But after a few more visits to hospitals of late, interviewing doctors and patients and administrators, I’m seeing first-hand how that pretty good system is getting gutted. Spanish tax rolls are down as unemployment soars to over 21 percent.

So the Spanish government is slashing spending. More than any other sector, healthcare has its head on the chopping block.

I’m afraid we’re witnessing the dismantling of the European welfare system. Unless economic growth returns soon, the budget cuts will keep coming.

This morning at a city hospital a nurse named Encarna said to me that she really hoped Spain didn’t end up like America, “with so many poor people who can’t get healthcare.” Shame on you, she said, turning away the poor at hospitals.

The poor and any tourist without a suitcase full of $20s, I thought. Viva España.

• Official website of Tiyatien Health

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The text below is a phonetic transcript of a radio story broadcast by PRI’s THE WORLD. It has been created on deadline by a contractor for PRI. The transcript is included here to facilitate internet searches for audio content. Please report any transcribing errors to theworld@pri.org. This transcript may not be in its final form, and it may be updated. Please be aware that the authoritative record of material distributed by PRI’s THE WORLD is the program audio.

Marco Werman: Liberian-born Raj Panjabi co-founded a Liberian healthcare organization, it’s called Tiyatien Health.  Tiyatien means truth and justice in the local Liberian dialect.  Dr. Panjabi, who’s based in Liberia and Boston, set a straightforward goal for his organization, to help Liberians, but he got more than he bargained for. An estimated 170,000 refugees from neighboring Ivory Coast have fled to Liberia.  They’ve escaped the violence that marked a power struggle in their country.  Now, Dr. Panjabi says many need medical care.

Dr. Raj Panjabi: A lot of them have experienced extreme violence — gunshot wounds, burnings, malnutrition, food shortages — it’s a major problem.  We have a unit where the whole unit is filled with kids that are starving from hunger. And then you see the things that you typically see, like this was a very poor place from the beginning — complications from childbirth, HIV, malaria, tuberculosis — these are the ranking health problems facing both Ivorian refugees and the Liberian relatives that they’re living with now.

Werman: How many months or even years of a setback to Liberia’s healthcare system do you think the Ivory Coast crisis has prompted?

Panjabi: We are at this point really trying to focus on building back the public health sector by investing in training local health workers.  There’s also a need for medical supplies and for building mobile clinics in these hard to reach villages.  We know that medical care alone, treatment and cure, aren’t enough.  We’ve gotta hit at the root of the problem.  And one of the major challenges facing all of the partners and the communities there are the food shortages. Liberian farmers have reached out to the Ivorian relatives in an act of kindness and generosity, housed them, and have been providing food for them.  And they’re using the same seeds and crops to be able to feed both their own families and now their relatives who’ve come over.  Some villages have multiplied five times their own usual number of people, so you can imagine the food shortages are high.  We just lost a two-week old infant after her mother had lost her breast milk because she herself had gone hungry. So we’re trying very hard at this point also to address the food crisis.  There are a couple things that we’ve been focusing — one is to try to advocate for the UNICEF and the World Food Program to get immediate food relief.  That’s gonna help us stave off children from dying acutely from starvation. In the medium term we need also farming materials, and assistance to the local farmers who have used up their seeds and crops for this new incoming population.  And in the long term we’d like to see the U.N. start to procure food locally from these farmers so as to help stir back up the economy.

Werman: It seems as if the violence has subsided a little bit in Ivory Coast since Laurent Gbagbo, the defeated president in November’s elections, stepped down a few weeks ago.  Are there any signs that the refugees are returning to their homes in Ivory Coast now because you’d assume that would take the pressure off Liberia a little bit.

Panjabi: They are continuing to flee across the border.  In fact, there’s a bit of a slow down, but we’re not going yet in the other direction.

Werman: Coming into Liberia.

Panjabi: Coming into Liberia, that’s right.  There’s a lot of fear of reprisal now that Quattara is in power and Gbagbo has been captured; and for good reason, given the massacres that they faced in just recent weeks.

Werman: So it doesn’t sound like you’re very hopeful that there’s gonna be a mass exodus very soon back to Ivory Coast?

Panjabi: What we know from other crises around the world like this is that people have to have a sense of security that’s met; when you’ve seen, like I’ve seen some of my patients in Liberia, lose your husband suddenly while you’re taking cover on the floor of a hut and then escaping with your three children across the border — that puts you in a situation where security has to be recovered.  Part of that means meeting basic needs. A lot of people don’t feel like their needs will be met across the border if they go back.  They still fear a lot of the militias are lurking, and that’s something that has to be resolved first.

Werman: Dr. Panjabi, tell me why you co-founded Tiyatien Health.

Panjabi: Well, I felt a responsibility to my country.  I was born and raised in Liberia and my family and I fled in 1990 when Charles Taylor and his rebels entered Liberia.  We were suddenly evacuated one morning.  There were many people on that tarmac when we were being evacuated that we left behind.  And that was a memory that stuck with me as a child; a memory that eventually lead me to want to come back as a medical doctor.

Werman: Dr. Raj Panjabi, a physician at Harvard Medical School and the co-creator of Tiyatien Health in Liberia, thanks very much for speaking with us and best of luck to you.

Panjabi: Thanks.

Copyright ©2009 PRI’s THE WORLD. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to PRI’s THE WORLD. This transcript may not be reproduced, in whole or in part, without prior written permission. For further information, please email The World’s Permissions Coordinator at theworld@pri.org.

(image: BBC)

• BBC coverage: full speech itemized and video
• White House Facebook page
• NY Times interactive: Who sat where seating chart

Sputnik 1 - the world's first artificial satellite (Image:NASA)

President Obama’s message in the State of the Union address last night was clear. The United States needs to get its act together or risk losing its place in the world.

“This is our generation’s Sputnik moment,” said the President.

The president’s rhetoric got us thinking about the original Sputnik moment, and what it unleashed, and whether it’s relevant to today’s challenges.

On October 4, 1957 the Soviet Union launched the first artificial satellite into space. Cathleen Lewis, a curator at the National Air and Space Museum in Washington, said the spacecraft wasn’t that sophisticated.

“It was simply a hollow sphere with two transmitters on board, and batteries,” Lewis said.

And it while it didn’t surprise Americans involved in the space race, it shocked the public.

“The point of Sputnik was this was the first public awareness this competition was going on,” said Lewis. “And that the Soviet Union had the capability of launching warheads to anywhere in the world.”

That realization took the cold war competition between the United States and the Soviet Union to a whole new level. Von Hardesty, co-author of “Epic Rivalry: The Inside Story of the Soviet and American Space Race”, remembers watching Sputnik move across the sky through binoculars from the roof of his college dorm.

“This was a really traumatic moment,” Hardesty said. “It ran counter to our self-image as a country, that we were always on the cutting edge and the Soviet Union was still something of a technological backwater.”

What followed was a period of national soul-searching that resulted in major increases in spending on scientific education and research. Jim Lewis, a fellow at the Center for Strategic and International Studies in Washington, said the most important part of the federal response to Sputnik was probably the National Scientific Education Act.

“It created a whole generation of scientists and engineers,” Lewis said. “And we’ve lived off that bulge, that big pile of scientists and engineers that were created through the last few decades. These guys are just hitting retirement now and they’re going out of the work force and we’re not replacing them.”

Lewis says he groaned inwardly when he heard the Sputnik analogy being used once again last night. Not because he doesn’t support the President’s call for investment and innovation, but because the context is different now.

“The problem with the Sputnik analogy is that Americans were afraid when they woke up and realized that the Soviets had this immense new capability that we couldn’t match,” said Lewis.

“If you can orbit a satellite, you can land a warhead anywhere in the planet. That’s what people realized and it scared them. I don’t get that sense of fear, that sense of urgency today.”

Nor is there a specific focus like Sputnik according to Cathleen Lewis of the National Air and Space Museum.

“There’s nothing as discrete as Sputnik,” said Lewis. “There’s no discernible beeping in the sky.”

And there isn’t one overarching goal like the race to put a man on the moon. Instead President Obama spoke of a variety of clean energy Apollo projects, not one dramatic unambiguous finish line. Still, Von Hardesty thinks the President’s analogy works in a broad sense.

“The country has a perceived need to kind of reorganize ourselves,” said Hardesty. “To redeploy our resources, to once again gain a momentum or cutting edge in various spheres of life, including technology.”

Hardesty said in that sense President Obama is echoing some of the same feeling that rose out of the Sputnik area. Feelings are one thing though, action is another. Hardesty wonders out loud whether the United States has the economic and popular will to mount the kind of technological effort it did 50 years ago.

Clark Boyd on Laika’s mission (Sputnik II)

The discussion is live through next week.

• CDTI Haiti
• Slideshow from CDTI Haiti
• Audio Slideshow: Haiti quake opportunity to restore rural ecology?
• Haitian earthquake survivor in the U.S.
• In Haiti, a musical pre-quake tradition restored

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DAVID BARON: The earthquake that struck Haiti in January left hundreds of thousands of survivors in need of immediate medical attention. The international community responded with doctors, nurses and equipment. As a result, many Haitians received medical treatment for the first time. Parts of Haiti still have more free health care than ever before. But this has created a problem. The temporary abundance of free care appears to be a factor in the decline of Haiti’s own health care system. The World’s Amy Bracken has the story from Port-au-Prince.

AMY BRACKEN:  When CDTI Hospital opened three years ago, it was touted as the best medical facility in Haiti, with CT scanners and other technology rarely seen in the country. The private hospital catered to Haitians who could afford the 25 dollar consultation fee. After the earthquake, it provided round-the-clock free care to anyone who needed it. But today the hospital is quiet, empty, closed. Reynold Savain is a radiologist and the hospital’s director.

REYNOLD SAVAIN:  To have a private hospital operating right now, in this situation, it’s not possible.

BRACKEN: Savain says providing free care after the earthquake has driven him deeply into debt. To the bank, to the staffers who worked for months without full pay, to pharmaceutical suppliers whose products he gave away, and to local doctors who invested in the hospital.  Savain says he was grateful to the foreign organizations that provided medical staff and supplies after the disaster. But he also needed financial support.

SAVAIN: All these people wanted to give was medicine, medical supplies, and doctors, rotational doctors, and at one point I couldn’t take it any more. So at the end of March I said okay, this is it, everything has to stop.

BRACKEN: And after the emergency phase ended, Savain says his patient base dried up.  Many are now going to the free clinics run by international groups. Savain was forced to close down. Other private hospitals fear the same fate. Michel Théard is a cardiologist and board member at Hopital Canapé Vert, just up the road.

MICHEL THEARD: We have an average of 8 to 10 patients a day, which is not enough to maintain the hospital open. And the problem is that the NGOs are working giving the free care, so when they will leave, you will find nothing. The medical condition of Haiti will be worse than before.

BRACKEN: But Hans Van Dillen, Haiti mission chief for Doctors without Borders, or MSF, says aid groups that treat Haiti’s neediest should not be blamed for damaging the private system.

HANS VAN DILLEN: I don’t see MSF being responsible for destroying the private sector as has been said now. Well, not only MSF, of course, but the fact that there is free health care in Port-au-Prince is much more important.

BRACKEN: Still, MSF won’t be around forever. And neither will     other aid groups. Earlier this month, another NGO, International Medical Corps, pulled out of Port-au-Prince’s General Hospital. IMC had been running the public hospital since shortly after the earthquake. The Hospital’s director asked them to leave. Jason Erb of IMC says his staff were unhappy about going, but they understood that after the emergency phase, the presence of foreign doctors can be a problem.

JASON ERB:  In Haiti before the earthquake, I believe it was less than 45% of people actually had access to healthcare, and that includes private and public. And so we know that in coming in we have provided care to people who maybe never had it before. It’s difficult to stop providing that, but it’s not something that can go on forever. And it’s not something that helps to develop the health care system here in Haiti.

BRACKEN: Before the earthquake, the Haitian government financed the public hospital.  Emergency care was free, and the rest was heavily subsidized. But patients had to buy their own medications and bring them to the hospital. And hospital staff periodically went on strike, abandoning patients in their cots, because the government hadn’t paid them in months. Now Haiti’s government is pledging to make health care at the public hospital completely free with the help of international donations. That remains to be seen. But Alix Lassegue, who runs the main public hospital, is still concerned about the state of Haiti’s private health care system.

ALIX LASSEGUE: I think there is a necessity in a country like Haiti to have private sector. The majority of doctors or nurses working in the public sector work also in the private sector because the salary paid in the public sector is not sufficient to take care of the family, all the expenses for the daily life.

BRACKEN: In other words, if private health care in Haiti collapses, it will bring the public system down with it. Lassegue hopes the government will also help private medicine. Others, like Théard of Hopital Canapé Vert, say they’re hoping for a public-private partnership, one that would provide care for anyone, regardless of their ability to pay.

THEARD: I believe the new avenir of the future of medicine in Haiti has to be mixed. Private won’t work any more.

BRACKEN: But in order for a public-private system to work, Haiti will have to rely on international funding for the foreseeable future. For The World, I’m Amy Bracken, Port-au-Prince, Haiti.

Copyright ©2009 PRI’s THE WORLD. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to PRI’s THE WORLD. This transcript may not be reproduced, in whole or in part, without prior written permission. For further information, please email The World’s Permissions Coordinator at theworld@pri.org.

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JEB SHARP:  Roger Cohen is among those who view passage of the health care bill as a boon for President Obama’s foreign policy.  Cohen writes about the issue in today’s New York Times.  Roger Cohen why do you think this domestic victory gives Barack Obama political capital abroad?

ROGER COHEN: Well I think there was an impression growing around the world, and I’d certainly heard it both in Europe and in Asia, that President Obama was a man who had lots of good ideas, a fine turn of phrase, but could not deliver.  And I think he’s demonstrated with the passage of a health care bill that may not be all that he wanted, certainly isn’t, but he got something in the end.  He got a victory.  And think that combined with a nuclear deal with Russia demonstrates that you cannot write this President off as a man who is very smart but can’t close a deal.  I remember Henry Kissinger telling me at a dinner a couple of months back that Obama reminded him of a chess grand master who would play the openings in 6 games, but hadn’t finished a single game.  Well, that’s over.  He’s finished a couple now.

SHARP: Where do you think this momentum takes him next?

COHEN: Well it took him most immediately to Afghanistan where he had some tough words for Hamid Karzai, the Afghan leader, in terms of shaping up and fighting corruption.  I think it has also taken him and will take him to the Middle East where he has shown a sharper focus, I think, in the last three weeks.  It’s clear that the tensions between Israel and the United States that were brewing, particularly over the settlement in the West Bank, where back Cairo in his big speech about outreach to the Muslim world, Obama had said categorically and unequivocally that the settlements must “stop”.  He is really insisting on that and this has brought an open breach that we haven’t seen for a long time with Prime Minister Netanyahu.  We don’t know what will happen.  Might this Israeli government fall and a more moderate one come in, in any event I think it’s salutary that things are out in the open and differences are being aired.  The United States has to be an honest broker in the Middle East.  Has to be seen as an honest broker and that cannot come to pass unless it’s prepared to criticize both sides when necessary.

SHARP: Now yesterday in a speech at Columbia University, French President Nicolas Sarkozy said that he U.S. should reflect on what it means to be the world’s number one power.  What do you think it means to be the world’s number one power right now in President Obama’s second year in office?

COHEN: Well Jeb I think it means less than it meant a decade ago.  I think there’s no question and I think President Obama is acutely aware of this, that the relative power of the United States is declining.  That doesn’t mean that the United States is not the dominant power by a long stretch still.  But it does mean that on the thorniest issues in the world, take Iran, take the Middle East, I think it’s true that nothing can be done without the United States, but equally, the United States cannot do anything decisive alone.  So I think Obama has been engaged in the rowing back of expectations and it remains to be seen if the American people will accept this at the ballot box.  It’s a less inspiring vision, but it’s a more realistic one.

SHARP: What do you think President Obama has got eye on as the foreign policy objective that he must accomplish?

COHEN: I think he’s got his eye very firmly on the Middle East and on America’s difficulties with the Muslim world.  I think through upbringing, through his outlook on the world, through his family even, this is an issue that is very close to his heart.  Iran and Iran’s nuclear program is a very major issue, but he’s not going to allow that to eclipse the quest for some kind of breakthrough on Israel-Palestine now.  That’s the toughest puzzle to solve and whether he can do it is absolutely unclear.  But I think that’s the prize he’s got his eye on.

SHARP: Roger Cohen is a columnist for the New York Times and the International Herald Tribune.  Roger thank you so much.

COHEN: Thank you very much Jeb.

Copyright ©2009 PRI’s THE WORLD. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to PRI’s THE WORLD. This transcript may not be reproduced, in whole or in part, without prior written permission. For further information, please email The World’s Permissions Coordinator at theworld@pri.org.

• Q&A: US healthcare reform
• On The World: Living with American health care

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This text below is a phonetic transcript of a radio story broadcast by PRI’s THE WORLD. It has been created on deadline by a contractor for PRI. The transcript is included here to facilitate internet searches for audio content. Please report any transcribing errors to theworld@pri.org. This transcript may not be in its final form, and it may be updated. Please be aware that the authoritative record of material distributed by PRI’s THE WORLD is the program audio.

MARCO WERMAN:  The last piece of the health care reform law is now on its way to President Obama.  He’s expected to sign it next week.  The law’s main purpose is to extend health care coverage to millions of uninsured Americans.  Non-Americans who are here illegally are still out of luck.  Here’s The World’s Alex Gallafent on what that could mean for the nation’s health care system.

ALEX GALLAFENT:  Health care plus immigration equals political combustion.  Indeed, undocumented immigrants are not covered by the health care reform bill.  But even without Joe Wilson-style interjections, the fact remains that the problems of health care and immigration are related.  So says Ira Mehlman.

IRA MEHLMAN:  The growth of immigration in the United States over the past several decades has had a direct impact on the growth of the medically uninsured in the United States.

GALLAFENT: Mehlman is with the Federation for American Immigration Reform, a group devoted to capping immigration levels and stopping illegal immigration.  He says it’s correct that he health care reform bill doesn’t extend coverage to illegal immigrants.

MEHLMAN: Number one, it is costly to the tax payers.  Number two it bestows recognition and benefits on people who should not be in the country in the first place.

GALLAFENT: But in a place like New York City, thousands of undocumented immigrants are a present and immediate concern.  Alan Aviles should know, he’s President of the city’s Health and Hospitals Corporation.  He runs a network of 11 hospitals in the city, including six level one trauma centers.

ALAN AVILES:  So in New York City we have an estimated 500,000 undocumented immigrants.  The New York City public hospital system, which is the largest in the nation, has been the principal safety net for new immigrant communities across New York for decades.

GALLAFENT: That hospital system treated about 450,000 uninsured patients last year.  Aviles says a very large percentage of that number were undocumented, or illegal immigrants.  They didn’t have insurance, but they needed care, and so they went, more often than not, to places like this.  Emergency rooms.  The problem for Aviles, he says, is that the health care reform bill funds expanded coverage for Americans partly by limiting federal funding for public hospitals like his.

AVILES: And this is being done under the assumption that the uninsured that we currently serve will largely become insured and that will replace those dollars that are now being taken off the table.  But the reality in urban centers like New York, particularly gateway cities like New York, who have so many undocumented immigrants among the city’s residents, that will not necessarily play out as predicted.

GALLAFENT: So Aviles is concerned about a funding gap.  Less money from the federal government and not much more money from newly insured patients.  Aviles is especially galled by the fact that undocumented immigrants, many of whom do work and pay taxes, won’t be able to buy insurance from the new government run exchange, even at full cost.  When they’re sick, someone, somewhere is still going to have to pay for their care.  Aviles says there is a glimmer of hope.  The federal government might end up taking less money away from states with large numbers of illegal immigrants, keeping those emergency rooms going.  But that wouldn’t amount to a real fix, says Ira Mehlman at the Federation for American Immigration Reform.  Cities like New York, he says, should be doing more to limit illegal immigration in the first place.

MEHLMAN: We shouldn’t be dealing with this at the emergency room door.  We should be dealing with this far earlier in the process by seeing to it that fewer and fewer people come and remain in the United States illegally, and therefore draw less on our vital social services.

GALLAFENT: That means immigration reform.  And for Sonal Ambegaokar it could be an opportunity to deal with unfinished health care business.  She’s health policy attorney with the National Immigration Law Center.

SONAL AMBEGAOKAR:  So right now, newly arrived legal immigrants, immigrants who have their green card, have to wait 5 years before they can be eligible to enroll in what we call the Medicaid program, which serves the lowest income folks.

GALLAFENT: Maybe that’s fair, maybe that’s unfair.  At the very least Ambegaokar hopes it will be considered as lawmakers turn to immigration.  New York hospital administrator Alan Aviles also sees immigration reform as a necessary step in expanding health care.  If undocumented immigrants are allowed to earn citizenship, he says, health benefits will follow.  Now that doesn’t square with Ira Mehlman, although he is hoping for a sober discussion on what all agree is an emotive topic.

MEHLMAN: Respecting people and understanding why they come here doesn’t mean that we should not enforce laws, that doesn’t mean that we shouldn’t set restrictions.  We need to be able to deal with immigration policy just like we deal with any other public policy in the United States.

GALLAFENT: Given the tone of the recent health care debate, that should be fun.  For The World, I’m Alex Gallafent in New York.

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• BBC coverage
• Reporting US health care reform abroad
• Health coverage on The World

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MARCO WERMAN:  Democracy here in the U.S. can be a messy business.  The health care reform debate is but the latest example.  Today President Obama held a televised ceremony to sign the health care overhaul bill into law.  Mr. Obama told lawmakers and others at the White House that the bill marked the start of a new season for the country.

PRESIDENT BARACK OBAMA:  Here in this country we shape our own destiny.  That is what we do.  That is who we are.  That is what makes us the United States of America.  And we have now just enshrined, as soon as I sign this bill, the core principle that everybody should have some basic security when it comes to their health care.  And it is an extraordinary achievement that has happened because of all of you and all the advocates all across the country.  So thank you.  Thank you.  God bless you and may God bless the United States of America.

WERMAN: The rest of the world has been watching closely and we’ve been bringing you a variety of international perspectives on the U.S. health care debate.  Today we get that from Justin Webb.  He was based in the U.S. for the BBC for eight years before moving back to Britain last year.  Webb now anchors the BBC’s main morning news radio broadcast, the Today Programme.

JUSTIN WEBB:  The big picture viewed from here in Europe is that America has taken a really important step, not towards a British style NHS, but a step in the direction of every American has a right having some kind of health coverage.  And that to really the rest of the rich world to be honest, but certainly to Europe, just looks to most people including senior conservatives here in the U.K., and I was talking to one the other day, it just looks like America joining the normal world as it were.

WERMAN: And for you Justin, issues of health care came right into the spotlight of your life just before Christmas in 2008.  You were living in Washington at the time and your son Sam got ill.  What happened?

WEBB: He was diagnosed with Type I diabetes, which is a horrible life-threatening illness.  It’s not brought on by any kind of lifestyle thing, it’s an auto-immune disease actually that just comes in youngsters and lots of people will know people with it if not have experience of it themselves.  And it was fascinating for us once we sort of got over the shock and the sadness about it all, to see how the American health care system coped and then really not much more than six months later to move back to Britain and see how the British system coped.  And as you’d expect there are strengths in each.  I think in a way, people in each country don’t fully understand the strengths of the other country.  That’s what I brought away from this.  So in the United States we were very well treated.  Sam was wonderfully well treated.  He had access to fantastic medicine and fantastic technology as an insulin pump that was made available very quickly under the American system.  Now there are all sorts of co-pays and things, it’s not as if it was free and our insurance certainly paid a lot of money, but we were well insured, so everything went rather well. So that was the situation in America.  We came back to Britain and lo and behold everything’s free.  You know, the test strips, a lot of people with Type II diabetes will know what I’m talking about now.  There’s test strips that you test your blood with.  You go to a British doctor and you say I’d like some more please and they say yes, how many?  And they just give them to you.  To be honest, it was an extraordinary sort of change.  I was really used to the American system where everything is accounted for and paid for by someone and quite often by you.  So here in Britain all these thing are handed out, but, although the medicine is just as good, and there’s no question in my mind that Sam is as well treated as he is here in America, I have to say that the technology, in particular that pump that pumps insulin into him is a very state of the art thing.  It is not, at the moment, available in the U.K., the particular pump that Sam uses.  And that is, at least in part because, the pump makers can make money in America and they can’t make it under the British NHS.

WERMAN: I’m wondering when you went back to the U.K., how much health care actually kind of showed up in your calculations about getting back to the U.K .and finding something that was perhaps better?

WEBB: Well that’s an interesting thing.  We would not have moved back here for the health care.  There’s no question at all that we were perfectly happy in America and we were well insured and had no prospect of losing it.  But I have to say that my son would be in the category of those people who would go along to a health insurer in years to come, and he wants to be a film director in Hollywood at the moment, he’s 10 years old so he can still have those dreams, what would he do for health insurance had the Obama bill not passed?  Now of course, American health insurance companies would have turned him down because he has a serious pre-existing condition.  If that genuinely does change, which it seems that it is going to now, then that for someone like my son, is a major plus.  It means that for him there is a possibility of working on either side of the Atlantic.  Of course it just means for American as well, and for everyone who has a pre-existing condition, it’s a greater freedom for that group of people.

WERMAN: The BBC’s Justin Webb, thanks very much for sharing your views and experiences with us.  I greatly appreciate it.

WEBB: Pleasure.  Nice to talk to you.

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• Gregor Peter Schmitz: “US Health Care – Good for America, Bad for the World?”
• BBC coverage
• Video of President Obama’s reaction
• Health coverage on The World

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DAVID BARON:  Passage of President Obama’s health care overhaul made headlines around the globe.  The foreign reports who covered the debate and last night’s vote, include the Washington Bureau Chief for the Toronto Star, Mitch Potter, and Gregor Schmitz, he’s the U.S. Correspondent for German’s news magazine, Der Spiegel.  Both are in Washington.  Mitch Potter, to you first, how are Canadians reading the story of health care reform in America today?

MITCH POTTER:  Well it’s a bit of a paradox.  Canadians have been fascinated by this all along.  On one hand I think Canadians in large part are sort of cheering on Americans.  It in a sense validates the system we have.  We know that what President Obama has brought forward here is not a Canadian style system, but it’s moving in that direction and I think Canadians feel validated by the fact that the United States is moving in our direction, if you will.

BARON:  Right, well it would be interesting to point out that among some groups, Canada has been a bit of a punching bag.  People have said this is what we don’t want to become.  We don’t want Canada’s health care system.

POTTER: It’s true and it’s really been a political piñata.  Time and again the Canadian system has been cherry picked with isolate horror stories being conflated into something to scare away Americans.  And that, truly, has annoyed Canadians.  A lot of Canadians have taken offense as they have watched this play out.

BARON: Now Gregor Schmitz, you had an opinion piece in Der Spiegel today and the headline reads “U.S. Health Care Good for America, Bad for the World”.  Now what do you mean by that?

GREGOR SCHMITZ:  Well I think if you look at the more recent debates you see there is a real risk that Obama might become a one issue President.  And I think if you look more closely at his speeches over the past weeks or months, there was basically no reference to other conflicts, or say other challenges, let’s say Afghanistan, even though soldiers are fighting there increasingly there now in recent weeks or months.

BARON: Because he’s been so wrapped up in health care.

SCHMITZ: Exactly he has been so wrapped up in health care and I don’t think anyone has predicted for this to drag out for so long.  So I think there is a real risk.  If you look at other parts of the world, particularly Europe, they are becoming a little disillusioned by a lack of interest.  He had to cancel the trip to Asia which I think was understandable in the context of the health care debate.  But still, it sent a signal to the rest of the world that this is the most important issue to us, understandably, and we don’t really care about the other challenges.  So I think there is a real risk for him to become a one issue President.

BARON: Well something I would like both of you to address is the way that Barack Obama is perceived around the world.  We know that when he was elected President in 2008 he was extremely popular in other countries.  How popular is Barack Obama in your countries now and I wonder to what extent have people in your countries been cheering on health care reform in the U.S. because they wanted to see President Obama succeed.  Mitch Potter, let’s start with you from Canada.

POTTER: Well I think that’s largely the case with Canadians.  There’s a recognition that we may not have a force in this health care fight, but if anybody is looking to see an Obama administration assert itself on other foreign files, they recognize that he needs a victory.  You can debate the wisdom of whether to have invested do much political capital to make health care his signature project was the right thing to do, but imagine how politically ham strung he would be in trying to pursue the rest of his agenda if this had all fallen apart on him and he would be approaching these mid-term elections with absolutely nothing to show for this first period of his Presidency.

BARON: But bottom line he is still popular in Canada?

POTTER: Definitely.

BARON: And in Germany Gregor Schmitz?  What is President Obama’s approval rating over there these days?

SCHMITZ: It probably has slipped from 99% to 97%.  I think overall he is still very popular in Europe and I think it is true in this regard when you look at health care that it is not about Obama.  It is about America.  Mitch has already alluded to that.  Europeans are cheering on the Americans because for them it’s just beyond imagination that the richest country on earth hasn’t been able, for so long, to provide basic health care coverage to every citizen.  So for Europeans that is more of a moral issue.  Frankly, they just don’t get it.  And I think on this specific issue, Obama is getting a pass.  I think they look at Washington and they basically blame the Republicans for blocking everything.  But one thing that I think is missing in the European debate that makes it harder for us to explain the debates here in the U.S. is the fact that many Americans are actually happy with the health care system.  When Europeans look at the American health care system, they don’t fully understand that the people who are a part of the system now, who have coverage, who have insurance are often very happy with the way they are being treated and with their options.  So I think that is something we need to explain to our readers that these debates are so fierce because it is the question of whether they want to extend that coverage or an offer of more solidarity to other Americans and whether they want to include the people that are left out right now.

BARON: Well gentlemen I expect you didn’t get all that much sleep last night.  Thank you for coming in.  It was good to talk to you.  Mitch Potter is the Washington Bureau Chief for the Toronto Star, thank you Mitch.

POTTER: Thank you very much.

BARON: And Gregor Schmitz is U. S. Correspondent for Der Spiegel in Germany, thank you.

SCHMITZ: Thanks for having me.

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• Parliamentary enquiry into homeopathy
• An array of responses to the enquiry, collated by the BBC
• Britain’s Faculty of Homeopathy
• Hpathy portal

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MARCO WERMAN:  Britain’s state run health care system pays for some forms of alternative medicine; that includes homeopathy.  But this week a Parliamentary panel issued an unequivocal recommendation regarding homeopathy.  The panel said the British government should stop funding homeopathic treatments because they don’t work.  Here’s more from The World’s Alex Gallafent.

ALEX GALLAFENT:  We’ve heard this debate before.

DAVID COLGUHOUN:  It’s an open and shut question.  We’ve been going on 200 years now, there’s nothing in the pills, it’s very, very simple.

GALLAFENT: That’s a pharmacologist, Professor David Cahoon and here’s a homeopath, Dr. Sara Eames.

SARA EAMES:  One person thinks one thing, one person thinks another thing.  I see homeopathy helping patients every day.

GALLAFENT: Indeed this has pretty much been the back and forth since Samuel Hahnemann devised homeopathy back in the late 1790′s.  The German physician rooted his theory in a handful of basic propositions, including a couple that have stuck all the way up to the present day.  Number one – or translated from the Latin, like cures like.  The idea is that whatever might produce your symptoms, will also cure those same symptoms.  So if your eyes are streaming thanks to an allergy, onions might be a cure.  Unlike an inoculation, in which an agent related to an actual disease is placed inside the body to reproduce, homeopathy relies only on something that produces similar symptoms to the disease.  Here’s another of Hahnemann’s propositions.  “Dilution, dilution, dilution.”  The cure is diluted in water, one part to 100.  Then the resulting mixture is diluted again, the same way.  And then again, and again, 30 times over or more to make dry medicine you simply drip a bit of that diluted water onto a sugar pill.  It all gets a bit silly says Australian mathematician and skeptic Matt Parker.

MATT PARKER:  So after all these dilutions, they end up with one part active ingredient and so the pills I bought to have a go at all this were Arnica pills.

GALLAFENT: Arnica is a perennial herb that homeopaths use for pain relief.

PARKER:  And there was one part Arnica for every million, billion, billion, billion, billion, billion, billion, parts pill.  So the numbers are just mind bogglingly huge.

GALLAFENT: The British comedians Mitchell and Webb played with these ideas in a skit set in a kind of homeopathic emergency room.

MALE VOICE 1:  Okay, he’s stabilizing.  Now, does anybody know what sort of car hit him?

FEMALE VOICE 1:  Blue Ford Mondeo apparently.

MALE VOICE 1:  Right, get met a bit of Blue Ford Mondeo, put it in water, shake it, dilute it, shake it again, dilute it again, do some more shaking, dilute it some more and then put three drops on his tongue.  If that doesn’t cure him, I don’t know what will.

GALLAFENT: Ha, ha, very funny, say the homeopaths.  Countering that even if there’s nothing left of the original substance, water can retain a memory of any given active ingredient.  Now rather than offering up a present day critique of this notion, let’s turn instead to Oliver Wendell Holmes, Sr.  During a lecture delivered in Boston in 1842, the physician and author asked this:

OLIVER WENDELL HOLMES:  Is there not in this as great an exception to all the hitherto received laws of nature as in the miracle of the loaves and fishes?

GALLAFENT: It’s true, homeopathy does require a significant leap of faith.  Still, those British lawmakers did acknowledge in their report this week that homeopathy does make some patients feel better.  Sara Eames argues it’s good for Britain’s National Health Service too.  She’s President of the Faculty of Homeopathy which regulates the practice in the U.K.

EAMES:  By combining homeopathy and other complementary therapies, together with conventional medicine, actually you can save the NHS an awful lot of money.  Statistics don’t have the answer to everything.

GALLAFENT: But those lawmakers also said that any improvement in health is driven by belief, not science.  That’s what Columbia University medical historian Barron Lerner told me in an email message too.  He notes that homeopathy has a lot of emotional appeal for some people and that they may become convinced after treatment that it was the homeopathy that healed them and they may have just gotten better anyway.  The British government says it’s reluctant to get involved in all this noting that there are strong feelings on both side.  No such diplomacy from Oliver Wendell Holmes, to whom I leave the final words.

HOLMES:  I will not meddle with this excrescence.  Time is too precious and the harvest of living extravagances nods too heavily to my sickle that I should blunt it upon straw and stubble.

GALLAFENT: In other words, can’t we talk about something else now?  Evolution anyone?  For The World, I’m Alex Gallafent.

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MARCO WERMAN:  I’m Marco Werman and this is The World.  It’s been downhill for health care reform since September.  That’s when you may recall a Senator shouted you lie, after President Obama said that the proposed legislation would not cover illegal immigrants.  Actually the President was right about that.  But many countries provide health care for everyone, including undocumented immigrants.  An example is Spain.  But recently, two Spanish towns began to deny health benefits to illegal immigrants.  The World’s Gerry Hadden sent us this report from one of the towns, Vick.

GERRY HADDEN:   In a small square in his northeastern city, a 26-year-old man sits on a bench.  His name is Adolpho and he wears a white wool hat and a big glass earring in one ear.  Adolpho came to Spain from Bolivia as a tourist, but stayed illegally to work in construction.  He’s got the flu, he says, but he can’t go to the doctor, at least not here in Vick because he’s not registered as a resident in City Hall.

ADOLPHO:  [in Spanish through an interpreter]  I tried to register, he said, but they asked me for my Visa and my passport.  I told them that Spain doesn’t require Bolivians to get Visas but they just turned me away.

HADDEN: For weeks, the city of Vick has been denying undocumented immigrants access to doctors and schools.  City officials argue that such immigrants are either unemployed or working under the table.  That means they’re not paying taxes, says Vick’s Mayor, Josette Vida.

JOSETTE VIDA:  [through interpreter]  Vick is trying to get it’s registry of immigrants in order, he said.  The more organized we are, the better we can integrate foreigners in our city.  That’s why we decided to take the existing immigration law and apply it.

mgm:  Actually, Mayor Vida’s interpretation of that law is what has stirred a national controversy.  Human rights groups and politicians of all stripes have been speaking out against Vick’s action.  Celestine Corbacho is Spain’s Minister for Labor and Immigration.

CELESTINE CORBACHO:  [through interpreter] According to the law, he says, access to services are a right that come before whatever local norm a city might create.  Therefore Vick cannot deny health care and education to non-Spaniards without papers.

HADDEN: And Vick’s been feeling the pressure.  Late last week city officials backed down.  Immigrants like Adolpho, will once again be allowed to get government funded medical care like other people in Vick.  But the Spanish residents of Vick say the problem isn’t going away.  Business woman Manoli Morales says the city can’t afford to subsidize people who sneak into the country.

MANOLI MORALES:  [through interpreter]  She says they have a right to come to Spain if they have papers.  If they don’t have permission, we should boot them right out.  You understand?

HADDEN: Morales’ attitude reflects the ongoing frustration in many small Spanish towns.  Vick was virtually all Spaniards before Spain’s housing boom 10 years ago.  Today, immigrants make up 26% of the population.  That radical demographic shift, combined with the economic crisis has given rise to a radical Nationalist Party here.  The Platform for Catalonia won four City Council seats in recent elections on an anti-immigrant platform.  While immigrants’ rights groups have been condemning Vick as xenophobic, some mainstream politicians have come to its defense, at least partially.  The President of the Catalon region of Spain, socialist Jose Montilla, says Vick’s solution was wrong, but it’s problem is real.  The huge influx of undocumented immigrants has put strains on Social Services.  Montilla says denying it is like burying your head in the sand.  In a recent interview he lamented that it’s become to politically incorrect to acknowledge that while immigrants have helped Spain, sometimes they can also be a burden.  Other politicians are now calling for Spain’s immigration law to be overhauled to correct a key contradiction.  On the local level, towns are obligated to offer undocumented workers social services, while the federal government is obligated to deport them.  For the time being, one other Spanish town, Torrejon in Madrid, is still refusing undocumented workers benefits.  If it continues, the federal government has threatened to take town officials to Court.  For The World, I’m Gerry Hadden, Vick, Spain.

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