- Email: [email protected]
Health Care and the Political System
AMERICAN JOURNAL OF OPHTHALMOLOGY FRANK
W.
NEWELL,
Editor-in-Chief
160 East Grand Ave., Chicago, Illinois 60611 DERRICK VAIL,
Editor-in-Chief
Emeritus
2450 Lakeview Avenue, Chicago, Illinois 60614
EDITORIAL BOARD Bernard Becker, St. Louis Frederick C. Blodi, Iowa City Benjamin F. Boyd, Panama Thomas Chalkley, Chicago Sir Stewart Duke-Elder, London DuPont Guerry III, Richmond Michael J. Hogan, San Francisco Robert W. Hollenhorst, Rochester Herbert E. Kaufman, Gainesville Arthur H. Keeney, Philadelphia Bertha A. Klien, Chicago Alex E. Krill, Chicago
Carl Kupfer, Bethesda James E. Lebensohn, Chicago Irving H. Leopold, New York A. Edward Maumenee, Baltimore Edward W. D. Norton, Miami Albert M. Potts, Chicago Algernon B. Reese, New York Marvin L. Sears, New Haven David Shoch, Chicago George K. Smelser, New York Phillips Thygeson, San Francisco Gunter K. von Noorden, Baltimore
Published monthly by the Ophthalmic Publishing Company Directors:
DERRICK V A I L , President; ALGERNON B. REESE, Vice-President; F R A N K W . NEWELL, Secretary and Treasurer ; A. EDWARD M A U M E N E E , M I C H A E L J. HOGAN, EDWARD W . D. NORTON
H E A L T H CARE AND T H E POLITICAL SYSTEM T H E SORCERER'S APPRENTICE REVISITED
The specter of the automated robot or un loosed genie that starts out as the obedient, This paper was presented to the National Center for Health Care Services Research and Develop ment, Conference on Technology and Health Care Systems in the 1980s, January 19, 1972, at San Francisco, California, and the Association of Uni versity Professors of Ophthalmology, January 24, 1972, Key Biscayne, Florida. Reprint requests to Professor Anne R. Somers, Department of Community Medicine, College of Medicine and Dentistry of N e w Jersey, Rutgers Medical School, P.O. Box 2100, N e w Brunswick, New Jersey 08903.
hard-working servant of man and ends up as his potential master has haunted poets and philosophers throughout the ages. Goethe's sorcerer's apprentice, Aladdin's genie, and the Jewish legend of the Golem are all varia tions on this theme. In R.U.R., Karel Capek's successful play of the early twen ties, the universal robots revolt successfully against their human masters, kill all of them, and are only saved from extinction them selves when one robot couple learns the se cret of humanity—the capacity for love and suffering. An even more terrifying vision of an im minent future in which Western society has
600
VOL. 73, NO. 4
EDITORIAL
become a hyper-technologized, hyper-sexed, and violence-prone slum is being portrayed in a number of recent films such as Stanley Kubrick's widely acclaimed "Clockwork Or ange." According to this view, rather than being conquered by the robots, man's own personality is debased and vulgarized almost beyond recognition. In the beginning, modern industrial tech nology was greeted with fear and hostility. The Luddites, breaking up the new mechani cal looms in the English textile mills at the beginning of the Industrial Revolution, have become symbols of this fear. During the hundred years of almost continuous techno logical progress, from the mid-nineteenth to the mid-twentieth centuries, their fears and those of the artists were generally dismissed as irrational. Classical economists were confi dent that the marketplace was an effective self-regulating mechanism, with both supply and demand governed by man's basic ratio nality. Marxists rejected the marketplace as regulator but were confident that govern ment, acting on behalf of the masses, could control technology and turn it to constructive ends. Those whose economic and political philosophy fell somewhere between these ex tremes—European democratic socialists, Keynesian liberals, American pragmatists, and others—looked to various combinations of competitive and regulatory disciplines. Fearing overconcentration of power in gov ernment as well as uncontrolled private en terprise, the liberals or pragmatists agreed that the political process was not only a relia ble brake on the excesses of capitalism but an effective device for spreading the benefits of technology to the population at large. In the past few years, however, there has been a rapid increase in the ranks of those who fear that technology, like the appren tice's robot, may now be out of control ; that the economic philosophy of continuous growth, with which it is associated, may be doing more harm than good ; and that gov ernment, far from being an effective regula tor of technological excess, may have already been captured by it.
601
The physical scientists and ecologists were the first to warn of danger. For example, Dr. Dennis Gabor,1 winner of the 1971 No bel Prize in physics, has repeatedly criticized our "growth addiction" which, he says, is certain to lead to catastrophe, even without an all-out nuclear war. In January, 1972, 33 leading British scien tists, including the distinguished biologist Sir Julian Huxley, and other environmental ists, endorsed a report, "Blueprint for Sur vival,"2 that is one of the starkest doom warnings yet. They warned that the world is heading for an inevitable social and environ mental breakdown—"within the lifetime of someone born today"—unless man funda mentally alters his long-imbedded drive for growth and industrialization. Here is part of their reasoning : Continued exponential growth of consumption of materials and energy is impossible. Present reserves of all but a few metals will be exhausted within 50 years, if consumption rates continue to grow as they are. Obviously, there will be new discoveries and advances in mining technology, but these are likely to provide us with only a limited stay of execution. At the same time, we are sowing the seeds of massive unemployment by increasing the ratio of capital to labor so that the provision of each job becomes ever more expensive. In a world of fast diminishing resources, we shall quickly come to the point when very great numbers of people will be thrown out of work, when the material com pensations of urban life are either no longer avail able or prohibitively expensive, and consequently when whole sections of society will find good cause to express their discontent in ways likely to be any thing but pleasant for their fellows.
More recently, social scientists are begin ning to agree. Odin Anderson 3 points out that the automobile has become "an indepen dent variable determining the shape of our living patterns." John Kenneth Galbraith4 saw the origins of corporate giantism, "the new industrial state," and the military-indus trial complex in the imperatives of advanced technology. Jay Forrester 5 of M.I.T. says, "Our greatest challenge now is how to han dle the transition from growth into equilib rium." "The Luddites were not all wrong!" ac cording to the British economist, Ezra
602
AMERICAN JOURNAL OF OPHTHALMOLOGY
APRIL, 1972
Mishan,6 whose "Mishanic Message" of ture of the crucial interaction between tech anti-technology and anti-growth is attracting nology and the political process. It consists scholarly attention. Senators and congress of four related propositions : men, trying to cope with military technology, 1. There is a dynamic expansionist force and the victims of smog in many of our ma inherent in modern technology that leads to jor industrial communities, undoubtedly economic growth, higher costs, and increas agree. ingly centralized financing and administra Whether the Luddites were, in fact, right tive control, ending, almost inevitably, with or wrong ; whether man, the clever appren government. tice, by stealing the secrets of his master— 2. The primary results of this growing God or Nature or the Cosmos—has unloosed financial and administrative centralization, forces which he can no longer control is a combined with ever-larger markets or ser question that only the future can answer. vice areas, are likely to be positive, with di There is no question, however, that the com rect benefits in the form of more goods and fortable optimism of the late nineteenth and services for more people. At this point, the early twentieth centuries has been shattered driving force of technology appears fully and that the efficacy of all three major sup compatible with the democratic goal of maxi ports of this optimism—technology, eco mizing benefits for the maximum number of nomic growth, and government as the ulti people. mate regulator of both—is now widely ques 3. However, there are a number of seri tioned. ous negative results, including overpopula We in the health field have, in one sense, tion, overcrowding, pollution of our living less reason for concern than some of our environment, the vastly increased power— brethren in the physical sciences. The health for evil as well as for good—of the bureau care industry is still a labor-intensive service cracies in control of the technology, the industry. Despite advances of recent years, alienation of millions of young people, technology still plays a relatively minor role. blacks, country folk, and others who feel And despite the rapid recent increase in gov themselves redundant in this highly struc ernment financing, health care is still pre tured, technocratic society, and the general dominantly a private sector activity. Never overemphasis on material goods and values. theless, the general trends are clearly pres 4. Whatever the net balance of positive ent: more and more technology, ever rising and negative effects, the growth of technol costs, more and more billions of dollars be ogy is probably irreversible—at least until ing spent, more and more government in far more of the world's population has expe volvement. rienced more of its benefits. The challenge, How and why has this happened ? What is therefore, is to bring this formidable force the nature of the interaction between tech under social control and to develop political nology and the political process ? What have and other institutions adequate to this task. been the major benefits? The principal dan I will now restate each of these four prop gers? The net result? Should the process be ositions and discuss them briefly with special reversed? Can it? If not, what then? reference to medical technology and the in creasing "polidealization" of medicine in the A WORKING HYPOTHESIS United States. A discussion of this brevity There is no easy or graceful approach to cannot be anything more than suggestive. this outsize topic. I will start with a working Hopefully, the portentous issues raised will hypothesis, a broad general construct which, continue to receive serious attention from hopefully, may throw some light on the na both scholars and statesmen.
VOL. 73, NO. 4
EDITORIAL
1. T H E EXPANSIONIST FORCE OF MODERN MEDICAL TECHNOLOGY
There is a dynamic force inherent in mod ern technology that leads to economic growth, higher costs, and increasingly cen tralized financing and administrative control, ending, almost inevitably, with government. Among the many paradoxes associated with the triumphs of modern medical tech nology none is more striking than this : The more advanced and the more effective the technology, the greater the overall costs of health care. There are many reasons : the capital investment in the new equipment, the often high cost of maintenance, the need for specialized personnel to operate it, the need for an institutional setting in which it can be operated which usually means additional overhead costs, the longer average life ex pectancy of the population which means more health care over the lifetime of the in dividual and over the year for the nation as a whole, the ever-rising, albeit often unrealis tic, expectations on the part of consumer-pa tients, leading to an elasticity of demand that is almost total. In many industries the more effective the technology, the lower the unit cost of pro duction. This is possible as a result of the ef ficiency of mass production. There are ex amples of efficient mass production in the health services industry, including the manu facture of drugs, the automation of labora tory tests, and computerized business ser vices. Diagnostic screening could be handled on a mass basis from the production point of view. But health care, by and large, does not lend itself to the mass production approach. There seems little hope that the rising costs of medical care can ever be balanced by the same sort of productivity increases that we have witnessed in industry in general. Some authorities disagree on this point. Some see the progress of technology permit ting replacement of the physician and other very expensive personnel with lower cost,
603
highly specialized, technicians. According to this view, even if total costs rise and unit costs cannot be cut, still we will be able to provide more services to more people. Pre sumably this would be a net gain. I see little evidence, however, that things will work out this neatly. First, this view minimizes the effectiveness of health profes sionals in resisting technological replace ment. For example, the introduction of unit dosage into hospital pharmacy might be ex pected to reduce hospital costs by eliminating the necessity of a resident pharmacist. This is not likely to happen, however. On the con trary, the pharmacist is seeking, understand ably, to upgrade his role and salary from a supply function to that of a "clinical phar macist." More important, the technologists gener ally underestimate the continuing importance of interpersonal relations in health care. Much nonsense has been uttered in the re cent past with respect to the doctor-patient relationship and TLC ("tender loving care"). Many now make the opposite mis take and tend to overlook the often crucial role of subjective factors in illness, the im portance of treating the "whole man," and the essentiality of the professional's role as educator, as well as technician, in helping the patient to prevent or cope with his illness. Moreover, heavy emphasis on technologi cal economies and productivity may lead to overemphasis on those health services which can most easily be mass-produced—drugs, laboratory tests, x-ray studies, even some types of surgery. But these are precisely the areas where there is already danger of too much, rather than too little, consumption. I will return to this point later. This is not to say that many more effective cost controls cannot be devised. They can and should. But, if past experience is any guide, further improvements in medical technology will, almost inevitably, lead to further increases in the cost of care and fur ther pressures to spread or socialize those
604
AMERICAN JOURNAL OF OPHTHALMOLOGY
costs, over larger and larger population bases, as well as to bring in outside controls in the effort to moderate the rise. In most of the world, the cost of health care, like the cost of education, is already paid for almost entirely by government—be cause this is the only social entity with the necessary financial resources. We would un doubtedly have gone the same route long be fore now except that our wealth and the spe cial circumstances of collective bargaining in U.S. industry enabled us to absorb the rising costs of health care through the price of other goods and services. Every bikini, every tin can, incorporates in its price the cost of health care for the garment worker and her family, for the steel worker and his family. The major theme of medical economics for the first two decades after World War II was the "great cost pass through" to the gen eral consumer. After 1965, the story began to change. The private sector proved unable to absorb the total costs, especially for high-risk groups such as the aged. For the first time, the federal government was brought into the picture as a major factor in health care financing. Within four years, the public share of total U.S. health expenditures in creased from less than 26%, a figure never before exceeded except in war, to 38%. 7 Costs are now passed through to the tax payer as well as the consumer. But this does not mean that a viable equi librium has been achieved. On the contrary, the pressures are even greater in 1972 than in 1965. Describing the successful 1971 drive for a major federally-funded campaign against cancer, Medical World News* edito rializes, "The politicization of cancer sug gests a possible politicization of the entire biomédical enterprise." Along with the rise in the government share of expenditures has come a phenome nal increase in the total expenditure figure itself—to over $75 billion in fiscal year 1971. Consumer dissatisfaction with rising prices forced even a reluctant administration to in
APRIL, 1972
flation control measures for the economy in general and the health care industry in par ticular. Both state and federal governments are trying to put the lid on rising health in surance premiums. A taxpayer revolt, at state and local levels, is forcing even conservative politicians to call for national health insurance. The Ways and Means Committee has been holding hearings on the subject, an unthinkable phenomenon even five years ago. Adoption of some sort of universal health insurance system seems inevitable within the next few years. Despite our wealth, despite our preference for non governmental financing, despite the ingenu ity and efforts of private insurance carriers, despite the fears of many providers and con sumers, there seems to be no other way that we can cope with the ever-rising costs of modern medical technology. 2. T H E HONEYMOON OF TECHNOLOGY AND GOVERNMENT
The primary results of this growing cen tralization of control, combined with everlarger market or service areas, are likely to be positive with direct benefits in the form of more goods and services for more people. At this point, the driving force of technology appears fully compatible with the democratic goal of maximizing benefits for the maxi mum number of people. Due to a number of fortunate circum stances in the United States—particularly its size and natural resources and our constitu tional and other traditions—science and technology, on the one hand, and politics and government on the other, have generally coexisted in a state of creative or dynamic tension. In general, government has done that which the people were unable to do for themselves—and not much more. In the medical field the atmosphere has sometimes been acrimonious, but never fa tally so. The expansion of government health care programs has, thus far, been generally limited to categories of persons that could not provide their own care and for whom no
VOL. 73, NO. 4
EDITORIAL
adequate source of support existed in the private sector. The unit costs of health ser vices have generally not been lowered. This is not only because of the limits of mass pro duction in health care but because provider organizations tend to be stronger than con sumer organizations and once a program be comes "politicized" it becomes especially vul nerable to such pressures. Thus far, however, the tax base has proved flexible enough to absorb the rising costs, chiefly by involving broader govern mental units and larger population bases. So, thanks to "politicalization," millions of Americans—including Indians, disabled veterans, the indigent, and nearly all over 65 —who would otherwise be denied the fruits of the new technology have access to some health services. At the same time, the in comes of most providers have improved sub stantially. Medical research, professional education, and construction of facilities have been lib erally supported, both by public and private funds. Belatedly, but now quite generously, government is supporting research into new methods of organizing and financing health care, with strong emphasis on new technol ogy, as this conference indicates. Further triumphs of such technology, such as telemedicine, which may give new mean ing and potential to the individual doctor-pa tient relationship, and computerized medical records, which could make possible lifetime continuity and true comprehensiveness of care, are just over the horizon. The honey moon of government and politics has obvi ously been productive of many social goods. 3. T H E FAUSTIAN DILEMMA: IS THE PRICE TOO HIGH ?
However, there are a number of serious negative results, including overpopulation, overcrowding, pollution of our living envi ronment, the vastly increased power—for evil as well as for good—of the bureaucra cies in control of technology, the alienation of millions of young people, blacks, country
605
folk, and others who feel themselves redun dant in this highly structured, technocratic society, and the general overemphasis on ma terial goods and values. War, violence, crime, the arrogance of power, and the exploitation or alienation of the weak : None of these evils are peculiar to the age of technology. They have been with us since the dawn of history. But just as the hydrogen bomb is infinitely more lethal than the bow and arrow or the gun, so the de structive possibilities inherent in modern production, transportation, communications, space, biochemical, and other technologies give pause to even the congenital optimist. Some students see in this train of events the eventual self-destruction of the human race. Thus far, the fear of sophisticated medical technology—experimental surgery, computer medicine, telemedicine, mind and mood con trol drugs, biological engineering, etc.—per verted in the hands of some native Hitler seems most unlikely. But this does not mean there have been no negative effects. Among those who feel that many patients have suf fered unnecessarily, either as a result of ex perimentation or incompetence, is Dr. Ber nard Towers. 9 He states : When I consider the sheer power, for both good and harm, that resides in such a simple technical procedure as setting up an intravenous saline drip, I am frightened for the safety of the patient. Advanced medical technology has helped to exacerbate two preexisting evils—infla tion and fragmentation. In both cases, this results from acceptance of the advantages of technology and politicalization without will ingness—either on the part of the industry or government—to apply the voluntary re straints or public controls necessary to pro vide relative price stability and coordination of services. The term "bureaucratic" is so frequently and indiscriminately applied as an epithet to condemn government in general that one hesitates to use the term. Certainly, the char acteristic is not peculiar to government—ei ther in its technical or pejorative sense. Bu-
606
AMERICAN JOURNAL OF OPHTHALMOLOGY
reaucracy is primarily an attribute of largescale operations, regardless of public or pri vate status. To many a ghetto patient, the worst "bureaucrats" are not in Washington but in the nearest medical school or teaching hospital. The fact remains, however, since govern ments tend to be larger than private enter prises, the danger of bureaucracy in govern ment is increased. Moreover, once a govern ment program is established and acquires a constituency of its own, it is harder to dis continue it, regardless of social utility, than a similar program in the private sector which has to depend on a direct relationship be tween user satisfaction and willingness to pay the price. Within government, the further removed the agency is from actual operating responsi bilities, the greater the difficulty of evaluat ing its performance and of maintaining ac countability to Congress and to the people, and the greater the danger of self-perpetuat ing, unresponsive offices and personnel. In short, the cliché is not without substance. Sometimes one wonders if all the goings and comings in Washington and throughout the industry, all the conferences, the proj ects, and the protocols have any appreciable effect on the nation's health. On the con trary, there seems to be a perverse negative correlation between the rising expenditures and many of our health indices. For exam ple, we have just learned that during the six ties—the decade of the greatest increase in health expenditures and of government in volvement—there was also an upturn in mortality rates for most U.S. men. Among young men, the rise was dramatic: 2 1 % among whites ages 15-19 between 1963 and 1968; 35% for nonwhites.10 When one considers the major cause of death among young men of both races—mo tor vehicle accidents, homicide, suicide—it is obvious that we cannot blame poor health care. It is equally obvious that we are miss ing the target in trying to improve the na tion's health simply through improved medi
APRIL, 1972
cal technology, by reorganizing the delivery system, or by spending more money for medical research. The clue to many, if not most, of our health problems, not only among the young but the middle-aged, appears to be lifestyle. This, in turn, is at least partly related to mo rale. The principal causes of death among men 45-64 years of age include lung cancer, emphysema, heart disease, and cirrhosis of the liver. The relation of these diseases to smoking, drinking, and overeating is gener ally acknowledged. The symptoms of alienation, boredom, ap athy, and irresponsibility with respect to health are all about us. Odin Anderson 3 calls it "the short-range hedonistic model" and hopes that it will be replaced by "the long range moderate and balanced pleasure model." Neither of us is very optimistic. It seems that the more effective the technology, the less responsibility many consumers exer cise with respect to their own health. This phenomenon has been widely noted in the case of venereal disease where the easy reli ance on contraception and penicillin has led to widespread disregard of elementary hy giene. When we have heartburn rather than cut down on eating, we take Alka-Seltzer. Emotional problems ? Rather than face up to the cause, we take a tranquilizer. Tired? A pep pill. Etc. A related issue involves the effect of tech nology in inducing an artificial rise in use, whether or not medically indicated. For ex ample, one authority points out :" The fact that typical equipment designs [of clinical chemistry laboratories] can handle more than the usual daily needs of even a large hospital may lead the administration to adopt standing orders for a battery of screening tests for each admission.
The drug industry is that portion of the health care industry most clearly in line with general technological trends and the econo mies of mass production. Its achievements have been tremendous. Chemotherapy is to day one of the most powerful arms of mod ern medicine. But overused and abused, it
VOL. 73, NO. 4
EDITORIAL
becomes a powerful pollutant. Its effluence is the current drug culture and its Franken stein offspring, the heroin epidemic. Here, indeed, the sorcerer's apprentice has lost control. 4. T H E CHALLENGE BEFORE US
Whatever the net balance of positive and negative effects, the growth of technology is probably irreversible—at least until far more of the world's population has experienced more of its benefits. The challenge, there fore, is to bring this formidable force under social control and to develop political and other institutions adequate to this task. It is possible that the Congressional vote on the SST and the reduced appropriations for space exploration may have marked the end of the honeymoon between American technology and the American government. In the health field, the anti-technology sen timent is pervasive among doctors and pa tients alike. "Everyone" laments the loss of the traditional doctor-patient relationship— even those who never had it. "Everyone" de plores the increasing depersonalization of care—even those who never knew good personal care. Senator Fulbright's accusa tions against the "military-industrial com plex" for its "arrogance of power" are echoed in a hundred journalistic diatribes against over-specialism, the hospital, which Walter McNerney calls a "technological em porium," and the nascent "medical-industrial complex." After a year of frenetic activity, the epidemic of heart transplants seems to have come to an end—at least for the time being. One Houston cardiologist, who was involved in a number of the operations, calls the whole experiment "dehumanization by technology."12 But how many Americans would be will ing to pay the price of a clampdown on sci ence and technology? How many really agree with Professor Mishan that for the average man life was better a half century ago and the whole world would be better off now if we had stopped technological and eco
607
nomic growth around 1919? Remember, at this time U.S. steel workers were still work ing a 12-hour day, child labor was the rule, Southern blacks still lived in a state of serf dom little different from their previous slav ery, and medicine had just passed the point which Dr. Lawrence Henderson of Harvard identified as that when "for the first time in human history, a random patient with a ran dom disease consulting a doctor chosen at random stood better than a 50-50 chance of benefiting from the encounter." If 1919 is not the right date, how about 1950? Or 1972? Who is to decide on the magic hour when the human race is supposed to have achieved the optimum balance be tween the good and bad results of technol ogy ? We in this comfortable hotel room ? Or the unemployed steelworker and his family? Or the hundreds of millions still living in pre-industrial dark ages. In Gary, Indiana, where massive layoffs in the steel industry have produced a community-wide depres sion, a shopkeeper was asked to suggest a so lution.13 His prescription, "Make those smoke stacks blow their beautiful dirty smoke again !" Even if we in the affluent West do become frightened enough of pollution, crime, and the drug epidemic to impose effective re straints on our own technological and eco nomic growth, we obviously lack the power to enforce any such decision on the whole world. We represent only about 6% of the 3.5 billions who inhabit this planet and the technological abundance that is becoming su perfluity or worse to us is still a vision of hope to the vast majority. What will probably happen is that the present striking imbalance between U.S. consumption of world resources and that of the rest of mankind will not continue indefi nitely. Either we will share voluntarily, or involuntarily, or we will spend more and more of our gross national product (GNP) on armaments to try to defend our privileged position—another way of reducing domestic consumption.
608
AMERICAN JOURNAL OF OPHTHALMOLOGY
In any case, the politics of growth—how to cut up an ever-expanding economic pie based on a continually expanding landmass, population, technology, and GNP—may now be superseded by the politics of equilibrium or even decline. The result could be further exacerbation of domestic intergroup and po litical tensions. Control over technology, es pecially communications, could become a ma jor source of conflict. Small groups, enjoy ing privileged positions—known to some as islands of excellence, to others as ivory tow ers of elitism—will be hard put to defend their privileges. Basic scientific research could be threatened. Still, it seems unrealistic to anticipate any immediate dramatic change in national pol icy. The multitude of conflicting pressures coming to bear on government in a democ racy tend to maintain a relatively constant and centrist position. To talk of stopping technology or reversing the trend to govern ment involvement seems to me romantic nonsense, a copout on the issues that we may —just possibly—be able to do something about. Tough, practical, inescapable prob lems such as the following : How to assure that technology is kept un der accountable human control ? How to restrain technological innovation to a rate that is socially assimilable—from the point of view of employment, consump tion, and our value systems—without im pairing the creative drive that has contrib uted so much to our past progress ? How to broaden, strengthen, and further democratize our governmental and other de cision-making institutions ? How to decentralize government to the point that people can, once again, feel some sense of meaningful participation and, at the same time, adjust boundaries to conform more nearly to expanding market and ser vice areas ? How to maintain—if necessary even build in—effective counterweights to government at all levels so as to minimize the danger of
APRIL, 1972
repression while avoiding the opposite dan gers of anarchy or stalemate? How to share our technological and other resources with other nations, peacefully and to our mutual advantage? How to improve the decision-making pro cess at all levels so that good intentions can be matched by clear understanding of proba ble consequences ? In the health care field, the acid test of our ability to cope with these problems will prob ably come with our eventual decisions on na tional health insurance. But these decisions, in turn, will be greatly influenced by what we do, or do not do, today and tomorrow, with respect to a multitude of subsidiary or related issues, including medical education, professional licensing, hospital franchising, regulation of the private health insurance in dustry, HMO's, Medicaid, drug abuse, day care centers, consumer health education, etc. Vitally important, of course, is the ques tion as to who will develop and control the health care technology of the future: The health professions and consumers through their elected representatives ? Or the technol ogists themselves, both in and out of govern ment? If the latter happens, I believe it will be primarily due not to greed on their part but to default by those who have the greatest stake in accountable democratic controls. Finally, our ability to cope with the basic issues listed above will depend on the nature and effectiveness of our national research ef fort—with respect both to the pursuit o r biomédical knowledge and its application. Significantly, Dr. Bernard Towers, 9 with all his fears of new "iatromechanical" and "iatrochemical" techniques, concludes with a plea for greater use of the computer : It seems to me that intelligent use of the com puter could give medicine the most powerful, and yet most in-nocent (in the literal meaning of the word) technique ever discovered. All knowledge, all understanding, involves four stages, all of them requiring the handling of information. They are, in order, information accumulation, filtering (selec tion), storage, and retrieval. The last stage involves not simply the régurgitation of data previously
CORRESPONDENCE
VOL. 73, NO. 4
"memorized," but the juxtaposition and synthesis (in both space and time) of data culled from vari ous sources, and at various times. This is the es sential element in scientific discovery, in "insight," in the exercise of clinical "diagnostic flair." This is the process that the good clinician uses continually, a process of analysis and synthesis, with many feedback loops, both positive and negative. Cyberneticians refer to the process as "systems analysis" ; and this concept marks a radical break with the linear, cause-effect paradigm of "good" natural sci ence which was at the basis of what Bernard called "l'iatromécanique" and "l'iatrochimie". . . . I see the computer as a tool to help us to a much deeper understanding of man, of man seen in "biological space-time." I n other words, some forms of technology, appropriately applied, could be our salvation. But with or without the insights of the com puter, with or without the advantages to medicine, D r . Gabor, 1 the physicist, has the last word : The insane quantitative growth must stop; but innovation must not stop—it must take an entirely new direction. Instead of working blindly toward things bigger and better, it must work toward im proving the quality of life rather than increasing its quantity. Innovation must work toward a new harmony, a new equilibrium ; otherwise it will only lead to an explosion. T h e ultimate challenge to man, the clever, competitive, conceited apprentice, is whether he can learn to use his new-found knowledge with the wisdom, self-discipline, and humil ity necessary for survival. I n the words of that great philosopher, Pogo, " W e have met the enemy—and it is u s . " A n n e R. Somers REFERENCES
1. Gabor, D. : Innovation Must Go On. New York Times, November 7, 1971. 2. Excerpts : A Blueprint for Survival, The Ecologist, January, 1972. "Op Ed" page of the New York Times (Op Ed page), February 5, 1972. 3. Anderson, O. W. : Health Services and the Political System of the 1980's. Presented before Na tional Center for Health Services Research and Development, Conference on Technology and Health Care Systems in the 1980's, San Francisco, January 19, 1972. 4. Galbraith, J. K.: The New Industrial State. New York, Houghton Mifflin, 1967. 5. Forrester, J. W. : Counterintuitive Behavior of Social Systems. Alumni Association of the Massa
609
chusetts Institute of Technology, Technology Re view, January, 1971. 6. Greene, W., and Golden, S. : The Luddites were not all wrong. New York Times Magazine, November 21, 1971. 7. Rice, D. P., and Cooper, B. S. : National health expenditures, 1929-71. Social Security Bulle tin, January, 1972, p. 5. 8. Editorial : What's happening at the National Institutes of Health. Med. World News, January 21, 1972, p. 46. 9. Towers, B. : The influence of medical tech nology on medical services. In McLachlan, G., and McKeown, T. (eds.) : Medical History and Medi cal Care : A Symposium. Oxford, Oxford Uni versity Press, 1971, pp. 172, 173. 10. Leading Components of Upturn in Mortality for Men, U.S., 1952-67. U.S. Department of Health, Education, and Welfare, Series 20, No. 11 (Table 1), p. 24. 11. McLaughlin, C. P.: Technology and medical care costs : Some basic evaluation problems. Temple University School of Business Administration, Eco nomic and Business Bulletin, Fall, 1971, p. 42. 12. Nora, J.: In Thompson, T.: The Year They Changed Hearts. Life Magazine, September 17, 1971, p. 69. 13. Steel layoffs transform Gary into economic disaster area. AFL-CIO News, December 4, 1971, p. 2.
CORRESPONDENCE U L T R A V I O L E T - I N D U C E D RECURRENT H E R P E S S I M P L E X VIRUS KERATITIS
Editor, American Journal of Ophthalmology : Recurrent corneal disease due to herpes simplex virus ( H S V ) is common and debili tating. Recurrent forms of H S V infection are generally held to be associated with virus which remains latent in the host in the inter val between recurrences. T h e nature and lo cation of this latent H S V are not clear. O b servations by others 1 indicate that recurrent H S V keratitis may be due to virus shed from chronic, low-grade infections of ocular adnexal tissues. T h e r e are still other obser vations, 2 however, which support the hypoth esis that the nervous system is the site of la tent H S V infection and the source of virus in recurrent disease. Heretofore, the tissues
W.
NEWELL,
Editor-in-Chief
160 East Grand Ave., Chicago, Illinois 60611 DERRICK VAIL,
Editor-in-Chief
Emeritus
2450 Lakeview Avenue, Chicago, Illinois 60614
EDITORIAL BOARD Bernard Becker, St. Louis Frederick C. Blodi, Iowa City Benjamin F. Boyd, Panama Thomas Chalkley, Chicago Sir Stewart Duke-Elder, London DuPont Guerry III, Richmond Michael J. Hogan, San Francisco Robert W. Hollenhorst, Rochester Herbert E. Kaufman, Gainesville Arthur H. Keeney, Philadelphia Bertha A. Klien, Chicago Alex E. Krill, Chicago
Carl Kupfer, Bethesda James E. Lebensohn, Chicago Irving H. Leopold, New York A. Edward Maumenee, Baltimore Edward W. D. Norton, Miami Albert M. Potts, Chicago Algernon B. Reese, New York Marvin L. Sears, New Haven David Shoch, Chicago George K. Smelser, New York Phillips Thygeson, San Francisco Gunter K. von Noorden, Baltimore
Published monthly by the Ophthalmic Publishing Company Directors:
DERRICK V A I L , President; ALGERNON B. REESE, Vice-President; F R A N K W . NEWELL, Secretary and Treasurer ; A. EDWARD M A U M E N E E , M I C H A E L J. HOGAN, EDWARD W . D. NORTON
H E A L T H CARE AND T H E POLITICAL SYSTEM T H E SORCERER'S APPRENTICE REVISITED
The specter of the automated robot or un loosed genie that starts out as the obedient, This paper was presented to the National Center for Health Care Services Research and Develop ment, Conference on Technology and Health Care Systems in the 1980s, January 19, 1972, at San Francisco, California, and the Association of Uni versity Professors of Ophthalmology, January 24, 1972, Key Biscayne, Florida. Reprint requests to Professor Anne R. Somers, Department of Community Medicine, College of Medicine and Dentistry of N e w Jersey, Rutgers Medical School, P.O. Box 2100, N e w Brunswick, New Jersey 08903.
hard-working servant of man and ends up as his potential master has haunted poets and philosophers throughout the ages. Goethe's sorcerer's apprentice, Aladdin's genie, and the Jewish legend of the Golem are all varia tions on this theme. In R.U.R., Karel Capek's successful play of the early twen ties, the universal robots revolt successfully against their human masters, kill all of them, and are only saved from extinction them selves when one robot couple learns the se cret of humanity—the capacity for love and suffering. An even more terrifying vision of an im minent future in which Western society has
600
VOL. 73, NO. 4
EDITORIAL
become a hyper-technologized, hyper-sexed, and violence-prone slum is being portrayed in a number of recent films such as Stanley Kubrick's widely acclaimed "Clockwork Or ange." According to this view, rather than being conquered by the robots, man's own personality is debased and vulgarized almost beyond recognition. In the beginning, modern industrial tech nology was greeted with fear and hostility. The Luddites, breaking up the new mechani cal looms in the English textile mills at the beginning of the Industrial Revolution, have become symbols of this fear. During the hundred years of almost continuous techno logical progress, from the mid-nineteenth to the mid-twentieth centuries, their fears and those of the artists were generally dismissed as irrational. Classical economists were confi dent that the marketplace was an effective self-regulating mechanism, with both supply and demand governed by man's basic ratio nality. Marxists rejected the marketplace as regulator but were confident that govern ment, acting on behalf of the masses, could control technology and turn it to constructive ends. Those whose economic and political philosophy fell somewhere between these ex tremes—European democratic socialists, Keynesian liberals, American pragmatists, and others—looked to various combinations of competitive and regulatory disciplines. Fearing overconcentration of power in gov ernment as well as uncontrolled private en terprise, the liberals or pragmatists agreed that the political process was not only a relia ble brake on the excesses of capitalism but an effective device for spreading the benefits of technology to the population at large. In the past few years, however, there has been a rapid increase in the ranks of those who fear that technology, like the appren tice's robot, may now be out of control ; that the economic philosophy of continuous growth, with which it is associated, may be doing more harm than good ; and that gov ernment, far from being an effective regula tor of technological excess, may have already been captured by it.
601
The physical scientists and ecologists were the first to warn of danger. For example, Dr. Dennis Gabor,1 winner of the 1971 No bel Prize in physics, has repeatedly criticized our "growth addiction" which, he says, is certain to lead to catastrophe, even without an all-out nuclear war. In January, 1972, 33 leading British scien tists, including the distinguished biologist Sir Julian Huxley, and other environmental ists, endorsed a report, "Blueprint for Sur vival,"2 that is one of the starkest doom warnings yet. They warned that the world is heading for an inevitable social and environ mental breakdown—"within the lifetime of someone born today"—unless man funda mentally alters his long-imbedded drive for growth and industrialization. Here is part of their reasoning : Continued exponential growth of consumption of materials and energy is impossible. Present reserves of all but a few metals will be exhausted within 50 years, if consumption rates continue to grow as they are. Obviously, there will be new discoveries and advances in mining technology, but these are likely to provide us with only a limited stay of execution. At the same time, we are sowing the seeds of massive unemployment by increasing the ratio of capital to labor so that the provision of each job becomes ever more expensive. In a world of fast diminishing resources, we shall quickly come to the point when very great numbers of people will be thrown out of work, when the material com pensations of urban life are either no longer avail able or prohibitively expensive, and consequently when whole sections of society will find good cause to express their discontent in ways likely to be any thing but pleasant for their fellows.
More recently, social scientists are begin ning to agree. Odin Anderson 3 points out that the automobile has become "an indepen dent variable determining the shape of our living patterns." John Kenneth Galbraith4 saw the origins of corporate giantism, "the new industrial state," and the military-indus trial complex in the imperatives of advanced technology. Jay Forrester 5 of M.I.T. says, "Our greatest challenge now is how to han dle the transition from growth into equilib rium." "The Luddites were not all wrong!" ac cording to the British economist, Ezra
602
AMERICAN JOURNAL OF OPHTHALMOLOGY
APRIL, 1972
Mishan,6 whose "Mishanic Message" of ture of the crucial interaction between tech anti-technology and anti-growth is attracting nology and the political process. It consists scholarly attention. Senators and congress of four related propositions : men, trying to cope with military technology, 1. There is a dynamic expansionist force and the victims of smog in many of our ma inherent in modern technology that leads to jor industrial communities, undoubtedly economic growth, higher costs, and increas agree. ingly centralized financing and administra Whether the Luddites were, in fact, right tive control, ending, almost inevitably, with or wrong ; whether man, the clever appren government. tice, by stealing the secrets of his master— 2. The primary results of this growing God or Nature or the Cosmos—has unloosed financial and administrative centralization, forces which he can no longer control is a combined with ever-larger markets or ser question that only the future can answer. vice areas, are likely to be positive, with di There is no question, however, that the com rect benefits in the form of more goods and fortable optimism of the late nineteenth and services for more people. At this point, the early twentieth centuries has been shattered driving force of technology appears fully and that the efficacy of all three major sup compatible with the democratic goal of maxi ports of this optimism—technology, eco mizing benefits for the maximum number of nomic growth, and government as the ulti people. mate regulator of both—is now widely ques 3. However, there are a number of seri tioned. ous negative results, including overpopula We in the health field have, in one sense, tion, overcrowding, pollution of our living less reason for concern than some of our environment, the vastly increased power— brethren in the physical sciences. The health for evil as well as for good—of the bureau care industry is still a labor-intensive service cracies in control of the technology, the industry. Despite advances of recent years, alienation of millions of young people, technology still plays a relatively minor role. blacks, country folk, and others who feel And despite the rapid recent increase in gov themselves redundant in this highly struc ernment financing, health care is still pre tured, technocratic society, and the general dominantly a private sector activity. Never overemphasis on material goods and values. theless, the general trends are clearly pres 4. Whatever the net balance of positive ent: more and more technology, ever rising and negative effects, the growth of technol costs, more and more billions of dollars be ogy is probably irreversible—at least until ing spent, more and more government in far more of the world's population has expe volvement. rienced more of its benefits. The challenge, How and why has this happened ? What is therefore, is to bring this formidable force the nature of the interaction between tech under social control and to develop political nology and the political process ? What have and other institutions adequate to this task. been the major benefits? The principal dan I will now restate each of these four prop gers? The net result? Should the process be ositions and discuss them briefly with special reversed? Can it? If not, what then? reference to medical technology and the in creasing "polidealization" of medicine in the A WORKING HYPOTHESIS United States. A discussion of this brevity There is no easy or graceful approach to cannot be anything more than suggestive. this outsize topic. I will start with a working Hopefully, the portentous issues raised will hypothesis, a broad general construct which, continue to receive serious attention from hopefully, may throw some light on the na both scholars and statesmen.
VOL. 73, NO. 4
EDITORIAL
1. T H E EXPANSIONIST FORCE OF MODERN MEDICAL TECHNOLOGY
There is a dynamic force inherent in mod ern technology that leads to economic growth, higher costs, and increasingly cen tralized financing and administrative control, ending, almost inevitably, with government. Among the many paradoxes associated with the triumphs of modern medical tech nology none is more striking than this : The more advanced and the more effective the technology, the greater the overall costs of health care. There are many reasons : the capital investment in the new equipment, the often high cost of maintenance, the need for specialized personnel to operate it, the need for an institutional setting in which it can be operated which usually means additional overhead costs, the longer average life ex pectancy of the population which means more health care over the lifetime of the in dividual and over the year for the nation as a whole, the ever-rising, albeit often unrealis tic, expectations on the part of consumer-pa tients, leading to an elasticity of demand that is almost total. In many industries the more effective the technology, the lower the unit cost of pro duction. This is possible as a result of the ef ficiency of mass production. There are ex amples of efficient mass production in the health services industry, including the manu facture of drugs, the automation of labora tory tests, and computerized business ser vices. Diagnostic screening could be handled on a mass basis from the production point of view. But health care, by and large, does not lend itself to the mass production approach. There seems little hope that the rising costs of medical care can ever be balanced by the same sort of productivity increases that we have witnessed in industry in general. Some authorities disagree on this point. Some see the progress of technology permit ting replacement of the physician and other very expensive personnel with lower cost,
603
highly specialized, technicians. According to this view, even if total costs rise and unit costs cannot be cut, still we will be able to provide more services to more people. Pre sumably this would be a net gain. I see little evidence, however, that things will work out this neatly. First, this view minimizes the effectiveness of health profes sionals in resisting technological replace ment. For example, the introduction of unit dosage into hospital pharmacy might be ex pected to reduce hospital costs by eliminating the necessity of a resident pharmacist. This is not likely to happen, however. On the con trary, the pharmacist is seeking, understand ably, to upgrade his role and salary from a supply function to that of a "clinical phar macist." More important, the technologists gener ally underestimate the continuing importance of interpersonal relations in health care. Much nonsense has been uttered in the re cent past with respect to the doctor-patient relationship and TLC ("tender loving care"). Many now make the opposite mis take and tend to overlook the often crucial role of subjective factors in illness, the im portance of treating the "whole man," and the essentiality of the professional's role as educator, as well as technician, in helping the patient to prevent or cope with his illness. Moreover, heavy emphasis on technologi cal economies and productivity may lead to overemphasis on those health services which can most easily be mass-produced—drugs, laboratory tests, x-ray studies, even some types of surgery. But these are precisely the areas where there is already danger of too much, rather than too little, consumption. I will return to this point later. This is not to say that many more effective cost controls cannot be devised. They can and should. But, if past experience is any guide, further improvements in medical technology will, almost inevitably, lead to further increases in the cost of care and fur ther pressures to spread or socialize those
604
AMERICAN JOURNAL OF OPHTHALMOLOGY
costs, over larger and larger population bases, as well as to bring in outside controls in the effort to moderate the rise. In most of the world, the cost of health care, like the cost of education, is already paid for almost entirely by government—be cause this is the only social entity with the necessary financial resources. We would un doubtedly have gone the same route long be fore now except that our wealth and the spe cial circumstances of collective bargaining in U.S. industry enabled us to absorb the rising costs of health care through the price of other goods and services. Every bikini, every tin can, incorporates in its price the cost of health care for the garment worker and her family, for the steel worker and his family. The major theme of medical economics for the first two decades after World War II was the "great cost pass through" to the gen eral consumer. After 1965, the story began to change. The private sector proved unable to absorb the total costs, especially for high-risk groups such as the aged. For the first time, the federal government was brought into the picture as a major factor in health care financing. Within four years, the public share of total U.S. health expenditures in creased from less than 26%, a figure never before exceeded except in war, to 38%. 7 Costs are now passed through to the tax payer as well as the consumer. But this does not mean that a viable equi librium has been achieved. On the contrary, the pressures are even greater in 1972 than in 1965. Describing the successful 1971 drive for a major federally-funded campaign against cancer, Medical World News* edito rializes, "The politicization of cancer sug gests a possible politicization of the entire biomédical enterprise." Along with the rise in the government share of expenditures has come a phenome nal increase in the total expenditure figure itself—to over $75 billion in fiscal year 1971. Consumer dissatisfaction with rising prices forced even a reluctant administration to in
APRIL, 1972
flation control measures for the economy in general and the health care industry in par ticular. Both state and federal governments are trying to put the lid on rising health in surance premiums. A taxpayer revolt, at state and local levels, is forcing even conservative politicians to call for national health insurance. The Ways and Means Committee has been holding hearings on the subject, an unthinkable phenomenon even five years ago. Adoption of some sort of universal health insurance system seems inevitable within the next few years. Despite our wealth, despite our preference for non governmental financing, despite the ingenu ity and efforts of private insurance carriers, despite the fears of many providers and con sumers, there seems to be no other way that we can cope with the ever-rising costs of modern medical technology. 2. T H E HONEYMOON OF TECHNOLOGY AND GOVERNMENT
The primary results of this growing cen tralization of control, combined with everlarger market or service areas, are likely to be positive with direct benefits in the form of more goods and services for more people. At this point, the driving force of technology appears fully compatible with the democratic goal of maximizing benefits for the maxi mum number of people. Due to a number of fortunate circum stances in the United States—particularly its size and natural resources and our constitu tional and other traditions—science and technology, on the one hand, and politics and government on the other, have generally coexisted in a state of creative or dynamic tension. In general, government has done that which the people were unable to do for themselves—and not much more. In the medical field the atmosphere has sometimes been acrimonious, but never fa tally so. The expansion of government health care programs has, thus far, been generally limited to categories of persons that could not provide their own care and for whom no
VOL. 73, NO. 4
EDITORIAL
adequate source of support existed in the private sector. The unit costs of health ser vices have generally not been lowered. This is not only because of the limits of mass pro duction in health care but because provider organizations tend to be stronger than con sumer organizations and once a program be comes "politicized" it becomes especially vul nerable to such pressures. Thus far, however, the tax base has proved flexible enough to absorb the rising costs, chiefly by involving broader govern mental units and larger population bases. So, thanks to "politicalization," millions of Americans—including Indians, disabled veterans, the indigent, and nearly all over 65 —who would otherwise be denied the fruits of the new technology have access to some health services. At the same time, the in comes of most providers have improved sub stantially. Medical research, professional education, and construction of facilities have been lib erally supported, both by public and private funds. Belatedly, but now quite generously, government is supporting research into new methods of organizing and financing health care, with strong emphasis on new technol ogy, as this conference indicates. Further triumphs of such technology, such as telemedicine, which may give new mean ing and potential to the individual doctor-pa tient relationship, and computerized medical records, which could make possible lifetime continuity and true comprehensiveness of care, are just over the horizon. The honey moon of government and politics has obvi ously been productive of many social goods. 3. T H E FAUSTIAN DILEMMA: IS THE PRICE TOO HIGH ?
However, there are a number of serious negative results, including overpopulation, overcrowding, pollution of our living envi ronment, the vastly increased power—for evil as well as for good—of the bureaucra cies in control of technology, the alienation of millions of young people, blacks, country
605
folk, and others who feel themselves redun dant in this highly structured, technocratic society, and the general overemphasis on ma terial goods and values. War, violence, crime, the arrogance of power, and the exploitation or alienation of the weak : None of these evils are peculiar to the age of technology. They have been with us since the dawn of history. But just as the hydrogen bomb is infinitely more lethal than the bow and arrow or the gun, so the de structive possibilities inherent in modern production, transportation, communications, space, biochemical, and other technologies give pause to even the congenital optimist. Some students see in this train of events the eventual self-destruction of the human race. Thus far, the fear of sophisticated medical technology—experimental surgery, computer medicine, telemedicine, mind and mood con trol drugs, biological engineering, etc.—per verted in the hands of some native Hitler seems most unlikely. But this does not mean there have been no negative effects. Among those who feel that many patients have suf fered unnecessarily, either as a result of ex perimentation or incompetence, is Dr. Ber nard Towers. 9 He states : When I consider the sheer power, for both good and harm, that resides in such a simple technical procedure as setting up an intravenous saline drip, I am frightened for the safety of the patient. Advanced medical technology has helped to exacerbate two preexisting evils—infla tion and fragmentation. In both cases, this results from acceptance of the advantages of technology and politicalization without will ingness—either on the part of the industry or government—to apply the voluntary re straints or public controls necessary to pro vide relative price stability and coordination of services. The term "bureaucratic" is so frequently and indiscriminately applied as an epithet to condemn government in general that one hesitates to use the term. Certainly, the char acteristic is not peculiar to government—ei ther in its technical or pejorative sense. Bu-
606
AMERICAN JOURNAL OF OPHTHALMOLOGY
reaucracy is primarily an attribute of largescale operations, regardless of public or pri vate status. To many a ghetto patient, the worst "bureaucrats" are not in Washington but in the nearest medical school or teaching hospital. The fact remains, however, since govern ments tend to be larger than private enter prises, the danger of bureaucracy in govern ment is increased. Moreover, once a govern ment program is established and acquires a constituency of its own, it is harder to dis continue it, regardless of social utility, than a similar program in the private sector which has to depend on a direct relationship be tween user satisfaction and willingness to pay the price. Within government, the further removed the agency is from actual operating responsi bilities, the greater the difficulty of evaluat ing its performance and of maintaining ac countability to Congress and to the people, and the greater the danger of self-perpetuat ing, unresponsive offices and personnel. In short, the cliché is not without substance. Sometimes one wonders if all the goings and comings in Washington and throughout the industry, all the conferences, the proj ects, and the protocols have any appreciable effect on the nation's health. On the con trary, there seems to be a perverse negative correlation between the rising expenditures and many of our health indices. For exam ple, we have just learned that during the six ties—the decade of the greatest increase in health expenditures and of government in volvement—there was also an upturn in mortality rates for most U.S. men. Among young men, the rise was dramatic: 2 1 % among whites ages 15-19 between 1963 and 1968; 35% for nonwhites.10 When one considers the major cause of death among young men of both races—mo tor vehicle accidents, homicide, suicide—it is obvious that we cannot blame poor health care. It is equally obvious that we are miss ing the target in trying to improve the na tion's health simply through improved medi
APRIL, 1972
cal technology, by reorganizing the delivery system, or by spending more money for medical research. The clue to many, if not most, of our health problems, not only among the young but the middle-aged, appears to be lifestyle. This, in turn, is at least partly related to mo rale. The principal causes of death among men 45-64 years of age include lung cancer, emphysema, heart disease, and cirrhosis of the liver. The relation of these diseases to smoking, drinking, and overeating is gener ally acknowledged. The symptoms of alienation, boredom, ap athy, and irresponsibility with respect to health are all about us. Odin Anderson 3 calls it "the short-range hedonistic model" and hopes that it will be replaced by "the long range moderate and balanced pleasure model." Neither of us is very optimistic. It seems that the more effective the technology, the less responsibility many consumers exer cise with respect to their own health. This phenomenon has been widely noted in the case of venereal disease where the easy reli ance on contraception and penicillin has led to widespread disregard of elementary hy giene. When we have heartburn rather than cut down on eating, we take Alka-Seltzer. Emotional problems ? Rather than face up to the cause, we take a tranquilizer. Tired? A pep pill. Etc. A related issue involves the effect of tech nology in inducing an artificial rise in use, whether or not medically indicated. For ex ample, one authority points out :" The fact that typical equipment designs [of clinical chemistry laboratories] can handle more than the usual daily needs of even a large hospital may lead the administration to adopt standing orders for a battery of screening tests for each admission.
The drug industry is that portion of the health care industry most clearly in line with general technological trends and the econo mies of mass production. Its achievements have been tremendous. Chemotherapy is to day one of the most powerful arms of mod ern medicine. But overused and abused, it
VOL. 73, NO. 4
EDITORIAL
becomes a powerful pollutant. Its effluence is the current drug culture and its Franken stein offspring, the heroin epidemic. Here, indeed, the sorcerer's apprentice has lost control. 4. T H E CHALLENGE BEFORE US
Whatever the net balance of positive and negative effects, the growth of technology is probably irreversible—at least until far more of the world's population has experienced more of its benefits. The challenge, there fore, is to bring this formidable force under social control and to develop political and other institutions adequate to this task. It is possible that the Congressional vote on the SST and the reduced appropriations for space exploration may have marked the end of the honeymoon between American technology and the American government. In the health field, the anti-technology sen timent is pervasive among doctors and pa tients alike. "Everyone" laments the loss of the traditional doctor-patient relationship— even those who never had it. "Everyone" de plores the increasing depersonalization of care—even those who never knew good personal care. Senator Fulbright's accusa tions against the "military-industrial com plex" for its "arrogance of power" are echoed in a hundred journalistic diatribes against over-specialism, the hospital, which Walter McNerney calls a "technological em porium," and the nascent "medical-industrial complex." After a year of frenetic activity, the epidemic of heart transplants seems to have come to an end—at least for the time being. One Houston cardiologist, who was involved in a number of the operations, calls the whole experiment "dehumanization by technology."12 But how many Americans would be will ing to pay the price of a clampdown on sci ence and technology? How many really agree with Professor Mishan that for the average man life was better a half century ago and the whole world would be better off now if we had stopped technological and eco
607
nomic growth around 1919? Remember, at this time U.S. steel workers were still work ing a 12-hour day, child labor was the rule, Southern blacks still lived in a state of serf dom little different from their previous slav ery, and medicine had just passed the point which Dr. Lawrence Henderson of Harvard identified as that when "for the first time in human history, a random patient with a ran dom disease consulting a doctor chosen at random stood better than a 50-50 chance of benefiting from the encounter." If 1919 is not the right date, how about 1950? Or 1972? Who is to decide on the magic hour when the human race is supposed to have achieved the optimum balance be tween the good and bad results of technol ogy ? We in this comfortable hotel room ? Or the unemployed steelworker and his family? Or the hundreds of millions still living in pre-industrial dark ages. In Gary, Indiana, where massive layoffs in the steel industry have produced a community-wide depres sion, a shopkeeper was asked to suggest a so lution.13 His prescription, "Make those smoke stacks blow their beautiful dirty smoke again !" Even if we in the affluent West do become frightened enough of pollution, crime, and the drug epidemic to impose effective re straints on our own technological and eco nomic growth, we obviously lack the power to enforce any such decision on the whole world. We represent only about 6% of the 3.5 billions who inhabit this planet and the technological abundance that is becoming su perfluity or worse to us is still a vision of hope to the vast majority. What will probably happen is that the present striking imbalance between U.S. consumption of world resources and that of the rest of mankind will not continue indefi nitely. Either we will share voluntarily, or involuntarily, or we will spend more and more of our gross national product (GNP) on armaments to try to defend our privileged position—another way of reducing domestic consumption.
608
AMERICAN JOURNAL OF OPHTHALMOLOGY
In any case, the politics of growth—how to cut up an ever-expanding economic pie based on a continually expanding landmass, population, technology, and GNP—may now be superseded by the politics of equilibrium or even decline. The result could be further exacerbation of domestic intergroup and po litical tensions. Control over technology, es pecially communications, could become a ma jor source of conflict. Small groups, enjoy ing privileged positions—known to some as islands of excellence, to others as ivory tow ers of elitism—will be hard put to defend their privileges. Basic scientific research could be threatened. Still, it seems unrealistic to anticipate any immediate dramatic change in national pol icy. The multitude of conflicting pressures coming to bear on government in a democ racy tend to maintain a relatively constant and centrist position. To talk of stopping technology or reversing the trend to govern ment involvement seems to me romantic nonsense, a copout on the issues that we may —just possibly—be able to do something about. Tough, practical, inescapable prob lems such as the following : How to assure that technology is kept un der accountable human control ? How to restrain technological innovation to a rate that is socially assimilable—from the point of view of employment, consump tion, and our value systems—without im pairing the creative drive that has contrib uted so much to our past progress ? How to broaden, strengthen, and further democratize our governmental and other de cision-making institutions ? How to decentralize government to the point that people can, once again, feel some sense of meaningful participation and, at the same time, adjust boundaries to conform more nearly to expanding market and ser vice areas ? How to maintain—if necessary even build in—effective counterweights to government at all levels so as to minimize the danger of
APRIL, 1972
repression while avoiding the opposite dan gers of anarchy or stalemate? How to share our technological and other resources with other nations, peacefully and to our mutual advantage? How to improve the decision-making pro cess at all levels so that good intentions can be matched by clear understanding of proba ble consequences ? In the health care field, the acid test of our ability to cope with these problems will prob ably come with our eventual decisions on na tional health insurance. But these decisions, in turn, will be greatly influenced by what we do, or do not do, today and tomorrow, with respect to a multitude of subsidiary or related issues, including medical education, professional licensing, hospital franchising, regulation of the private health insurance in dustry, HMO's, Medicaid, drug abuse, day care centers, consumer health education, etc. Vitally important, of course, is the ques tion as to who will develop and control the health care technology of the future: The health professions and consumers through their elected representatives ? Or the technol ogists themselves, both in and out of govern ment? If the latter happens, I believe it will be primarily due not to greed on their part but to default by those who have the greatest stake in accountable democratic controls. Finally, our ability to cope with the basic issues listed above will depend on the nature and effectiveness of our national research ef fort—with respect both to the pursuit o r biomédical knowledge and its application. Significantly, Dr. Bernard Towers, 9 with all his fears of new "iatromechanical" and "iatrochemical" techniques, concludes with a plea for greater use of the computer : It seems to me that intelligent use of the com puter could give medicine the most powerful, and yet most in-nocent (in the literal meaning of the word) technique ever discovered. All knowledge, all understanding, involves four stages, all of them requiring the handling of information. They are, in order, information accumulation, filtering (selec tion), storage, and retrieval. The last stage involves not simply the régurgitation of data previously
CORRESPONDENCE
VOL. 73, NO. 4
"memorized," but the juxtaposition and synthesis (in both space and time) of data culled from vari ous sources, and at various times. This is the es sential element in scientific discovery, in "insight," in the exercise of clinical "diagnostic flair." This is the process that the good clinician uses continually, a process of analysis and synthesis, with many feedback loops, both positive and negative. Cyberneticians refer to the process as "systems analysis" ; and this concept marks a radical break with the linear, cause-effect paradigm of "good" natural sci ence which was at the basis of what Bernard called "l'iatromécanique" and "l'iatrochimie". . . . I see the computer as a tool to help us to a much deeper understanding of man, of man seen in "biological space-time." I n other words, some forms of technology, appropriately applied, could be our salvation. But with or without the insights of the com puter, with or without the advantages to medicine, D r . Gabor, 1 the physicist, has the last word : The insane quantitative growth must stop; but innovation must not stop—it must take an entirely new direction. Instead of working blindly toward things bigger and better, it must work toward im proving the quality of life rather than increasing its quantity. Innovation must work toward a new harmony, a new equilibrium ; otherwise it will only lead to an explosion. T h e ultimate challenge to man, the clever, competitive, conceited apprentice, is whether he can learn to use his new-found knowledge with the wisdom, self-discipline, and humil ity necessary for survival. I n the words of that great philosopher, Pogo, " W e have met the enemy—and it is u s . " A n n e R. Somers REFERENCES
1. Gabor, D. : Innovation Must Go On. New York Times, November 7, 1971. 2. Excerpts : A Blueprint for Survival, The Ecologist, January, 1972. "Op Ed" page of the New York Times (Op Ed page), February 5, 1972. 3. Anderson, O. W. : Health Services and the Political System of the 1980's. Presented before Na tional Center for Health Services Research and Development, Conference on Technology and Health Care Systems in the 1980's, San Francisco, January 19, 1972. 4. Galbraith, J. K.: The New Industrial State. New York, Houghton Mifflin, 1967. 5. Forrester, J. W. : Counterintuitive Behavior of Social Systems. Alumni Association of the Massa
609
chusetts Institute of Technology, Technology Re view, January, 1971. 6. Greene, W., and Golden, S. : The Luddites were not all wrong. New York Times Magazine, November 21, 1971. 7. Rice, D. P., and Cooper, B. S. : National health expenditures, 1929-71. Social Security Bulle tin, January, 1972, p. 5. 8. Editorial : What's happening at the National Institutes of Health. Med. World News, January 21, 1972, p. 46. 9. Towers, B. : The influence of medical tech nology on medical services. In McLachlan, G., and McKeown, T. (eds.) : Medical History and Medi cal Care : A Symposium. Oxford, Oxford Uni versity Press, 1971, pp. 172, 173. 10. Leading Components of Upturn in Mortality for Men, U.S., 1952-67. U.S. Department of Health, Education, and Welfare, Series 20, No. 11 (Table 1), p. 24. 11. McLaughlin, C. P.: Technology and medical care costs : Some basic evaluation problems. Temple University School of Business Administration, Eco nomic and Business Bulletin, Fall, 1971, p. 42. 12. Nora, J.: In Thompson, T.: The Year They Changed Hearts. Life Magazine, September 17, 1971, p. 69. 13. Steel layoffs transform Gary into economic disaster area. AFL-CIO News, December 4, 1971, p. 2.
CORRESPONDENCE U L T R A V I O L E T - I N D U C E D RECURRENT H E R P E S S I M P L E X VIRUS KERATITIS
Editor, American Journal of Ophthalmology : Recurrent corneal disease due to herpes simplex virus ( H S V ) is common and debili tating. Recurrent forms of H S V infection are generally held to be associated with virus which remains latent in the host in the inter val between recurrences. T h e nature and lo cation of this latent H S V are not clear. O b servations by others 1 indicate that recurrent H S V keratitis may be due to virus shed from chronic, low-grade infections of ocular adnexal tissues. T h e r e are still other obser vations, 2 however, which support the hypoth esis that the nervous system is the site of la tent H S V infection and the source of virus in recurrent disease. Heretofore, the tissues