The success of American medicine is often attributed to the profession’s ability to serve the public on its own terms. Why should doctors care if, from the patient’s point of view, the terms chosen—solo practice and emphasis on the “doctor-patient relationship”—mean that a doctor performs unsupervised services for unregulated fees? What does it matter to them that the poor are outside the system altogether, treated in charity wards or public hospitals which are the medical equivalent of Andrew Carnegie’s libraries, a small concession to charity from an accelerating machine of wealth, power, and influence? In a country proud of its “pluralism” and fearful of “government interference,” a monolithic self-regulating profession is taken as a sign of health. Few people are persuaded that medical care is a fit object of social planning: We have no national health policy and we are mostly proud of it.
It has left us in an extremely unfortunate mess. At its best American medicine may very well be the best in the world, as its practitioners claim, which is why retired English kings and Arabian sheiks turn up regularly in our hospitals. But though excellent treatment is usually available to the very rich, the rest of the population finds even adequate services hard to come by. The charge frequently made by critics that ten countries have lower rates of infant mortality and longer life expectancies does not mean that the Peter Bent Brigham Hospital, for instance, is somewhat sliphod; it means that most people will never set foot in any place half so good.
The situation of the poor is particularly appalling. In Boston, a health survey of a public housing project indicated that among individuals over 65, 25 per cent had chronic bronchitis, 20 per cent had chronic nervous disorders, 12 per cent were blind or had visual defects, and that 40 per cent of these were not receiving treatment. In New York, former Health Commissioner George James has estimated that 13,000 poor people died last year because adequate professional care was not available. The maternal mortality rate for U. S. whites (in 1961) was 2.5 per 10,000 live births. For Mississippi Negroes, it was 15.3, more than six times as high. In a South Carolina county, every tenth Negro child died in the first year of life.
THE POOR ARE NOT wholly without opportunities for medical care. But the public facilities that do exist perpetuate a grotesque circle of personal humiliation and medical lunacy. In many cities a mother cannot take a well baby for a check-up to the same place she must take a sick child for diagnosis or treatment. If she suffers from both migraine headaches and pains in her chest she may have to go to two different clinics herself. Clinics (and emergency rooms) are often far away, in a sometimes unfamiliar “downtown.” For a suburban mother with a car and a maid such problems would be easy to surmount. For the …