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The Coming Medical War

For the same amount of money, the hospital might have handled 20,000 outpatient visits each year, or set up a vast screening program in East Harlem to detect lead poisoning and anemia in children. But such equipment is fashionable and modern, and a “good” hospital must have it if it is to keep up with the others. Doctors have, according to Shaw, “an intense dread of doing anything that everybody else does not do, or omitting to do anything that everybody else does.” So, apparently, do hospitals.

Of course, some of the new medical machines and procedures can help some patients if they are humanely used and if the public has an equitable chance to be treated by them. To criticize the excesses of the medical technocracy is not to deny the real achievements of the profession, or the potential of serious medical research. Certainly doctors will always need to be competent diagnosticians and skilled therapists. But they will also need to be concerned with the quality of their patients’ lives as well as their length, with the patient as a person and even a friend, as well as an intriguing collection of organs.

The management of a problem like juvenile diabetes, for example, requires less erudition about metabolism than social and psychological sensitivity. To know the protein structure of insulin may be useful, but to know intimately the child’s family situation, to be aware of and able to ameliorate feelings of guilt and dependency and fear, may be crucial. The rise of the medical elite, which denigrates the experience of the patient in the way Greenberg describes, distorts the very nature of healing.

IV

The American Health Empire: Power, Profits and Politics, a report from the Health Policy Advisory Center (Health-PAC) in New York City, is the most solid criticism of American health care now available. It may make its readers feel terrible, which is right, because that is how it feels to be a patient, an orderly or technician, a nurse, and even a doctor these days. The “diagnosis” which the authors supply is not of the familiar health care crisis which Mr. Cray and even the AMA are now at last discovering, but of the very solutions which the sophisticated medical experts have begun noisily to offer.

Health-PAC is a research and action collective in New York City which grew out of the Institute for Policy Studies in Washington, D.C., and which for over two years has conducted inquiries into municipal and national health care policies.14 This book is a selection from the monthly Health-PAC bulletins in a revised and readable form. The authors present the problem of health care as follows:

Traditionally, liberals have explained that America is not a healthy place to live, in either a medical or a social sense, simply because health and other social services are low priority items in a nation whose resources are committed to military and economic expansion. “If we could only spend the money we spend in Vietnam on hospitals, housing, schools…” goes the refrain.

So we have reasoned. But on looking closer, we began to understand that national priorities are only part of the problem, perhaps the more manageable part. Billions of dollars could be diverted from America’s aggressive, defensive, and interplanetary enterprises with no appreciable effect on the quality of health care. For even within the institutions that make up America’s health system—hospitals, doctors, medical schools, drug companies—health care does not take the top priority. Health is no more a priority of the American health industry than safe, cheap, efficient, pollution-free transportation is a priority of the American automobile industry. [italics added]

The victims, then, are not just the poor, the blacks, the Puerto Ricans, who cannot afford to buy what the health industry is selling, but also all the millions of middle-class and working-class people who try to extract health services from the health industry.

Health-PAC’s description of New York City wholly undermines Mr. Greenberg’s description of Boston. “Increasingly,” the authors note, “control of health resources and facilities has become centralized in a few towering medical-school-linked systems…. At least two million New Yorkers are wholly dependent, and another four million partially dependent, on these medical empires for their health and strength.” The authors then show that “the private, university-connected empires have failed to deliver in all areas of promised performance.” Not only do they contend that there has been demonstrable malfeasance involving large sums of federal, state, and municipal funds, but that “in many cases, the narrow research, teaching, and profit priorities of the private empires have actually led to worsened conditions in the public hospitals, greater fragmentation, dehumanization, and neglect of basic health services.”

These are strong accusations indeed, and they are supported by ample documentation in the text. (Neither footnotes nor bibliography nor index are supplied, however; these are serious omissions, not because the authors’ statistics are questionable but because the sources used here might provoke further investigations.) The authors expose Medicare and Medicaid, each of the current proposals for National Health Insurance, the Blue Cross Associations, the federal Regional Medical Programs, and Comprehensive Health Planning legislation as constituting “openhanded public subsidy of the unregulated health system [which] is not only wasteful, but leaves permanent distortions.” And on the evidence of the New York experience they conclude that the medical elite’s current attempt to secure control of American health care is based upon “the philosophy guiding the American effort in Vietnam: if something was a mistake in the past, it deserves another try, but on a much bigger scale.” This seems an appropriate comment on the hope Mr. Greenberg saw glimmering in Boston.

A chapter of The American Health Empire provides a documented description of the vastly expanding and almost completely unregulated health industries: the pharmaceutical and hospital supplies firms, proprietary nursing homes, and the growing medical technology business. The authors note, “Trustees and upper-level staff of medical schools and hospitals are always welcome on the boards and top staffs of health industry firms and vice versa,” and conclude that “the consumer can expect no mercy from the new Medical-Industrial Complex.”

But I think the analysis of this alliance, which Shaw was able to foresee, is not carried as far as it can go. If, as it has done in the past, the medical elite continues to rely upon its technological expertise as an excuse for consolidating its power and for continually narrowing and elevating its ranks, the stage will soon be set for a new and unprecedented coup: the technocrats will assume unchallenged control of American medical practice. Our doctors will be computers. This is not humorously intended.

In Medicines for Man,15 Harry F. Dowling, a knowledgeable physician, documents the American pharmaceutical industry’s remarkable, almost dictatorial, power over the prescribing habits of physicians as well as its exorbitant profit structure.16 In the Health-PAC book we are reminded not only that (in the words of one trade journal) “Medicare is the computer manufacturer’s friend” but that, because physicians are ill-equiped to evaluate new medical machines, they are willing to buy almost anything; the flashier it looks and sounds, the better. (“As a matter of fact,” Shaw said, “the rank and file of doctors are no more scientific than their tailors.”) In The Quality of Mercy, Dr. Howard L. Bleich, a young researcher, “provides a glimpse into the future of medicine as he communed with a small computer console, no bigger than an electric typewriter.” Dr. Bleich entered information about the patient, but neglected to enter the patient’s weight.

The computer promptly called attention to this omission. After the weight was given, it printed out its evaluation of the patient’s acid-base disorder along with the recommended therapy, the appropriate drug dosage and two references to the literature bearing on the condition. It also politely thanked Dr. Bleich “for referring this interesting patient to us.”

To the old arrogance of doctors, then, has been added the arrogance of machines, of technology, of the corporate and governmental forces which control them, which increasingly control the doctors, and indeed all of us. The relationship between doctor and patient is very old, and was considered a “sacred trust” centuries before the AMA thought to insist that its sanctity depended upon the exchange of money. But where is sanctity in an era of medical systems analysis? If we want to touch and be touched by another person when we are sick or hurt or dying are we being immature? Should we “talk it out” with a psychiatrist? with a computer? (They can be programmed now to say “I see” and “Tell me more” and prescribe Librium in a lifelike voice.) If we have difficulty accepting doctors’ assurances that we “need not despair,” are we guilty, as Selig Greenberg suggests, of trusting our superfluous feelings, of failing to bow to the relentless pressure for change?

I think the Health-PAC analysis is not clear enough on this point. It rightly criticizes the academic medical leaders for subordinating the health needs of people to narrow research, “education,” and institutional priorities. The authors speak (as even the “liberals” now do) of the “ironic” contrast “between the promise of bio-medical technology and the tawdry reality of medical care.” They recall the liberal vows (in the case of the Regional Medical Program, for example) that “medical excellence would be decentralized from the current handful of major medical centers to a whole network of little pockets of excellence, all under the general guidance of the medical centers.” And, finally, they document the miserable failure of the medical elite to deliver on its promises.

The argument seems to run as follows: the “liberal” answer has not worked; therefore it will not work; and it cannot work, because the liberal doctors and their new corporate colleagues are not interested in making it work; they have other priorities. Therefore “profits must be phased out, for they have no place in an enterprise in which human life is at stake. A publicly accountable system must replace private enterprise in providing all health care and health products.”

That conclusion is inescapable. But the medical elite will insist that their “solutions” have not been given enough of a chance; that more money should be allocated for them; that the people then will be served. The Health-PAC position would be enhanced, I think, if it argued that even if the new doctors could, at great expense, fulfill their promises, the consequences would be disastrous; that what is considered “medical excellence” is, for the most part, not excellent at all; that the new medical priesthood, by the nature of its increasing dependence upon a complex technology it neither fully understands nor wholly controls, cannot have truly human priorities.

The dilemma of Shaw’s Dr. Ridgeon was whether he ought to use his cure for tuberculosis to “save” Jennifer’s husband, a brilliant young artist whom he detested and of whom he was jealous, or to “save” someone else and let the young man die: He chooses the latter and, in the final scene, presents himself to the widow, certain she will now become his wife. Jennifer has, however, remarried. “Oh, doctor, doctor!” she exclaims. “Sir Patrick is right; you do think you are a little god. How can you be so silly?” And all along, to be sure, Ridgeon’s “opsonin” was no cure for tuberculosis at all.

Were Shaw alive today, he would probably understand that the modern medical scientist works not merely for fame and money and power but because he believes that if cancer and heart disease are “conquered” the pain of being alive and mortal will be lessened, the potential for being human will be enlarged. Clearly this is what Shaw hoped for too, but he hoped differently. “Please do not class me,” he wrote

as one who “doesn’t believe in doctors.” One of our most pressing social needs is a national staff of doctors whom we can believe in, and whose prosperity shall depend not on the nation’s sickness but on its health.

But Shaw’s faith was less in science and machines than—as simple as it seems—in people living together more sensibly. This is how the health movement’s struggle for the community control of health institutions, described briefly at the end of The American Health Empire and now intensifying throughout the country, must be understood. “The social solution of the medical problem,” Shaw insisted, “depends on that large, slowly advancing, pettishly resisted integration of society called generally Socialism.”

And it was not the doctors, Shaw believed—as arrogant as they might be—who would make the decisions, but the patients themselves and the communities the doctors serve. Shaw hoped that we would learn to insist on certain things: on nationalizing the medical profession, on taking the profits out of dealing in people’s health and pain. What was needed in his view was “not really medicine or operations, but money…better food and better clothes…well-ventilated and well-drained houses.” “Otherwise,” he wrote in the final sentence of the Preface on Doctors, “you will be what most people are at present: an unsound citizen of an unsound nation, without sense enough to be ashamed or unhappy about it.”

We might remember Shaw as the medical war intensifies and more people become angry. Precisely because American medicine is in such a mess it presents unique opportunities. The rise of the new medical elite, ominous as it is, is only a relatively recent development. The technocrats may have less of a foothold in the medical system than in any other aspect of our society; by a concerted effort, they may still be stopped. In addition, although the Health-PAC people assert that “the age of the guild-dominated, individual medical craftsman is over” and although AMA membership is rapidly declining, the victory of the medical elite has not been assured.17

It is at least possible that the community practitioners may begin to understand that whatever remains sacred in medical practice cannot be preserved by clinging to the idea of fee-for-service, but that it may indeed be saved by aligning with the movement to provide medical care in thousands of small community free clinics. The fact is that free clinics are springing up across the country (there are an estimated 200 functioning now or in preparation). The struggle for community control of health facilities is gathering momentum. Workers and patients and students and professionals are beginning to work for the first time as colleagues.18

More than the war in Indochina, the military, even the schools, the issue of better and more democratic health care may provide a focus for constructive political action. In the past few years and even months the health movement has grown impressively. Several new chapters of the Medical Committee for Human Rights have been founded (there are now about forty) and the organization is increasingly finding a national voice; meanwhile its local affiliates staff free clinics, perform draft physicals, arrange abortions, provide medical care at antiwar demonstrations, collect medical supplies and literature for North Vietnam, organize within the military itself and in prisons. (Jane Kennedy, a nurse and past national vice-chairwoman of MCHR, remains in the Detroit House of Correction for her part in a raid on the Dow Chemical Research Center in Midland, Michigan, on November 6, 1969, during which magnetic tapes containing critical information about napalm were erased; Dow now produces antihistamines and other pharmaceuticals.)19

The Health-PAC collective is now at work on a documentary history of the movement, and similar groups are active in other large cities, such as the Health Information Project in Philadelphia and the Northwestern Health Collective in Chicago. Women, who constitute the majority of both health care “consumers” and workers, but who are especially victimized by the current system, are beginning to press for changes. (Pregnancy and childbirth are now treated by male doctors as routine diseases; the medical hierarchy is exclusively male-dominated; many hysterectomies and even mastectomies are performed without sound medical reasons; labor is too often induced, especially in the case of poor and black women, by oxytocin—an unsafe procedure when unnecessarily done—so that the woman will deliver at the doctor’s convenience.) Doctors are resisting the draft which takes them away from patients and from seriously understaffed hospitals. Not only ghetto organizers such as the Black Panthers and the Young Lords, but, increasingly, middle-class church and community groups are becoming interested in the idea of neighborhood clinics.

At the same time, hospital and insurance rates continue to rise, doctors become even harder to find. The air grows more difficult to breathe. The brains of black babies are poisoned by paint. The war for a decent chance to live a healthy life has started too late; but there are signs, at least, that it has started.

  1. 14

    Contributing to this book were: Robb Burlage, Barbara and John Ehrenreich, Oliver Fein, Maxine Kenny, Mills Matheson, Phil Wolfson, Leslie Cagan, Vicki Cooper, Ruth Glick, Kenneth Kimerling, Howard Levy.

  2. 15

    Harry F. Dowling, Medicines for Man, Knopf, 347 pp., $7.95.

  3. 16

    The pharmaceutical industry boasts of ratios of net income/sales and of net income/invested capital which are roughly twice as great as the national industrial median. The companies collectively spend nearly a billion dollars for promotional purposes, more than $3,000 per year on every doctor in the country. About half goes for printed journal ads and circulars (notoriously misleading, discriminatory, or blatantly false), more than a third for “detail men” assigned to push drugs to individual physicians on a personal basis (according to the maxim, as a former Squibb physician has testified, “If you can’t convince them, confuse them.”)

    It is in this sphere that the tactless waxes almost comic. In a single year one general practitioner was assaulted by 3,636 advertisements and samples promoting 604 “different” drugs. New physicians, their prescribing habits still up for grabs, are courted with a special fervor: students and practitioners have been treated to free instruments and leather bags, records, movies, books, drugs (no hallucinogens, to date), cocktail parties, steak and lobster dinners, fishing contests, bowling tournaments, golf lessons, and golf balls stamped with the names of the doctor and of the company in contrasting colors.

  4. 17

    Voluntary membership in the AMA is now under 50 percent of practicing physicians nationally, but the organization remains rather more strong than the Health-PAC book suggests. There can be no doubt that the medical elite in New York City is more advanced than it is in other cities.

  5. 18

    There is a partial listing of national free clinics in the January-February Health Rights News. Copies are available at request from HRN, 1613 E. 53rd Street, Chicago, Illinois 60615. The cost of a single issue is fifty cents; a one year subscription is three dollars.

  6. 19

    While in prison, Jane has worked actively to improve health conditions. One of her most recent campaigns was to improve dental treatment in the jail. According to her warden, interviewed in the Chicago Sun-Times: “She keeps telling everybody she’s a political prisoner. I’ve been in prison work more than forty years and I’ve never seen anything like her. Every time she’s told to do something, she has to ask why…. She started a lot of trouble about the dentist we have here. She said the prisoners didn’t like the dentist and wanted a new one. It was her idea they had a right to pick their own dentist because he was working on their teeth. Well, that’s none of their business. We pick the dentist we want.”

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