476

Round the World

United States

PIECEMEAL APPROACHES TO NATIONAL HEALTH

The new President, with his political party dominant inCongress, and its convention promise to provide a mandatedfederal national health service not forgotten, has a plenitudeof proposals to ponder. The time is ripe for some appraisal ofthe subject, for it is clear that all the piecemeal approacheswhich have been attempted in the last three decades have pro-ved costly, wasteful, inequitable, and ultimately unsuccessful.We have more acute hospital beds than we need in most of thiscountry, thanks to the Hill-Burton Act. We have a profusionof specialty and sub-sub-specialty care, but a shortage of pri-mary-care physicians, thanks largely to the Regional MedicalPrograms. Special interest groups have proliferated hugely,demanding, and often getting, funds for specific needs whichunbalance the whole-for example, payments that providehelp for end-stage renal disease, or sickle-cell anaemia, but notfor the early stages of renal disease. All sorts of factors com-bine to ensure payments for expensive resources such as hospi-tals, or very expensive components of hospitals, or very expen-sive procedures in hospitals. Duplication of facilities is

commonplace. But despite the great number of surgeons andthe vast numbers of surgical operations performed, there isreason to suppose that some surgeons operate so infrequentlythat their skills may be impaired.The quite remarkable thing is that, in this country which

abounds with computers and where ridiculous and useless stat-istics are widely quoted, there has been so little relevant infor-mation gathered, such careless fiscal control, and so littleattempt to assess the real needs of the public. It is true thata major hindrance has been the opposition of the medical pro-fession to any governmental interference in health care. Afterall, the famous - Dr Welch once said that all medical scienceneeded of the Government was "to be left alone", a view fewseekers of research grants today would endorse. However, eventhe A.M.A. is now proposing a national health insurancescheme. But it is clear that if we are to have a national scheme,it’s going to be costly, wasteful, and inequitable unless a lotmore basic information is rapidly gathered and sensibly ana-lysed. Perhaps it is the realisation of this urgent need that hasled to the latest H.E:W. warning that any legislation will takeat least a year before it can be brought forward.Maybe we should take a close look at our northern neigh-

bour’s experience of national health-care schemes. We shouldalso ponder on some facts that the chancellor of Toronto Uni-versity, Dr John Evans, remarked on two years ago. The maincauses of death of Canadians aged 5 to 35 are motor-vehicleaccidents, other accidents, and suicide; for those aged 35-75years the top killers are cardiovascular and lung diseases, es-pecially cancer-those diseases that take their toll of the sinsof youth, of obesity, high-fat diets, smoking, and so on. InCanada, too, piecemeal approaches have been costly, wasteful,and inequitable, but they seem to have produced happier pa-tients and more contented physicians. Our new President maynot have the time to think on these things, but one certainlyhopes his advisers will.

CONTINUING CONTROVERSY ON FOREIGN DOCTORS

The setting up of bars against the admission of foreign med-ical graduates to the U.S. provoked, so we are told, the char-tering of a private plane to fly 75 medical men from SouthAfrica, so that they could beat the deadline. That seems at themoment to be all that is happening, save for the mounting

volume of protests against the proposals. The source of theprotests are the States themselves and the officials chargedwith maintaining the various basic medical services demandedof the individual States. It seems that perhaps 50% or more ofjunior positions and not a few senior positions in State institu-tions, such as in New York State, may be held by foreign medi-cal graduates. They are in many cases harboured, paid, pro-tected, and used by the State without necessarily being fullylicensed or recognised for medical practice outside the institu-tion where they are employed.

Such a state of affairs can be heavily criticised as exploi-tation, as dishonesty, and as undermining the status of the pro-fession. But the plain fact of the matter is that the physicians,inadequate as their qualifications may sometimes be, are badlyneeded, and, indeed, essential to the maintenance of some ser-vices, and that they can now hardly be replaced save withothers like them. Moreover, they are in many instances muchbetter off (by material standards) in pay, facilities, housing,and life-style than they would be in their native countries. Ifthe restrictive proposals on immigration are enforced, it seemsinevitable that some hospitals will have to close or run a res-tricted service; there may be scope for some staff reduction, butnot on the scale envisaged. However, it seems unlikely thatsurgeons with time on their hands, as surgical beds are closed,will move to the prisons or mental service institutions. So theofficials of the various States that will be hardest hit protestand argue, and we shall see what will happen.

COLD WEATHER AND HYSTERIA

THE present winter has broken all records for severity.Many southern States have had temperatures well below 0°F

every day for one or two weeks, with the high never reachingfreezing point. It snowed in Miami, and also, for the first timein living memory, in the Bahamas. Following a blizzard whichbrought traffic to a standstill and buried many cars in snow,four persons were found dead sitting in their cars well withinthe city limits of Buffalo. The Mississippi, Ohio, Missouri, andMonongahela rivers have been frozen solid, and -the manythousands of tons of coal, oil, grain, and other commoditiesthat are normally transported by barge are accumulating atthe loading docks. Coal that has been loaded into freight trainwagons cannot be decanted since the snow and -ice that havesettled on the wagons have frozen solid. The Cassandras whohave been predicting for the past several years a natural gasshortage have been more than vindicated. Most of the industryin Ohio, Pennsylvania, New York, and New Jersey has shutdown because of a lack of natural gas and coal. Some easternseaboard and midwestern schools have been closed since

Christmas, and many colleges in Ohio, Kentucky, and Appala-chia have sent their students home for a month’s recess. Inseveral States emergency laws have been passed that make itillegal for thermostats to be set at more than 650F in the day=time and 60 °F at night-temperatures which the British con-tingent still regard as semi-tropical and more than slightly un-healthy. Requests have also been made to the general publicto turn down the thermostats on their water heaters and toconserve electricity. Meanwhile, the papers and television pmclaim the imminent destruction of the U.S. economy and wes-tern civilisation as a whole. -

All this is vaguely amusing to anybody who lived in wartimeEurope, with no central heating and with a meagre coal ration.These days bring back memories of 5 inches of tepid water inthe bath, and bedroom temperatures which occasionally foundtheir way up to 450F during a warm winter. So much is takenfor granted by the majority of U.S. city dwellers that the fewminor inconveniences we are experiencing have become magni-fied by the press and T.v. into a national catastrophe. Indeed,many State governors have appealed to have their Statesclassified as disaster areas, thereby qualifying for Governmentfunds.