EDITORIALS A BICENTENNIAL EDITORIAL ESSAY
Another Approach to Health Care Problems? FOR THE PAST DECADE the federal government has been moving into the field of health with a comprehensive and more or less coordinated attempt to regulate almost every aspect of health care from research to education, facilities, drugs, products, and the distribution and delivery of any and all services rendered by "providers." For years it had been said that if the private sector could not, would not or did not solve the evident problems in health care-uneven access, quality that was not always assured or costs that were too high-the government would have to step in to protect the public interest and the public purse. The problems were not solved to the public satisfaction and the government indeed has stepped in. However, after a decade there is little evidence that very much more has been solved as a result of this intervention. The plain truth is that the track records of both the private sector and of the government, since it began to intervene on a significant scale, leave much to be desired. Initially there was enlightened cooperation in the field of medical science and much was accomplished. But more recently and particularly in the field of health care delivery, cooperation has been less evident and it appears to have- been replaced by something more like an adversary approach. In fact this, rather than cooperation, seems to have become the order of the day, and there is a growing government concern, public disenchantment and professional dissatisfaction with what is going on and with what it costs.
It is suggested that the true nature of the health system has really not been understood by either the private sector or the government, whose spokesmen sometimes simplistically refer to it as a "nonsystem." On the one hand the private sector has tended to believe that relatively unregulated and uncoordinated free enterprise together with a free market, if left alone, could and would solve all the problems. But more and more experience care
310
OCTOBER 1976 * 125 * 4
indicates that this is not the case and that it is not in the nature of the health care system to respond to these forces as do other less complex systems of industry and trade. Therefore that assumption, still held by many, seems incorrect. The government, on the other hand, clearly believes that the health care system can be brought under control, systematized and managed by the use of laws, regulations which have the force of law, and control of funding. This assumption is now being tested on an increasingly grand scale. Yet after a decade of mounting effort, far less than the proponents expected has been accomplished-either toward solving the problems of access, quality and costs, or toward improving the health of the nation. So it seems this assumption may also be questioned. And in any case the evidence suggests that it is not in the nature of the health care system to respond well to this approach. One aspect of the health care system that is seldom noticed is that it is a system in continuing change and the rate of change is relatively rapid when compared with other systems in our society. The bald fact may be that change in the health field is so rapid that neither the free enterprise and free market system nor any formal system of laws and regulations can ever adapt quickly enough to keep up with changes as they occur. There is considerable to suggest that this is the case, and if so it could account for much of the apparent ineptness of the present approaches. A second aspect of the nature of the health care system is the unusual degree of interdependence among its various elements. It appears that no part of it can be significantly changed without farreaching and often significant effects throughout the system-this may be the best evidence that it is not a "nonsystem." But perhaps the most important characteristic of all is that the health care system is a thing of people. It is a thing for people and by people. It therefore reflects all of the irrationalities, assumptions, beliefs and quirks of the people who serve it and whom it serves, and this means that in many ways it is certain to be unpredictable and often inexplicable. When one takes these characteristics, their extent and their ramifications all into account, it is evident that neither of the approaches, laissez faire or controls
EDITORIALS
imposed from outside the system, are likely to work well. And indeed they have not. What then is to be done? Clearly some new approach is needed. In this bicentennial year one's thoughts turn to early America and to the principles upon which this nation's greatness was built. In early America there was rapid change and interdependence, and life was certainly a thing of people. When there was a common problem or a community problem the approach was for everyone to turn to and deal with it. First a consensus was reached and this was followed by a will on the part of all concerned to carry out the consensus and get done what needed to be done. This was the principle of the town meeting and the way of the frontier. The decision and the action were within the system. The method worked. One wonders if there is anything in this approach that might be applied to problems in health care today. The essential ingredients appear to be (1) agreement among all concerned that there is a problem and what the problem is, (2) a consensus or decision involving all those concerned as to what should be done and how to do it and (3) a will by all concerned to do their part to carry out the consensus or decision. These ingredients are all obviously related to one another. They are related by a common denominator-the involvement and consent of a critical mass* of all those concerned. It is the involvement, and the consent of those involved, that produces the consensus and commitment, which in turn release the will and energy to solve the problem cooperatively. This is something quite different from either laissez faire or regulatory compulsion by government. Might it be useful to try this as a new approach to some of the health care problems of today? To do so, one would have to think of the health care system (with both its private and public components) as having somehow to perform the functions of a town meeting in the sense described. Just how this might be brought about in today's world is not entirely clear. Again it is a problem having to do with people. Perhaps to try it out, representatives of the public, the government and some major organizations in the private sector of health care might get together on an ad hoc basis. The object would not be to dwell on their differences, disagreements or adversary attitudes (which *The term "critical mass" is used here to express the coming together of the essential amounts and kinds of necessary ingredients to cause a reaction to take place-as in nuclear physics.
is usually the agenda or the hidden agenda of such meetings these days), but to see if they could identify and agree on a problem in health care that is relatively noncontroversial and fairly readily understood and defined. The next step would be to see if it was possible to develop a consensus as to what can and should be done about the problem-an approach to which a critical mass of those involved would consent. If this could be achieved, a broadly-based will on the part of all concerned to get it done should naturally follow and this would show itself in a cooperative rather than an adversary kind of effort throughout the system. If one or two successes, even minor ones, could be achieved in this way, a base of confidence and support might be established. There would be precedent and strength for this new approach to be tested gradually with some of the more complex problems of the health care system. If this were tried, it might signal a refreshing and even exciting start for America's third century. Will it be? -MSMW
Why People Die of Iron Poisoning THE SPECIALTY CONFERENCE on iron poisoning presented by Stein and co-workers in this issue is significant not only because of the demonstrated effectiveness of chelate therapy in iron poisoning, but because of the more integrated approach to the treatment problem achieved. Iron poisoning has been the stepchild of iron treatment; as the use of oral iron has increased or decreased, so has the prevalence of poisoning. It is usually the youngster of two or three who discovers and consumes the brightly colored tablets prescribed by an obstetrician during the mother's pregnancy. Poisoning may follow consumption of 1 to 5 grams of iron. Such doses of iron may inflict severe local damage (necrotizing gastroenteritis) and internal damage (consumptive coagulopathy and hepatic necrosis) with clinical manifestations of acidosis and hypovolemia. 12 Profound mitochondrial damage oc-curs within --cells.3 The diagnosis is a simple matter if iron ingestion is suspected, what with a rapid test to show a plasma iron level elevated to greater than 400 ,tg per 100 ml4 and a flat film of the abdomen showing radiopaque pills. The THE WESTERN JOURNAL OF MEDICINE
311
Another Approach to Health Care Problems? FOR THE PAST DECADE the federal government has been moving into the field of health with a comprehensive and more or less coordinated attempt to regulate almost every aspect of health care from research to education, facilities, drugs, products, and the distribution and delivery of any and all services rendered by "providers." For years it had been said that if the private sector could not, would not or did not solve the evident problems in health care-uneven access, quality that was not always assured or costs that were too high-the government would have to step in to protect the public interest and the public purse. The problems were not solved to the public satisfaction and the government indeed has stepped in. However, after a decade there is little evidence that very much more has been solved as a result of this intervention. The plain truth is that the track records of both the private sector and of the government, since it began to intervene on a significant scale, leave much to be desired. Initially there was enlightened cooperation in the field of medical science and much was accomplished. But more recently and particularly in the field of health care delivery, cooperation has been less evident and it appears to have- been replaced by something more like an adversary approach. In fact this, rather than cooperation, seems to have become the order of the day, and there is a growing government concern, public disenchantment and professional dissatisfaction with what is going on and with what it costs.
It is suggested that the true nature of the health system has really not been understood by either the private sector or the government, whose spokesmen sometimes simplistically refer to it as a "nonsystem." On the one hand the private sector has tended to believe that relatively unregulated and uncoordinated free enterprise together with a free market, if left alone, could and would solve all the problems. But more and more experience care
310
OCTOBER 1976 * 125 * 4
indicates that this is not the case and that it is not in the nature of the health care system to respond to these forces as do other less complex systems of industry and trade. Therefore that assumption, still held by many, seems incorrect. The government, on the other hand, clearly believes that the health care system can be brought under control, systematized and managed by the use of laws, regulations which have the force of law, and control of funding. This assumption is now being tested on an increasingly grand scale. Yet after a decade of mounting effort, far less than the proponents expected has been accomplished-either toward solving the problems of access, quality and costs, or toward improving the health of the nation. So it seems this assumption may also be questioned. And in any case the evidence suggests that it is not in the nature of the health care system to respond well to this approach. One aspect of the health care system that is seldom noticed is that it is a system in continuing change and the rate of change is relatively rapid when compared with other systems in our society. The bald fact may be that change in the health field is so rapid that neither the free enterprise and free market system nor any formal system of laws and regulations can ever adapt quickly enough to keep up with changes as they occur. There is considerable to suggest that this is the case, and if so it could account for much of the apparent ineptness of the present approaches. A second aspect of the nature of the health care system is the unusual degree of interdependence among its various elements. It appears that no part of it can be significantly changed without farreaching and often significant effects throughout the system-this may be the best evidence that it is not a "nonsystem." But perhaps the most important characteristic of all is that the health care system is a thing of people. It is a thing for people and by people. It therefore reflects all of the irrationalities, assumptions, beliefs and quirks of the people who serve it and whom it serves, and this means that in many ways it is certain to be unpredictable and often inexplicable. When one takes these characteristics, their extent and their ramifications all into account, it is evident that neither of the approaches, laissez faire or controls
EDITORIALS
imposed from outside the system, are likely to work well. And indeed they have not. What then is to be done? Clearly some new approach is needed. In this bicentennial year one's thoughts turn to early America and to the principles upon which this nation's greatness was built. In early America there was rapid change and interdependence, and life was certainly a thing of people. When there was a common problem or a community problem the approach was for everyone to turn to and deal with it. First a consensus was reached and this was followed by a will on the part of all concerned to carry out the consensus and get done what needed to be done. This was the principle of the town meeting and the way of the frontier. The decision and the action were within the system. The method worked. One wonders if there is anything in this approach that might be applied to problems in health care today. The essential ingredients appear to be (1) agreement among all concerned that there is a problem and what the problem is, (2) a consensus or decision involving all those concerned as to what should be done and how to do it and (3) a will by all concerned to do their part to carry out the consensus or decision. These ingredients are all obviously related to one another. They are related by a common denominator-the involvement and consent of a critical mass* of all those concerned. It is the involvement, and the consent of those involved, that produces the consensus and commitment, which in turn release the will and energy to solve the problem cooperatively. This is something quite different from either laissez faire or regulatory compulsion by government. Might it be useful to try this as a new approach to some of the health care problems of today? To do so, one would have to think of the health care system (with both its private and public components) as having somehow to perform the functions of a town meeting in the sense described. Just how this might be brought about in today's world is not entirely clear. Again it is a problem having to do with people. Perhaps to try it out, representatives of the public, the government and some major organizations in the private sector of health care might get together on an ad hoc basis. The object would not be to dwell on their differences, disagreements or adversary attitudes (which *The term "critical mass" is used here to express the coming together of the essential amounts and kinds of necessary ingredients to cause a reaction to take place-as in nuclear physics.
is usually the agenda or the hidden agenda of such meetings these days), but to see if they could identify and agree on a problem in health care that is relatively noncontroversial and fairly readily understood and defined. The next step would be to see if it was possible to develop a consensus as to what can and should be done about the problem-an approach to which a critical mass of those involved would consent. If this could be achieved, a broadly-based will on the part of all concerned to get it done should naturally follow and this would show itself in a cooperative rather than an adversary kind of effort throughout the system. If one or two successes, even minor ones, could be achieved in this way, a base of confidence and support might be established. There would be precedent and strength for this new approach to be tested gradually with some of the more complex problems of the health care system. If this were tried, it might signal a refreshing and even exciting start for America's third century. Will it be? -MSMW
Why People Die of Iron Poisoning THE SPECIALTY CONFERENCE on iron poisoning presented by Stein and co-workers in this issue is significant not only because of the demonstrated effectiveness of chelate therapy in iron poisoning, but because of the more integrated approach to the treatment problem achieved. Iron poisoning has been the stepchild of iron treatment; as the use of oral iron has increased or decreased, so has the prevalence of poisoning. It is usually the youngster of two or three who discovers and consumes the brightly colored tablets prescribed by an obstetrician during the mother's pregnancy. Poisoning may follow consumption of 1 to 5 grams of iron. Such doses of iron may inflict severe local damage (necrotizing gastroenteritis) and internal damage (consumptive coagulopathy and hepatic necrosis) with clinical manifestations of acidosis and hypovolemia. 12 Profound mitochondrial damage oc-curs within --cells.3 The diagnosis is a simple matter if iron ingestion is suspected, what with a rapid test to show a plasma iron level elevated to greater than 400 ,tg per 100 ml4 and a flat film of the abdomen showing radiopaque pills. The THE WESTERN JOURNAL OF MEDICINE
311
