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THE POUND OF CURE JOHN L. DUSSEAU* We know that the tail must wag the dog,for the horse is drawn by tL· cart. [Rudyard Kipling] Medicine is a social institution and cannot any more escape from the ideas or the conflicts within society than can any other human institution. Its very structure and organization are social and so reflect both the fetishes and objectives alive in the human mind. As a culture ages and hardens, its ideals stratify and solidify. Self-determination within society through the intercourse of ideas gives way to rigidity and to unalterably fixed notions. We shall here look at the fixed notions of medicine. "Priority" is, these days, a word wonderfully popular in the jargon of politicians, scientists, physicians, sociologists, and others presumably dedicated to the public good. A random sample of contemporary rhetoric indicates that the word means a justified right to take precedence in obtaining support, services, and supplies in pursuit of socially approved goals. Economics, then, is the touchstone of priority. In the traditional economic theories of Adam Smith, long since discarded for their coolness of mind and heart, a single prevailing idea governed all others. It was, simply, that desirable objectives should be encouraged, undesirable objectives penalized. In the modern, governmentally centralized, problem-oriented state this translates into a ready axiom: What you want, you subsidize; what you don't want, you tax. The purposes of this axiom are plain enough; but in turning out Adam Smith we have perversely turned both his principle and his purpose upon their heads and so have succeeded in subsidizing through taxes abstinence from work, immoderate and harmful consumption, illness of mind and body, indebtedness, a vast army of the incompetent and unemployed, and downright failure. Through taxation we have discouraged work, productivity, success, thrift, investment in new enterprise , prudence, and willingness to take shrewd chances. What is strange about all this is that everyone stands amazed at the outcome—more and more of what we don't want, less and less of what we do want. ?Address: 609 Fox Fields Road, Bryn Mawr, Pennsylvania 19010.© 1981 by The University of Chicago. 0031-5982/81/2403-0225$01.00 352 I John L. Dusseau ¦ The Pound ofCure Equally misconceived has been our commitment to a vast, humane, and incredibly expensive program to assist the poor and the dispossessed both at home and abroad. This effort, along with our devotion to what is euphemistically called "defense," has attacked and nearly destroyed almost everything in sight except one thing—our natural enemy: poverty itself. And, of course, we have tried to impose our curious concepts of salvation on the Third World, where they prove to be neither attractive nor workable. The revolt against the shah of Iran was not reaction against corrupt power, it was struggle against messianic materialism. Describing the arrival of a few British technicians to build a radio station on an Aegean island, Lawrence Durrell tells us that their intrusion destroys "the tightly woven fabric of this feudal village with its tense blood relationships and its archaic festivals. Its wholeness will dissolve under these alien pressures. It was so tightly woven, so beautiful and symmetrical , like a swallow's nest. We are picking it apart like idle boys, unaware of the damage we inflict. It seems inescapable, the death we bring to the old world without wishing it." Let us, within this perspective, regard whatever priorities are in effect in the great fields of medicine and its supporting biosciences. The cost of their support, too, is massive and destructive. Is this monstrous expense creating more and more of what we don't want and less and less of what we do want? The key to a possible answer lies in the somewhat offhand pronouncement by a Blue Cross official: "What we have in this country," he said, "is not a health-care system; it's a sickness-care system." Under the glorious banner of Health, Education and Welfare we give our support entirely to illness. Medicare, for example, is specifically forbidden to pay for prevention of illness. Neither Blue Cross/Blue Shield nor major insurance plans will pay for immunization against measles, diphtheria, cholera...


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