VIII. Answer the following questions.

1. Where does the author suggest the USA lead the way to?

2. What is described as a terrible reflection of the futility and indul­gence of modem medicine?

3. The author refers to "placebo technology". What does he mean by this?

4. How much does a course of interferon cost?

5. What level of care is suggested as being a human right?

FUTURE DIRECTIONS IN HEALTH CARE

The USA leads the way, but where to?The high and rapidly increasing cost of modern medicine is seen at its most extreme in the USA. In 1968 a week's stay in a hospital there cost $469 in 1978 it cost $1543, and in 1983 it cost $2872. Even a normal antenatal patient can be asked to pay $900 on booking in and $1000 later in pregnancy. Falling ill in America can be financially ruinous, and no less than half the private bankruptcies there are said to be caused by med­ical costs. Medicine has often failed to reach the very poor, but this is the first time that it has been able to bankrupt the middle classes in signifi­cant numbers.

When so much money is spent on health, it is important to know how and when it is spent. Much of it is spent when no reasonable expectation of useful life is possible. For example, one study showed that no less than $35 billion, or about 17 per cent of all health expenditure in the United States, was spent on the care of the terminally ill.

There can hardly be a more terrible reflection on the futility and indulgence or modern medicine than this: of our roles as physicians to struggle so pointlessly, so cleverly, and so expensively to keep people alive, and of our roles as patients to refuse to accept that ultimately we too must die. In our determination to grasp even a few more days or even hours of life we use resources that are badly needed elsewhere in the com­munity and the world. We have long had placebo medicines, we now have an enormously more expensive placebo technology. If ever there was need for a change in the direction of modern medicine, it is this. Away from the emphasis on coronary bypass surgery and silastic aortas towards the prevention of preventable disease and the saner and more equitable use of the world's resources.

MODERN MEDICAL TECHNOLOGY

How effective and at what cost?

Although some of the miracles of modem medicine, such as penicillin, now cost less than the bottle they are put in, the price of others is enor­mous. At the time of writing, interferon, for example, costs upwards of $30 000 a course, or more than $20 billion a kilogram, if indeed such a quantity existed. Modern technologies have become so expensive because of the huge number of man-hours they now demand, not only in directly investigating and caring for the patient, but also in developing and man­ufacturing new drugs and equipment by the industries that have arisen to serve modern medicine. These man-hours must ultimately be paid for, and account for most of the cost of the new medical care. It was former­ly impossible to spend nearly $400000 on a single piece of equipment, which is what a 16-channel auto-analyzer costs today.If we spend resources on one thing we cannot spend them on anoth­er, so we must also ask ourselves what the opportunity costs are? Of this there can be no more extreme case than that of the Prime Minister of one developing country who asked that the entire allocation of WHO funds for his country be used to buy one sophisticated scanner. For the same money he could have immunized all the children in his country against measles for several years, and have saved half a million lives.

Something for everyone, or more for the fortunate few?

Technologies do not exist in isolation, and if a patient has access to a technology of a particular degree of cost and sophistication, he probably has access to other technologies of a similar kind, and to any that are sim­pler. For example, if he can reach a health centre, he has access to all the simple things it can do. If a mother can get a Caesarean section at a dis­trict hospital, she can get a Pott's fracture set, or a chest X-ray, or any of the other services which such a hospital offers. If a patient is so for­tunate as to be able to get a kidney transplant, he certainly has access to anything that modern medicine can provide. It is thus possible to make a scale of technologies of increasing sophistication and cost, such that a patient having access to those at a particular point on the scale can expect to get any of those beneath it, should he need them. This scale also shows the technologies that can be provided by a community health worker, a health centre, a district hospital, and a regional or national one.

In a developing country, the fortunate urban elite have access to almost any highly sophisticated technology, either in the capital city or abroad, while many of the rural poor have no modern health care what­ever. In an industrial country, not only is the average technological level of care much higher, but it is also distributed much more equitably.

It is also possible to represent a "basic human right" in health care or the essential technologies that might constitute the primary health care described later. Caesarean section, for example, and anything simpler, should surely now be one of the rights of all the world's mothers.

Are limited resources to be spent in the direction of the "something for everyone" or more for the fortunate few? To increase the quantity and the sophistication of medical care, or to see that everyone has at least something? Which is of the greater benefit, when resources are scarce? To transplant kidneys, or to see that every mother has surgical help when her labour obstructs?

Since the health care in a society is such an integral part of it some would argue that as individual doctors we can do nothing about it. We do however have a complete responsibility for one small part of it - what we ourselves choose to do.IX. Read the text and give a short summary using these key

sentences as a plan.