BMJ 2003;326:1405

More than 30 years ago I asked my surgical instructor about petechial lesions on the scrotums of some criminals interned in the surgical ward. The shocking answer was, “Oh, yes, the police make them all go through ‘the machine’ before taking them to the hospital.” The machine, the “picana el?ctrica,” was a device for torturing prisoners with electric shocks, usually in the vagina, testicles, mouth, anus, or nipples. I was horrified by the fact itself but no less by the matter of fact tone in which the answer was given. As a medical student I was pretty powerless, but I went to the head of the surgical service and tried to lodge a formal complaint. I was rebuffed without any chance to make my argument heard.

Since 1983 we have been living under a “democratic” government, but torture is still rampant in Argentina. Sergio Gustavo Dur?n was arrested by the police in 1992. He was 17 years old. The arrest was routine – he wasn’t involved in any criminal activity. The next day he was found dead. Puncture wounds reported in the autopsy by the police doctor were explained as “scratching lesions.” A subsequent non-official autopsy described intraalveolar haemorrhages typical of the “dry submarine,” a torture in which a plastic bag is put over the head until the victim nearly suffocates. The authors of this crime were not detained until four years later, when some of them, though fugitives, were still getting their monthly pay from the police. The police doctor is being prosecuted, but the verdict has not yet been issued. Every year several episodes of this kind are denounced by human rights organisations, each time starting the usual chain of denial and cover up from official institutions, often with the collusion of doctors.

We should make human rights central to our teaching

But what I wish to comment on is the continuing passivity of medical teaching organisations’ difficult to understand in a democracy. Sergio Pesutic, a Chilean psychiatrist, has described the phenomenon of torture and the role of Chilean health professionals, ranging from active complicity to denial of its existence and sometimes to resistance. He concluded that several primary prevention measures should be taken to avoid torture, including the incorporation of human rights teaching into formal and non-formal medical curriculums, the application of codes of medical ethics, and research into the long term effects of torture. It’s high time to heed Dr Pesutic’s suggestions.

Although most Argentinian doctors react with horror to the idea of torture, the medical establishment has not come to the same categorical rejection. Human rights is not yet a standard subject in medical schools, even in bioethics courses. The national academies remained silent on the issue after the end of the military dictatorship in 1983. In 2001 most of the members of the National Commission of Biomedical Ethics resigned in protest at the appointment of Alberto Rodr?guez Varela, a former justice minister in the military dictatorship. Ironically but alarmingly, Dr Rodr?guez Varela was proposed by the National Academy of Moral and Political Sciences.

Dr Pesutic described torture as the “criminal expression of a perversion of society’s values.” The criminal and unethical behaviour of doctors involved in or colluding in torture reflects a society’s moral decline. The US bioethicist Edmund Pellegrino wrote: “Protection of the integrity of medical ethics is important for all of society. If medicine becomes, as Nazi medicine did, the handmaiden of economics, politics, or any force other than one that promotes the good of the patient, it loses its soul and becomes an instrument that justifies oppression and the violation of human rights.” I agree with other writers that the social and economic status of doctors places them closer to the well off and influential than to the poorer sectors of society and that, historically, torture has targeted poor people and their advocates. Almost all current victims of police brutality and torture practices in Argentina are poor and so are relatively defenceless. Argentinian doctors, although not usually rich, have high social prestige – perhaps this accounts for their silence.

Until a serious effort is made to reconstruct a values system that is based on people’s intrinsic dignity, torture will persist – as it did in my student years, long before the military took power. This reconstruction must involve access to education and health for all and the eradication of misery. As doctors we should make human rights central to our teaching, and students must learn that to be complicit with torture is despicable.

However, military dictatorships are not responsible for all our evils. Shared social values in Argentina have deteriorated so much that there is little chance of putting an end to these crimes against humanity without a serious commitment to change by all social groups. Perhaps this is a warning to other countries in these uncertain days, when the deaths of human beings are termed “collateral damage”- an expression of scorn for human dignity.

Luis Justo, chair in bioethics
Comahue National University, Argentina

Briefing on the Health and Social Care
(Community Health and Standards) Bill 2003
Allyson Pollock and David Price
Public Health Policy Unit, University College London
Published in association with
The Society for Social Medicine and the NHS Consultations Association
A Catalyst Briefing Paper.
Published: July 2003

“The Health and Social Care (Community Health and Standards) Bill now before Parliament provides for the incorporation of NHS Trusts and non-NHS bodies as competing trading companies, “Foundation Trusts”, that are no longer part of government but part of a market.

In response to fears that these changes would have a negative impact upon equity, the government has built into the Bill a series of safeguards which it says will guarantee the fundamental goals and principles of the NHS as a comprehensive and universal service, free at the point of delivery and providing equal treatment in response to equal need.

We are concerned that these safeguards are inadequate, and we explain in this briefing why we have come to this view. We strongly urge the government to withdraw the part of the Bill that creates Foundation Trusts in order that better public health safeguards can be devised.”

D Banerji, New Delhi

Using Scientific Critiques as an Instrument to Resist Foreign Domination

CONSTRAINTS IN DEVELOPING SCIENCE AND TECHNOLOGY

The composition of the WHO sponsored the Macroeconomic Commission on Health (MCH) and the sheer range of their terms of reference had tempted me to undertake the rather forbidding task of writing a critique on their Report. I had looked forward to the outcome of their work of two years to get to know what is their prescription for dealing with the health problems of the poor of the world. From a scientific point of view, the Report was a great disappointment.

As students, we were taught about the European Enlightenment which had laid the foundation of modern science and technology. We were taught to expand our knowledge by using the well established method of experimentation, observation and drawing inferences. It appears from hindsight that I had taken science too seriously. Even when I was barely 20, I felt considerably disturbed at the enormous gulf that existed between fast accumulating medical knowledge and its access to the people – the people of Calcutta, of West Bengal, of India and, later of the world at large. Looking back, I realise that this commitment to the unserved and the underserved was my original sin. I could not help ruffling quite a number of feathers. As on so many occasions in the past half a century, my analysis of the Report of the MCH is a part of the `sinful’ activities which have so often been frowned upon by the dominant power elites. It turns out that because of the pronounced shift in the balance of power in favour of the dominant power elites, this Report has turned out to be an example of a particularly advanced form of distortion of discourse on science and technology to subserve the interests of the power elites. Though there has long been a marked tendency to disregard facts and figures in scientific discourse for quite sometime, this trend has increased at a rapid pace in the recent years.

Most of the scientists have been so programmed by their fund providers that it took considerable time for them to realise that science and technology are not value neutral. However, notwithstanding this realisation, most of the scientists have been willing to `sell’ their `talent’ in the market place for a price; indeed, they have become willing partners with the power elites. As an observer of the scene for such a long time, this trend had worried me a great deal. It is in this context that I had felt that the victims of this manipulation by the power elites have to mobilise intellectual resources from among themselves to wage the obviously unequal struggle against the misuse of science. The resources that are needed for this purpose are of three kinds. First, those who choose to be on the side of the oppressed ought to have the capacity to challenge the scientific postulates of the agenda that is dished out by the oppressors. Second, there ought to be an alternative, scientific agenda presented from the side of the oppressed. Third, the oppressed ought to be ever vigilant and constantly monitor the gains they have achieved is not eroded or completely wiped out by the power elites.

Sketches of my work include items from each of the foregoing categories. However, as they span over a period of over half a century, they provide a dramatic panorama of the changes that have occurred over this period. In the early fifties, there was still some enthusiasm left at the socio-political level to fulfil the longstanding dream of doing something substantial to improve the health of the people of the country. The health administration of the country, led by officers of the Indian Medical Service (IMS), had the needed motivation and competence to work towards its fulfilment. The Report of the Bhore Committee provided the inspiration for putting on the ground institutions like primary health centres as a component of the the overall Community Development Programme, social orientation of medical education and, backing up the All India Institute of Hygiene and Public Health, with institutions like the National Institute of Health Administration (NIHAE) and the National Tuberculosis Institute (NTI). At the other end of the time spectrum we have the gloomy picture of almost total abdication of responsibilities by the political leadership, withering away of the IMS, domination of the health services by bureaucrats, fewer and sudued raising of the voices of dissent and servile acceptance of the prefabricated agenda imposed on the country by external agencies.

Apparently stimulated by the academic atmosphere prevailing at that time, as a starry-eyed junior most official of the National Tuberculosis Institute (NTI), I could venture to raise with some of the most venerable specialists certain critical issues about logistics, fragility and protective power of the liquid BCG vaccine and the long term epidemiological impact of the programme in the implementation of the world wide programme of Mass BCG Campaign. There was considerable debate on the issues raised. Finally, considering particularly that they had been committed to the programme for a decade or more, they did not want any change. However, some two decades later, when it was conclusively proved that the vaccine had no protective value, the programme was abandoned.

The same prevailing spirit of enquiry made me question certain scientific, economic and sociological justification of advocating use of mass miniature mobile radiography for case finding for tuberculosis control in India. Probably, the instinct generated in me from my work with the deprived people in remote areas in Himachal Pradesh and Western Tibet made me design a field study to find out what tuberculosis patients in rural India do and we found that more than half of them had visited government health institutions where they received no help whatsoever. Who is chasing whom? we asked. The vigour with which some of the foreign consultants were pushing the case of mass radiography gave me an early opportunity to understand political economy of decision making: a strong motive force behind the advocacy was the creation of market for the equipment in a big country like India.

The sociological data obtained by us led to the formulation of a number of important concepts whose relevance went over a wide area of public health practice. Formulation of people oriented technology for tuberculosis diagnosis, developing social dimensions of epidemiology, assigning primacy to the felt needs of the people, dealing suffering due to tuberculosis to be an integral component of dealing with suffering due to other health problems, making the programme more acceptable, opening up new vistas for concepts and practice of health education, were some of the outstanding among them.

Inspired by P C Mahalonobis’ ideas on the use of the approach of operational research for social planning, we joined others in NTI in undertaking the big task of using this approach in formulating the National Tuberculosis Programme (NTP). The data produced by the NTI also had had a major influence in formulating the recommendations of the WHO Expert Committee on Tuberculosis of 1964. NTI also got involved in becoming the focal point for training different categories of the personnel of the team for implementing the NTP and for monitoring it.

We went to the patients to find out why some of them did not take the treatment under NTP. We found that in most of the cases it was due to flaws in the organisation and management and in the definition of a case.

The mandate to work for the deprived, insisting on high quality of research on the relevant disciplines, intense in-house debates on research plans and the findings, blending of the findings to formulate the NTP, and providing training and monitoring and evaluation, were the hallmarks of the activities of NTI. Halfdan Mahler, when he became the DG, WHO, had termed it as the `NTI Philosophy’; he had also stated how deeply it had influenced the articulation of the Alma Ata Declaration. My five years at NTI (including 15 months at Cornell to get a Master’s degree in cultural anthropology) had made a deep impact on my working life. It gave an academic base for the cause I had chosen to follow. I got irrevocably committed to scientifically sound research on the health of the deprived.

RAPIDLY CHANGING SCENARIO

With the formulation of the NTP I sought out opportunities where I could explore applying in the approach we had developed at NTI to other major health issues such as family planning, other communicable diseases, maternal and child health and optimisation of rural health systems. I discovered to my dismay that a sea change had taken place at the national level. At the advice of consultants from the USA, the family planning was given the overriding priority over all other programmes, including NTP. From the political leadership downwards, the entire government machinery at the Centre and states conformed. This was an antithesis of the NTI Philosophy. I stood by my convictions because I considered the programme so obviously flawed and against the interests of the deprived. I wrote extensively, including my first book, FAMILY PLANNING IN INDIA: A CRITIQUE AND A PERSPECTIVE (1971). Among many others, I strongly opposed the following aspects of the decisions: breaking up the ministry of health into two separate departments of health and family planning; handing over the control of the much more favoured and rapidly expanding department of family planning to generalist administrators, both at the Centre and in the states, who neither had the technical comptetence and who could not be held accountable for their decisions; mobilising the infrasturcture of the health services to attain family planning targets, leading to the decimation of the general health services (including NTP!); use of coecive practices to get people sterilised which culminated in the massive forcible sterlisation of nine million people during the Emergency. Very few, including the intellectuals and parliaments stood up against this unacceptable onslaught on the hapless people by their own government. Despite almost exponential
rise in the allocations, the population the population of the country shot up from 301m in 1951 to over one billion in 2001.

The Alma Ata Declaration offered a small window of opportunity of serving the deprived. However, it was tightly shut by `inventing’, with little scientific data, what was called Selective Primary Health Care (SPHC). I had written paper called CAN THERE BE A SELECTIVE PRIMARY HEALTH CARE?. Taking note of this, the Institute of Public Health at Antwerp had called a meeting of over 80 scholars to discuss the paper. They declared that that SPHC is a contradiction in terms. David Nabarro, the present Chief Executive in WHO, was the rapporteur. All these did not make any impression on the exponents of SPHC. In connivance with the key national personnel, they let loose a number of vertical programmes on a global scale. They were assigned high priority, thus further eroding the infrastructure of the health services, The Universal Programme if Immunization was one of them. A Task Force in India had hailed it, without producing any evidence, as `the most cost effective method ever known to mankind’. I had written extensively, expressing fears about its viability. Expectedly, it failed to attain the objectives set for it. When the AIDS pandemic broke out, I had written a monograph entitled, DEALING WITH AIDS AS A PUBLIC HEALTH PROBLEM. This was meant to be a discussion document, but it was simply ignored. Perhaps the hardest blow came in the form of the World Bank/WHO Global Programme on Tuberculosis, which involved the DOTS approach. I wrote a an extensive monograph under the title SERIOUS IMPLICATIONS OF THE REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME.. I could not have any dialogue with the proponents. The programme was pushed through. The latest information in the form of the WHO’s annual report on the programme (2002) and the report of the Comptroller and Auditor General of India confirmed the fears expressed in the monograph.

Over the 38 years, the NTI Philosophy got expanded considerably. However, it continued to be a source of strength and inspiration for me to counter, almost single-handedly, some of the very pernicious elements in the practice and research in public health that were imposed on the country by foreign agencies. Finding inadequate interest among the younger generation of scholars (a danger signal for the future!) I have made conscious efforts to record accounts of my work to expose them to academic scrutiny.

RECORD OF THE WORK

I had undertaken a field research to extensively study 19 villages from eight states of the country over a period of 26 years. I published part of the report in a book, POVERTY, CLASS AND HEALTH CULTURE (1982). Subsequently, I have used the data collected extensively in my other writings. Realising that the I had done considerable amount of work, using the expanded form of the NTI Philosophy,. I had been tempted to put them down systematically in a book form. I had found it a formidable task. I pay tributes to Dr Tarlok Singh whose sustained persuasive efforts led to the publication of my magum opus: HEALTH AND FAMILY PLANNING IN INDIA: AN EPIDEMIOLOGICAL, SOCIO-CULTURAL AND A POLITICAL ANALYSIS AND A PERSPECTIVE (1985). I then put together what I considered the newer thinking in health social sciences by bringing out, SOCIAL SCIENCES AND HEALTH SERVICE DEVELOPMENT IN INDIA: SOCIOLOGY OF FORMATION OF AN ALTERNATIVE PARADIGM (1986). Health policy analysis was the focus in my next publication: ANALYSIS OF HEALTH POLICIES AND PROGRAMMES IN INDIA IN THE EIGHTIES (1990). I undertook even a more ambitious than my magnum opus when I was commissioned to write: INDIA’S FORGOTTEN PEOPLE AND THE BREAKOWN OF THE PUBLIC HEALTH SERVICES IN INDIA: A PRESCRIPTION FOR THE MALADY (1996). The manuscript contained 84 chapter and it covered 1,400 computer pages. This time I resisted the temptation of publishing it. I had published the summary of the manuscript in three parts in HEALTH FOR THE MILLIONS. It did not evoke a satisfactory response. My last publication was: LANDMARKS IN THE DEVELOPMENT OF HEALTH SERVICES IN COUNTRIES OF SOUTH ASIA (1997)

These publications as well as the others which have been cited earlier in the paper contain long lists of references, which can give an idea of my other publications in learned journals and as chapters in edited books. I would also refer to three papers in the INTERNATIONAL JOURNAL OF HEALTH SERVICES which were published specially to give a wider international exposure to my views:

(i) Report of the Commission on Research on Health and Development and the Countries of the South;
(ii) A Simplistic Approach to Health Policy Analysis: The World Bank Team on the Indian Health Sector; and
(iii) A Fundamental Shift in the Approach to International Health by WHO, UNICEF and the World Bank: Instances of Practice of ” Intellectual Fascism” and Totalitarianism in Some Asian Countries.

The Editor of the IJHS had invited me to write a critique of the Report of the Macroeconomic Commission on Health for his journal. It is expected to be published soon.

The turmoil created in the health services of the poor countries by the rich ones is a part of the wider convulsions that are taking place in the world order or disorder. Loan conditionalities, ensuring market penetration by aggressively promoting globalisation and unequal and unfair terms of trade pushed by the WTO, are examples. The deprived sections of the population get further marginalised in each case. A modest effort to take the side of the deprived will be to expose the scientific infirmities in the programmes suggested and in making an analysis of the political economy may be of help in eroding their credibility appears to be one way of doing so.

Paper presented at European Network for the Defense of Public Health of the European Social Forum Anti-Summit Conference on Globalisation, Thessaloniki, 18 June 2003.

Since the 1970s, advanced medical care throughout the world has been dragged through a painful but apparently necessary and inevitable metamorphosis. This can be summed up as transformation of medicine to a system of material production, through which an infant culture of trying, based on faith, hope and mutual self-deception, has matured to an adult culture of verified doing, based on evidence, and measured inputs, outputs, and efficiency. Medical care has at last become recognised as a production system, an economy which can be analysed and measured. This could be either a major advance, or a strategic defeat for health care. The answer depends on who will control this new process of production, and whose purposes it will serve.

Britain was the birthplace of the first industrial revolution, which in one craft-based industry after another, successively destroyed the manual skills and supporting customs of individual workers, changing them from intelligent subjects with some control over their work process, into human components of an industrial machine. By the end of the 19th century, virtually no craft skills remained, that were not by orders of magnitude less productive than industrialised production. Productivity was an irresistible force.

Industrialisation of production met huge popular resistance. It violated custom and often broke existing laws, which at least nominally limited the extent to which employers could replace human skills by machines for manufacture. Laws passed by Charles II after England’s puritan revolution of 1648 even specified that machine breaking by craftsmen was legal, if employers misused machines to displace skilled manual labour, because the skills of labourers were their property, as much as machines were property of employers. Resistance was therefore able to draw on the huge potential force of popular conservatism, the almost invariable preference of common people for past devils they know to future devils yet to be experienced. Only when the English parliament failed to enforce these protective laws, did popular resistance become machine-smashing, in the Luddite riots in northern English textile counties in 1811-1812. Between 1809 and 1815, all laws regulating employers in textile and other mechanising industries were repealed, machine breaking was made a hanging offence, and many were hung. Though backed by a huge majority of popular opinion, by many landowners and small employers, and by cultural leaders like Byron and Shelley, the machine breakers were themselves broken. They fought to defend ground already won through past struggles, but they had no convincing outline of an alternative future, more productive than the subordination of men, women and children to machines. Their appeal was therefore to sentiment. Though this sentiment was shared by a large majority of people, they could make no claim to higher productive efficiency, and that is the rational test of history.

In the past 30 years or so, health workers and their dominant medical culture have entered the same process of industrialisation that defeated the handloom weavers more than 200 years ago, and in their present state, seem likely to share the same fate. Neither health workers nor patients like what is happening to health services, but they have not yet convinced even themselves, let alone their enemies, that they have any clear picture of an alternative, depending not upon sentiment, but on evidence that it will deliver health and health care more efficiently and with more effective imagination than consumerism in the globalising market.

Medical care is being industrialised because it has at last been recognised as a particular kind of production, with added life as its product. Through medical care, lives can now be made longer and wider. This product is no longer just a hope, resting largely on placebo effects and collusive illusion (as for the most part it was until around 1935) but a reality, growing exponentially as knowledge advances. Today, limits to this reality are set not by the boundaries of knowledge, but by ruling assumptions about the nature of the medical care economy. The minds of politicians with their hands on state power recognise only one possible kind of economy and one possible mode of production, capitalist production for the market, expanding not to meet human needs, but to maximise profit. They believe that if medical care is a production system, then its products must be commodities. Though they pay lip service to the needs of whole populations, in practice they assume these can be met by pursuing only the immediate demands of consumers, giving priority to the most profitable transactions.

For all other commodities, consumer demands are limited only by ability to pay, and the ability of advertisers to make people think that they need something more when they already have everything. When medical science makes added life a probability, or at least a convincing possibility, and when medical care becomes a commodity, two consequences follow. First: in a free public service, consumer demands will be unaffordable by the state. Second: in a free market, corporate providers will find infinite demand for a product of infinite perceived value – the ultimate commodity. We now have free markets for almost everything else, why not for health care? From the point of view of politicians in power, there is no need even to ask this question; they already have the answer.

In September 1996 leaders of US managed health care plans met in Mexico City to discuss opportunities for extending their business internationally. They had rapidly and profitably expanded their business at home to include more than 100 million US citizens, almost all those healthy and rich enough to be profitable customers. As one chief executive of a managed care plan put it, ‘We are soon going to run out of people in the United States.’

The managed care discussed at that conference was industrialised care, managing each individual process or episode to minimise costs without obvious loss of quality, perhaps even raising it. Though there is still no solid evidence that managed care has in fact reduced costs or raised quality, its advent did coincide with a plateau in hitherto rapidly rising US health care costs for the first time in two decades. In USA, where most health care was still in the hands of entrepreneurial doctors, managed care was an advance. For the first time, it made US doctors accountable to somebody other than themselves ‘ but not to the communities they served, but to for-profit corporations now closely linked to the State.

Managed care made health care extremely profitable for its first couple of years, until it collided with the costs of people with chronic problems, and without spare money. Health care for the ‘affluent worried well’ could provide huge returns for investors, so long as it had no responsibility for very sick, very poor, or very chronic patients. Schemes in which more than 65% of insured people made a significant claim during the year were not profitable. Competitive Health Maintenance Organisations selected and deselected their enrolled patients so as to leave care of these unprofitable people to the State, either to cope with them itself through some lower tier public service, or to purchase care from private agencies at public expense.

This policy, advocated by the World Trade Organisation, the World Bank, and by the EU ministers meeting tomorrow at Chalkidiki, is now generally known as ‘reform’. This is now being sent around the world, wherever governments can be persuaded to accept it. The chief outward port for this ideological export programme has been the UK National Health Service, now committed to partnership between for-profit corporations and the State. Step by step since the late 1980s, the ideas of US health economists, notably Alain Enthoven, have been imposed on the NHS, which has then been used for rehearsals of managed care in an inclusive public service the United States was itself unable ever to provide. European policy formers who understand the extravagance and incompleteness of US health care seem easily deceived by promises of large savings in cost and improvements in quality which will surely occur in England, as soon as the latest managed care reforms have had time to work. So far, these improvements have not occurred, and the problems ‘reform’ was supposed to solve have got worse.

In reformed care systems, managed care will be offered by competing providers in contract with the state. Though direct patient charges will be needed to limit consumer demand, much or even all costs may be met by the state, at least in the first stages while the public still remembers it once had a National Health Service. Unprofitable people, too poor, too sick, too demented or too incontinent of urine or faeces to attract any corporate provider, will continue to be provided for somehow by the State public service. There is no question of total privatisation, in the sense that medical care for the mass of the people will ever be wholly returned to the market. The new global capitalism is a true and devoted partnership between governments and multinational corporations. In the UK in the 1970s, just over 25% of government public spending (other than income transfers such as pensions and allowances) went to private companies. By 1996 this had risen to 60%, and is still rising.

Since 1945, much of the moral authority of postwar European governments has depended on making health care a citizens’ right rather than a purchased commodity. The United States is the only industrialised country, other than Turkey and Mexico, without universal health insurance coverage. Though all industrialised states have either signed up to the World Trade Organisation’s General Agreement on Trade in Services at Seattle, or hope to do so, even GATS recognises that traditionally free, universal and comprehensive public medical care services can’t simply be handed over to for-profit corporations overnight. European governments must proceed cautiously, first laying the foundations for market competition, before retreating step by step from responsibility. In the UK National Health Service these foundations have already been laid, by separating purchasers from providers, and by fragmenting care into marketable units. In principle, the purpose of the NHS as an organisation is no longer to plan and provide care itself, but to commission it from whichever providers offer best value for money.

According to classical economic theory, the way to contain costs is to introduce price competition for purchasers (not patients, but NHS governors and administrators). The way to improve productivity is to ascertain the most efficient way to do each procedure or handle each sickness episode, and then ensure that staff follow these production guidelines. The way to improve quality is to expose competing providers to consumer choice. The consuming public needs league tables that rank doctors and hospitals according to productivity (measured by waiting lists), and quality (measured by operative deaths, delays between admission and finding a bed, or similar indicators). When all this fails either to control costs or to improve quality, Enthoven claims this is because governments have not yet dared to let competition rip through the system, letting failing units go bankrupt.

None of this is what people want, either patients or health professionals. Guidelines for care have been prepared by expert committees, mainly composed of super specialists working in university hospitals, for management of all common specific disorders. Hospital doctors and nurses feel that they now spend more time meeting the requirements of guidelines than on caring imaginatively for their patients. Professional morale is now lower than ever before in my professional lifetime. Real people have more complex problems than can be foreseen by any guidelines. The commonest single clinical problem in European primary care is high blood pressure, but less than 10% of people with high blood pressure have this as a single clinical problem, uncomplicated by other disorders. Even if we exclude complicating social problems like bereavement, bad marriage, or unemployment, complex problems involving several different chronic disorders are not exceptional, but the rule. Solutions to these complex problems require a combination of clinical judgement and attentive listening to evidence brought by patients, their personal stories. If we want substantial health gains at affordable cost, we must accept complex, labour-intensive, continuing solutions, rather than larger, faster, industrialised production of episodic intervention processes.

Through managed care, guidelines are now being applied as frameworks for organising production of health care on standard lines. The quality of doctors’ and nurses’ work is now measured according to protocols developed from these guidelines, so that much clinical judgement has given way to checklist automatism. There is some evidence of positive effects on the volume, speed, and population coverage of some intervention processes, but huge negative effects on staff morale are obvious. Long before the advent of managed care, there were huge rises in productivity for process: between 1982 and 1991, NHS output per capita rose almost 30%, compared with 16.5% for the economy as a whole. Measured as procedures delivered, not health gain, this was obtained by eliminating long-stay beds, shortening patient stays, closing small hospitals, and intensifying labour throughout the workforce. All these trends were well established before the internal market. There is almost no evidence of positive effects on health gain, other than in a few specialised areas like early diagnosis and accurate treatment of breast cancer, and even these are probably caused mainly by eliminating amateurs at the margins of specialism, rather than managed care itself.

Let me give a typical example of how industrialisation works. A friend of mine is a consultant gastroenterologist, working with three specialist colleagues in a major regional unit in England. To preserve its funding, her hospital must demonstrate its efficiency, so each specialist unit within the hospital has to show high output and acceptable quality for whatever intervention processes are characteristic of each specialty, used as indicators of industrial efficiency. For gastroenterologists this includes endoscopy, searching for disease downwards through the mouth, or upwards through the rectum. Output is measured by number of endoscopies in unit time. Quality is measured by the rate of gut perforations, a potentially lethal accident occurring less than twice per 1000 procedures in units of acceptable standard. Obviously the efficiency indicator encourages work at high speed, less obviously the quality indicator may discourage investigation of old or frail patients at higher risk of perforation. Complex decisions about the balance of risks and benefits for each patient should be considered carefully both by clinicians, and by patients and their relatives, taking into account the resources and experience of the local unit, and the hopes, fears and attitudes of local people, but they should not be influenced by crude administrative targets. My consultant friend was rated worst in her unit for output efficiency, but curiously, unit nursing staff all said they would prefer her if they needed endoscopy themselves. They knew that if patients were in too much pain, discomfort or fear, she stopped, regardless of the effect this would have on measures of efficiency.

Health ministers, economists, administrators and managers are, with few exceptions, deaf and blind to the gross limitations of the industrial model of production and the market model of distribution when applied to medical and nursing care. This is the way most other goods and many services have been produced for the past 200 years, and their salaries and promotion may seem to depend on imagining no other.

The ultimate aim of the global wave of Neo-Liberal ‘reforms’ is to create profitable new markets for capital investment, and permanently to delete from the world’s political agenda public services, pursued not because they are profitable, but because they are needed. As we all know, the sickest people in greatest need are always least profitable, and therefore worst served wherever markets rule. The greatest profits can be most easily gained from the fears and envies of people who already have everything except peace of mind. As a system for distributing health care, marketing of any kind cannot reach the poorest and sickest sections of society, who then threaten the health even of rich people.

What I want you to consider more seriously is the failure of for-profit industrialised care as a production model. A systematic review by researchers at McMaster and University of Buffalo shows that patients in for-profit hospitals in USA are more likely to die than those in not-for-profit hospitals, even after all corrections for case-mix (which mostly favour for-profit hospitals). Over the period 1982-95, including 15 different studies of 26,000 hospitals and 38 million patients, this showed 2% higher risk of death in the growing proportion of US hospitals run for profit, than in the diminishing proportion of US hospitals still run by voluntary or charitable trusts or local government authorities. Another US research study compared the fate of the 67% of US patients with end-stage kidney failure who attend for-profit dialysis centres, with the fate of the other 33% who attend centres run as a non-profit public service. Over three to six years of follow-up, patients attending for-profit centres were 20% more likely to die and 26% less likely to be referred for a kidney transplant, probably because they then ceased to be profitable patients for dialysis. A further study comparing US for-profit Health Maintenance schemes with not-for-profit schemes found worse outcomes in for-profit schemes for all of 14 quality indicators examined. This was the most complete data-set studied so far, but eight other similar comparisons showed similar results, and only two showed no difference. In yet another comparison, for-profit hospitals failed to reduce costs to the State, compared with not-for-profit care. Notoriously, in US for-profit hospitals administration costs were 34% of all costs, compared with 6% in the NHS before the onset of ‘reform’ in the 1980s, and just under 12% after ‘reforms’ were in place in 2001.

If pursuit of profit fails in terms of quality and efficiency compared with previous public service, why reorganise care systems on an industrial model originally designed to maximise profit? The only excuse for this seems to be that nobody knows any other model, except the old system of leaving all decisions to doctors, with no accountability to anyone.

If health ministers, economists, administrators and managers can see no alternative, this must be because they are looking the other way. It stares them in the face. Medical care is indeed a productive system. Every encounter between health professionals and patients should have a product – greater mutual understanding of the nature of patients’ problems in the context of their personal life stories, on which joint decisions can be taken about clinical interventions. The most important variable in any health care system is less the quality of interventions themselves, than the quality of decisions to initiate them. These in turn depend on evidence brought both by patients and by health professionals, through which rational and appropriate joint decisions can be reached. At every point this evidence and these decisions relate not to engineering certainties, but to social and biological approximations and probabilities. Even the best guidelines for management of common clinical problems provide only a crude and usually obvious outline within which to make these complex judgements. Health care is, and will remain, an extremely labour-intensive industry, and why not? With fewer and fewer people required to make nearly all manufactured commodities, why not invest more people in health care, education, and other use-values which cannot be made into commodities, without fundamentally distorting and damaging their nature?

In terms of health gain, industrialised care will not raise but depress productivity. The industrialised machine we are offered is clinically inefficient and socially destructive, and neither health professionals nor patients want it. Instead, doctors need to develop as socially responsible and accessible human biologists, and patients need to develop as citizen co-producers of health rather than consumers. Neither development can occur within the machinery of industrialised care. Health care and education are the principal growing points for an entirely new and different economy, based not on trade but on gift relationships, aiming not to maximise profit, but to meet human needs.

These gift relationships provide the main hopes we can still retain for a humane global future, resuming history as an ascent toward higher civilisation, rather than a decline to greed and brutality. In our local schools, hospitals and primary health care centres we already have the beginnings of these relationships, supported by local customs with deep roots. These can develop further only through initially local working alliances between patients and professionals, and between students and teachers. Unlike the Luddites, we can develop a clear and convincing vision of a more humane, more efficient, and more sustainable future, where we can use machines to meet human needs. These beginnings are sacred; let nobody sell them, nor take them away.

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