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Health reform


longer a hot issue

Innumerable political autopsies The country seems to be taking the of health-care reform with tend to agree on the factors that collapse i indifference. Congressmen returning doomed the best shot yet at providfrom the summer recess almost uniing this country with universal health formly report scant interest in the care. Perhaps of primary importance, issue. The Clintons have shied away from the subject in recent weeks, thus signalling that they know a dead horse when they see one. And now there is serious talk that in the homestretch to adjournment for the Nov 8 elections, Congress may avoid even modest health-related measures. : home for bondGoing pre-election ing with their constituents, legislators expected to encounter strong sentiments, on one side or the other, concerning Washington’s number-one domestic topic for most of the past year. But by general account the outspoken members of the electorate are concerned with crime, welfare

and health-care the President then devoted with things as woes, industry intermittent attention to health they are, though they feel strains and only The lobbies for the major care. anxieties. The Clinton camp broadeconomic interests in the health cast many true and heartrending .’. industry produced a cacophony of reports about the uninsured 15% of fearsome warnings of danger to the population and the many others if their self-serving preferwho are inadequately covered. But patients ences were not enshrined in healthmost Americans are safely insured for reform law. health care and not receptive to taxaLacking a majority coalition on tion for the benefit of the downtrodwhat to do, Congress is inclined to den. Arguments that health care for do little, if anything, about health the uninsured is really financed by reform in the remaining weeks of the higher prices for those who are covsession. The soothing argument of ered did not seem to register with the ’. the moment says avoid haste, wait till public. Cost shifting, as it is next year, and then proceed carefully does not visibly affect the wellin dealing with the difficulties of reform, immigration, jobs-not with insured. health care for all. But health-care reform. Typical among Many corporations that insure attaining knows that is a everyone specious the legislators, a midwestern Democtheir workers came out against a govthat the next Conratic Congressman who strongly Supernment-decreed employer mandate . argument, given will almost surely be less ported the Clinton health plan told for insurance, arguing that it would gress inclined to reform. The most imporme that he had gone home prepared . cramp their options if later on they tant factor seems to be that the voters to do a lot of explaining about the had to cut costs. Doubt and conare not fired up about health-care fizzled effort. He found little interest ’. tention swirled around the White reform. In fact, they seem bored by it. in the subject. House’s claims that, over the There are signs that major segrun, universal coverage could be ments of the public are weary of the achieved at no additional cost by cut- Daniel S Greenberg debate and perhaps not so dissatisfied with the present economics and CALCUTTA PERSPECTIVE organisation of the health-care System, despite its well-publicised failMother Theresa’s care for the ings. The leading exemplar of reform as a winning political issue is DemocOn Sept 8 the Calcutta Telegraph : work (my wife and I fed some of the ratic Senator Harris Wofford of ’. reported that an unidentified man residents and scoured the metal Pennsylvania, who won an aged about 65 had been found dead plates and drinking vessels with wood election two years ago in a victory : near the Kalighat Temple. The ash). There are two large rooms, for credited to his belabouring of the remarkable thing is that this incident men and women, each with three Bush administration for neglect of was newsworthy. A walk through that rows of concrete benches with green health care. Wofford faces the voters squalid part of the city will show you plastic mattresses. In a central lobby two sisters of Mother Theresa’s disease and degradation on a grand again in November because he is filling the remaining portion of the late scale. The fact that people seldom order, the Missionaries of Charity, Senator John Heinz’s term. This .’. die on the street is largely thanks to were coordinating the efforts of five time, however, health-care seems to the work of Mother Theresa and her volunteers (young people from Belhave lost its political lustre, and Wofmission. The citizens have been sengium, Germany, and Japan). Along ford is in a difficult campaign. Some sitised by her work over the past with two novices from the order, they retrospectives on his surprise election 40 years; and, where formerly they ‘°. were distributing rice, vegetables, now question whether his champitended to avert their eyes, now they . and water to about 90 men and of health-care reform was are likely to call an ambulance. And, women. oning the decisive factor. Whatever the case, if the hospitals refuse admission, I was surprised to see many of the reform of the health system is closely Mother Theresa’s Home for the v inmates eating heartily and doing associated with a President low in the Dying will provide. well. These days, it seems, more than Democratic The home is a former popularity ratings. Many pilgrim’s two-thirds leave the home on their candidates are keeping a safe distance hostel close to the temple. Visitors feet. Their common feature is not from Clinton.: are welcome, especially if willing to that they were originally perceived to

of the


ting waste in the system. Add in, too, the inherent political weakness of Clinton, elected with 43% of the vote and barely workable majorities in Congress. Even with those handicaps, the Clinton Health Security Act seemed to be off to a promising start at its launching last autumn. But, distracted by other governmental issues and his personal


known, ;








dying but that they had failed to : the sisters must remain on equal terms with the poor. So the most gain admission elsewhere. What sort of medical care do they get? It is hap- : important features of the regimen are hazard. There are doctors who call in : cleanliness, the tending of wounds from time to time but usually the sis- j and sores, and loving kindness. (One ters and volunteers (some of whom requirement is that all prescriptions have medical knowledge) make decibe written in pencil, and subsesions as best they can. I saw a young : quently rubbed out, to allow re-use man who had been admitted in poor of the paper.) If you give money to Mother Theresa’s home, don’t shape with high fever, and the drugs prescribed had been tetracycline and expect it to be spent on some little a doctor paracetamol. Later, visiting luxury. Finally, how competent are diagnosed probable malaria and sub- ! the sisters at managing pain? On a stituted chloroquine. Could not ! short visit I could not judge the v someone have looked at a blood film? power of their spiritual approach, but I was are seldom I was disturbed to learn that the Investigations, told, permissible. How about simple algoformulary includes no strong analrithms that might help the sisters and gesics. Along with the neglect of volunteers distinguish the curable ; diagnosis, the lack of good analgesia from the incurable? Again no. Such marks Mother Theresa’s approach as systematic approaches are alien to clearly separate from the hospice . movement. I know which I prefer. the ethos of the home. Mother ; Theresa prefers providence to planning ; her rules are designed to prebe
vent any

Apologies for Nazi crimes
For decades the German medical community abstained from discussing crimes committed by Nazi doctors. But two medical societies have now broken the silence by making the issue a major topic at their annual conferences. In Munich the German Society for Gynaecology and Obstetrics and in Darmstadt the German Society for Psychiatry, Psychotherapy, and Neurology publicly accepted responsibility for dealing with the horrors committed by their medical colleagues in the

drift towards


Preventing spread of BSE
on bovine spongiform Experts encephalopathy (BSE) called for compul: sory reporting of BSE and worldwide surveillance of the disorder when they were brought together at a meeting in Paris earlier this month by the International Office of Epizootics and WHO. The main

aims were to assess the worldwide extent of BSE and the risks it poses to trade, and to reach a consensus on the connection between BSE and Creutzfeldt-Jakob disease.


The group concluded that BSE continues to affect largely the UK (133 766 cows dead since 1986), although the number of suspected cases has fallen by 32% over the past year. Veterinary advice to stop giving animal-derived foodstuff to cows since 1988 has been estimated to have saved the lives of 50 000 animals to date. Four other European countries have reported cases after the import of infected cows or through feeding cows infected animal- Jean-Yves Nau

past. The president of the gynaecologists’ organisation, Prof Hermann Hepp from Munich, offered his apology to the women who were sterilised or forced to have abortions. He admitted that after World War II gynaecologists had failed by not talking about the physical and psychological harm done to women and by not giving them special help. It is impossible to go on talking about ethics if the past is not faced, Hepp said. A recent poll has shown that about twoRobin Fox thirds of the directors of university gynaethink that the Nazi past derived foodstuffs imported from the UK. cological hospitals was never properly discussed. However, The number of cases, however, is compar- ’, there are few ideas on how to deal with atively small: 98 in Switzerland, 92 in this problem or how to help the remaining : victims. Ireland, 10 in Portugal, and 8 in France. About 300000 men and women Another conclusion was that progress of were sterilised, of whom 5000 died as a research into prion-transmitted diseases is consequence of the surgery. 75 000 handislow despite annual funding of a million capped people were killed by doctors, and ECUs per year by the European Union. at least 100 000 lost their lives in medical Prof D C Gajdusek, who chaired the experiments. Of all the professions, docmeeting, hoped that a partial solution to tors had the greatest involvement with the the difficulties would be through the Nazi party, 45% being members. of chimeric mice with human genes. The When the war ended, victims did not group also requested that until more data receive compensation, and many Nazi are available "infected countries take all doctors were able to continue with their possible precautions to avoid any spread careers. This unfairness was also true for of BSE, however remote the probability of psychiatrists and their patients. At their it occurring to human beings ... Even annual conference, psychiatrists likewise though prions are likely to be dangerous . discussed the responsibility that their disonly when ingested in large amounts, all cipline holds for the Nazi crimes. But the organs of infected cows that might coninjustice persists today; there are survivors tain prions must be destroyed, and no of the Holocaust who are still waiting to suspect material used in the manufacture be rehabilitated. of pharmaceuticals". :


Annette Tuffs

German health



introduction will lead




: patients

The allegations, made by doctors and some of their societies, have been strongly By January, 1995, members of the obligatory health-insurance system in . denied by the federal health ministry. The Germany (which covers about 95% of ministry argues that the card will lead to the population) will carry yet another less abuse, since it could be lent to only plastic card in their pockets. It will replace one person at a time, during which the the vouchers that the health-insurance rightful owner would have no access to and will contain the medical care, whereas the vouchers could companies issue, be more widely distributed. In either case basic personal and membership data to be read by a practice’s computer. The the identity of the carrier is usually not : card has been tried out in a few states, checked by the doctor. such as Bavaria and Hessia, and a controThe ministry also insists that fears of doctor shopping when the card replaces versy has arisen over claims that the cards are open to abuse and that their general vouchers are based more on myth than on


tendency tor consult specialists without first seeing their general practitioner, but says that the trend is not new. However, a recent survey by the Central Institute for Health Care and the Scientific Institute of Local Health Insurers has concluded otherwise-ie, that the card has encouraged patients to go direct to specialists. There has been no accompanying increase in health-care costs so far. Whether the quality of medical care has been affected remains to be seen.

tact. it admits that tnere is a

Annette Tuffs