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NEITHER GOOD HEALTH, nor bad, is ever distributed fairly. In 1973 there were 178 doctors for every 100,000 people in the United States. But while there were 265 active physicians per 100,000 in California, in North Dakota there were only 103. Three years later, fairness is in even more critical condition. According to the Federal Bureau of Community Health Services, in 826 American rural areas there is only one doctor for every 4000 people. Meanwhile in Beverly Hills there is a doctor for every 60 residents.
Senator Edward M. Kennedy '54 and the members of his Health Subcommittee have considered more than a dozen proposals in their search for a remedy to the unequal distribution of the wealth of doctors in America. With the House recommending that medical schools build rural health units and the administration insisting that primary care techniques be taught within existing classroom walls, the bills agreed only that medical education and a national health care system are, or at least should be, part of the same package. The teeth in each proposal came with the government placing stipulations on the previously freely provided, unrestricted money given to schools per student known as capitation funds. And the schools, predictably, were scared.
Anxious to bolster Harvard's sense of independence, Robert H. Ebert, dean of the Med School, last year focused his annual report on the costs and benefits of health manpower legislation. "The internal life of every institution is marked, for better or for worse, by events which take place externally," Ebert began. Although he was painfully aware that 58 per cent of Harvard's budget was support from the government, Ebert sought ways to preserve what he termed "the integrity of the educational system" in the face of increasing governmental interference. "If it ever got to the point where our programs are dictated by legislation," he said last spring, "I would seriously consider not complying."
With the assistance of the Health Professions Educational Assistance Act last month, Ebert and the deans of the 105 other American medical schools can breathe more easily. By treating the maldistribution of doctors as an evil that can be cured on an individual basis, the new legislation leaves the foundation of a national health care system to the random career choice of thousands of medical students. Beginning next year, each student who needs financial aid but does not qualify for a school scholarship can contract with the federal government for yearly loans, paying the sum back after graduation in the form of primary care practice in the National Health Service Corps. Through these contracts, the government hopes to direct 50 per cent of all first year physicians into either general, family or pediatric medicine by 1980. Only if this goal is met will medical schools either have to solve the distribution problem or spend the last of their capitation funds. But since, as the American Medical Student Association has testified before Congress, the "vast majority" of students will request these loans and since, as Ebert himself admits, the national goal will almost certainly be met, the question of compliance will successfully be avoided.
The major selling point of the new bill is its maximization of choice for the individual student. Rather than being edged into forgotten regions of the country, young doctors will eagerly apply to serve. Or so the theory goes. Hopefully then, as Harold Bursztajn, co-chairman of the Poor Whites Health Organization at Harvard Med has pointed out, rural people will be treated by doctors who want to treat them which can have a great impact on the quality and continuity of care.
The health professions have assumes that, given the opportunity, the socio-economically disadvantaged will return to their place of origin, a theory almost universally accepted as false. Although there is evidence that physicians from rural areas are more likely to practice medicine there than are students bred in the cities, there is no evidence that a majority of these "country boys" go home, as F. Sargent Cheever, Harvard's dean of admissions, has said.
But far more pernicious than this falsehood is the patronizing attitude underlying the bill. The disadvantaged in rural America are entitled to have doctors to cure their flu and deliver their babies but, the bill implies, they should have their own people serve them and not distract the rest of us from our more socially significant specialization and research.
The new legislation points to the basic prejudice at the center of the American health care system, but it recoils from striking at the heart of the beast. Somewhere in the shuffle of proposals, Kennedy's own recognition, expressed in a letter to The New York Times last March that "while 60 per cent of all American failies earn less than $15,000 a year, only 35 per cent of the students in medical school are their children," got lost. At Harvard, where the admissions policy is more liberal than most, only about 10 per cent of the student body could be classed as "poor white."
But legislating admissions quotas for medical schools would be a pyrrhic victory at best. There would be reverse discrimination and deans would fight hard to retain their right to determine who is qualified for the profession. It is in the admissions office that Ebert's talk of academic freedom is made flesh. The uproar over a provision in the new bill requiring medical schools to reserve places in their third year class for students who have completed two years in a foreign school and passed part one of the national board exam, is no freak accident.
A FAR MORE COGENT CASE for recruiting and accepting more socio-economically disadvantaged students into medical schools can be made on moral and utilitarian grounds. It is simply wrong to discriminate against people based on their social backgrounds. And society would benefit from admitting more of the rural poor since and coal miners' kids have heard the cry for a different kind of medical care. As John Mills, president of the national fund for medical education, wrote in his 1971 report to the directors:
Maldistribution in the geographic sense can be cured with the education of more physicians and better organization, transportation, and communication. Maldistribution in the cultural sense will not be solved by just more physicians and the relatively easy solutions of problems of transport and communication... The effectiveness of a physician is determined by what he knows and who he is... We shall not have adequate service for our medically deprived citizens, of whatever cultural background, until we have physicians from all cultural backgrounds.
The new health manpower act does attempt to organize a nation-wide health plan for a heterogeneous culture. Medical care for everyone, the bill recognizes, is a right. What is needed is diversity, but meanwhile medical schools continue to prescribe uniformity. Hungering after new research funds and prestige, they will never encourage their graduates to go practice in the hills. And until working in a lab and treating infections are considered equally important, and until everyone is equally free to do either, those people in North Dakota will continue to cry for a doctor in the dark.
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