Medicine at the Crossroads: The Crisis in Health Care.

MEDICINE AT THE CROSSROADS

The Crisis in Health Care

Melvin Konner, M.D.

Pantheon, $23, 298 pp.

Medicine at the Crossroads, a companion to the PBS series, is a thoughtful survey of health-care problems and possible solutions. The book's greatest strength is Melvin Konner's clear presentation of simultaneous realities. He honors both scientific achievement and spiritual life, and sees social progress-- especially if it learns from and includes tradition--as the basis for the prevention and cure of suffering.

Konner is a physician, an anthropologist, and a writer. He's a good instructor, who smoothly leads the reader through chapters covering doctor-patient relationships, the history of medicine and its current practice, drug research and use, genetic research, surgery' s fights and wrongs, psychiatric treatment and social life, ways of helping the aged and dying, and the AIDS epidemic. Each chapter includes convincing personal stories and explanatory information, and negative and positive examples. The stories are always lively--this is a highly readable book-- and usually enlightening.

For instance, in "The Magic Bullet," the chapter on pharmaceutical remedies, Konner writes about the impact of a newly engineered drug called mifepristone on James Nelson, a man suffering from Cushing' s syndrome. Once Nelson became ill, says Konner, "by his own testimony and that of his wife his life had become practically unlivable, their marriage little more than shared anguish." After receiving treatment developed by a drug company scientist, "'His life was like a complete turnaround--it was like a miracle. To go from one side of life and then to see the other, it was actually beautiful,"' Mrs. Nelson said. Konner shares the Nelsons' enthusiasm, but he also discusses the tragic consequences of pharmaceutical disasters like DES, and the questionable wisdom of investing in limited successes, such as AZT in the treatment of AIDS.

Often, doctors don't know exactly what to do. Konner says so, and the uncertainty and complexity of medical and social decision making are well presented. Though forthright in criticism of antigay bigotry, Konner also points out that other, far more widespread health problems, such as maternal deaths in childbirth and heart disease, get much less attention and financial support than AIDS does. Medicine at the Crossroads is particularly strong when it shows that there isn't one simple way of looking at illness and treatment. The cures scientific medicine has effected are sometimes wonderful, but sometimes ephemeral, sometimes false. Konner explains the more rigorous kinds of evaluation, such as controlled testing and outcome studies, that should be applied more widely than they are to both medical treatment and surgical procedures.

Konner's description of mental illness and its treatment is particularly good, especially his discussion of the wonders of antipsychotic drugs and the failure of deinstitutionalization. While stressing the critical usefulness of scientific knowledge, Konner emphasizes two other central components of cure: supportive communities, and the spiritual life. Tormented people need empathy and acceptance. Konner, however, does not seem to have adequately examined his proposed solutions. For example: "Where are the chaplains?" he asks, speaking of their absence, in his experience, in psychiatric hospitals. Having heard more than one psychiatrist ridicule and dismiss religious belief, I suspect that it isn't the chaplains' choice to be absent from the psychiatric floors of secular institutions, but Konner doesn't hint at this possibility. Nevertheless, his plea to involve people concerned with spiritual life in the treatment of diseases of the spirit is worthy.

Some of Konner's suggestions are less convincing. He describes Sun City, Arizona, a retirement community where old people, self-isolated from other generations, are neglected when their diseases are treatable, and tortured with end-of-life measures that turn out to be futile. He then contrasts Sun City to Clifden, "a beautiful old seaside town in the rolling Connemara countryside of County Galway," with its aging population constantly monitored by a kindly GP, a knowledgeable nurse, an attentive home health-care worker, and committed family members. This juxtaposition seems exaggerated, a mere contrasting of extremes in order to make a preconceived point. Similarly, an Italian town is presented as a model of compassion and acceptance of the mentally ill, and Banaras, India, as a place where both doctors and family do all they can and then know when to quit with dying people. But these vignettes seem incomplete and romantic.

The flaws of Medicine at the Crossroads are also its virtues. The book's attempts at breadth and conciseness lead to occasional omissions of relevant medical or social facts. Part of this is the result of limited space, but Konner compounds the problem by overgeneralizing. He is deeply distressed at the suffering he rightly wants society to alleviate, and temperate in criticizing various methods of treatment. However, this urgency leads to the greatest problem I found in the book. Konner's strong feeling and conviction about how to solve the health-care crisis sometimes translate into a judgmental railing of the reader. In the Epilogue he lambastes an "us" for being infantile and unrealistic in our demands; irresponsible in accepting what we, not doctors and the government, must do. This mystified and antagonized me. Many of "us" are more than willing to be well-informed about health and illness, and to cooperate in our care, and we believe ourselves to be the government.

Still, Medicine at the Crossroads is jampacked with interesting information and insight. It's a graceful polemic, a stimulant, and a contribution to the general medical education everyone needs in order to become the good health-care providers, policy makers, and consumers Melvin Konner says we must be.