Thursday, June 4, 2009

Engineering and Freedom, Part 3

click here to read part 
click here to read part 2 

The automobile has advanced scientific and social engineering, to the expense of personal freedom and privacy, in less obvious ways. 

In particular, as the immediate effect of the car was catastrophic, it was the ground for institutionalization of medicine and medicare in Western societies. Prior to the twentieth century, hospitals were for the old and young, the only people that tended to be habitually ill. However, most people up until the nineteenth century were born, and died, at home. 

When Abraham Lincoln was gunned down in Washington in 1865, there were no special facilities to aid the stricken top elected official of the United States. He was simply removed to a nearby townhouse, where he died several hours later. Victorian times saw a great boom in hospital-building, partly due to advances in medical science, partly due to the evangelical fervour of the time which encouraged Catholic and denominational sects to spend money on mercy houses to save the souls of the damned of the new bourgeois society. Indeed, most hospitals in Western Europe and North America existing today trace their origins in one form or another to the nineteenth century. 

During the first decade of the twentieth century, newly-institutionalized (but not yet socialized) medicine began to encounter the results of the internal-combustion engine: automobile accidents. Westerners today, when travelling in Africa or Asia, always marvel at the reckless drivers they encounter there, but the early auto-age in every country invariably sees a sudden spike in the death rate, as drivers drive heedless of other drivers. 

At least the newer-modern countries have the benefit of the Occident’s initially blind attempt to develop a communications system organized around motorized transport. Conveniences like street markings and stop-lights are relatively recent things, however. In North America, automobile ownership became a mass (but not majority) phenomenon in the teens of the century, a decade or so prior to this happening in Western Europe. 

When, by the ‘20s, most North Americans had access to a car, the rate of death by accident reached catastrophic levels. Today, with improvements in automobile design, policing and road safety, the number of road deaths is lower in absolute numbers than 80 years ago, even though the number of cars on the road, and the number of hours driven per capita, have increased many times since then. 

At first, however, the social response to the casualty rate on the roads was to set up emergency facilities, adjunct to the traditional hospitals. The now-fabled E/R physicians and the departments in which they worked were more than anything responsible for the socialization of medicine. Emergency rooms were at first run for a fee, but the injuries received through automobile accidents could result in astronomical medical bills. 

Soon enough, health insurance was invented to take care of the middle- and upper-classes. This left many people, even relatively comfortable people, without access to medical coverage. Further, as demand for medical professionals increased, the corpus of knowledge that was necessary to learn in order to be legally qualified to practice medicine expanded, the expense of health services steadily increased. 

At the same time, the E/R remade hospitals into facilities used by all members of the community. A hospital emergency room, prepared to treat accidents, could hardly turn away those with other life-threatening conditions, too. And what about those with catastrophic injury who, as it happens, could not pay their bills? How would admitting nurses know if a person did or did not have insurance coverage? Often hospitals would receive bad press when they turned deathly sick or injured children or women away for lack health insurance. 

In any case, the deprivation of the old and poor of on-going medical care came to be seen as a scandal throughout the “civilized” world. Nevertheless, it was less this controversy over health-care access that initially got the state involved in subsidizing health care. Rather, the hospitals themselves, weighed down by the cost of providing emergency care, came to depend on government hand-outs to keep afloat. Many hospitals were saved from closure during the Depression by direct take-over by government. 

After the Second Great War (where emergency medicine was further enhanced in battlefield hospitals), the involvement of the state diminished the profit-motive in emergency and general hospital care, and as governments assumed the medical debts of those unable to pay, the demands for them to assume those who could pay (barely) increased. 

In most places, state-subsidized health care became the norm. Even the “free market” United States could not resist state medicare, and that country’s failure to introduce universal coverage (with "Hillarycare" in the mid-1990s) has less to do with popular distaste for it, than the determination of the for-profit health sector to prevent their nest egg, that is, partial coverage for the poor and the elderly, so they can go on making big bucks charging high fees to others for the relatively meagre care they offer in return. It is not coincidental that the age of emergency-medicine has been the great era of the advance of medical knowledge. 

The emergency room was a dandy way for physicians to gain experience of all sorts of weird injuries and maladies. Medicine was traditionally ineffective because people viewed the body as a temple, filled with all sorts of magical essences (necessitating, for example, the practice of bleeding to “get the humours in balance”). E/R doctors and surgeons had no choice but treat the body as a live cadaver if they wished to save lives at all, and the injuries to most every part of the anatomy became the domain of countless specialist practitioners. 

The new role wrought by the emergency room, that of the doctor as habitual life-saver, has converted a once semi-dreaded professional into the beau of the single world, and self-regarding mortal deity, too. The indifferent and haughty style of the emergency-room doctor, who has little need of bedside manner, was imported elsewhere into the medical profession (most doctors at least train or spend their first few years practising in emergency wards). 

Today’s demand for “alternative medicine”, that is, medicine that runs directly counter to conventional medicine’s treatment of patients as body parts, was reflected decades ago in the lament over the loss of doctor’s house calls, when physicians mostly eschewed this form of treatment as inefficient. 

The impetus for all this was the invention and diffusion of the automobile, a device that not only requires state intervention in civil society in order to be functional in the first place; it inspires yet more interventionism as a "side-effect" of its use. 

click here to read part 1  
click here to read part 2  

Part 4 of Engineering and Freedom

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