Journal of Community Health Vol. 1, No. 2, Winter 1975
EDITORIAL
A TALE OF TWO CITIES
There is a growing fear among health services researchers that we are leaving the best of times to enter what m a y prove to be the worst of times. For some years, the eyes of medical researchers have reflexively turned to Washington at the faintest rumble of the cash register drawer. This instinctual behavior has allowed various groups to influence the direction of research and demonstration efforts b y a deliberate, and perhaps sometimes not so deliberate, use of carrot and stick. The counterweight to such a gravitational model has been the availability of limited funds from private foundations for innovative ideas in teaching, research, and health services delivery. The recent expansion of a major foundation has altered the balance of influence to the point that those interested in health services research must consider two capitals, instead of one. The arrival on the scene of this new giant may well frighten away others who have been influential in the past. Fearing that their impact and identity may be imperiled b y competition with a source of funds so unequally affluent for health, these foundations are already beginning to seek other areas to support. This leaves the health care field under the powerful sway of two cities, Washington and Princeton. When they decide to emphasize health care delivery, without concerning themselves with the scientific basis for such delivery systems, the future of health services research is cast into a shadow. The critics of contemporary medicine delight in pointing out the extent to which we feel free to exorcise b y computer, to propagate dogma, and to accept science on faith. The lack of clinical trims or careful evaluation of effectiveness and efficiency grows more acute with each new technological development. Few Luddites arise to demand that all medical delivery technology cease and desist. Yet, as more innovations b e c o m e accepted as current modes of practice, they will no longer be available for critical inspection. Unfortunately, the role of the health services researcher is that of house skeptic. This makes him neither popular nor attractive. In a society which trades on novelty, it is hardly surprising that such folk are shunned. Moreover, H S R is expensive. No Arrowsmith in a dusty laboratory can test the impact of altering the health manpower mix or changing the financial basis for medical care. Such experiments call for defined populations and the patience to wait for long-term (or at least intermediate-term) effects. 89
90
JOURNAL OF COMMUNITY HEALTH
The decision b y two cities to de-emphasize health services research in favor of health care delivery will have serious consequences. The lack of interest and support for H S R from b o t h government and private sources threatens to make this best of times the worst of times. Emphasis placed exclusively on "doing something", on getting services to people, may offer immediate solace to one's conscience, b u t in the long run it may be wasteful. At a time when the mention of health expenditures sends shivers down the straightest spines, any program which establishes new standards for delivering more, ineffective services is extravagant. And if those services involve subjecting patients to new care risks, it may be dangerous as well. We can prophesy our regrets at not being able to assess the effects of what we have done, b u t we must continue our struggle to influence the events that set the course of history. More efforts should be directed toward assessing the knowledge we have and toward gathering planned data on which we can base subsequent decisions. If federal resources cannot withstand pressures for increased services, then we must look all the harder to the private foundations for leadership in this sphere. We ask not that research be supported for its own sake, b u t rather for that which it can contribute. R o b e r t L. Kane, M.D.
EDITORIAL
A TALE OF TWO CITIES
There is a growing fear among health services researchers that we are leaving the best of times to enter what m a y prove to be the worst of times. For some years, the eyes of medical researchers have reflexively turned to Washington at the faintest rumble of the cash register drawer. This instinctual behavior has allowed various groups to influence the direction of research and demonstration efforts b y a deliberate, and perhaps sometimes not so deliberate, use of carrot and stick. The counterweight to such a gravitational model has been the availability of limited funds from private foundations for innovative ideas in teaching, research, and health services delivery. The recent expansion of a major foundation has altered the balance of influence to the point that those interested in health services research must consider two capitals, instead of one. The arrival on the scene of this new giant may well frighten away others who have been influential in the past. Fearing that their impact and identity may be imperiled b y competition with a source of funds so unequally affluent for health, these foundations are already beginning to seek other areas to support. This leaves the health care field under the powerful sway of two cities, Washington and Princeton. When they decide to emphasize health care delivery, without concerning themselves with the scientific basis for such delivery systems, the future of health services research is cast into a shadow. The critics of contemporary medicine delight in pointing out the extent to which we feel free to exorcise b y computer, to propagate dogma, and to accept science on faith. The lack of clinical trims or careful evaluation of effectiveness and efficiency grows more acute with each new technological development. Few Luddites arise to demand that all medical delivery technology cease and desist. Yet, as more innovations b e c o m e accepted as current modes of practice, they will no longer be available for critical inspection. Unfortunately, the role of the health services researcher is that of house skeptic. This makes him neither popular nor attractive. In a society which trades on novelty, it is hardly surprising that such folk are shunned. Moreover, H S R is expensive. No Arrowsmith in a dusty laboratory can test the impact of altering the health manpower mix or changing the financial basis for medical care. Such experiments call for defined populations and the patience to wait for long-term (or at least intermediate-term) effects. 89
90
JOURNAL OF COMMUNITY HEALTH
The decision b y two cities to de-emphasize health services research in favor of health care delivery will have serious consequences. The lack of interest and support for H S R from b o t h government and private sources threatens to make this best of times the worst of times. Emphasis placed exclusively on "doing something", on getting services to people, may offer immediate solace to one's conscience, b u t in the long run it may be wasteful. At a time when the mention of health expenditures sends shivers down the straightest spines, any program which establishes new standards for delivering more, ineffective services is extravagant. And if those services involve subjecting patients to new care risks, it may be dangerous as well. We can prophesy our regrets at not being able to assess the effects of what we have done, b u t we must continue our struggle to influence the events that set the course of history. More efforts should be directed toward assessing the knowledge we have and toward gathering planned data on which we can base subsequent decisions. If federal resources cannot withstand pressures for increased services, then we must look all the harder to the private foundations for leadership in this sphere. We ask not that research be supported for its own sake, b u t rather for that which it can contribute. R o b e r t L. Kane, M.D.
