can be forecast best from the experience of New York City. For reasons special to the city's history as the country's melting pot, as an early center of great wealth and philanthropy and, perhaps above all, as the capital seat of medicine in America, New York long ago incorporated the notion of medical indigency into its municipal constitution. Well before the Federal Congress offered the present subsidies, public funds were paying a significant portion of the cost of personal medical care in New York City. By 1962, according to the pivotal study conducted by Nora Piore, outlays from tax funds had mounted to $500 million and covered one-third of the total expenditure. These funds provide medical care for nearly 40 percent of the population. The clientele includes the city's welfare families, but it embraces a much larger number of families headed by persons gainfully employed and otherwise able to pay their bills. The medical care they receive on public funds reaches them through 25 different public and private agencies, under a bewildering confusion of terms and conditions. Fragmented, discontinuous, depersonalized, it is the most expensive kind of care; 70 percent of the outlay is for hospital services. The dependents of this system get the care they need only when they "are very sick and very broke."

The New York model-with annual expenditures per capita increased by public funds a full 60 percent above the national averageshows that money alone cannot produce good medical care. It is becoming clear that there is a serious mismatch between the system for delivery of medical care and the real needs of the American people, now that those needs can be stated in dollar. The failure to make connections is implicit in the expressions of disquiet that are heard in presumably responsible quarters about the future training of surgeons. If the new arrangements are to eliminate wards and ward patients, it is asked, where is the necessary teaching material to be found? Of course, the teaching subject often receives better care than anyone can buy outside a teaching hospital. Yet the question lays bare the moral void at the heart of the dual system, the double standard, of American medicine.

Ability to pay for medical care bears no natural connection to the care needed by the person in question. All the vital statistics insist that the relationship is invariably inverse. But here is the point of ethical disjunction. It is precisely here that the system became disjoined from the needs it is bound to serve in the future.

The system of medical care now prevailing in America embodies, above all, the satisfaction of its beneficiaries on both sides of the physician-patient relationship. The system is wonderfully designed to manage acute, episodic, and unusual diseases and injuries. Understandably, crises of disease and injury take absolute precedence in the consumer's budget; for the worst occasions the best off are ready to spend the most. Correspondingly, among the members of the highest paid of all the learned professions, the most richly rewarded are the physicians and surgeons trained to cope with the severest and rarest of afflictions.

In order to prepare the medical student for the opportunity of such service, the medical schools in turn concentrate on acute, episodic, and unusual diseases and injuries. The research budget and effort inevitably tend to follow the same pattern. As Willard C. Rappleye has

observed, the afflictions that are the object of this outlay of treasure and talent "constitute only a small segment of the total spectrum of health problems."

The sensitive senior student also takes note that the interesting cases on the ward are vastly outnumbered by the "crocks." In preparation for the face-to-face, physician-patient practice of medicine, however, he can tackle only a small segment of the total spectrum.

Without doubt, the system that functions under these extremes of social and economic pressure has produced care of extraordinary perfection and efficacy for those portions of the population that it serves and reaches. When it comes to vital statistics, however, the evidence indicates that this system has not played as significant a role in the general improvement of the public's health as the overall steady growth of the economy as a whole.

Now that medicare and medicaid are to lend economic sanction to human need, the medical care delivery system must give priority to new and neglected services. With Federal funds to share the burden already carried by the State and city treasuries, New York City may pioneer replicable models for other communities in the Nation. The city's new health services administration is seeking the functional coordination of the institutions in the private and public sectors to provide community-based health care tied to the teaching hospitals and the seven medical schools in the city. Against the high infant and maternal death rates in the ghettos the new system will have to pioneer the development of educational as well as preventive services. For people at the other end of life, the system must provide facilities and services that do not now exist for the care of chronic disease. Adequate response to the demand generated by medicare and medicaid for preventive and ambulatory services could empty one-third of the beds in the general hospitals whose occupants do not belong there. The 1965 amendments to the Social Security Act promise to provide the most effective way to accelerate the application of biomedical knowledge.

Without doubt there are also significant gains to be made by accelerating the movement of new knowledge from the laboratory to the clinic. John M. Russell quotes a medical school dean as saying, "Now if a child with cystic fibrosis happens to live in Boston, he gets superb services there. If he lives in another part of the country near a medical center, his services might be routine because the pediatrics department there might be principally interested in the newborn infant or in mental retardation." With the encouragement the health legislation enacted by Congress in 1965 and with the support of Federal funds, Russell concludes, "this sort of thing will not happen much longer."

There are hazards, of course, in the process of acceleration. One is posed by the already high speed with which new drugs and treatments get into circulation. The schools and the professions as well as the Government agencies are on the alert, however, and the United States did escape the thalidomide catastrophe.

There is another more pervasive and intangible hazard in the climate of opinion enveloping the country's medical establishment. No one has suggested that the research effort be reduced in favor of application,

and the flow of research funds from Bethesda has not been reduced. But the 20-year upward trend in research appropriation has halted and, to a certain extent, the new programs threaten to absorb new funds that would otherwise go to research. It can be argued, no doubt, that an occasional fiscal squeeze of this kind is a good thing for all concerned. The project contract/grant system has tended to set up positive feedback loops that have amplified some lines of work out of reasonable relationship to the whole. Throughout this period, however, the Federal investment in biomedical research has borne about the same percentage relationship to the medical economy as the total R. & D. budget to the gross national product. If the medical system is to grow soundly toward the predicted 8 or 9 percent of the gross national product the research outlays must grow with them.

Beyond what may be accomplished by the introduction of equity into the delivery of medical care, large increases in longevity and significant decreases in the mortality rate can come in the future only as the result of a general breakthrough on the broad front of human development and aging. The cardiovascular diseases and cancer involve the deepest questions man can ask about the nature of his existence. Correspondingly, the biomedical sciences seek answers that go far beyond "results." Research in these realms claim public support because it enlarges life's meaning and the purposes for which men live.

THE PERILOUS PROMISE OF BEHAVIORAL SCIENCE

By Kingsley Davis, Dr.

Chairman, International Population and Urban Research, University of California, Berkeley, Chairman of the Division of Behavioral Sciences in the National Academy of Sciences.

There can be no doubt about the importance of the behavioral sciences. These fields of knowledge have as their object of study, not viruses or bacteria, not molecules or hormones, but the social relations, behavior, and organization of man himself. Whereas the other sciences, insofar as they are applied, deal with the instrumentalities with which men solve their problems and attain their goals, the social sciences must perforce study and analyze the very creatures-human beings themselves for whom the rest of science is largely a means. In this lies the secret of the great promise of behavioral knowledge.

The behavioral disciplines study human beings, not as collections of organs and cells or as hosts for parasites, but as motivated animals who seek goals, talk to each other, imagine things, and get into all sorts of trouble. Looking at mankind from this point of view-that is, looking at them as people-means analyzing their goals and aspirations as well as their instrumentalities; it means investigating the process by which they define their problems, by which they reach agreement or fail to reach agreement on the nature of a problem. Obviously, then, the behavioral sciences deal with a potent source of human difficulties. It is trite but nevertheless worthwhile to repeat a truth that is often swept under the rug; namely, that most human problems are those created by human beings themselves. This is true

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regardless of how much physical and natural science they happen to have to help them solve their problems. In fact, one can make out a case for the proposition that the more complex the technology, the greater the problems generated by human conduct. For this reason the study of man's behavior goes directly to the heart of human problems.

I need give only an example or two to illustrate my point. Mr. Piel, in the present symposium, talks about the problem of medical care. This is much more a social problem than a technological one. We already know enough about medical science to provide sound medical care. The technological problem is therefore not an issue in what he is saying. What is at issue is the question of the distribution of medical care, and that is a social and economic matter. Mr. Piel points out that a cause of death in the United States is poverty. Poverty is not a disease, and it is not soluble by biological science; it is a social and human problem, and it is soluble only by social and economic means. Obviously the more efficient and powerful man's technological means are, the more destructive those means can be if they are used for the wrong purposes. As yet, for instance, the application of modern physical science to the making of armaments has not solved the problem of war. If anything, it has greatly exacerbated that problem by increasing the potential devastation of warfare beyond the wildest dreams of past misanthropists.

One can say, indeed, that technological solutions to problems tend to create new problems, often human in character. For example, our remarkable success in learning how to keep people alive until past the reproductive age (95 percent of girls born reach age 40, according to American mortality experience in 1964) has virtually eliminated mortality as a selective agent in human evolution. This leaves only differential reproduction as a selective factor, but we have almost eliminated that too by birth control (which reduces the reproductive performance of highly fertile women) and by new skills in treating infertility, fetal illness, and reproductive pathology (which increase the performance of otherwise subfecund women). As a consequence of these scientific achievements, we have begun a rapid erosion of the genetic heritage of the species-a heritage built up during hundereds of thousands of years of evolution under conditions of high mortality and uncontrolled reproduction. The solution does not lie in medical and biological technology. The more we learn how to treat genetic disorders, the more serious the problem will grow. Rather the solution lies in the social regulation of reproduction with respect to genetic effects. Our technological triumph in keeping people alive has given rise to another great problem, the sheer multiplication of human beings. This, despite decades of warning, has reached such a pitch that the human race is doubling itself approximately every 30 years and is contaminating the water, air, and land of the earth to a disgusting and alarming degree. The solution lies again in a social direction-it lies in the regulation of reproduction, this time from a purely quantitative point of view.

If our greatest problems are those created by man himself, if our accomplishments in technology and physical science tend to multiply

1 See J. D. Roslansky (ed.), Genetics and the Future of Man (Amsterdam, North-Holland Publishing Co., 1966).

social problems, and if social solutions are required for social problems, we can see that the potential role of the social sciences is very great. Why not study man himself, as a thinking and talking animal, and his communities and societies, in order to find more direct solutions to his problems than the roundabout process of always calling on the physical and natural sciences? Why not invest more money in the social sciences, instead of treating them financially like a stepchild?

This argument is quite persuasive. When we want to control a given disease, we bring together the most relevant disciplines to discover the causative agent and devise ways of combating it. Why not, therefore, solve human problems by bringing the human sciences to bear on them? If the problem is war, why not endow an "Institute for Peace" and set political scientists and sociologists to work to find the cause of war and to invent ways of eliminating it? If the problem is racial strife, why not ask the social scientists who study race relations to suggest the solutions? If the problem is poverty, why not simply turn it over to the economist, since he studies income and how to increase it?

WHY NOT UTOPIA?

Given the great promise that social science holds out for solving our problems, one is puzzled by what appears to be a mocking reality. I have observed, for example, that solutions to social problems tend to have three characteristics: First, they are extremely simple, especially compared to technological solutions. Second, they are foolproof that is, if they were applied, they would solve the problem. Third, they are not applied. If my observations are correct, perhaps there is something wrong with the analogy between social science and other kinds of science. Often people say that the difference is that one is not really scientific but the other is. In my opinion, however, this is mistaking the symptom for the cause. Let us look at the three traits I have just cited as characterizing social solutions.

An example can be found with reference to the problem of diseases due to tobacco smoking. A technological solution resides in finding precisely how it is that smoking causes cancer and cardiovascular disturbances. If this can be discovered, then it should be possible to treat the tobacco and cigarette paper chemically, to filter the smoke, or adopt some other physicochemical stratagem that will eliminate the offending chain of causation. The cost might be several billion dollars and might take several years, but if we stack this up against the medical costs of treating tobacco-induced diseases for a century, it will be worth it. Curiously, such reasoning is so familiar that we hardly entertain the thought of other alternatives. One alternative would be a human solution that is, people could simply stop smoking. There can be no doubt that this would be simple; it would not cost billions of dollars or require years of research. Nor would it be subject to failure; it would effectively and certainly solve the problem. Yet we know that it is not going to be applied. We know that a warning on cigarette packages will not induce people to stop smoking, that, if anything, the prevalence of smoking rises rather than falls as the dangers of smoking are made.

known.

Another example is the problem of urban congestion, with its attendant problems of environmental pollution and housing blight. In