The Best System in the World

Imagine that a well-respected, politically powerful group of people had been given charge of America's school lunch programs. Gradually, over many years, some standards had been established; and all school lunch workers felt that it was absolutely essential that these standards be maintained, whatever the cost. Students ate lunch by candlelight, upon linen tablecloths, off gilt-edged china with sterling silver utensils, drinking from crystal stemware. The lunches, prepared by highly trained gourmet chefs, contained only the choicest ingredients. Food was prepared individually for each student and rushed piping hot to the table; extra cooks and servers were always on hand to make sure that no student ever had to wait too long. ("Standing in line for lunch," they said, "is maybe something that people would accept in Canada or England; but American children would never put up with that." These standards of excellence for the school lunch program, it turned out in retrospect, had evolved over many years based on advances in food preparation technology and in the skill of the gourmet chefs. Since at the start of this evolutionary process costs were quite low, hardly anyone stopped to ask whether there were any limits of affordability. Quite naturally, the costs of today's school lunch program threaten to overwhelm not only the education budget, but indeed the entire local economy. Teachers are laid off and subjects are dropped from the curriculum so that even more elegant crystal can be purchased for the dining room. Imagine further that critics of the program come to find out that this wonderful dining experience is not shared equally by all the children. Because of the great expense of the standard lunch, and because of the limited ability of society to afford the escalating costs, some children end up getting left out. There is one set of children, mostly from the poorest families, who get quite a different lunch program, eating week-old leftovers off paper plates with plastic silverware. But that group of children are better off than the children of some lower-income working families, who for one reason or another end up not getting fed at all on any particular day. Imagine that the critics find out something else about this program. Even the mainstream, middle-class children who receive the gourmet food and the luxurious table settings sometimes don't get what they really want or need. Sometimes children are made by the gourmet chefs to eat food that they dislike terribly or even are allergic to, because that food is on today's menu or demands the highest skill to prepare. Other children who are already full are forced to eat rich desserts, again because the skills of the chefs and the fineness of the ingredients cannot be allowed to go to waste (though cynics note that the cafeteria managers have traditionally made hefty profits out of this sort of overconsumptive behavior). Imagine finally that the critics call for radical changes in the school lunch program, arguing that all children need to be fed lunch; that adequately nutritious lunches could be provided at far lower cost; and that too often the system forces unwanted services on children, to their detriment. The powerful managers are indignant: "How could anyone ask us to change things and lower our standards? After all, we are talking-about the finest school lunch program in the world." The school lunch analogy ignores one critical feature of U.S. medical care over the past half-century. The hypothetical lunchroom managers, while perhaps benevolently motivated, certainly seem out of touch with any real social needs. By contrast, the medical leaders who developed first the scientific research base for today's medicine, and next the hospital system to deliver the fruits of that research into the community, were responding to pressing individual and social concerns; and the world is a much better place today for their work. The difficulties we currently face result not from an across-the-board failure of previous efforts,[1] but rather from the application of Epstein's Law ("If you think the problem is bad now, just wait till you've solved it"). …