Medical Inflation (1980)

MEDICAL INFLATION* WILLIAM A. SILVERMAN^ Retrolental fibroplasia (RLF), a newly recognized eye disorder of premature infants, was described in 1942. After 12 years of bafflement, this form of blindness (which affected approximately 10,000 children throughout the world) was found to be associated with the use of supplemental oxygen in the management of babies in the first days of life [I]. The outbreak was followed by a series of similar treatment disasters. In retrospect, one may ask, Why did most of these catastrophes begin in the United States? Clues to the answer to this question are to be found, I believe, in some developments which took place immediately after World War II and in the material circumstances of the country during this period. It was an optimistic time in the history of American medicine . When peace was restored, this country, unlike most others, was in a position to direct its attention and considerable resources to deal with medical issues of national importance. Prominent among these was the frequent loss of life among newborn infants. The attack mounted to respond to this challenge in the arena of public health was similar in many ways to the all-out strategem which brought American victory in the war: mobilization of enormous material assets and rapid increase in technologic development. But we can argue, with the wisdom of hindsight, for the advantage of limited strategies in medical "warfare ": slower and safer approaches used in the face of spotty "intelligence ." Let us consider some of the consequences of the "mass action" approach—how sheer expansion ofactivities influenced events in American nurseries in the 1940s and 1950s. I suggest that the momentum of actions continues to the present time. Some of the elements in this inflation were increased visibility of premature infants; affluence; proliferation of programs, facilities, and equipment; publicity; and the in- *This article will appear as a chapter in William A. Silverman, Retrolental Fibroplasia: A Modern Parable, Monographs in Neonatology, ed. T. K. Oliver (New York: Grune & Stratton ). tAddress: 90 La Cuesta Drive, Greenbrae, California 94904.© 1980 by The University of Chicago. 0031-5982/80/2304-0178$01.00 Perspectives in Biology and Medicine ¦ Summer 1980 | 617 creased influence of authoritative opinion. Several of the disastrous "events" which I will describe bore a striking resemblance to the RLF prototype. Innovative effort usually follows closely on the heels of newly visible problems. This relationship was seen in developments which took place in the United States when there was a sharp change in perception of the scope of the topic of premature birth: In 1949, the underdeveloped newborn infant suddenly achieved numerical prominence [2]. Before this time, there was a limited amount of statistical information on prematurity from local areas or from individual hospitals. The Standard Certificate of Live Birth, prior to 1939, did not call for a statement either on the duration of pregnancy or on birth weight. An item on "Number of months of pregnancy" was carried on the revised certificate for 1939, but the data were not satisfactory for tabulation. On the 1949 revision of the certificate, the items "Length of pregnancy—weeks" and "Weight at birth" were added. At intervals beginning in 1949, the National Office of Vital Statistics published special reports which indicated that infants weighing less than 2.5 kg (5 lb, 8 oz) accounted for a higher toll of infant life than any other condition. The U.S. Children's Bureau presented these data in its publication, Statutical Series, and emphasized the need for concerted action at local, state, and national levels. In 1949, the Committee for the Study of Child Health Services of the American Academy of Pediatrics pointed out that in medical schools in the United States, training in the care of newborn infants was the weakest feature in the pediatric course and that many teaching hospitals provided very little experience in the care of premature infants. During the same year the U.S. Children's Bureau recommended to the New York Department of Health that the Department of Pediatrics of the New York HospitalCornell Medical Center in New York City offer a series of institutes on premature infant care for physicians and nurses. This program of...