LIFE WITHOUT DISEASE - The Pursuit of Medical Utopia by William B Schwartz, MD. University of California Press, Berkeley, 1998, xii + 178 pp, $22. ISBN 0-520-21467-6.

Academic physician Doctor William Schwartz has been studying health policy for more than two decades. In 1994, he coauthored The Painful Prescription: Rationing Hospital Care. Schwartz spent the last five years writing Life Without Disease - The Pursuit of Medical Utopia. His research, findings, and understanding of our present healthcare delivery dilemma and proposals for the future provide a link to a possible answer.

Schwartz reviews the health-care system in the US since mid century pointing out that all attempts at controlling costs have been merely one-time adjustments and have failed because they do not attack the root of the problem. He takes issue with others who feel that medical services can be brought under control in piecemeal fashion. Schwartz does not feel that managed care is an effective means for long-term cost control of an ever-expanding medical technology; it only encourages eliminating inefficiencies. When the increasing competition has squeezed out any remaining inefficiencies in the system, managed care can produce further savings only when competing providers impose serious restrictions on the availability and quality of care offered. He believes that managed-care organizations will inevitably limit not only marginal and unnecessary care but also possible beneficial care deemed too expensive. He then uses microeconomics to calculate the "expected benefits per dollar."

Dr Schwartz feels the long-term solution to cost-control lies in molecular biology and genetic engineering. He envisions a drug that can be designed that works only on the molecule affecting the disease in the body and on no other. He predicts that as we eliminate disease through prevention and molecular intervention, our healthy life span will increase by 40 years. The next generation may live to be 130, free of the chronic illnesses that now plague us. Consequently, the need for medical services will be greatly reduced.

Schwartz traces the birth and growth of "big medicine" to the post World War II period and the success of research efforts such as the Manhattan Project. Scientists and government leaders reasoned that aggressive government support of medical research could yield equally dramatic results. Schwartz considers this a pragmatic rather than a utopian dream. There was no concept of the scale of either the costs or the success of a technological revolution. Leaders were aware that medical progress was costly but believed the American people were ready to harness the nation's economic muscle in the fight to eliminate disease. Schwartz recounts the story of Albert and Mary Lasker, who through their wealth, influence, and determination welded together a coalition of public and private leaders dedicated to putting medical research funding on the national agenda. The Laskers exploited their friendships with influential physicians and powerful politicians to further their cause. The couple heavily contributed to election campaigns, befriended presidents, charmed the press, and built a network of like-minded movers and shakers, all of which Elizabeth Drew memorably describes in an Atlantic Monthly article "The Health Syndicate: Washington's Noble Conspirators." As a result of these efforts, the National Institutes of Health (NIH) began its rise from a small agency with a budget of $26 million in 1948 to become the Goliath it is today with a budget of $12.4 billion. This rise in technology has driven the cost of health care out of reach of many of our citizens.

Schwartz gives us neither economic nor political solutions for this dilemma. It would seem a giant leap to envision a minority of working Americans supporting the retirement and health care needs of the majority through 65 plus years of leisure (age 65-130). When F D Roosevelt started Social Security, and the average life expectancy was 60. Retirement was set at 65 years of age. Thus, those that had prepared for their old age (including healthcare), who lived more than 5 years beyond the life expectancy would have Social Security to fall back on. Later, Medicare was set for the same age. If Social Security and Medicare had kept pace by keeping benefits starting 5 years beyond the average life expectancy, we would not now have problems financing these systems. But politicians are unable to bite the economic bullet. Physicians in politics seem equally impotent.

Books such as this one, do provide informative medical background, and in the long picture may aid us in generating practical new policies. Thus, they are necessary for us to read to remain in the dialog of the future for our patients and ourselves. However, the book that puts it all together in a cohesive plan--the medical, economic, legal, and ethical--has yet to be written.

Del Meyer, MD