VANDALS AT THE GATES OF MEDICINE - Historical Perspectives On The Battle Over Health Care Reform, by Miguel A Faria, Jr, MD, Hacienda Publishing, Macon, Georgia, 401 pages, $42.

Review by Del Meyer, MD

Miguel A Faria, Jr, a neurosurgeon, Clinical Professor of Surgery and Adjunct Professor of Medical History at Mercer University School of Medicine in Macon, Georgia, escaped from Cuba with his father in 1966 at age 13. Years later, after a three-month odyssey through several Caribbean islands, he was reunited with his family in the United States. He dedicates this book to his father and the Odyssey which ended in freedom and changed his life. Since graduating Magna Cum Laude from the University of South Carolina, he has edited the Journal of the Medical Association of Georgia, the Medical Sentinel, and published over 60 articles ranging from the scientific to the more recent socio-economic and political issues affecting American society in general and health care in particular. With this world view, he is well qualified to give us this treatise on the historical perspective of health care reform.

Faria believes that no health care delivery system will succeed unless the two parties who have the most at stake in the system--the patients and the doctors--cooperate, without coercion from the state. We should therefore rekindle, for the patient consumer-based incentives to contain costs. He feels this point is particularly important as our population ages, technologic advances proliferate, and expenses mount as further demands are placed on our overburdened health care system.

As a medical historian, Dr Faria is deeply convinced that many of the answers to today's perplexing questions regarding health care reform, the allocation and use of medical resources, and the direction that health care should take, can be found in the wisdom recorded in the pages of history. If we know history, we can at least avoid the mistakes of the past.

Faria thinks the economic basis has already been well-established by such economic giants as Milton Friedman, and insights are provided by venerable and commendable physicians from antiquity to the Renaissance. By becoming enlightened by the physicians of yore, we can contribute something tangible to the present health care debate and even provide answers and solutions to our present quandary.

Dr Faria then takes us on an odyssey beginning with humanity's first attempts to treat injuries through the medicine man, the special individual who possessed cryptic and forbidden knowledge separating him from the rest of the clan. The privilege of wearing elaborate ceremonial costumes emblematic of the office and symbolic of power were contingent upon proper fulfillment of his responsibilities to the tribe. The survival and well-being of the tribe depended on it.

Faria continues the journey through Egyptian civilization, where the first physician Imhotep, the first physician of whom we have a written record, was also a magician, sorcerer, and priest. Akhenaton, the sun-god, is credited as the inaugurator of the use of solar energy as a source of healing and health (i.e. heliotherapy and phototherapy) in recent centuries.

The Greeks reflect ancient history through their great epics and mythology. On Olympia, we find mighty Apollo, god of healing, and wise Athena, the goddess of wisdom. But more pertinent to the medical lexicon and our eventual working medical structure, are the god Aesculapius, (son of Apollo,) and his daughters, Hygeia, the goddess of health, and Panacea, the goddess of remedies. Chiron, who raised Aesculapius, was knowledgeable in medicine, which he learned from Apollo, and he conferred upon Aesculapius "the art of healing by using herbs, potions, and incantations." The forerunner of the first rudimentary indigent hospital, as well as over 200 temples, were formed by Asclepiad physician-priests. These Asclepiads developed the equivalent of the office and a hospital-based practice.

Not until the 5th Century BC did Hippocrates (who reportedly claimed to be an 18th generation descendent of Aesculapius,) begin in earnest to separate secular medicine from magic and religion. Thus began the lofty code of medical ethics.

Faria goes on to trace the development of medical practice through the middle ages to the renaissance when great explorations and acquisitions of medical knowledge and science occurred. The list of notable medical scientists and clinicians of that period is breathtaking in scope and accomplishment.

He believes the Renaissance is comparable to our present state of affairs in medicine. Practicing physicians, he asserts, must be as bold, resourceful and innovative as their medical forefathers in order to confront the health care problems of our own age. He deplores the fact that private practitioners, the backbone of the health care delivery system, have been essentially excluded from the policy debate process. He sees doctors finally willing to participate in the health care debate, but given scant opportunity to participate in the gladiatorial arena of the health care reform contest. However, he remains hopeful for the future despite the perilous waters physicians find themselves navigating. As we stand at the crossroads of change in medical care, physicians have a moral obligation to render advice to the public and to health care planners.

He concludes that the profession must not capitulate at this late hour to the "lusting barbarian hordes." The gates must not fall, for it would mean the demise of the venerable medical profession and abject betrayal of their patients' sacred trust. Physicians, and their patients must educate and learn from each other and then show the legislators they will not allow the demoralization, disintegration, and eventual subjugation of Medicine, nor a government takeover of the American health care delivery system. Faria's odyssey ends with a look ahead: Physicians, patients, citizens: The world is watching. The future of the American health care delivery system rests in your hands.

Del Meyer, MD