OWNERSHIP IN PUBLIC HEALTH SERVICES: OUR MOST DIFFICULT PROBLEM, OUR GREATEST OPPORTUNITY

Lecture to University of Galway Conference on health equality, 2 July 1999.

I am most grateful to Cecily Kelleher, and honoured by your University, for inviting me and my wife Mary to visit the West coast of Ireland for the first time. 

We are old friends, because Cecily was central director for the UK Medical Research Council’s Thrombosis Prevention Trial,[1] for which our Glyncorrwg and Blaengwynfi practices, and our research team, led by Mary, provided one of the two pilot sites for that large multicentre trial.

In 1986, when the pilot trial began, its feasibility was a real question.  We had to ask men aged 45-64 first to accept screening to identify the top 20% of coronary risk.  We then had to ask men thus identified to accept randomisation either to treatment with low dose warfarin, or to placebo.  Aspirin was introduced later as another variable, using a Latin square design, but at first the choice was simply between warfarin and placebo.  Because this was a double blind trial, we had to ask them to accept that staff would not know which group they had been randomised to, and that both groups, would have to be subjected to venepunctures at least once every three months, for at least five years.  Finally, we had to explain to them the nature of this trial in simple terms allowing them a truly informed choice.  This entailed calling a spade a spade, or in this case, calling warfarin rat poison, which in lay terms indeed it is.  This frankness proved fortunate. One of our first triallists was the Council Rodent Officer for Blaengwynfi.

One year after the pilot trial began, 85% of this target group was participating.  Our men entered the trial for five years, but because five years later the MRC was still recruiting more practices from its General Practice Research Framework (GPRF), our men ended up serving 12 years in the cause of science, not five.  This could easily have been anticipated, had anyone, including me, thought further ahead from the standpoint of its participants, rather than its staff.  In research as in clinical medicine, always the same dominant mistake, and always the same dominant remedy: listen to the patient.

As these 12 years rolled by, expected terminating events picked men from the trial one by one.  The first death taught all of us, both participants and staff, how important it was to respect and enforce the trial’s double-blind design.  Had we known from which group the first few deaths came, continued experiment would have been impossible, however obvious it might seem that these could be chance events.  When a participant fell off his horse, suffering fractured ribs and a dangerous haemopneumothorax, everyone, both participants and staff, were sure he must be on warfarin.  When the trial ended, we learned he was on placebo.  To perform experiments well we have to learn that they really are experimental.  We do them not to confirm an answer we already suspect, but to create a useful new answer which does not yet exist.

Both patients and staff learned from personal experience that randomised controlled trials are the surest way to increase our small volume of measurable knowledge, and reduce our still immeasurably vast ignorance.  Both patients and staff learned from personal experience the difference between the certainties of precise engineering, and the measurable doubts of hugely complex, and therefore uncertain human biology.

The results of this trial added significantly to knowledge, owned by the world and accessible to anyone who can use it.  This would have been so, whatever its results, so-called positive or so-called negative.  We knew more about how to help people at the end of the trial, than we did at the beginning.  We added to the cumulative pool of freely shared, publicly owned knowledge.

Here endeth the first lesson.

In retrospect, historians will easily define the year 2000 as an economic and cultural world transition.  Within five or 10 years either side, the leading edge of every economy and culture will move from power-assisted but still dominantly physical labour producing material objects, to mental labour producing knowledge and ideas, with machine production of objects taken for granted.

Virtually all our trial participants were either former coal miners, or came from coal-mining families.  Miners have always known that all manual labour requires mental as well as physical skills.  No clerk or company director would ever have survived long underground, unless they learned very quickly much of which they were previously ignorant.  More slowly, and much more painfully, miners learned that though people who live not from what they own but from what they do, must sell their bodies to an owner for most of their lives, they can and must retain ownership of their minds.  They learned to keep their minds to themselves, to develop ideas and a culture of their own.[2]  With their own brains they learned a lesson which owners are compelled by their ownership to forget: that though a few can advance themselves one by one on the backs of their friends and neighbours, the only sure path for either local communities or entire societies to advance is together in solidarity, sharing social property rather than owning it.  Their motivation to enter and remain in the trial reflected that cultural maturity, and largely explains the difference between the 85% participation rate achieved in our pilot, and the 60% participation reached by the trial as a whole.

Everyone now understands that machines can produce most material objects better than even the most skilled human labour, either by hand or with powered assistance.  Of course, most objects still need some human labour for their production, but the future is already clear: no manual skill is now indispensable, elimination of human labour from every material production process will increase, and even the most skilled manual workers will increasingly.be compelled to defend whatever jobs remain by negotiating their own retreat, as the automated machine army advances irresistibly to occupy the world they had learned to live in.[3] 

The economic and cultural effects on the huge majority of the human race who live from what they do rather than what they own are comparable with the effects of the industrial revolution: For all communities previously engaged in heavy industry they are initially devastating, particularly for male culture.  In every sense, their past strengths suddenly seem useless and irrelevant.  For young men particularly, their inherited basis for self-respect has disintegrated.

Obviously the only growing future for human employment in commodity production must lie in what machines cannot do: that is, production of new knowledge, experimental discovery and design.  This is an area of value production which has only recently begun to be taken seriously as a field for profitable investment.  Even in USA, science-based commodity production still depends on publicly funded universities.  In 1984, pharmaceutical companies provided between 8 and 24% of all collaborative project-specific funding at US universities.  By 1990 the US federal government and the companies each provided about 45% of all pharmaceutical R&D funding.[4]  In USA, commodity production for profit is eating up formerly independent universities, and is now more than halfway through the meal.  However, it will soon find, if it has not found already, that universities must retain their independence, and resist the notion of intellectual property, if they are to produce new knowledge effectively and efficiently.

Production for profit depends on private ownership of property.  Production of knowledge as a commodity for sale, or even as a raw material for production of such commodities, depends on private ownership of intellectual property.  There is an inescapable and absolute contradiction between production of knowledge for the whole world to share, the bedrock of all universities throughout history, and production of knowledge for corporate use, constrained by commercial secrecy and distorted by search for profit.  This presents obvious problems for the integrity and credibility of universities, but it also poses serious problems for corporate industry.  Scientific advance depends on human imagination, modified by collective criticism and free access to all available evidence, and motivated by curiosity and ambition to leave the world better than it was when we entered it.  Of course these qualities require material support, and to the extent that corporate interests concentrate wealth, they must somehow provide that.  The simplest and most cost-effective way to do this is by paying taxes.

Free imagination and open access to knowledge require protection from corporate interests and corporate culture, with public access to knowledge protected from speculators in intellectual property.  Some major players at the centre of life sciences-based industry recognise the necessity of compromise in this field.[5]  A consortium including the Wellcome Trust has set up a two year £28 million program to create a map of genetic markers available free to all researchers, to encourage rational development of new medications.  So in the research field, two entirely different and opposed concepts of intellectual property co-exist, neither entirely at peace, nor openly at war, but hopefully in states of wary mutual respect for the immediately foreseeable future.