| Summary: |
MANY of the vexing problems of health affairs in Britain and the
United States in the 1980s are the unanticipated consequences of a
policy, more precisely, a set of policies and ideals that, for most of
this century, seemed self-evidently the best way to advance science
and improve the health of the public. I call this policy hierarchical
regionalism, by which I mean a particular logic of organization
based upon a theory of how medical knowledge is discovered and
disseminated.
I use the phrase hierarchical regionalism to summarize three assumptions
that became the basis of health policy in Britain, the
United States and, I believe, most industrial countries in the twentieth
century. These assumptions are: 1) The causes of cures for
most diseases are usually discovered in the laboratories of teaching
hospitals and medical schools. 2) These discoveries are then disseminated
down hierarchies of investigators, institutions, and practitioners
that serve particular geographic areas. 3) Health policy
should stimulate the creation of hierarchies in regions that lack
them and make existing ones operate more efficiently
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