RADICAL SURGERY

From President Carter's secretary of health, education, and welfare, a clarion call for a cultural revolution in how we think about health. Washington insider Califano (The Triumph and Tragedy of Lyndon Johnson, 1991), a top aide to LBJ in the 1960s when Medicare and Medicaid were conceived, knows intimately the limits of legislative fixes and the unintended effects of well- intentioned programs. After a brief recital of the history behind the present health care crisis, he warns that we must stop focusing on the financing and delivery of sick care and start paying attention to what really counts: health promotion and disease prevention. For example, he would shift research dollars toward public health issues, away from the search for miracle cures and high technology aimed at prolonging the life of the terminally ill. In Califano's view, substance abuse is ``America's Public Health Enemy Number One,'' and he offers a number of proposals for tackling this problem. He also asserts that we are spending too little to promote healthy lifestyles and to ensure that the elderly live independently, free of injuries and ailments, that pregnant women deliver full-term healthy babies, and that children get the best start possible. Califano does not ignore the possibilities for reform of the present system; he offers opinions on several issues, such as medical monopolies, but tends to paint with such a broad brush that complex issues are oversimplified. In any case, he cautions, don't expect much action from Congress until the power of special interests is checked, and even then don't look for a ``legislative silver bullet'' that will give all Americans affordable health care. The key, he says, lies in ourselves: our conduct, our values, our attitudes, our culture. Close to being a sermon, but redeemed by its brisk and lively style.