tempt to conform to new ideas. I am working in a largely service-ori ented medical system, also at the university level, and I know that that means you never get time to think. In the words of Yale presi dent Kingman Brewster: you are compelled to meet today's needs now. In my opinion, this is the task of the overall medical care system, but not of the university medical center. The tasks of the latter are to foresee and work on tomorrow's problems and their solutions, today. You cannot easily do both things at the same time. What I have said does not, of course, exclude the notion of the university engaging in experi ments in what is labeled here "community medicine." The crucial question is, whether the university shall attempt this on the size of 15,000 people, 150,000 people, or 1,500,000 people. It is my firm conviction that while the university might handle successfully a commu nity of 15,000, the medical coverage of 150,000 or 1,500,000 is the task of local public health authorities. Quite another thing is, of course. that the university should aid in all possible ways, in a consultant capacity, to developments within the organization of medical care within its area of influence.

Let us, however, not forget that many of the health problems of today are not within the area of competence of medicine proper. Por erty, bad housing, and unemployment are basic factors in many diseases, but these problems cannot be solved by doctors. Drug abuse. alcoholism, and excessive cigarette smoking lead to severe diseases: yet they are part of our culture, morbid solutions of states of dissatis faction with life, against which medical efforts so far have been re markably unsuccessful. I think it is timely to try to decide what medi cine and doctors can do, and what they cannot be expected to do, if we are to avoid the rising dissatisfactions that will result from unduly rising expectations on the side of the consumers. Crime is not the fault of law schools, nor is a deficit health situation the fault of the medical school. That responsibility rests with the government-local, state, or federal.

It seems not unlikely that you need more physicians and a better congruency between the location of your health resources, including all kinds of health personnel, and the populations most in need of health services. The latter can be achieved either by command or by attraction. It will probably not be achieved without some action by your governments. It should be possible to capitalize on the idealism of certain young people, to a limit. I see a cause of concern in some plans to double the intake of medical students and at the same time shorten medical schools from four to three years. It is unlikely that with larger classes, fewer teachers per student, and a somewhat lower average scholastic level of students one should be able to produce the same quality as today. Some may, of course, possibly consider the present quality well too high in meeting the needs of the community. I do not share that view. I think a bad doctor may be more expensive to the community in the long run than a good doctor.

Finally, in looking toward the future, let me warn you on one score where you should not fool yourselves.

In epidemiological studies from this country, one seems always to be dealing with "men 40 to 64" years of age. Above and besides this. the rest is silence. But with improved general health-not least

through efforts within the area of preventive medicine-you may gain those five, six, seven years of life expectancy in which you differ from us, and you may increasingly have to face the repeated acute episodes from one or more chronic diseases in your retired population, men and women, 65 to 90+ years of age. These people cannot be taken care of during conventional office hours in health centers, and they will not be helped by multiple health screenings; they remain the task for emergency services, intensive care units, and wards of large hospitals and competent institutions for the chronically ill.

These are the people who during their active lives made this country prosper and provided the means upon which the present American "health empire" (to use a phrase from a wicked and vicious pamphlet) was built. They should have the right of being properly-which means well-taken care of, and not discarded as useless and nonproductive. Therefore, do not demobilize your hospitals in a wave of enthusiasm for "health centers." You will need both.

And in order to support both, I believe that you-and we-must do away with the easy dreams of futurologists: that paradise will come to use without effort, only as a product of technology and selfperpetuating economic growth. With present-day emphasis on values other than material gain and productivity, we may easily run into a situation with diminishing or discontinuing growth, contracting budgets, and less money available for health purposes.

Medical men may well be playing two roles-and those who are fit to do so should do so-namely, one professional role and one role as citizen. It is in the latter capacity, more than in the first, that a medical man may have to attack and try to solve major problems in the society which may cause ill health. These two tasks and two roles should not be confused with each other.

To decide upon priorities in a rising economy is difficult, but to do it in a declining one is worse. I feel we should all remember—and the youth "movement" in particular-what William Osler once said: "The master word in medicine is work."

INTRODUCTION

Sweden is often cited as having one of the best medical care systems in the world. Admirers of the Swedish health system point to the planning, organization and implementation which makes high quality health care available to all Swedish citizens, regardless of cost, and has made Sweden one of the healthiest nations of the world. When assessed by a number of indices of health, such as its infant mortality rate, the lowest in the world, or its longevity rate, the second highest in the world, Sweden is ahead of many other nations, including America, which ranks eighteenth in the infant mortality rates and twenty-second in life exectancy.1

On the other hand, detractors have claimed that the Swedish national medical system provides care that is impersonal and second rate. They see increasing socialization as weakening the system further by increasing patient demands, costs, and thus taxes, while lessening personal incentive, thereby increasing existing shortages of doctors, nurses and medical facilities.

How does the Swedish health care system really work? How effective is it? How happy are patients? Doctors? What changes have taken place recently, and what will change in the future? Accurate answers to these questions are crucial before any comparisons can be made between Swedish and American medicine, before we can ask: what features of the Swedish health system should America adopt and which should we avoid?

I spent two months in Sweden with my Swedish wife in 1970. During the time we spent in her home town, Gothenburg (Göteborg in Swedish), Sweden's second largest city, I was able to visit medical facilities and tal