The Bladerunner

by Alan E Nourse

  It couldn’t go on like that, of course. If Doc in his simple office had foreseen a breaking point ahead, the nation’s leaders had foreseen it even more clearly. By late in 1992 several disturbing facts began to surface in the national administration and, by leaks, to an increasingly concerned and frightened public. With all the aging beneficiaries of the medical and geriatric programs, there was an alarming leveling-off of the national economy as an ever-smaller proportion of the population actually produced anything. Younger breadwinners were forced to shoulder the spiraling tax burden, yet the total tax revenues began to fall. Money became scarce, outdated medical equipment was continued in use, necessary hospital repairs were postponed, and new hospital construction rumbled to a halt. Perhaps most frightening of all was a secret economic study commissioned by the President, and then unaccountably leaked to the press, that contended that the whole national health care program, supposedly so well funded, was in fact approaching bankruptcy, and predicted that a massive economic breakdown would occur before the year 2010 unless some way could be found to halt the increase in population growth and curb expenditures on medical programs. With an aging Congress and national administration unable or unwilling to do anything to alter the developing pattern, there was a massive public outcry from the younger citizens, and scare headlines appeared in the news media across the country. One liberal Washington newspaper proclaimed: REPORT PREDICTS DISASTER IN FIFTEEN YEARS; HEALTH SERVICES MAJOR FACTOR, while a large midwestern paper reported COMPUTER SAYS COUNTRY GOING BROKE in two-inch banner headlines. At the same time, sporadic outbursts of violence began to occur, moving in an accelerating spiral into the full-blown national Health Riots of 1994.

  It was a time of fear and anguish for the doctors and others involved in health care. Blamed for increasing health care costs, lack of concern, and inhumanity toward their patients, doctors became the scapegoats for an angry and vengeful public, with medical leaders all over the country the victims of public attacks by rioting mobs. An American Medical Association annual convention was mobbed by thousands of angry citizens and was forced to disband in a retreat that became a rout as police and National Guardsmen held back, fearful of involving an entire city in the conflagration. A major New York City hospital was invaded by a mob, the medical and nursing staff slaughtered, and the building set on fire, killing multitudes of aged patients unable to escape the inferno. Across the country, hospitals and clinic buildings were bombed, burned or occupied by renegade bands of reformers — and the cries of the Naturists, who advocated an end to all kinds of professional health care in a back-to-nature-and-home-remedies movement, were heard more and more loudly in the leadership of the rioting mobs. Ultimately the convulsive events involved virtually everyone. The stock market, long uneasy, dropped through the floor in a wave of emotional selling unequaled in sixty years. Labor unions threatened massive general strikes against excessive taxation and old-age benefit programs their workers were forced to support, and as unemployment rose, laborers and executives alike joined in the protest marches and riots aimed at the doctors.

  It was in the midst of this accelerating turmoil that a small and mild-mannered man at a Midwestern university dropped a sociological bombshell that was destined to revolutionize the nation’s entire concept of medical care in the space of a few short years.

  Rupert Heinz was certainly an unlikely candidate for fame of any kind. Doc had met him once, as lecturer at a medical meeting: a shy, tweedy pipe-smoking man who was far happier working out biomathematical formulas in his dusty office at the University of Minnesota than giving lectures — or making headlines. Few doctors even understood clearly just what it was that a biomathematician did, and Heinz himself had trouble explaining — but years of statistical study of the occurrence patterns of certain diseases had led Rupert Heinz to a quietly frightening hypothesis: that the miracles of medical progress in the nineteenth and twentieth centuries might, in some cases, have ultimately led to more human illness, rather than less.

  An early study of Heinz’s had dealt with diphtheria, a dangerous throat infection known for centuries as a destroyer, or crippler, of children. Commonplace in the early 1900s, diphtheria had killed as many as one out of every ten of its victims — until widespread vaccination of children in the 1940s and ‘50s had brought the disease almost to a standstill. A medical triumph, it had seemed, until sporadic outbreaks of a more virulent, drug-resistant form of diphtheria began striking adults in the 1970s, with antibiotic treatment now ineffective and the death rate rising to over 60 percent of all victims. Within another ten years widespread epidemics were sweeping the country and mass immunization campaigns were needed to damp the flame of a dreadful disease running wildfire through a population left naked of any natural resistance.

  Rupert Heinz had analyzed this pattern and come up with a frightening thesis: that medical intervention in itself had contributed the lion’s share to the massive spread of this virulent infection. Without immunizations earlier in the century, natural resistance would have kept the milder disease under control; now even a massive immunization campaign would be no more than a stop-gap, with horrible future epidemics to be expected as new virulent strains of diphtheria developed in the population. Heinz reported his predictions, almost apologetically, in an obscure scholarly journal, and there they remained, largely unnoticed, as the diphtheria epidemics raged on.

  A second study, however, dealt with diabetes, and this time Heinz’s findings could not be ignored. Throughout most of history diabetes had been a relatively uncommon affliction that was uniformly fatal for lack of any effective treatment. As a disease strongly influenced by heredity, the fatal nature of diabetes served as a powerful limitation on its spread. Death often occurred during childhood, and even in adulthood the development of a pregnancy so greatly accelerated the destructive nature of the disease that few children were born of diabetic mothers. For centuries the disease, cause unknown, had remained stable and uncommon, a tragedy for those few who developed symptoms, but with very few of them passing the disease tendency on to their children.

  The discovery of insulin in the early 1920s changed all that. For the first time, diabetes could be treated, and more and more victims survived long enough to have diabetes-prone children. By the time of his study in 1993, Rupert Heinz estimated that as many as 40 percent of the nation’s entire population carried at least one part of the complex genetic linkage for diabetes, up from 37 percent just ten years earlier. Looking into the future, Heinz quietly predicted that, as a result of medical intervention in detecting and treating diabetes, as much as 85 percent of the population would be carrying some diabetic factors within another forty years, and that some 42 percent would be actively diabetic. His message was simple and to the point: keep treating diabetes the way it had been treated for three quarters of a century and everybody would be diabetic or diabetes-prone by the late part of the next century.

  When news reporters picked up the story and accused Heinz of doom-singing and rabble-rousing, the man merely withdrew, refusing to discuss his work any further. He had evolved complex biomathematical equations predicting the spiraling incidence of the disease; he knew his findings were valid; but he had no solutions to offer. Inevitably his reticence was interpreted to mean that he was concealing something, and soon he was the focus of alarming newspaper headlines: DOOMSDAY SCIENTIST REFUSES COMMENT ON WORK! CAN DIABETES BE STOPPED? TOP EXPERT WON’T TALK! As the storm raged Heinz withdrew still further, extending his studies to mental illness, ulcer disease, hypertension, cancer — the whole spectrum of illness that had been affected by medical intervention over the past centuries. And in each of these areas he found the overall occurrence of these diseases steadily increasing as a direct result of medical interference with age-old natural balances.

  Of course, it was all only theory, the uncorroborated findings of one man working in a field of science that was inexact at best. For all of the scare headlines, Heinz’s predictions might still have been ignored
except for the interest of Charles Lafferty, a young sociologist eager to find a way around the grim pattern that Heinz had forecast. Working at Stanford, Lafferty began collaborating with Heinz to develop certain “solution constructs” that might be used to turn the course of history and prevent or minimize the medical and social disasters that Heinz’s work predicted. Almost immediately the federal government classified this work as top secret and provided money for the development of a practical Eugenics Control program to curb the transmission of genetically linked diseases, even as the Secretary of Health Control and other official spokesmen were publicly scoffing at Heinz’s predictions and denying the implications of his work. But within months Heinz and Lafferty reached a startling and unpalatable conclusion: that a eugenics program alone would not be enough to turn the tide. Even with compulsory sterilization of all victims of diabetes, schizophrenia and a dozen other heredity-connected diseases and the compulsory euthanasia of all identifiably defective babies, the destructive spiral would continue as long as widespread medical intervention continued. Only if all individuals who wished to have medical treatment were first sterilized was there hope that the spiral could be broken.

  It was this staggering concept that Heinz and Lafferty finally settled upon as a tentative working approach. Eugenics control — weeding out defective genes — and a diminishment of medical intervention had to be inextricably tied together. Health care, in the form of government-run, tax-supported clinics, hospitals and medical staffs would continue to be available throughout the land, providing a high quality of medical care to every citizen, from cradle to grave, who could qualify. And qualification for that medical care would be simple and easy to achieve: the only requirement for treatment of any ailment would be that the patient first be sterilized. Those who wished to have children would, of course, be free to do so — at the sacrifice of any type of legal medical care. Once such a program was instituted, Heinz and Lafferty predicted, the economic crisis centering on health care delivery would be relieved almost immediately, and the program would show measurable eugenics effects within forty to fifty years. By that time it would also show measurable and beneficial impact on population curves; the population crisis would be over. If the program was ultimately applied on a worldwide basis, Heinz and Lafferty calculated, dependence on health care facilities would diminish to a bare minimum within a few decades and world population figures would ultimately be reduced by two-thirds.

  As a tentative working program, the Heinz-Lafferty proposal was carefully worked out — but their work was far from complete. A hundred details of the plan remained to be tested — the impact of the proposal on religious convictions, the attitudes the doctors might take, above all the attitude of the general public, all had to be studied in meticulous detail. A dozen more years of work were needed to crystallize the plan into sound policy, and neither Heinz nor Lafferty had any idea that the federal government might ever try to implement such a program before that vital work was done. But they had not counted on the sheer desperation of the government at the precise time that their preliminary studies were completed. Faced with an economic and political crisis, with the spreading Health Riots and threatened social disintegration, the aged President and his aged Congress were aghast at any program which sought to limit medical care in any way whatever. But an ambitious and liberal young opposition saw in the proposals the makings of a revolutionary reform program. Even as the incumbent administration floundered, the opposition broadcast the Heinz-Lafferty proposals as a panacea for the future, and in 1996 a frightened and riot-weary electorate bought the package in a landslide vote of historic proportions. Within sixty days after inauguration the tentative, untested Heinz-Lafferty proposals had been written into law, and for better or for worse the nation moved down a murky road of social and medical revolution.

  No one at the time could see the end of that road, least of all Heinz and Lafferty, who shouted themselves hoarse warning that their work was incomplete, or the new President, to whom doing something seemed synonymous with improving something. Yet as the fledgling program was instituted, the stage was set for the emergence of a strange and extralegal medical black market, existing solely to thwart the law. It was into this world of underground medicine that Billy Gimp, with his shadowy personal history, his youthful ambition and his half-repaired club foot, found work as a bladerunner — a procurer of illegal surgical supplies; and it was in this same underground world that men like Dr. John Long and multitudes of his professional colleagues set about with dogged determination to defeat a system they considered intolerable to the ideals and training of physicians anywhere, any time. And now, some eighteen years later, the network was tightening and the struggle reached a new level of ferocity, with no end in sight.

  III

  DOCTOR LONG! DOCTOR JOHN LONG! The paging speaker on Doc’s office wall broke into his reverie. With a sigh, he reached for the phone switch. “Doctor Long? This is Miss Rupert on Nine North. We’re about to give Mabel Turner her preoperative medication. Did you want to see her before your surgery?”

  “Oh, yes, of course. I’ll be right there.” Doc checked his watch and saw that he had just an hour’s leeway before he was due in the operating suites. As he had expected, the computer had designated Mabel Turner as his first case this morning, to be performed with a full neuropantograph hookup to trace and record his every move, his every surgical decision from beginning of the case to the end. And in this case Doc was ready and waiting for them with a large measure of undisguised glee. It would be a case to be remembered. For weeks now Doc had been carefully planting erroneous data in the computer record of Mabel Turner’s case history — a false lead here, a manufactured response there, a subtly incorrect clinical summary from one hospital visit, a totally erroneous electrocardiograph interpretation from another visit — in short, a craftily designed patchwork of misinformation and half truths about the patient’s clinical course, all concocted for the sole purpose of misleading the computer into a slightly erroneous diagnosis, prognosis, and plan for treatment.

  And it had worked. As a result of his efforts, Mabel Turner had been identified by the computer as a high-risk, desperately ill cardiac case, candidate for an immediate heart transplant — precisely the kind of case that Dr. Katie Durham and the other medical directors of the hospital so eagerly wanted him to perform with a full neuropantograph hookup, a case involving multiple difficult, perhaps even life-and-death, surgical decisions to be made from opening to closing. Now Doc smiled to himself in satisfaction. With the case finally scheduled, despite his formal, almost ritual, objection to the neuropantograph hookup filed with Dr. Durham, there could be no backing out without extreme embarrassment in high places. For all their claims and contentions, Health Control authorities were really not all that certain of the reliability of their computerized diagnosis and prognosis systems, so that the error could as well have arisen in their system as in Doc’s machinations, and only a time-consuming and costly retrospective analysis would spot the difference. And now that they were boxed in, the case would give him a splendid opportunity to play hob with the neuropantograph, first confusing it thoroughly at the discrepancy between the procedure scheduled and the procedure he intended to do, and then almost certainly sending it into a paralyzing feedback crisis when he, as surgeon-in-charge, changed the projected procedure entirely.

  And change the case he would, for he had no intention of performing a cardiac transplant on Mabel Turner this morning or any other time. He had never intended to.

  Walking down the corridor from his office, Doc nodded to the occasional intern or resident who hurried by, then paused to wait at the north side elevator bank. Moments later the elevator dropped him off on the ninth floor, devoted exclusively to pre- and postoperative patients, and he hopped a jitney moving briskly down the main central corridor, passing wing after wing of perpendicular ward corridors. Hospital No. 7 was loudly acclaimed by Health Control authorities as one of the most modern and best desig
ned of all the new federal Hospitals built in the last decade, with each patient bed within comfortable view of an outside window, with holo-TV stages with multiple projectors in each room so that each of four different patients could watch a different program projected on the same holography stage at the same time without any overlapping or interference of the images. With its thirty-eight stories, and thirty-six wings branching from the main central corridor, the hospital housed four thousand patient beds and, as usual, was filled to within 10 percent of capacity at all times. What was more, internal hospital transit was so efficient that a doctor could, if necessary, travel from the main lobby to the farthest end of the top-floor main corridor in no more than fifteen minutes of travel time, a significant improvement over some of the earlier pentagonal and hexagonal hospital designs in which just finding a patient’s bed might well consume an hour of a doctor’s time.

  Mabel Turner had already received the first stage of her preoperative medication and when Doc finally reached her room, the small, chipper middle-aged woman was relaxed and a little drowsy, but still alert. Doc greeted her like an old friend, which indeed she was. a patient that Doc had been following closely in the outpatient clinics for nearly three years before the decision for surgery had to be taken. Now he rolled the bed into an upright position and carefully checked out the woman’s vital signs, read the nurse’s notes on her chart, then began his final pre-op examination. “No fever,” he said. “That’s fine. I warned you not to get a cold at the last minute. Blood pressure … well, that’s behaving. Let’s just listen to you breathe.” Finally he finished and smiled at her. “You’re in good shape,” he said. “I don’t think there’ll be any problem.”