"Soylent Green" and Serious Medicine

I saw the Charlton Heston movie "Soylent Green" as a kid when it came out in 1973, and I loved it. Back then, the most static-analysis pessimism--as seen in The Club of Rome's notoriously influential (and wrong-headed) work, The Limits to Growth, was taken to be austerity gospel. And so the scenario of a consumer goods dearth, including food, that "Soylent" spun for the year 2022 seemed perfectly plausible to impressionable audiences. In addition, the film offered its own distinctly paranoid vision institutionalized corruption, hypocrisy--and cannibalism.

Back when the film was made, in the early 70s, it seemed possible that the world might simply run out of everything, and that people would make, er, hard choices. Few back then knew about Moore's Law, nobody imagined that China would go capitalist, or that population growth would flatten out; in addition, nobody had reckoned on the pro-growth influence of Margaret Thatcher and Ronald Reagan.

In addition, watching "Soylent" again for the first time in 36 years, I was, uh, not so overwhelmed by the film itself. The movie is not only low budget, but also strikingly unimaginative and incompetent, visually--note the orange-colored blood that flows from Heston. It's hard to believe that "Soylent Green" was chronologically sandwiched between two other much more accomplished sci-fi films, "2001," directed by Stanley Kubrick, released in 1968, and "Close Encounters of the Third Kind," directed by Steven Spielberg, released in 1978. Both of those films, the one that came before "Soylent," and the one that came after, are vastly superior to "Soylent" in both imagination and technique.

So "Soylent" is mostly a period piece, an artifact of its time. It's a film for a time for a particular era of limits. If there isn't much to go around, what what will "not much" look like? The answer the film puts forth is that the system will look sort of Soviet--lots of long lines for short rations, everything, including the clothing, dull and drab and tractor-factory-ish. (By contrast, Ridley Scott's futuristic dystopia, "Blade Runner," released in 1982, set in 2019, which has many plot similarities to "Soylent Green." Yet "Blade Runner" catches the idea that in the future, we will be richer than ever in the future, but at the same time, we will be more screwed up than ever.)

And then, of course, at the heart of the movie is The Secret of Soylent Green. I'll stop there, because not only don't I not want to write a movie review, I don't want to write a spoiler movie review. The issue at hand is what "Soylent" might say about health care today, and what's possible tomorrow.

By coincidence, I read Theodore Dalyrmple's health care op-ed in Saturday's Wall Street Journal, in which Dalrymple covered much ground, including this sum-up of the British National Health Service:

There is very little that can be said in favor of a health system which is the most ideologically egalitarian in the western world. It supposedly allots health care independently of the ability to pay, and solely on the basis of clinical need; but not only are differences in the health of the rich and poor in Britain among the greatest in the western world, they are as great as they were in 1948, when health care was de facto nationalized precisely to bring about equalization. There are parts of Glasgow that have almost Russian levels of premature male death. Britain’s hospitals have vastly higher rates of methicillin-resistant Staphylococcus aureus (a measurement of the cleanliness of hospitals) than those of any other European country; and survival rates from cancer and cardiovascular disease are the lowest in the western world, and lower even than among the worst-off Americans.

In other words, according to Dalrymple, the NHS looks today like the world that "Soylent" imagined back in the 70s--austerity, equal shares are small shares, and so on, to a depressing and dusty death. And since so many features of the 1970s have returned (big government and the sense that the Democrats are the natural majority party) maybe "Soylent" deserves a second look, not for its art, not for its resource economics, but for its politics.

Because in one sense, the central horror of "Soylent" was a daring political prediction for 1973. Back then, the Holocaust was well known, but the full mass-murderous horrors of Stalinist Russia and Maoist China were not. Also, in 1973, the most lethal regime ever on a per capita basis, the Khmer Rouge of Cambodia, were still two years from taking power. So for "Soylent" to imagine that governments would do something horrible, and then cover it up so effectively, using Madison Avenue-level propaganda--well, that was a daring act of politico-cinematic prognostication. And it's that daring that gives the movie its punch, nearly four decades after its release.

I should hasten to add that I do not think that the US government has anything sinister planned for us, in the vein of "Soylent." Incompetent, yes, dangerous, maybe, but not deadly sinister. (Which is not to say, of course, that things couldn't get worse, as they oftentimes do in bureaucratic settings.) So like any good science fiction, "Soylent" is a commentary, and perhaps a warning. And if the warning in "Soylent" of a bad fate staves off the bad fate itself, well, great--we'll take it.

But while there are those superficial (at least) "Soylent"-like elements within the British health care system, as noted, the world overall looks nothing like the world depicted in "Soylent." And Dalrymple touches on this, too, in his WSJ piece; he reminds us that it's hard to predict the future:

In the New England Journal of Medicine for July 3, 2008, we read the bald statement that ‘Medicare’s projected spending growth is unsustainable.’ But in the same journal on Jan. 24, 2008, under the title ‘The Amazing Noncollapsing U.S. Health Care System’ we had read that ‘For roughly 40 years, health care professionals, policy-makers, politicians, and the public have concurred that the system is careening towards collapse because it is indefensible and unsustainable, a study in crisis and chaos. This forecast appeared soon after Medicare and Medicaid were enacted and have never retreated. Such disquieting continuity amid changes raises an intriguing question: If the consensus was so incontestable, why has the system not already collapsed?’

The fact that collapse has not occurred in 40 years does not, of course, mean that it will not collapse tomorrow. The fact that a projection is not a prediction works in all directions: prolonged survival does not mean eternal survival, any more than a growth in the proportion of GDP devoted to health care means that, eventually, the entire GDP must be spent on health care.

As the famous economist Herb Stein always said, "If a trend can't go on forever--it won't." So there's usually little point in getting hung up on long-term predictions.

For his part, Dalrymple throws up his hands when it comes to prescribing a better system. He knows what he is against, but he is not sure what he is for:

Therefore I, who have no solution to my own health-care problems, let alone those of the United States, say only, beware of health-care economists bearing statistics that prove the inevitability of their own solutions. I mistrust the fact that, while those people who work for commercial companies (rightly) have to declare their interests in writing in medical journals, those who work for governmental agencies do not do so: as if government agencies had not interests of their own, and worked only for the common good.

Advocates of Serious Medicine have answers, of course, starting with a commitment to actually defeating, through the medical equivalent of firepower, the diseases and disabilities that Americans fear most. But a movie such as "Soylent" reminds us that there's always an undertone of fear in the way people think about the government, and what it does. Experts will reject Sarah Palin's Facebook jibe about "death panels," but in the wake of Hitler, Stalin, the Khmer Rouge, and a wide variety of well-documented efforts at euthanasia, people have a right to be suspicious about their government. And so would-be governors have a special duty to all that they can to reassure the folks that they aren't at all part of the mindset that could create a "Soylent Green."

Because people have seen it. They know The Secret, and they don't want it to happen here.