QWERTY Healthcare

18 August 2009


P. G. Wodehouse with a favorite Royal typewriter.

P. G. Wodehouse with a favorite Royal typewriter.

Throughout the industrialized world we rely daily on the QWERTY keyboard to enter information about our technically complex and information-saturated lives. As automation and computerization penetrate every aspect of life, the QWERTY keyboard is not far behind as the default data entry device. And I am, of course, at present, typing on just such a QWERTY keyboard.


The QWERTY keyboard has proved itself a robust technology, but it is not an optimal technology. We have the QWERTY keyboard because we have a history, because the QWERTY keyboard has a history, and because these two histories are intertwined. The QWERTY keyboard was designed to slow down typing speeds. The earliest mechanical typewriters were quickly overwhelmed by the speeds that typists were capable of typing, so a keyboard was designed for the purpose of awkwardness and inefficiency. As mechanical and electronic technologies caught up to human manual dexterity, the QWERTY keyboard was retained because everyone who learned to type knew it, and almost all business machines with a keyboard used the QWERTY keyboard.

In short, the QWERTY keyboard is nothing less than an absurdity, but it is our absurdity, a human-all-too-human absurdity, and we are insufficiently motivated to change it. It is easier to accept the all-too-common absurdities of life than to attempt to change them.

As the health care debate moves through the Congress, it struck me today that we can count on a political deal that will deliver QWERTY health care. That is to say, we will have an absurd system that is a product of our history.

The Agnew Clinic, Phialdelphia

This is not a partisan rant. I do not support the Democrats or the Republicans or any of the interest groups or anyone else on this issue. And it is pointless to throw mud over the issue as all sides have impugned themselves. It would be difficult to imagine anything more absurd than the previous attempt to create a universal health care system under the Clinton administration. It is worth recalling why it was absurd. The Clinton plan was going to create “managed competition.” The health care delivery network was to remain intact, the insurance companies were to remain intact, and the relations between delivery, insurance, and the consumer were to be managed in the attempt to keep it all afloat. The whole thing was so ridiculously ungainly, so obviously a Rube Goldberg construction, that it is difficult to understand how anyone could have taken it seriously.

rube goldberg

It would be interesting to consider the ability of a society of rid itself of poor institutions and to create new institutions from scratch as a measure of the strength and intelligence of that society. There are few societies that by this measure possess strength and intelligence. The only example from history that I can think of that possibly applies is when the citizens of Knidos (or Cnidos, or Cnidus) abandoned their old city for a beautifully built new city some distance from the old.

surfing nurse

It seems clear that our society is insufficiently strong and intelligent to scrap our present non-functional health care system and to craft a new health care system de novo. This is a shame. We are intelligent enough to conceive a better system, but we simply don’t have what it takes to put it into place because an intelligently designed health care system for three hundred million people would be wrenching change, and, perhaps more importantly, it would mean doing away with powerful vested interests.


It is apparent that the politicians are approaching the health care mess in the US by way of reform and not revolution. To scrap the old and to begin again de novo would be revolutionary, and that is not happening. Yet it would still be possible through reform to arrive at a radically distinct system, though this would perhaps require even greater political will and even more intelligent institutions than an attempt at revolutionary health care change. A revolution can begin spontaneously, and, once started, can be difficult to stop: it is a form of Freudian discharge and obeys a psychodynamic rather than a rational model. This is not true of reform.


If one were to design an optimal health care system for a large and diverse nation-state such as the US, really aiming at something as close to perfect as is humanly possible, and then find a way to incrementally implement the plan over a long period of time — and I do mean a long period of time, as in decades, and not what politicians mean when they talk about a long period of time — the change would be sufficiently gradual that it would not have the wrenching social consequences of a revolution. Many people in affected industries would retire before the change was complete, and new individuals and businesses entering the industry would know what they were getting into. Such a plan would create a history, would create a history of change and reform with which our lives would become entwined, and this would give the program a feeling of familiarity and thus reduce the fear and anxiety associated with change.


This is not likely to happen. Reform remains a theoretical possibility at present. Given time, it might someday become a political possibility, but by that time the pressure to change the system might have built until only revolutionary change rather than mere reform can satisfy the felt need for change. This is as absurd and as human as anything else in the health care calculation — easily as absurd as pop culture nurse novels — and we cannot afford to dismiss it. Fear-mongering militates against change — even rationally planned reform — until desire for change simply overwhelms entrenched and escalating fear, and at this unpredictable tipping point just about anything can happen.

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Grand Strategy Annex

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