Prisoners learn from their mistakes

To learn from mistakes? (!)

Last revision: November 9th, 2019

content

  • Mistakes are milestones
  • Medicine learns from aviation
  • The Swiss model of system failure
  • Learning from medical disasters?
  • Is the development over?

Science is the belief in the ignorance of experts. Richard Feynman

If you try to avoid mistakes, you will learn nothing.

Especially not if he or she is rowing backwards and claims that there are no problems looking forward. Because (looking at the past) none can be seen.

Rowers could sometimes pause and look ahead and suspect possible obstacles there in the fog. Or, they could carefully try course corrections. The resulting deviations from the desired result remained relatively small in both cases.

However, the process (of rowing) then slowed down, and instead of a straight line to the goal, there might be curves and detours. Behaving in this way (process-oriented) rarely leads to quick results. And that is why goal-oriented and time-optimized people seem far too laborious.

And that's why it sometimes goes wrong

Like the sinking of the “Titanic” in 1912, when around 1,500 passengers perished. You learned from that. And built a new ship: the "Eastland". She was equipped with everything that was needed in an emergency on the high seas: including many lifeboats. Unfortunately, no consideration was given to the fact that this would shift the ship's center of gravity upwards.

In 1915 the "Eastland", well moored, overturned in the port of Chicago, killing almost 900 people.

Why was the Eastland forgotten?

Perhaps because the memory of her unspectacular departure is more unpleasant than the seemingly fateful Titanic disaster. The Eastland example is unsettling because it is a typical "Disimprovement”Shows: A technical problem solution that was supposed to" safely "eradicate an old error, and thereby created a new problem that no one had thought of before.

“There is always another bug. There is always one more bug ". Bloch

To err is human.

In principle, mistakes are inevitable. They should therefore be called “learner”. And at least ensure that what has already gone wrong once does not happen a second time.

To do this, mistakes have to be perceived and accepted. In order to then examine them honestly, openly and transparently. If, on the other hand, they are covered up or glossed over, there is no learning effect.

Full article (pdf)

Medicine learns from aviation

Lufthansa has been seizing mistakes as opportunities since around 1990. Because only when what has gone wrong is named can causes uncovered and standards improved. Errors do not just happen, but are usually the result of many minor inaccuracies and attentions.

Most accidents happen as a result of incorrect behavior. The German Society for Orthopedics and Trauma Surgery therefore started a training program on interpersonal skills together with Lufthansa. The “human factor” is the focus of attention.

First and foremost, errors are prevented if we can communicate with one another in an open, clear and transparent manner. Rigid hierarchies, on the other hand, lead to so-called error avoidance behavior. People should not admit to having done something wrong or observed mistakes. No such system learning. For example, a student nurse does not dare to point out to a chief physician that he should remove his watch and disinfect his hands before the rounds.

We can only learn from mistakes if everyone involved looks at an unfortunate chain of events in an unbiased, sober, open and hierarchical manner in order to discover the system gaps. Immediately indicting the supposedly guilty, on the other hand, leads to justifications, attack and defense strategies. The war of words that follows blocks learning effects.

In Switzerland, a patient safety system has been established in which, as with flight companies, error analyzes are used for training purposes in order to stimulate structural change management (www.patientensicherheit.ch). There it was learned that the same errors can happen again even if they were to be prevented by a new backup (reason 2004). It is therefore not enough “not to want to make the same mistake again” and just concentrate on more precise standard instructions. Instead, an understanding of risks, uncertainties, imponderables and unpredictable dynamics must lead to the support and training of competent, innovative employees in such a way that they can creatively adapt to new circumstances. This requires typical human competencies, such as effective communication and professionally guided learning through experience. All employees must be involved, especially those who have been involved in unfortunate, erroneous events without malicious intent. Quickly parting with seemingly guilty, pre-convicted people is not effective. Because the remaining staff is threatened with stressful and uncreative error avoidance behavior. It should feel safe if it precisely adheres to instructions and rules. But experience has shown that the atmosphere of fear generated by a quick prejudice could (to protect oneself from accusations) lead to a deterioration in the quality of the patient (through responsibility behavior, “a lot helps a lot” or unreflected obedience). The resulting narrow-minded government thinking could further increase the risk of errors, especially if those involved are overburdened and insufficiently trained.

The cooperation of the German Society for Orthopedics and Trauma Surgery with Lufthansa could therefore initiate useful changes in many other areas of medicine in Germany.

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The Swiss Cheese Theory of System Failure

Sometimes the same errors happen again even if a completely new backup should prevent them. For example, with a blood transfusion. Because all the safety precautions that have been devised so far and that are connected one after the other are the same slices of Swiss cheese, which may ward off most of it, but are perforated in at least one (previously undreamt-of) place. This is usually not a problem, because further penetration after an initial security check is usually stopped by the next "cheese" slice (Reason 2004, Peltomaa 2012).

But if the "Swiss cheese slices" are shifted so that their holes are in a line one behind the other, a risk can pass unhindered through all safety obstacles.

That rarely happens. But then disasters that occur despite all precautions turn out to be particularly malicious (Thaleb 2019).

Errors happen (despite precautions)

So it is not enough “not to want to make the same mistake again” and cling to standard instructions that derive their wisdom from the past. Instead, risks, uncertainties, imponderables and unpredictable dynamics have to be taken seriously in order to be able to deal creatively with completely new circumstances. This requires typically human skills that are trained through learning through experience. While instructions, rules and processes are processed much more efficiently by algorithms.

Experience arises only after the event for which it would have been used.

We learn by observing the discrepancies between a desired outcome and the reality achieved. That works well if we try something carefully. Because then the inevitable errors remain relatively small.

The aviation industry has learned from this and is very open about mistakes. For example, with the experience of the crash of Air France flight 440 in 2009. So that this disaster (influenced by human behavior) cannot happen again, pilots are now being trained to act prudently even when their measuring instruments and computers indicate nonsense . How else (without analyzing this crash catastrophe) would they have learned that?

Pilots train their ability to communicate more openly, clearly and without hierarchies. Especially in emergency situations. Such a “courage to be open” would be very strange in many medical institutions. (Schmidt-Sausen 2018)

But health workers in particular should

„… Sharpen awareness of situations in which mistakes can occur. And to be effective, these skills have to be trained regularly. "(Reason 2004)

literature

  • Edrees: Supporting clinicians after medical error, BMJ 2015; 350: h1982
  • Jäger: To err is human - safety and the human factor, Sicherheitsingenieur 2012 (8): 8-15 (PDF download)
  • Peltomaa K: James Reason: Patient Safety, Human Error, and Swiss Cheese, Quality Management in Health Care. 21 (1): 59–63, JAN 2012
  • Reason: Beyond the organizational accident: the need for "error" wisdom on the frontline. Qual Saf Health Care 2004, 13 (Suppl II): ii28-ii33
  • Schmidt-Sausen .: Courage to be open. Pilots train doctors and nurses. DÄB, 2018, 115 (7): B244-46

Error management in medicine

Until 200 years ago, medicine was mostly ineffective & harmful. (Wooton 2006)

Today, however, the sick feel relatively safe (with us) if they believe in treatments and hope for a cure. They trust that past mistakes have been learned from. Is that so?

Can medical crimes no longer repeat themselves?

Seventy years ago in Nuremberg medical trials it was discovered how prisoners were tortured to death in university research projects (e.g. in Dachau). One of the doctors in charge, Prof. Peter Mühlens, the head of the Tropical Institute Hamburg, had, for example, infected concentration camp inmates and psychiatric patients with typhus and malaria from 1933-43. Many of these doctors believed, like the camp doctor Karl Gebhardt: to have acted completely correctly,

“So, as I tried to show, the Third Reich [...] gave me a great opportunity in the medical field. I took the chance. "(Gebhardt 1947)

How did such doctors become perpetrators?

Why, for example, were American prisoners of war operated on to death in the context of research into tuberculosis treatment in Japan during World War II? The Japanese literary award winner Shūsaku Endō was fascinated by this question, evaluated all available documents and created a psychogram of those involved. Rich in nuances, he described the personalities of “normal” nurses and doctors who were drawn into the events, got entangled, and who finally no longer managed to break free from the dynamics of madness.

Was it psychopaths disguised in doctor's coats, torturing and murdering? Endo doesn't believe in that. Rather, he sees the guilt in the external circumstances, which through ideology, dogmas, belief in medical progress, social obligations, standardization, career opportunities and social incentives, in principle, make well-meaning and also doubting people guilty. Given these social constraints, a free will to act morally is a pure illusion:

“If I had been faced with decisions like Dr. S.? Who am I to say that I would have acted differently? "(Endō 1958)

Could crimes repeat themselves?

This is supported by the fact that only a few years after the Second World War, physicians in other regions of the world again made human experiments.

In Guatemala, for example, soldiers, prisoners, prostitutes and the mentally ill were infected with syphilis from 1946-48. The list of similar attempts (in the USA alone) is long:

Another example: In the French colonies, attempts were made in the 1950s to eradicate sleeping sickness with the drug lomidine / pentamidine. In mass campaigns, the necessary syringes were forcibly administered and, if necessary, also with force. The benefit was little. Instead, many fell ill or died of the consequences of illness. In 1957 these human experiments were finally stopped and everything was done to cover up the damage caused (Lachenal 2014)

And even today there are “areas without medical ethics” (medical ethics free zones) (NEJM 2013). Doctors monitor torture and executions or are involved in organ trafficking (BMJ 2015).

And of course people are still being used as guinea pigs to test out new products from the pharmaceutical industry (Somo, CNN, Pandemrix).

Including the 800,000 children who received an immature vaccine in the Philippines in 2016-2017. Fourteen of them died (BBC 02/03/2018).

Damage also occurs when good is to be done.

Most doctors want to help, support, alleviate or heal. And in doing so, they are usually deeply convinced of the meaningfulness of their actions.

But even then, they sometimes cause problems that would not have existed without their treatments. For example with the

Neurosurgery of mental diseases

Rosemary Kennedy, the fun-loving sister of the later President JFK, was extradited to the renowned psychiatrist Walter Freeman at the age of 23, who was able to operate on psychological problems. Her father suffered from mood swings and could not bear her inability to achieve the high intellectual and athletic performance expected of him.

Dr. Freeman was a recognized authority in his field in 1941. His teacher was the Portuguese neurologist Egas Muniz, who received the Nobel Prize in 1949 for discovering the “therapeutic value of prefrontal leukotomy in certain psychoses”.

Rosemary was one of Freeman's first and arguably most famous victims. He drove a hook-shaped instrument into her skull between her nose and eye. And there destroyed the front part of the brain, which is particularly typical for human behavior.

After this procedure, Rosemary was no longer a "pain in the ass". She acted like a toddler, stared motionless at the walls, could only babble incomprehensible word structures, and remained a nursing case until her death.

Freeman himself performed the "frontal lobotomy" about three thousand five hundred times, and toured across the United States with a "Loboto-mobile". More than 40,000 people in the USA were mutilated by other “psycho-surgeons” who then vegetated in asylums.

Freeman himself can of course not recognize the nonsense caused by him, because he is "hammering" in a trance. And it is precisely this seemingly absolute self-certainty of delusional behavior that pulls those around you under the spell of his pseudo-scientific model of belief. In view of the rational authority of “eminence based medicine”, compassion for the victim only has its place in the gesture of helping hands, which are supposed to convey to the victim that “everything will now be all right”. Image: Spiegel 02/28/2014

When Freeman was banned from mutilating interventions in 1967 at the latest, psychosurgery should have moved from the operating rooms to the museums. She didn't. On the contrary:

Freeman paved the way for more and more refinements of “neurosurgical interventions in the psyche”. (Mashour 2005, Jeha 2007, Stone 2008, Lapidus 2013). This mechanical fiddling with highly complex system relationships that can only be grasped in a quantum-physical manner (Buzsáki 2018) naturally makes no sense. But it happens anyway: It is only a matter of time before the first head is transplanted. (Ren 2017) “Anyone who has a hammer as a tool sees a nail in every problem.” Watzlawick

The lobotomy disaster was not an isolated incident.

As examples of the multitude of small and large undesirable developments in modern medicine, there are three interventions in pregnancy that were considered completely harmless at the time of their introduction:

a) Thalidomide (Contergan ©)

In 1954, thalidomide (α-phthalimidoglutarimide) was discovered and manufactured as a sleep and sedative with few side effects. From 1957 at the latest, it was prescribed to pregnant women as a remedy for insomnia, anxiety and nausea. From 1960, women were finally able to buy the drug in Germany without a prescription. As a result, 10,000 to 20,000 babies were born with severe deformities of the arms, legs and, in some cases, the eyes and ears. Much of this damage resulted in death. 46 years after the first deformities became known, the manufacturing company Grünenthal agreed to pay compensation, and it was not until July 15, 2009 that € 50 million could be distributed to those affected.

b) Diethylstilboestrol in pregnant women

In 1938 a synthetic estrogen diethylstilboestrol (DES) was developed at Oxford University. In 1940 it was approved in the USA for the treatment of various menopausal symptoms and for weaning. DES proved to be largely free of side effects.It also seemed to help against repeated miscarriages and nausea during pregnancy. Probably more than 3 million pregnant women received DES, mostly in the USA, but also in other countries. In fact, the benefit of the drug was very little (AMJOG 1953, 66: 1062-81). Nevertheless, thanks to ingenious marketing, it was sold en masse. It was not until 1971 that it was shown for the first time that taking DES during pregnancy (14-22 years after birth) increased the incidence of a rare type of cancer (light-cell adenocarcinoma of the vagina) (NEJM 1971, 284: 878-81); today it is known: about forty times as much. Other disorders that are thought to be related to DES administration during pregnancy are infertility, a higher risk of miscarriages, and breast cancer. Some of the serious side effects were not discovered earlier because (in contrast to thalidomide) they did not show up until many years later. And there won't be a single-mono-causal relationship, because many harmful effects in complex relationships influence each other unfavorably.

c) Leukemia and low dose X-rays during pregnancy

In many industrialized countries it was recommended after 1945 that the pelvic bones of pregnant women be x-rayed. One wanted to deduce from this whether a birth could take place naturally, and thus reduce the number of difficult births. The X-ray technique was very easy to use and painless. The risks appeared to be very low because the “large-scale experiment” recently carried out in Hiroshima and Nagasaki exposed pregnant women to much higher x-ray doses, but if they survived, the authorities reported relatively little permanent damage to children. In addition, no significant side effects occurred in the observations immediately after low-dose diagnostic radiation. The unborn children did not seem to be affected in their well-being.

In principle, it was argued in the same way as it is still common today for other interventions in pregnancy: There is probably a certain benefit that cannot be withheld from pregnant women for ethical reasons. In addition, increased mortality for both mother and child is ruled out, and there is no evidence of long-term damage of any unknown nature. So use the method without hesitation.

As a result, in some hospitals in Europe and North America, up to 25% of pregnant women were x-rayed according to the then-current guidelines (Lewis 1960). In the 1950s, the epidemiologist Stewart noticed an increase in childhood leukemia in England. Since this seemed unusual to her, she looked for clues to events that were increasingly true of the children concerned.

In her first study, she found that of 296 children who died of leukemia under the age of ten, 46 had been x-rayed in their wombs. In the control group of 269 children there were only 24 (Steward 1956). Two years later, she published that leukemia (and a few other cancers) occurred in 13.7% of 1,299 children who were X-rayed during pregnancy. In the control group, the rate was only 7.2% (Stewart 1958). These publications in no way led to a change in the expert recommendations. Instead, it was discussed, among other things, that the observations, at least in one hospital, did not confirm the high probability of illness assumed by Stewart (Lewis 1960). However, Alice Stewart and her colleagues were later able to clearly confirm their suspicions through more intensive data analyzes and longer observation periods, and on this solid basis they began to discuss the possible causal relationships (Stewart 1962).

Nevertheless, the method continued to be recommended as effective (Barron 1964). It was not until 1974 that it finally seemed no longer controversial that the risk of later dying of leukemia in irradiated unborn babies was about 2-3 times greater than in non-X-rayed children, and that there was no lower limit value for this phenomenon. (Mole 1974)

A decade later, it was also proven that low-dose diagnostic X-rays after birth also increase the risk of later onset of acute lymphoblastic leukemia (Steward 1986, Wakeford 2003, Bartley 2010). Meanwhile, leukemia is the most common cancer in children. And the number of sick people continues to increase in developed countries (Shah 2007).

The usefulness of x-ray pelvic measurements had been questioned as early as 1975 (Kelly 1975). Because the inherently elastic pelvis deforms during the dynamic birth process. From 1997 it was then undisputed that the rates of cesarean section even prenatal examinations with magnetic resonance scanners (MRI) could not be reduced (von Loon 1997). And in 2007 it was finally recommended that the method no longer be used because of the lack of benefit. (Rosenberg 2007).

It took about half a century before an intervention that brought little (or no) benefit to pregnant women, but caused significant long-term harm, was abolished. Hopefully everywhere and worldwide. But that is not certain, as no one can guarantee that in individual cases poor quality will not continue to be offered.

Precautionary or intervention principle?

The first health philosophers in Greece and China wanted to prevent damage. They therefore demanded that doctors adhere to the precautionary principle. And they recommended that the one who advises whether a leg needs to be removed should not be the one to amputate the leg afterwards. Today it is more the rule that those who advise sell the right solutions straight away.

literature

Complex systems (including the brain)

Medicine ethics

  • Lachenal G. The Lomidine Files. The Untold Story of a Disaster in Colonial Africa. John Hopkins Univ Press 2017 (original in French 2014)
  • Shūsaku Endō: Sea and Poison, Fischer TB, Frankfurt 1984, first edition: Tokyo, 1958. Book reviews: 1) "aus.readesen 2011", 2) Roy, BMJ 2009; 338: b782
  • Wooton D: Bad Medicine: Doctors Doing Harm Since Hippocrates, Ox Univ Press 2006

Literature on Alice Stewart: X-rays in pregnancy

Psychosurgery

history

literature

  • Christmas D et al Neurosurgery for mental disorder, Advances in Psychiatric Treatment May 2004, 10 (3) 189-199
  • Jeha EL et al .: Surgical outcome and prognostic factors of frontal lobe epilepsy surgery, Brain 2007, 130: 574-584
  • Lapidus KA et al: History of psychosurgery: a psychiatrist’s perspective. World Neurosurg. 2013; 80 (3-4): S27.e1-16 - Neuromodulation for Obsessive Compulsive Disorder. Neurotherapeutics. 2014 Jul; 11 (3): 485-495.
  • Mashour et al: Psychosurgery: past, present, and future, Brain Research Reviews 48 (2005) 409-419
  • "Neurosurgery for Mental Disorders"
    • in England 2015: Mind.org.uk
    • in China 2013: Heeramun-Aubeeluck A, Afr J Psychiatry 2013; 16: 177-181)
  • Stone A: Psychosurgery: Old and new Psychiatric. Psychiatric Times 06/02/2008
  • Ren X, Canavero S: HEAVEN in the Making: Between the Rock (the Academe) and a Hard Case (a Head Transplant), AJOB November 17, 2017: 200-205

The US President Harry S. Truman announced a new international "development" strategy on January 20th, 1949, which was intended to distinguish itself from both the "colonial civilization mission" and the (socialist) "liberation movements":

"The growth of production (of the underdeveloped countries) is the key to prosperity and peace". H.S. Truman, Inaugural Address 01/20/2049

President John F. Kennedy then shaped this idea into a global program:

“We promise to do our best to help out, however long it takes, to the inhabitants of huts and villages halfway across the planet who are struggling to break the chains of mass misery. (...) if a free society cannot help the mass of the poor, it cannot save the small number of the rich. ”J.F Kenndy, Inaugural Address, 01/20/1961

Few who lived in “the free world” dared to contradict these bold American theses. One of them was the theologian and philosopher Ivan Illich.

He described the newly invented "development policy" as "externally determined" modernization of poverty "(quote from Paquot 2017), and considered it to be" more dangerous than colonial proselytizing. "(Quote from Paquot 2017)

Today his criticism is largely forgotten. But are many of his thoughts not always relevant?

The following Quotes are taken from:

  • Ivan Illich (1972): “Planned poverty as the fruit of technical assistance” in “Schools do not help - About the myth-making ritual of industrial society.” Pages 120-135

What is "development aid"?

Today, out of goodwill, rich nations give poor nations a straitjacket made of traffic jams, hospital stays and classrooms and call this "development" according to international agreements. The rich, school-educated, and old of this world are trying to share their dubious blessings by imposing their packaged solutions on the Third World. Traffic congestion occurs in Sao Paulo, while one million people in northeast Brazil cover 800 kilometers on foot to escape the drought. Latin American doctors receive training at the New York Specialty Surgery Hospital that they only benefit a few, while amoebic dysentery remains endemic in the slums, where 90 percent of the population live. A tiny minority in North America receives advanced training in the basics of science, the cost of which is not infrequently paid for by their own governments. If they return to Bolivia at all, they will become second-rate teachers in high-class subjects in La Paz or Cochibamba. The rich export outdated models of their standard products.

It is a common demand today that the rich nations convert their military apparatus into a development program for the Third World. [...] But that could in turn cause incurable despair, because the plows of the rich can cause just as much damage as their swords. American trucks can do more permanent damage than American tanks. It is easier to get a mass poll of those than of these. Only a minority require heavy weapons, while a majority may find themselves unrealistically dependent on the supply of productive machinery, as modern trucks do. Once the Third World has become a mass market for goods, products and processes that the rich have designed for themselves, the disparity between the demand for these Western products and their delivery will grow for an indefinite period of time. The family car cannot transport the poor into the jet age, a school system cannot provide education for the poor, and the family refrigerator cannot ensure healthy nutrition for them. ...

What is underdevelopment?

Underdevelopment as a form of consciousness is an extreme consequence of what we, like Marx and Freud alike, can call “reification”: the perception of real needs hardens to the demand for products of mass products. I mean the translation of thirst into a need for Coca Cola. Such reification takes place in the manipulation of basic human needs by huge bureaucracies that have managed to control the imagination of potential consumers. Let us return to my example from education. The intensive promotion of the school system leads to such an extensive identification of school attendance and education that the two terms can be used interchangeably in everyday language use. Once the imagination of a whole population is “schooled” or drilled into the conviction that schools have a monopoly on education, the illiterate can be taxed in order to provide free school and higher education for the children of the rich.

Underdevelopment arises when desires are raised through the intensive sale of "patent products". In this respect, the dynamic underdevelopment currently taking place is exactly the opposite of what I consider education to be: namely, the awakening awareness of new heights of human ability and the use of one's own creative power to further human life. Underdevelopment, on the other hand, means that social consciousness surrenders to packaged solutions.

The process by which the sale of “foreign” products increases underdevelopment is often only understood very superficially. The same person who is indignant at the sight of a Coca-Cola factory in a Latin American slum often feels proud to see that a new elementary school is being built next to it. He disapproves of the foreign license for a soft drink and would rather have "Cola-Mex". But the same person is ready to force schools on his fellow citizens at any cost; he does not notice the invisible license by which this facility is closely linked to the world market. ...

Who do “package solutions” benefit?

Every car that Brazil sends out onto the streets does not have a good bus network for fifty people. Every refrigerator sold diminishes the chances of a public refrigerator being built. Every dollar given to doctors and hospitals in Latin America costs, as the eminent Chilean economist Jorge de Ahumada said, a hundred lives. If every dollar had been spent providing safe drinking water, the lives of a hundred could have been saved. Every dollar spent on education means more privileges for the few at the expense of the many; at best, it increases the number of those who, before failing, learn that those who stay longer acquire the right to more power, wealth, and prestige. Such a school system only teaches the trained that the better trained are superior to them.

In terms of their layout, the “packages” I am talking about are the main cause of the high cost of meeting basic needs. As long as everyone “needs” their car, our cities have to put up with ever longer traffic jams and grotesquely expensive remedies. As long as health is synonymous with maximum lifespan, our patients will be given increasingly unusual surgical interventions and drugs to relieve the subsequent pain. As long as we want to use schools to take the children from their parents or to get them off the streets or to keep your job market away, our youth will experience endless classes and need ever stronger incentives so that they can endure this torment.

Are there alternatives?

I am thinking of a completely different, particularly difficult type of research which, for obvious reasons, has so far been almost neglected. I call for research into alternatives to the products that dominate the market today: to hospitals and the profession that seeks to keep the sick alive; to schools and the resulting process that denies education to those who are not of the right age, who have not completed the correct curriculum, who have not sat enough hours in a row in the classroom, who do not want to pay for their learning by themselves Subject to caring oversight, scrutiny and certification, or allow the values ​​of the ruling elite to be funneled into you.

We have embodied our world in our institutions and are now prisoners of them. Factories, mass media, hospitals, governments, and schools produce goods and services that are packaged in our worldview. We, the rich, think of progress as an extension of this establishment. We understand increased mobility as luxury and security in packages from General Motors or Boeing. By promoting general welfare, We mean increasing the availability of doctors and hospitals who deliver health in a package with increased suffering. We have got used to identifying our need for more learning with the demand for longer and longer confinements in classrooms. In other words, we have packed education together with supervisory care, authorization, and the right to vote, and wrapped that up in teaching about Christian, liberal, or communist virtues.

Industrial societies can supply such packages for most of their citizens for personal use, but that does not prove that these societies are sensible or economical, or that they serve life. The opposite is true. The more the citizen is drilled into the consumption of packaged goods and services, the less he appears to be able to shape his environment. His strength and money are drained into making new models of his standard goods, and the world becomes a by-product of his consumer habits.

The Third World needs a radical revolutionization of its institutions. The revolutions of the last generation were predominantly political in nature.A new group of men with new ideological justification seized power to administer essentially the same institutions in education, health care and business life for the sake of a new group of beneficiaries. Since the institutions have not changed radically, the new group of beneficiaries remains roughly as large as the previous group.

The time of prophecy lies behind us. The only chance now lies in our taking this vocation as that of the friend. This is the way in which hope for a new society can spread. And the practice of it is not really through words but through little acts of foolish renunciation. "Ivan Illich

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