Comments on

by Advisory Committee to the Federal Bureau of Narcotics

JULY 3, 1958.

Note: To fully understand this document, and the context in which it arose, you should also read these other documents which are in the Schaffer Online library:

Superintendent, Division of Narcotic Control,

State of Illinois

I thing we take too much time from constructive discussion of the narcotic problem for a purposeless working over of what has been called an "English System." With a technique reminiscent of the Hitler "Big-lie," a few people assiduously have spread through the length and breadth of this land an impression that in England there is some magic afoot which is the key to the narcotic addiction and the narcotic control problem. Let us try to lay that ghost once and for all. Actually, of course, the English system of narcotic law control is not too different from our own. The United Kingdom subscribes to the same international conventions and agreements that we do. Their system of law enforcement does not diverge too greatly from that of this country and Canada. I read from a United Kingdom Home Office publication of February 1956 to doctors and dentists: "In no circumstances may dangerous drugs be used for any other purpose than that

of ministering to the strictly medical or dental needs of his patients. The continued supply of dangerous drugs to a patient solely for the gratification of addiction is not regarded as 'medical need,' " etc., etc.

That certainly sounds like American policy, does it not? The "fine print," if any, is in appendix Four, paragraph 51(C),which refers to a case, "where it has been similarly demonstrated that the patient, while capable of leading a useful and relatively normal life when a certain minimum dose is regularly administered, becomes incapable of this when the drug is entirely discontinued." Whether there really are such people is certainly a matter for debate. If there are, their number would be so small as to have no weight whatever in the determination of the program, in my opinion.

Dr. R. G. E. Richmond, who for years specialized in psychiatric work in prisons both in Canada and England, testified in a Canadian Senate committee hearing in 1955, in response to a question as to the reason there is so little drug addiction in Britain compared with Canada, considering the huge difference in the population:

I have thought so deeply about this and the answers that I can give I am afraid sound rather vague, but I feel that tradition, cultural standards and perhaps discipline during childhood enter into it to some extent. The tradition that "it just isn't done" in a way I think dies very hard in people.

But is not this all beside the point a one can be relatively ignorant of law enforcement and still know that what will produce good law enforcement for England will not necessarily produce good law enforcement in the United States of America. We read in the contemporary newspapers that some of the English police are considering carrying guns, but generally they do not. There were 38 homicides in the London Metropolitan area last year. I suppose that covers about 10 million people. In Chicago, with much less than half that population, there were 131 homicides for the first half of 1957, an annual rate of 282. This point could be labored in a comparison of practically every type of crime between the countries. One should first know the climate in which a garment is to be worn before he considers the kind and quality of cloth and how to cut it.

Despite our possibly tighter interpretation of the same fundamental philosophy, we nevertheless as late as the 1930's suffered from the outrages of a Ratigan who under the guise of practicing medicine sold in 1 year 400,000 doses in office-administered shots of morphine to addicts in Seattle, several times as much as all the other doctors and all the hospitals in that city dispensed in the same time. Ultimately, of course, he did 7 years in the penitentiary. The most vociferous promoter of the English system myth in this country has defended Ratigan and has referred to him as a hero. I refer to Mr. Rufus King who is member of a Joint Committee of the American Bar Association and the American Medical Association on Narcotic Drugs.

Perhaps taking advantage of a slightly more complacent interpretation in England and despite the usual rigid English conformity to the law, that country recently had its John Bodkin Adams (whom the press seemed to like to refer to as Irishman). According to press accounts Dr. Adams was investigated when deaths among his patients became a public scandal. He was acquitted of murder, perhaps for the good reason that he may not have been guilty, perhaps again only because there were uncomprehensible lapses in the investigation of his case. In any event he later pleaded guilty to violations of the Dangerous Drug laws and was barred from practice. The ironical thing about the English system is that Dr. Adams' narcotic deviations were not discovered until there was a charge of murder. Adams apparently made many heroin addicts, most of whom I suggest do not appear in the English addiction statistics, but in the mortality tables.

So, it may well be that the better addiction incidence ratio in the British Isles is not due to any superiority in their system or magic in their medicines. Is not it likely that it is in spite of the small differences in the systems rather than because of theses Did it ever occur to our friends that people, countries, and cultures differ?

Let me try to ventilate the fog surrounding this "English system" with one more blast of the cold air of common sense and then I am done with it. There are more smoking opium and hashish violations in the United Kingdom than there are in this country. When we informally query our English contemporaries, this situation is dismissed with the observation-"Well, this applies only to the colored or Chinese population." We wish we could dismiss our problem so lightly.

Reading the report of the United Nations Commission on Narcotic Drugs for the April-May 1957 session, one sees such things as references to 17,897 narcotic arrests in Hong Kong, 12,787 related to heroin.

These narcotic arrests loom up to about half as many as for the whole United States. Reports on Singapore are of a similar tenor.

What is the significance of this? Why nothing more than the all important and inescapable fact that these are Crown Colonies of Great Britain, governmental entities ruled from Whitehall and the direct responsibility of the Queen's ministers. And under what kind of a narcotic law enforcement system? Why, the "English system," of course. If there is any magic in an "English system," why do these conditions exist? The simple answer is that it all depends on the circumstance under which you operate your system.

In passing, Canada has the same rate of addiction as the United States. Dr. Paul Martin, Minister of Health, stated to a Senate committee that he has been unable to find any difference between the

British and Canadian narcotic laws. Let us be done with this English system foolishness and get on to sounder matters.

From the Joint ABA-AMA report under the heading GREAT BRITAIN, page 18:

"In 1956 the Minister of Health, allegedly responding to pressure from the United States, announced that he proposed to ban the use of heroin in Great Britain for medical purposes. Following this announcement medical practitioners began to buy up supplies, prices rose, and it is believed that a small black market may have made its appearance. Some prominent doctors there-upon organized a campaign to oppose the ban, prevailing upon the Minister, after a much-publicized controversy, to prohibit only the exportation of the drug. Thus the Minister saved face while leaving the profession free in the matter. There is still mild resentment over the fact that because heroin was removed from the British Pharmacopia in 1956 when the ban was proposed, American authorities hailed this as a prohibition and still make statements to the effect that England has joined the United States in outlawing the drug."

The allegations regarding the United States are an outright falsehood.

Letter dated June 3, 1958, to Bureau of Narcotics from the Home Office, Whitehall, London:

Mr. Harney's remarks seem to make a good deal of sense and I hope that the publication of the record of what he said will help to do some good in your country.

As regards the visits of Americans to this country we are in this difficulty, that it is not possible for us to refuse to have a talk with visiting Americans who ask to be allowed to visit the Home Office to discuss the so-called "British System." However when we do see these visitors any remarks which we make are rather on the lines of what Mr. Harney has said, and we make it clear that there is not in fact any such, thing as a "British System," which is an, invention of certain Americans who wish to prove a: particular point of view. I usually recommend such visitors to read John Walker's statement to the Canadian Senate Committee of Inquiry of 1955 which is a factual and objective statement of our practice.

* * * * * * *

The higher consumption of narcotic drugs in the United Kingdom as compared with the United States is in my view mainly a reflection of the fact that we have a free National Health Service.

Letter dated July 8, 1958, to Commissioner Anslinger from Mr. T. C. Green, Chief, Dangerous Drugs Branch, Home Office, Whitehall, London:

I have recently had a letter from the National Association of Attorneys General asking how the problem of drug addiction is handled in England.

I have replied to this enquiry on the usual lines, sending them a copy of John Walker's evidence given to the Canadian Senate Committee in 1955. As, however, that evidence refers to the advice given by our departmental committee on morphine and heroin addiction in 1924, I mentioned that the Minister of Health has recently set up a new committee to review the advice given by the previous committee, and I enclosed a copy of the Parliamentary Question and answer giving the terms of reference and composition of the committee.

I imagine that you will already have heard about the new committee, but in case you should not have done, and should be embarrassed by fist hearing of it from someone else, I am enclosing a copy of the Question and answer.

Hansard, Monday, 16th June, 1958.

Written answers

Morphine and Heroin Addiction Committee 1956 (Review)

Sir H. Linstead asked the Minister of Health whether he will now review the advice given by the Departmental Committee on Morphine and Heroin addiction in 1926.

Mr. Walker-Smith: Yes. In consultation with my right hen. Friend the Secretary of State for the Home Department, my right hon. Friend the Secretary of State for Scotland and I have appointed a Committee with the following terms of reference:

To review in the light of more recent developments the advice given by the Departmental Committee on Morphine and Heroin Addiction in 1926; to consider whether any revised advice should also cover other drugs liable to produce addiction or to be habit-forming; to consider whether there is a medical need to provide special, including institutional, treatment outside the

resources already available, for persons addicted to drugs; and to make recommendations, including proposals for any administrative measures that seem expedient, to the Minister of Health and the Secretary of State for Scotland.

The membership of the committee is as follows:

Sir Russell Brain, Bart., D. M., F. R. C. P., (Chairman)

Laurence Abel, Esq., M. S., F. R. C. S.

D. M. Dunlop, Esq., M. D., F. R. C. P., Ed., F. R. C. P., F. R. S. E.

Donald W. Hudson, Esq., M. P. S.

A. D. McDonald, Esq., M. Sc., RI. D.

A. H. Macklin, Esq., O. B. E., M. C., T. D., RI. D.

S. Noy Scott, Esq., M. R. C. S., L. R. C. P.

M. A. Partridge, Esq., M. A., D. M., D. P. M.

EXCERPTS FROM TESTIMONY

By Dr. A. W.MacLeod,

Director, John Howard Society of Montreal,

Before the Senate of Canada, Special Committee on the Traffic in Narcotic Drugs in Canada, May 27, 1955

Since 1938 I have been concerned with the treatment of individuals suffering from psychiatric illness. Most of my experience of the treatment of drug addicts was gained while I was assistant director of an inpatient psychiatric unit attached to one of the teaching hospitals of London University. The majority of the cases under my care were professional people, mainly doctors, although the list included nurses and nonprofessional people as well. Some of the patients were under voluntary treatment and some as a result of court probation order. I was also fortunate in being able to call on members of the Dangerous Drugs Inspectorate of the Home Office for help and advice. Perhaps I should take this opportunity of stating that no matter how lenient the recommendations of the departmental committee (1924) on morphine and heroin addiction might appear on paper, in actual practice, in my time, all members of the inspectorate staff were strongly opposed to any line of action that would allow a known addict to continue his addiction with the help of a doctor who was willing to attempt to keep the addict on a minimum maintenance dose. I use the word "attempt" advisedly as I never discovered a case in which this method proved successful. This is not to be wondered at when one takes into consideration that nearly all persons who become addicted have clearly recognizable psychological disturbances to start with, coupled with the fact that toleration of the drug soon develops and requires an ever increasing dose for temporary relief from psychic distress.

In the first place the problem of drug addiction is a complex problem involving social, psychological, medical and legal aspects. The temporary separation of the addict from his drug of choice presents no unsurmountable medical problem, although the physicians' task can be greatly complicated by the absence of such measures as some form of legal restraint to insure that the patient carries out the withdrawal treatment during which time his judgment concerning himself is far from valid.

The social rehabilitation of the temporarily-withdrawn addict presents almost impossible difficulties although here and there one comes across the odd case which provides a glimmer of hope. Some evidence has been given before the committee, I believe, to the effect that the drug addict on a maintenance dose is less of a danger to society than say an alcoholic and that there are no epidemiological problems related to this illness. This has not been my experience. Without exception every addict whom I had in treatment either attempted to give expression to or fought against a clearly recognized desire to involve nonaddicts. Although it would be logical to assume that the reason for such proselytism is the desire to render surer a source of supply of the drug, it was my opinion that this activity was the outcome of much deeper psychological conflict, and indicated a perverse inner need of the addict to turn his self-destructive drives against those around him as well as against himself. Drug addicts are predominantly sociable people, and they cannot stand any degree of social isolation for very long without attempting to find a suitable companion. As a matter of medical interest, I found this desire to make converts much more pronounced in the male addicts than in the female addicts. It is my belief that drug addiction has many features of an infectious disease. This is more clearly seen of course in the case of chronic alcoholism and barbiturate addiction but the present observation that new addicts are not being sought by the drug pedlar is probably more an indication of the stepped-up efficiency of the enforcement officers, than it is of the tendency of the demand for narcotics to reach a stable level.

To begin with the problem must be recognized as affecting the whole community. The public must be educated to recognize its present inadequacies for the treatment of this serious illness. In the light of our present knowledge there is little evidence to support attempts at ambulatory treatment on an outpatient basis for the confirmed addict, and arguments in favour of the establishment of narcotic clinics where registered users could receive their minimum required dosage of the drug, can only be put forward by those with little experience in this field as there is no scientific basis for the proposal whatsoever.

Drug addiction leads to a remarkably unstable physiological state, and increasing toleration of the drug calls for increasing dosage.

The confirmed drug addict has an illness which involves the loss of power of self-control and his treatment requires some means whereby be can be legally detained for the period during which his judgment concerning himself is not valid. Moreover, his treatment must advance equally in the field of social readaption as in the field of personal psychological insight.

EXCERPT FROM STATEMENT ON THE NARCOTIC DRUG TRAFFIC

By the Hon. PAUL MARTIN, Minister of National Health and Welfare, before the Senate of Canada, Special Committee on the Traffic in Narcotic Drugs in Canada, Tuesday, March 15, 1955

Legal Distribution to Registered Addicts

The third proposal made in the Vancouver brief is perhaps the most controversial proposal that has been made in connection with a treatment program. I do not propose to go into the implications of this in detail because I see that Dr. Stevenson, to whom I have already referred, has published in the January issue of The Bulletin an article entitled "Arguments for and against the Legal Sale of Narcotics."

In this article, Dr. Stevenson deals adequately and exhaustively with this proposal and I would only add to what he convincingly sets forth that enforcement authorities in Canada and the United States are unanimously opposed to any plan involving free drugs to registered addicts for self-administration, Perhaps Dr. Stevenson, if he appears before this committee, will wish to explain a further proposal which I understand he has made involving the withdrawal of addicts in general hospitals followed by a specialized rehabilitation program. A proposal for the treatment of addicts under an approved plan, which as part of it would require the administration of narcotic drugs under medical supervision, would not involve any change in the existing law. The provision, however, of drugs to compete with the illicit traffic is not, in my view, proper treatment and is not a matter that I could ever support. Apart from these reasons, there is the additional question of our international commitments by which we have agreed to limit narcotic drugs to medical and scientific use. It is highly doubtful if the provision of drugs to addicts could be said to come within such use.

There is a further suggestion which has been advanced but is not one made in the report which I have referred to. It is, however, one that has been put forth by many experienced enforcement authorities as offering the most practicable and realistic approach to the solution of the drug addict. This involves the establishment of treatment institutions with legal authority for the committal and detention of addicts for such period as is necessary for their treatment and rehabilitation. It would require the legal right to return to such institution an addict who has been released on discharge which, in turn, recognizes that a certain number of addicted persons might be more or less permanent inmates in that little hope could be held out for their successful treatment.

A close study of the operation of the treatment center at Lexington, Ky., which I have already commented upon, is strongly recommended in connection with any such plan. Incidentally, I should point out that the Lexington institution would appear to be a very costly operation because of its size and the very elaborate facilities as well as the staff which is required. There is also a treatment center for juvenile addicts being operated by the City of New York at Brothers Island in that city. Here again, the cost of the operation on a per patient basis is very high.

The question may arise as to whether, if this is a proposal which has been recommended by enforcement authorities, the Federal Government should not undertake it. I would point out, however, that there would be no legal authority for the Federal Government to enact the kind of legislation requiring the compulsory committal and detention of drug addicts while undergoing treatment. This is a matter with which only the provinces could deal for the reasons which I have previously referred to in discussing the jurisdictional aspects of the problem.

It is pointed out by the authorities that the compulsory committal of drug addicts either upon their own application or upon the application of interested friends or relatives would effectually remove them from access to the illicit market and would thus bring about a reduction and eventual elimination of the traffic. Perhaps others who will appear before the committee will wish to say something with respect to the operation of such a plan. I merely wished to include it with my other comments so as to give to this committee the benefit of a brief review of various proposals which have from time to time been urged by persons who are interested in Canada's drug problem.

United Kingdom

Undoubtedly there will be made during the course of this committee's investigation some reference to the British treatment plan as constituting something that Canada should adopt.

In this connection, I would refer the Honorable Senators to the article by Dr. G. H. Stevenson in the January issue of The Bulletin to which I have already referred. In that article, Dr. Stevenson discusses informatively this so-called British Treatment System and I would recommend a perusal of this to the members of the committee.

I should like to add something to what Dr. Stevenson has said. We have unsuccessfully endeavored to ascertain through the R. C. PM. Police liaison in the United Kingdom, as well as by direct discussion with the United Kingdom authorities, wherein their system of narcotic control differs from ours to an extent that would constitute anything that could properly be called the British Treatment Plan. according to the information which has been officially given to us by the United Kingdom authorities, they maintain as strict a control over the supply and distribution of narcotic drugs as we do.

I understand, however, that they do not have the same requirements in that country respecting reports to be made by wholesalers and druggists as we do in Canada. The furnishing of narcotic medication to addicts solely to support addiction is regarded as improper in the United Kingdom. Ambulatory treatment is frowned upon and the authorities advise that they are quick to take appropriate action whenever a case comes to their attention that a doctor is supplying drugs to an addict. Insofar as the criminal addict population is concerned, the authorities report this to consist of a very few persons and nothing like the number that we admit to in Canada.

I am informed that the legal consumption of drugs in Canada on a per capita basis is, if anything, less than it is in the United Kingdom.

I do not suggest that there is any significant deduction to be made from this but it is a fact to be taken into account in trying to make a comparison between the two countries.

I thought it appropriate to say something along these lines because so much has been said about the merits of the British system as compared with the system employed in this country as to cast some discredit upon our methods of dealing with our drug problem. If anyone is able to explain wherein there is a difference between the British and the Canadian systems, I should be very glad to be informed. If anyone can explain to me why there should be virtually no criminal addict population in the United Kingdom in comparison with the admitted criminal addict population in Canada, I should be very glad to have their explanation. We have not been able to find out any logical reasons for the differences that are reported.

COMMENTS ON THE BRITISH SYSTEM

by Mr. LYNN A. WHITE,

Deputy Chief of Police; commander, Personnel and Training Bureau, Los Angeles Police Department; formerly head, Narcotic Division, Los Angeles Police Department

In the reporting of the addiction problems of England and the United States, "for comparative purposes," the negligence of the committee in failing to analyze the differences of the peoples of England and the United States is regrettable. The dissimilarities in the racial composition, attitudes, cultures, philosophies, and per capita income of the peoples of the two nations are known to even one poorly informed on the subject. This becomes evident even in a casual review of those factors which are substantial measures of a nation's sociological stability, or at least their degree of conformance to laws, mores, and social traditions. Several which may be considered are:

A. Major Crimes per Thousand Population.

1. For 1956, the crime report of the United States reports 20.8 major crimes per thousand population and during the same period, according to "Crime Statistics--England and Wales

1956," page 2, only 4.7 major crimes were reported per thousand population in that country. Therefore it may be safely stated that the reported major crime rate of the United States is more than four times greater than that of England.

B. Divorce Rate per Thousand Population

1. The 1956 divorce rate of the United States, as reported in Britannica Book of the Year 1958, indicates there are 2.4 divorces per thousand in this country as compared to the 1956 rate of .28 per thousand in England, as listed in Britannica Book of the Year 1957. It is plainly evident that this Nation's divorce rate is nearly 10 times greater than England's.

C. Alcoholism per 100,000 Population

1. According to the World Health Organization Technical Report, Series No. 42, Report On The First Session of The Alcoholism Subcommittee, the United States reports 3,952 alcoholics (with and without complications) per 100,000 population, as compared to 1,100 (with and without complications) per 100,000 population, estimated for England and Wales.

Here it is most apparent that, even in the use of alcohol, the English comparatively demonstrate their greater conservatism, restraint and moderation; our rate of alcoholism being nearly four times greater than that of the British.

D. Differences in Racial Components

It is utterly unbelievable that the committee, in comparing the narcotic addiction problem in the United States with that of England, failed to evaluate the disparity in the ethnological components of the two nations.

Categorically they are:

19541--England and Wales (total population, 50,880,000);

Caucasians, 50,780,000, or 99.81 percent;

Noncaucasians, 100,000, or 0.19 percent.

1950 2--United States (total population, 150,697,647) ;

Caucasians, 134,942,314, or 90 percent.;

Noncaucasians, 15,755,333, or 10 percent

This is highly significant for in 1957, of the 8,010 addicts reported to the Bureau of Narcotics by law-enforcement agencies in the United States, only 2,034 were of the white race.

Even if the investigator were to disregard the racial and antisocial behavior differences of the two nations, the extreme peril which accompanies a drug control program which permits easy or ready access to opiates is nowhere so clearly emphasized as it is in Britain's Home Office list of incurable addicts.

Before inferentially embracing the "English system," the committee should have been frightened into a sober consideration of the evidence that in England, the group with the most ready access to opiates or to whom opiates are most readily available, are the very people who have the highest addiction rate.

It is almost inconceivable that the committee neglected to evaluate this reality: That the people (doctors, nurses, members of hospital staffs, etc.), who must be presumed to have knowledge of the addictive qualities of opiates, have the highest group addiction rate of that entire nation.

It is utterly absurd to recommend that restrictions or prohibitions controlling access to opiates be eased, when under the English system--the medical group which represents .75 percent of Britain's population contributes nearly 33 percent of that nation's drug addiction.

When reduced to addiction rates per 10,000 population, it discloses that in England,

(1) The Non-medical Group, without ready or easy access to opiates, has a rate of .046 per 10,000 population (233 in over 50 million).

1 Colonial Office, Ministry of Labor, 1967.

United States Census. 1950.

(2) The Medical Group, with ready or easy access to opiates, has a rate of 2.6 per 10,000 population (nearly 100 in an estimated group of 382,000).

To summarize: In Britain, THOSE WHO CAN OBTAIN THE DRUG WITH EASE HAVE AN ADDICTION RATE THAT IS 5,500 PERCENT GREATER THAN DO THOSE WHO DO NOT HAVE THE DRUG READILY AVAILABLE TO THEM.

An impartial investigator needs no further evidence to reasonably conclude that the easier or more readily available opiates are to the English people, the greater is the possibility of their becoming drug addicts. This appears to be true regardless of their social, economic, or professional status, and irrespective of their knowledge of the perils accompanying the continued use of opiates.

In the light of this information, an interested person must ask- what would happen to the addiction rate in this Nation if drugs were made more easily obtainable

(Note: The writer acknowledges that the above figures may be in error. In the report, appendix (B), p. 6, regarding the chronic cases of narcotic addiction in England, it is stated, "It is of interest that around 100 of these cases are from the ranks of the medical profession itself (75,000 doctors, plus nurses, hospital staffs, technicians and persons in related careers).

This writer, lacking information as to the total numbers which are included in the group-75,000doctors, plus, etc., has turned to The Health Manpower Chart Books, U. S. Department of Health, Education, and Welfare, Public Health Service, August 8, 1957, for comparative information. This source lists 191,947 physicians and 947,902 others in allied professions in the United States and includes dentists, osteopaths, pharmacists, veterinarians, clinical psychologists, dieticians, nurses, technicians-medical and dental, hospital attendants, and practical nurses.

From this, it was established that there are 4.1 persons in allied professions for every one doctor in the United States. Therefore, it was assumed that Britain would have a similar ratio and that there would possibly be 75,000 x 4.1, or 307,500 persons in allied professions, plus 75,000 doctors, for a total of 382,500 doctors and persons in allied professions in that country.

CONCLUSIONS

The Advisory Committee is utterly amazed that the ABA-AMA group recommends measures similar to the British system as a panacea for the problem in the United States. This shows a complete lack of penetrating analysis.

Reference is also made to the report of the Council on Mental Health of American Medical Association which also recommends some form of the British system.

We unanimously reject these recommendations. The proponents of the British system conceal their ignorance by ostentation of seeming wisdom.

Our decision is based on the following:

1. Per capita narcotic consumption in the United Kingdom is double that of the United States, including both licit and illicit, according to United Nations documents.

2. Heroin consumption in the United Kingdom represents 70 percent of all licit heroin consumed in the world.

3. The Crown Colony of Hong Kong has more addicts than there are in the entire United States. The yearly number of arrests in Hongkong, about 17,000, indicates good police work. This British system is ignored by the proponents.

4. Smoking Opium addicts are not included in British addiction figures in the United Kingdom, and the advocates of the British system are silent on so-called minimal doses of smoking opium supplied to these addicts by physicians to keep them normal. The British physician would be in serious trouble with the authorities if he wrote prescriptions for smoking opium. According to seizures of smoking opium reported to the United Nations, there are more addicts to smoking opium in the United Kingdom than there are in the United States.

5. The unfortunate narcotic situation in the United Kingdom is a reflection on free National Health Service, otherwise known as socialized medicine.