THE RHETORICS AND REALITIES OF COMMUNITY-HEALTH CARE - THE LIMITS OF COUNTERVAILING POWERS TO MEET THE HEALTH-CARE NEEDS OF THE 21ST CENTURY

As the paradox of medical success leaves behind more chronicity, polic y makers around the world increasingly focus on community-based progra ms both to address chronic health problems and to prevent major disord ers. This essay presents my comparative sociological framework of idea l-type models for understanding the countervailing powers that underli e and shape different kinds of health care systems and their limitatio ns in addressing the health care needs of the twenty-first century. In this context, I then analyze the revival of community heath care rhet oric in the United States and compare it to the realities in which it operates. The realities of institutional power, fragmentation in fundi ng, illness as a private condition and health care as a private good, the lack of societal commitment, competition, and the waning of commun ity cohesion all suggest that communal democracy will be difficult to achieve. Current successes require further investigation. Examples fro m abroad suggest, ironically, that community health care develops best if the state and health professionals make a deep commitment to it, a gainst their own immediate interests but for their enlightened self-in terest.