It took forever, but the government has announced that Medicare will no longer pay for hospital-caused diseases. The policy will cover hospital-caused injuries, preventable errors and infections.

The Center for Disease Control estimates that hospital-caused infections alone result in 270 deaths a day, or nearly 100,000 deaths per year. In addition more than a million and a half patients needlessly contract hospital, or nosocomial, infections who do not die but do suffer, and often grievously. We’ll leave it to your imagination to calculate how many billions of dollars so much gratuitous illness costs.

Announcing a new policy may or may not lead to effective action. The hospital industry, which has fought tooth and claw for a generation to prevent statistics on hospitals’ success rates, can be counted on to do its best to sabotage carrying out the policy. On that topic The New York Times reported: “Dr. Kenneth W. Kizer, an expert on patient safety who was the top health official at the Department of Veterans Affairs from 1994 to 1999, said: ‘I applaud the intent of the new Medicare rules, but I worry that hospitals will figure out ways to get around them. The new policy should be part of a larger initiative to require the reporting of health care events that everyone agrees should never happen. Any such effort must include a mechanism to make sure hospitals comply.’”

In making this policy change Medicare is not reacting to a recently discovered scandal in the health care system. Widespread indifference to their patients’ welfare has been a fact of life in American medicine for many years. Harvard’s Dr. Lucian Leape, one physician who has not been indifferent, writes: “Since our Institute of Medicine committee issued the report ‘To Err is Human’ eight years ago, patient safety leaders have been calling on hospitals to get serious about safety, to make a commitment to eliminating preventable injuries, and to implement known safe practices that will prevent them. Some have. Most have not. It was as if the safety folks were speaking a foreign language. Now the hospitals are being spoken to by people with authority and in a language they understand: the language of money.”

Dr. Leape, who is a major figure in the field of patient safety, goes on to say: “Hospitals have had the opportunity for some time to help their patients and save money by implementing a number of proven safe practices—bar coding of medications, computerized ordering, prevention of blood stream and ventilator-associated infections, to name a few—and most have ducked it. The ‘business case’ for safety has been well-established. Now it is the payers, not the hospitals, who will save the money—and, if we’re lucky, the public—in the unlikely event that savings get passed on in reduced premiums.”

Doctors such as Lucian Leape have invented a number of step-by-step procedures or protocols to prevent infection and injury. These must be undeviatingly adhered to by hospital staffs, and if they are, gratuitous infections are significantly reduced.

It is a time-tested formula used in many organizations to overcome the damage done by lazy, indifferent and hostile employees. Strict protocols backed up by computerized record-keeping will lessen, though not end, hospital staff administering the wrong medication to patients or the wrong dosage at the wrong time. It is the battle of strict procedures against the sabotage of slovenly workers.

The protocol approach works fairly well, though it does not address the problem of lazy, indifferent and hostile employees—the people in the health care field who are not guided by the ethic of medicine, who do not put the patient first. These are the people who will leave patients in pain, vomit and agony if it’s lunchtime.

American hospitals were not always germ motels. If you go back a certain number of decades, the dirty floors vanish, as do the soiled sheets left on patients’ beds. That is back in the white era, the era when doctors wore white, as did nurses and attendants; the bed linen was white as well. The disadvantage of white was that it showed the dirt so immediately and so blatantly. Today’s hospital blues and greens do not soil quite so fast or offensively.

The undermotivated include doctors, dentists and nurses who know better but do not wash their hands before they put on sterile gloves and touch a patient. It is amazing, but they do it with the full knowledge that their negligence may kill the person whom they are treating. As you travel down the hospital hierarchy, undermotivation becomes more prevalent, not that it is not bad at the top.

The expression “people who empty the bedpans” is a synonym for people without skills in low- or no-status jobs whose labors are dismissed. We should not be surprised, then, that people in such positions dismiss themselves and hold their work in the same contempt that others place on it.

Once upon a time, when jobs were scarce and unemployment compensation nonexistent, persons manning the mops and bedpans could not afford to do their jobs indifferently. That was the era of the WASP ascendency, when everybody, or nearly everybody, agreed the people at the top were much too good for such work but the people at the bottom, swarthy immigrants and such, were superbly fitted for unpleasant, even disgusting, laborious tasks.

That’s gone. We live in the American Dreamland, the Lake Woebegone era where everybody is above average and much too good for cleaning up hospital vomit or the bowel movements of incontinent old people in nursing homes. We are so flat-out equal that The New York Times accords convicted murderer-rapists with the title “Mr.”, and “equal” means it is beneath us to tackle emptying bedpans with conscientious care. And yet without such workers, top to bottom, thousands will probably go on dying needlessly in our hospitals.

The politicians tell us with that freshness of language for which they are cherished that to compete in the 21st century, every man jack of us must be trained for the information age. Such training is our right and, deprived of it by politicians of the other party, we are doomed to working out our days in fast-food franchises or as hospital orderlies. Afflicted with the Woebegone syndrome, none of us are suited for unskilled, unpleasant work, no matter how vital, how essential the work may be. Some organizations try to meet this contradiction by employing semantic gymnastics. Stock boys, check clerks and aisle sweepers are called associates, though the pay is the same as it always was. Whether calling secretaries executive assistants gets more or better work out of them is debatable, but it implicitly disparages and devalues the nature of the work to be done. If the people and the work they do in such jobs were respected, and respected by themselves, there would be no need to confer junior CEO titles on them.

Lack of trying is not the only problem, or “challenge,” to use another euphemism, facing hospitals. The figures show that hospitals with the worst records for killing their patients are, more often than not, institutions with too few nurses. The elements contributing to the shortage in high-level professionals must be left for another day, but suffice it to say it bears heavily on hospital improvement.

Up and down the line the American health edifice is in a fragile state. Death house hospitals, though an appalling fact, are not the only problems facing what can only be sarcastically called the health care system.

The truth about the system’s deficiencies is in urgent need of recognition by the Democratic politicians running for their party’s presidential nomination. Their shouted promises to bring health care to everyone are reckless and undeliverable. When John Edwards gets in front of the TV cameras and says that if elected, he is going to make annual physical checkups mandatory for everyone, he is talking crazy. If he were to do so, the system would crash.

First, let’s see if we can get everybody to wash their hands.