Alan E. Nourse’s 1974 The Bladerunner is a standalone near-future medical SF novel. It is not the novel on which the 1982 Ridley Scott film Blade Runner is based. It is the novel on which the title of the film Blade Runner is based. More on that later.
In this novel’s 1994, America faced the perfect storm of population pressure, an aging population, soaring universal health care costs, and studies blaming the increased incidence of antibiotic-resistant diseases and the spread of genetic disorders like diabetes on modern medicine itself. Following the Health Riots the United States hastily adopted the Heinz-Lafferty Eugenics Control program.
Medical treatment is still available to all, but any individual who requires health care services for any reason is sterilized. Children under five are exempt, save for children who have known hereditary disease; the latter are routinely sterilized or euthanized.
Unsurprisingly, a considerable fraction of Americans want medical treatment without mandatory sterilization. Many physicians do not agree that the Heinz-Lafferty program is good public policy. The resistant Americans have provided demand, The resistant physicians have provided supply. The twenty years since the Riots have seen a black market in medical care firmly establish itself in the US. Such a vast black market needs its middlemen and that’s where Billy Gimp comes in.
Orphaned in the Health Riots and abandoned to the foster care system, Billy isn’t even sure of his surname; “Gimp,” comes from his untreated clubfoot. Neglected by the state, Billy discovered a talent for bladerunning, conveying medical supplies from the black market to the illegal doctors providing kitchen-table treatment. Billy has made his living at this for half his life.
Recently, Billy’s primary customer was the physician Billy knows as “Doc,” Dr. John Long. Long objects to many Health Control programs, from the sterilization programs to the on-going efforts to automate medicine (as the justice system has been). Long does what he can to counter the policies on a personal level, sabotaging the efforts of medical robots to record his techniques and providing medical care to the desperate unsterilized.
Billy is a small fish, too small to concern Health Control (HC). Or so he thought. A bug in his apartment reveals to Billy that for some reason HC is taking an intense interest in Billy. In short order, Billy is detained and despite the minor charges facing him, saddled with a locator/spy bracelet (legally considered the same as jail time). The ultimate target seems to be Doc himself and yet … HC is being oddly coy about detaining Long. It’s as though they want him for some task.
There is, of course, a simple explanation. The Heinz-Lafferty program was instituted without consideration of all possible consequences. Amidst its little bugs lurks a huge problem. 40% of Americans live without medical care. The Shanghai flu is sweeping through this unprotected population. The disease seems to be too minor to condemn sufferers to sterilization. What HC knows and the public does not is that 30 percent of the people who get the flu then develop meningitis. The fatality rate among meningitis patients is 30 percent. If nothing is done, tens of millions will die.
HC does not want to make public the crisis facing America. It fears mob panic. More important, from its perspective, it’s afraid that the pandemic might discredit the agency. HC comes up with a cunning scheme: use bladerunners like Billy to spread the word about the flu and physicians like Long to treat it. If appeals to public spirit are not enough, Health Control can blackmail dissenting bladerunners and physicians into compliance.
It’s up to Billy, Doc, and others like them to save America.
And Billy has a fever.…
First, the title. Alan E. Nourse’s novel was tapped for a film adaptation. It got as far as a script penned by William S. Burroughs
but the film itself never got made. The treatment was read by a scriptwriter working on the film adaptation of Dick’s Do Androids Dream of Electric Sheep, who suggested to his bosses that they use the title from Nourse’s book for the movie based on Dick’s. Thus history is made!
Although the idea of national heath care in the US is of course ludicrous, there was a time in the distant past when it almost seemed possible. It was plausible enough to warrant paired essays in the April 1975 Analog Magazine. Libertarian F. Paul Wilson took the anti-position (And Now, From the People Who Brought You Vietnam and Watergate …) while Nourse took the Fuck, I Guess We’re Stuck with It position (National Health Insurance: When Somebody Hands You a Lemon …). As The Bladerunner shows, Nourse had been thinking about how National Health Care might play out in the US well before he wrote his essay.
Given the dismal choices open to Americans in this book, one would expect many would seek medical care in nations not currently mass-sterilizing patients. Whether or not this is happening is unclear. Nourse does not really touch on global health care issues. The specific circumstances that led to the Heinz-Lafferty Program seem to have been peculiar to the US, but recent history suggests that if better health care were available overseas, most Americans would be unaware of it. Most of the informed minority would be too poor to dabble in medical tourism.
There is a common myth that eugenics was discredited by Nazi excesses. Although this might seem plausible to people who grew up in that passing moment when Americans collectively feigned decency, even the briefest consideration of the facts reveals this delusion as arrant nonsense. Eugenic programs continued well into the modern era, in nations of the West and elsewhere. They only faced setbacks when the people targeted by them began to gain political muscle. Thus it’s not that surprising to find in a novel published twenty-nine years after the fall of Nazi Germany passages like this:
compulsory sterilization of all victims of diabetes, schizophrenia and a dozen other heredity-connected diseases and the compulsory euthanasia of all identifiably defective babies
(explanatory but not exculpatory context: sterilization as an insufficient remedy for the deleterious effects of modern medicine).
Of course, one can see the point of such draconian policies. Many people lack the ability to synthesize vitamin C. You might think this is harmless. Not so! Not only do vitamin C junkies distort the economy by consuming billions of dollars of vitamin-C-rich fruit and pills, but every single criminal, from by-law scofflaws to mass murderers, has suffered from that genetic disorder. A one-time mass sterilization program for this genetic criminal class would end all crime forever.
In some ways, this is an oddly modern novel. Everyone seems to have a home computer, even if for some reason output is hard copy only. Communicators functionally like cellphones are common. Automation is busily spreading through all occupations. While organized crime seems immune, white collar occupations are not: many legal functions have been automated1, and the process of automating medicine is well underway despite Long’s efforts.
Speaking of Long, he is surprisingly unsympathetic for someone who shares the protagonist role. He has spent years carefully mishandling cases in a way calculated to foil attempts to mimic his techniques without quite killing his patients. Anyone who has Doc inflicted on them while a robot watches is the beneficiary of wilfully sub-par treatment. Worse, Doc convinced Billy to work for him with the promise that at some point Billy’s club foot would be corrected. Unwilling to lose his leverage, Doc keeps deferring the surgery.
My synopsis gives short shrift to two supporting characters: Long’s nurse Molly Barrett, who provides necessary medical support and moral suasion with respect to Billy’s foot. Doc’s boss, Dr. Katie Durham, not only unravels Doc’s covert sabotage campaign, she is revealed as more than the obstructive bureaucrat she might have been in another writer’s hands.
1: And hacked. When the authorities need Billy to be fitted with a transponder, they are able to make sure that he is fitted even though the charges against him do not warrant it.