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Consumers, Corporations,
and Public Health
Consumers, Corporations,
and Public Health
A Case-Based Approach to
Sustainable Business

John A. Quelch

1
 1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.

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© Oxford University Press 2016

First Edition published in 2016

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above should be sent to the Rights Department, Oxford University Press, at the
address above.

You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

Library of Congress Cataloging-in-Publication Data

Consumers, corporations and public health: a case-based approach to
sustainable business / edited by John A. Quelch.
p. ; cm.
ISBN 978–0–19–023512–3 (alk. paper)
I. Quelch, John A.
[DNLM: 1. Commerce. 2. Public Health—economics. 3. Health Promotion—methods.
4. Health Services. 5. Professional Corporations. WA 100]
RA427.8
362.1—dc23
2015029317

1 3 5 7 9 8 6 4 2

Printed by Webcom, Canada

 C O N T E N TS

Preface vii
Contributors ix
Introduction xi

Part I: Corporate Strategy and Public Health

1. Johnson & Johnson: The Promotion of Wellness 3
John A. Quelch and Carin-Isabel Knoop

2. Colgate-Palmolive Company: Marketing Anti-Cavity Toothpaste 31

John A. Quelch and Margaret L. Rodriguez

3. Royal Caribbean Cruises Ltd.: Safety, Environment, and Health 55

John A. Quelch and Margaret L. Rodriguez

Part II: Consumer Analytics and Healthcare Outcomes

4. Carolinas Healthcare System: Consumer Analytics 91
John A. Quelch and Margaret L. Rodriguez

5. Philips Healthcare: Marketing the HealthSuite Digital Platform 109

John A. Quelch and Margaret L. Rodriguez

Part III: Prevention and Adherence

6. Cancer Screening in Japan: Market Research and Segmentation 125
John A. Quelch and Margaret L. Rodriguez

7. “Dumb Ways to Die”: Advertising Train Safety (A), (B), and (C) 149
John A. Quelch

8. CVS Health: Promoting Drug Adherence 159

Leslie K. John, John A. Quelch, and Robert Huckman

Part IV: Consumer Access and Affordability

9. The Slingshot: Improving Water Access 173
John A. Quelch, Margaret L. Rodriguez, and Carin-Isabel Knoop
 vi Contents

10. Vaxess Technologies, Inc. 187

John A. Quelch and Margaret L. Rodriguez

11. Access Health CT: Marketing Affordable Care 205

John A. Quelch and Michael Norris

Part V: Consumerism and Paternalism

12. 23andMe: Genetic Testing for Consumers (A) and (B) 237
John A. Quelch and Margaret L. Rodriguez

13. Demarketing Soda in New York City 251

John A. Quelch, Margaret L. Rodriguez, Carin-Isabel Knoop, and Christine Snively

Part VI: Emerging Markets, Consumer Behavior, and Public Health

14. Fresno’s Social Impact Bond for Asthma 277
John A. Quelch and Margaret L. Rodriguez

15. E-Cigarettes: Marketing Versus Public Health 295

John A. Quelch and Margaret L. Rodriguez

Part VII: Consumer Power in Shaping Public Health

16. Rana Plaza: Workplace Safety in Bangladesh (A) and (B) 319
John A. Quelch and Margaret L. Rodriguez

17. Note on Mobile Healthcare 341

John A. Quelch and Margaret L. Rodriguez
 P R E FAC E

The case studies in this book, cobranded by Harvard Business School and Harvard
T. H. Chan School of Public Health, were all developed during the last three years
for use in my new Consumers, Corporations, and Public Health course. This course
was offered for the first time in 2015 to students enrolled in both Harvard Business
School’s MBA program and Harvard T. H. Chan School of Public Health’s MPH and
MS programs.
The principal aim of the course and of this book is to encourage dialogue and
mutual understanding between these two groups, which typically bring very differ-
ent assumptions and worldviews to the discussion of public health problems. Both
groups can agree on one thing: the consumer interest is an appropriate starting point
for determining both good business practice and good public policy.
I especially thank Harvard Business School Research Associate Margaret
L. Rodriguez for helping to develop many of the cases in this collection. She has been
not only highly productive but also creative and meticulous in her work. Thanks are
also due to other Harvard Business School Research Associates who have contributed
to individual case studies: Carin-Isabel Knoop, Michael Norris, and Christine Snively.
Harvard Business School faculty members Robert Huckman and Leslie John also con-
tributed materials.
My office assistant, Elaine Shaffer, worked diligently to organize the site visits and
executive interviews that many of the case studies required. She also collaborated
closely with Amy Iakovou at Harvard Business School Publishing to organize the
manuscript for delivery to my editor at Oxford University Press, Chad Zimmerman.
Chad’s support throughout the development and editing process is much appreciated.
This project has also received considerable support from Dean Nitin Nohria and
the Division of Research at Harvard Business School and Dean Julio Frenk of the
Harvard T. H. Chan School of Public Health.
John A. Quelch
Boston, June 2015

vii
 C O N T R I BU TO R S

Robert Huckman Margaret L. Rodriguez

Harvard Business School Harvard Business School
Boston, MA Boston, MA
Leslie K. John Christine Snively
Harvard Business School Harvard Business School
Boston, MA Boston, MA
Carin-Isabel Knoop
Harvard Business School
Boston, MA
Michael Norris
Harvard Business School
Boston, MA

ix
 INTRODUCTION

In 2014, a wave of Ebola killed over 3,000 people in West Africa. Nine months after
the first patient appeared in Guinea, the World Health Organization (WHO) belat-
edly declared a “public health emergency of international concern.” Meanwhile, fear of
the deadly virus disrupted trade, commerce, and international air service. The World
Bank estimated a $33 billion hit to regional economies over 18 months. The Liberian
economy, as one example, was forecast to contract by 12% in 2015.
The disease spread quickly. As family members and, indeed, health workers
cared for the sick, they came into contact with body fluids and subsequently became
infected. Hospitals were overwhelmed, and isolation wards were in short supply.
Once deceased, bodies were, according to local custom, again touched by loved ones
and friends prior to burial, resulting in further contamination. The speed with which
preventive information could be effectively communicated to people was often inad-
equate, especially to those living in poor, rural villages.
The Ebola outbreak put both local businesses and multinational companies at risk.
Many small businesses shut and, by November 2014, half of Liberia’s workers were no
longer on the job. One fast food chain, Monroe Chicken, saw its cost of raw materials
increase as borders closed. But, determined to continue operations despite fewer cus-
tomers, Monroe instituted daily employee temperature checks, installed handwashing
buckets, and required employees to eat free meals at the restaurants and avoid all street
food. Monroe laid off no workers during the crisis, maintaining employee morale and
reassuring customers with familiar faces.
In Liberia, ArcelorMittal had invested $700 million in a vast iron ore mine that
would produce 5 million tons per year. In the face of the Ebola crisis, the company
built a new medical clinic, implemented daily temperature checks and handwashing,
limited access to one point of entry per facility, and organized daily morning meetings
so employees could share information and concerns. Since its operations were spread
across a community of 25,000 people, ArcelorMittal mapped exactly where each
employee lived and established a 30-kilometer buffer zone around its mining conces-
sion. The company invested heavily in educating schoolteachers in the area about how
to avoid the disease.
Supporting public health means supporting social cohesion and political stability,
both essential to the free flow of commerce. These two examples illustrate how cor-
porations, large and small, can be impacted by public health events, and how they can
respond in ways that not only defend their own interests but contribute by deed and
by example to solve public health problems. Meanwhile, GSK and NewLink Genetics
began to accelerate the development and production of vaccines to counter the Ebola
virus, once the WHO requested that they do so and nongovernmental agencies guar-
anteed that they would make bulk purchases of the vaccine.

xi
 xii Introduction

New medicines, new medical devices, and new approaches to insurance and care
management stem from the efforts of the private sector, but are often stimulated by
basic research funding from public agencies such as the National Science Foundation
and National Institutes of Health. Public health has improved dramatically as a result.
Over the last six decades, global life expectancy has increased by 23 years and infant
mortality has decreased by 70%. Nevertheless, 6.3 million children died before their
fifth birthday in 2013. Even more troubling, success is spawning new problems: aging
populations in developing countries are increasingly suffering from the same sed-
entary lifestyles, consumption of processed foods, and consequent chronic health
problems, such as diabetes, that have been boosting healthcare costs in developed
countries. While infectious diseases remain a problem, health systems in emerging
economies are having to adapt to a new demand profile. State budgets are often inad-
equate to respond, and doctors are underpaid and in short supply, opening opportuni-
ties for creative solutions from the private sector and/or public-private partnerships
to fill the gaps.
In the United States, 18% of gross domestic product (GDP) is spent on health care.
Critics argue that this is due to the significant participation of the for-profit sector.
Drug companies try to persuade doctors to prescribe more drugs than patients need.
Hospitals with spare beds are motivated to extend patient stays and charge their insur-
ers. Second opinions and batteries of tests are needed to ward off malpractice suits in
the event a treatment goes wrong. Poor information technology connectivity among
competing private health providers makes joined-up patient care inefficient.
Others contend that US consumers (at least those who can pay) have access to the
best cutting-edge and consumer-responsive health care in the world. While European
and Japanese consumers benefit from the promise of universal coverage and the buy-
ing power of their single-payer national health insurance systems, these cumbersome
bureaucracies may be subject to diseconomies of scale, as well as employee demotiva-
tion and rationing of services to patients due to inadequate or uncertain funding. It
is common in the United Kingdom, for example, for patients to have to wait to see a
specialist or to wait months for a non-emergency operation. In addition, the elderly
are more likely to receive palliative care than expensive treatments that prolong their
lives. It may be true in the United States that 80%–90% of healthcare costs are spent
in the last six months of life. But how do we know if this is good or bad? There are, to
be sure, inefficiencies and fraud in the fragmented US healthcare system. But there are
also inefficiencies in any bureaucratic and nationally standardized healthcare system
that consumes perhaps only 10% of GDP. In a prosperous and civilized nation, what
(other than education) could be more important to spend money on than health care?
The motivation for this book is threefold. The first objective is to highlight the
importance to public policymakers and private sector executives in health care of
understanding consumer attitudes and behaviors when shaping their interventions.
Not all consumers are likely to respond in the same manner, and some may respond in
ways that are seemingly contrary to their best interests. Researching consumer behav-
ior in advance can result in more effective interventions. The second objective is to
highlight the different mindsets of public health and private sector executives and to
stress the need for mutual understanding. Private sector executives have the luxury of
being able to target profitable sub-segments of the population who can afford to pay
for their products and services, while public health officials are responsible for the
 xiii Introduction

health of the entire population, especially the most vulnerable. Many public health
problems can benefit from public and private organizations working in partnership
on solutions; for such engagements to be effective, mutual understanding and respect
are essential. The third objective of this collection of case studies is to demonstrate the
value of engaging and empowering consumers to take charge of their health care. The
results can be both lower costs and improved quality of patient outcomes, invariably
resulting in higher consumer satisfaction.
The book is organized into six modules of case studies. The following sections
summarize the themes and key issues of each module.

CORPORATE STRATEGY AND PUBLIC HEALTH

Every corporation is a player in public health. The products and services deliv-
ered to customers must be safe. Any claims made to customers regarding health
and safety must be valid. Advice must be given regarding proper use to ensure
against excessive or inappropriate consumption. Dosage advice on the packages
of over-the-counter pharmaceuticals and regulations regarding the design and
packaging of children’s toys are two areas where government regulators, working
in cooperation with industry, develop processes, guidelines, and rules that prevent
accidents.
A corporation’s public health footprint has three pillars: safety, sanitas, and sustain-
ability. Safety refers to the in-use safety of the products or services that the consumer
is purchasing. It depends largely on the existence of quality control protocols in sourc-
ing, production, and distribution. Sanitas refers to the health and wellness of employ-
ees and family members, not merely direct employees but all workers involved in the
supply chain, from ingredient producers to after-sales service people. Under cost pres-
sure from foreign competitors, many companies are downsizing, placing more work
(and often stress) on those employees whom they retain. Investing in physical and
mental health and wellness can attract and retain good employees, boost their motiva-
tion and productivity, and lower health insurance costs. Sustainability refers to the
impact of the company’s operations on environmental health, from carbon dioxide
emissions to water usage. DuPont appointed the first chief sustainability officer in
2004, and leading corporations are now expected by investors to publish an annual
sustainability report alongside their financial statements.
Companies that pursue a positive public health footprint may not always see an
immediate payback in performance or investor support. There is skepticism among
investors that the inclusion of a public health perspective may be a distraction to man-
agement and a drag on earnings. However, the chief executives of Pepsi and Unilever
would argue that the attention they pay to public health issues in shaping their product
portfolios and company operations will be a point of differentiation that will benefit
their shareholders in the long run.
For most corporate leaders, it may not seem advisable to market superior compara-
tive performance on something like safety. First, to advertise that your airline is the
safest highlights a negative that might deter some consumers from flying. Second, if a
safety issue arises, the company that touts safety is going to be severely embarrassed.
Third, most companies interested in advancing safety standards prefer to work within
 xiv Introduction

industry and trade associations rather than breaking ranks and promoting their own
capabilities.
BP’s green energy advertising campaign was upended by a series of safety problems
that culminated in the loss of life and severe pollution in the Gulf of Mexico resulting
from the Deep Water Horizon disaster. Volvo, on the other hand, successfully equated
its brand name with pro-safety auto design and touted this superiority to middle-class
families with young children.
Companies both within and outside the healthcare sector are focused on the health
and safety of both their consumers and their employees. Health insurance is often
second only to payroll among corporate expenses. Starbucks spends more on health
insurance each year than on coffee. If health insurance costs can be reduced by improv-
ing the physical and mental wellness of employees, that should boost a company’s
competitiveness and productivity as well as improving employee and, thereby, cus-
tomer satisfaction. However, three problems can arise if a culture of wellness is taken
too far. First, it may encourage selection bias toward the recruitment of a younger,
healthier workforce. Second, it may keep the well healthy (certainly a valuable out-
come) but may unnerve employees who are sick and in need of help. Third, it often
overemphasizes physical activity and underappreciates the value of stress-free work.
In 2014, Colgate-Palmolive launched a superior anti-cavity toothpaste, the first
demonstrable improvement in cavity prevention since fluoride was added to tooth-
paste 50 years ago. Rather than launching the product at premium prices in devel-
oped countries, Colgate decided to launch at accessible prices in emerging markets.
In Brazil, thanks to decades of relationship building by Colgate with the Brazilian
Ministry of Health, free samples of the new toothpaste were distributed to hundreds
of thousands of schoolchildren who are required to brush every day after school lunch.
These samples connect the Colgate brand to future purchasers, and the children take
the samples home to their parents. This is a clear case where doing the right thing is
both good for public health and good for business.
The case of Royal Caribbean cruise lines brings together all three strands of the
corporation’s public health footprint. The company has taken the lead in environ-
mental health, developing and installing progressively advanced emission purification
systems known as scrubbers on each new class of vessel it brings into service. In addi-
tion, Royal Caribbean has led the industry in implementing advanced on-board water
purification systems that treat waste water before it is released into the ocean. Royal
Caribbean has not waited to respond to new regulations. It has shaped industry regula-
tions and has implemented improvements several years ahead of regulatory deadlines,
all part of its “above and beyond compliance” (ABC) philosophy.
Royal Caribbean has shown similar leadership in workplace and passenger safety.
Crews come from many countries and cultures, and have to be trained not only in the
niceties of customer service but in being vigilant and speaking up on any matters that
pertain to passenger and employee safety and security. In addition, Royal Caribbean,
under the direction of its chief medical officer, takes special precautions to prevent
outbreaks of disease or medical emergencies on board its vessels. An outbreak of
norovirus in the middle of a cruise can result in damage control and customer com-
pensation costs, even after insurance payouts, approaching 5% of the annual profits of
the company. Preventive measures, from screening of passengers when they board to
 xv Introduction

rigorous cleanliness procedures, to activating prescribed protocols in the event of an

outbreak, can all enhance public health and reduce the risk of lost profits.
The Royal Caribbean case illustrates how companies not in the health sector nev-
ertheless have multiple public health impacts and responsibilities: on passenger and
workforce health and safety, on disease prevention and control, and on environmental
sustainability. Collectively, we call these impacts, both actual and potential, the public
health footprint of the corporation. Every company has a public health footprint. But,
often, the elements of the footprint are not seen as connected. Increasingly, however,
we see the appointment of a senior corporate executive to oversee health, safety, and
the environment. This executive is charged with ensuring that the net public health
footprint of the company is positive.

CONSUMER ANALY TICS AND HEALTHCARE OUTCOMES

In many industries, rising costs have prompted creative thinking that results in con-
sumers taking on more responsibility, and being rewarded for doing so by lower prices.
In supermarkets, for example, consumers gather their own merchandise rather than
asking for assistance from store clerks (except in the baked goods, meat, and seafood
departments). In some stores, they may even be encouraged to check themselves out
and to bag their own groceries. The consequent savings in store labor facilitate lower
retail prices. In the world of financial services, some consumers are confident enough
in their financial acumen or skeptical enough of traditional brokers that they invest
with lower cost providers like Vanguard and manage their own money.
A similar transition is occurring in health care. Thanks to the aging of the popu-
lation and more prevalent chronic diseases, plus advances in technology, healthcare
costs are rising faster than general inflation. Confronted by rising health insurance
premiums, and uncertain quality of health outcomes, more and more consumers are
investigating through online research, or by asking around, which insurance plan,
which hospital, or which doctor makes sense for them. Governments, not-for-profits,
and commercial websites are facilitating this trend by aggregating performance and
rating information to make such comparisons easier. A final issue is that engaged con-
sumers disproportionately include the worried well, while truly sick people lack the
energy, ability, or inclination to help themselves.
Of course, not all consumers have the time or inclination to be this involved. And
some may simply be too ill, mentally or physically, to help themselves. Others continue
to defer to the doctor as an authority figure without doing their own research. There
is also concern that engaged consumers may eat up their doctors’ time (and thereby
increase healthcare costs) by questioning their diagnoses and treatments. Others who
are empowered may end up making healthcare decisions that are not in their best
health interests. Many patients with chronic mental conditions, for example, believe
that they can calibrate the dose of their medications better than their physicians.
To benefit the healthcare system, empowerment must be accompanied by edu-
cation. Simply delegating decision-making responsibility to consumers without giv-
ing them relevant, accessible information and educating them in how to use it simply
causes more anxiety and distrust. The best insurance exchanges established by the
Affordable Care Act presented consumers with a simple set of healthcare insurance
 xvi Introduction

plan options, typically bronze, silver, and platinum, plus website information and
trained “navigators” and insurance brokers to help them make their choices.
As the prevalence of chronic diseases such as diabetes increases, effective education
becomes all the more important in controlling healthcare costs. In the United States,
treating chronic diseases accounts for 75% of all healthcare costs, and 5% of Medicare
patients account for 42% of program costs. If patients with chronic conditions—and
their family members and caregivers—can be educated on the benefits of behavior
changes such as improved diet and more exercise, hospital readmissions and health sys-
tem costs can be reduced. In the case of high-cost patients with multiple conditions,
investing in a customized behavior-change plan may pay off. For most chronic patients,
enrollment in a standard, regular exercise program or similar intervention is sufficient.
Consumer segmentation analysis is as essential in health care as it is in explaining
consumer behavior in other spheres. Consider shopping. One segment of consum-
ers prefers to shop online for the lowest prices, while another segment would rather
pay a little more to touch and feel the merchandise and interact with a salesperson
before buying in a department store. Or take financial services. One segment is pre-
pared to pay more for personalized handholding by a stockbroker or financial plan-
ner. Consumers in a second segment are confident enough to avoid these costs and
manage their own investments. Something similar is true in health care, with two
important contextual differences. First, health care and health insurance are grudge
purchases that consumers make only reluctantly. Second, consumers can only help
themselves up to a certain point, at which a doctor’s intervention becomes essential.
Imagine that we could profile all consumers in the population, overlaying all their
clinical records and all their health insurance claims data on top of demographic
information, family medical history, lifestyle data relating to exercise and food con-
sumption, plus attitudes and opinions that determine their overall optimism. Ideally,
we would then tailor our wellness messaging and interventions according to who is
in most need, who is most likely to respond, and where the payback to intervening
in terms of reduced healthcare costs and improved health outcomes is likely to be
greatest.
Privacy laws, the integration of multiple databases, and an actuarial mindset that
views patients as numbers rather than people are all challenges in this effort. However,
at least one life insurance company, Humana, is pursuing this consumer-centric strat-
egy. Many of their members qualify for Medicare Advantage government health insur-
ance, which reimburses at standard rates based on each member’s health conditions.
Humana believes that, through consumer segmentation research, it can discover how
to motivate members to change their behaviors, lifestyles, and medical conditions
and so save money through fewer doctor visits, hospital readmissions, drugs, and
procedures.
Not only payers but also providers are increasingly focusing on the consumer.
Carolinas Healthcare, a major hospital network, is also using big data analytics to inte-
grate multi-source health information and then customize interventions for specific
consumers, such as those at high risk of hospital readmission. Motivating doctors and
nurses to let data analytics guide their patient workflows is critical to achieving the
dual objectives of reducing costs and improving patient health outcomes.
Medical device companies such as Philips have millions of products worldwide
remote monitoring consumers’ vital signs and health metrics every day. Philips
 xvii Introduction

believes it, too, can be a force for patient data integration, especially as a trusted brand
known to many consumers. Emergency medical records companies such as Epic and
even IBM, through its Watson health project, are taking the same view. It remains to be
seen who will be the most powerful data integrator in health care.

PREVENTION AND ADHERENCE

Consumer attitudes and behaviors are important drivers of health and wellness.
Regular exercise, avoiding tobacco and alcohol addiction, and good diet can go a long
way to sustaining an individual’s health. The French author Anthelme Brillat-Savarin
famously stated, “Tell me what you eat and I will tell you who you are.” Minimal stress,
a spirit of optimism, and mindfulness are equally important. The will to live, often
correlated with the support of family and friends, can make the difference in seeing
someone through a serious illness.
Although an ounce of prevention is worth a pound of cure, few among us are doing
our part. Only 5% of Americans eat in accordance with the national dietary guide-
lines. Warren Buffett, for example, claims that the secret to his success is that he eats
like a six-year-old. Rising per capita incomes go hand in hand with a more sedentary
lifestyle, thanks to the automobile and the substitution of knowledge economy desk
jobs for those involving physical labor. Corporations selling us convenient, tasty, and
potentially addictive processed foods heavy on sugar, salt, and bad cholesterol, and
heavily advertised, also contribute.
Persuading consumers to take preventive action on behalf of their health is dif-
ficult. First, short-term gratification has to be sacrificed for the uncertain prospect of
longer-term gain. Second, with the exception of quitting smoking, it is hard to identify
the simple rule (avoiding one thing) that will make a significant difference to health
outcomes. Perhaps avoiding trans fats is approaching avoiding tobacco as a second
straightforward discipline. Third, average life spans continue to advance thanks to sim-
ply administered diagnostics that allow for early disease detection. Fourth, therapeutic
technologies suggest that we can live carefree until we run into trouble and still have a
good chance of being cured.
Changing the attitudes and behaviors of people who are set in their ways is difficult.
But there are at least three ways to motivate change. The first is information, includ-
ing public service advertising, media stories, and well-designed nutrition labels. Such
messages often rely on fear appeals delivered through traditional media, which turn
consumers off, rather than on humorous messages delivered through social media,
which can engage consumers on their own terms. In addition, the media weight sup-
porting preventive messages is invariably insufficient to counter the volume of com-
mercial advertising pushing potentially harmful products.
A second approach is to use financial incentives. An insurance premium reduc-
tion may be offered to a consumer for completing an annual health profile and health
checkup. Likewise, out-of-pocket copayments by insured consumers for accessing
health services will motivate some to stay healthy (though copayments should not
be so high that they dissuade consumers from seeking timely care when they need
it). However, it is politically unacceptable to charge sick people more for health insur-
ance: consumers with preexisting conditions, some perhaps genetically induced
 xviii Introduction

through no fault of the individual, cannot be excluded from insurance pools in the
United States following passage of the Affordable Care Act.
In addition to individualized consumer incentives, public policymakers may elect
to increase the cost of using a harmful product. For example, they can impose taxes or
distribution restrictions on commercial products, such as cigarettes, alcoholic bever-
ages, and, increasingly, sugary soft drinks, that are considered deleterious to health.
A third approach to prevention is regulation. The Food and Drug Administration
and the Consumer Product Safety Commission, for example, set standards for prod-
uct quality and manage a process of review and approval of what can be marketed
to consumers. In these cases, the government regulates the market in the interests of
public health, preventing harmful and untested (and therefore potentially harmful)
products from reaching consumers.
In sum, there is no doubt that consumer marketing has promoted the use of
products and services that collectively contribute—consumer freedom of choice
notwithstanding—to an unhealthy lifestyle. But for-profit corporations can also be
part of the solution. First, new food products can be developed that are healthy,
tasty, and affordable. New medical devices for in-home use can be better designed
for ease of use. Second, Fitbit and a host of other products linked to computer and
phone apps can help consumers monitor key health data and take preventive action.
Third, for-profit advertising agencies and market research firms regularly offer pro
bono creative and research services to develop public service advertising campaigns
in collaboration with nonprofit organizations such as the Advertising Council.
More important to positive health outcomes than initiating preventive action is
adherence, the sustained commitment to a preventive behavior. The consumer can-
not quit smoking for a week; she must quit forever. Likewise, regular exercise must
become a way of life. Fitbit and other similar products linked to computer and phone
apps enable engaged consumers to monitor health data and sustain preventive action.
These products, however, are largely used by people who are already healthy. What
about those who are sick and on prescription drugs?
Around a third of first-time prescriptions written in the United States are never
filled. And half the prescriptions for chronic conditions that are filled are not com-
pleted and refilled. Apart from the enormous wasted effort and the cost of unused
drugs, health outcomes are not being improved and health costs are not being reduced
because so many consumers do not adhere to the drug prescriptions given to them
by doctors. In some cases, the cost may be too high. In other cases, there is a lack
of confidence in the doctor, a skepticism regarding the drug’s efficacy, a tendency
to self-medicate, or simple forgetfulness—hence the commercial development of
electronic pill dispensers that glow or that notify a family member if unopened. In
addition, CVS Health has retrained pharmacists in its 7,800 stores to engage with con-
sumers when dispensing prescriptions and to follow up by phone, email, or text mes-
sage if they are not refilled on time. CVS aims to make sure that the right patient is on
the right therapy at the right time at the right dosage.

CONSUMER ACCESS AND AFFORDABILITY

Despite the benefits of globalization in lifting billions out of abject poverty and
spawning an emerging middle class in developing economies, many remain firmly
 xix Introduction

at the bottom of the pyramid without access to potable water, let alone vaccines and
basic health care. Though access to health care is not included in the United Nations
Declaration of Human Rights, a majority of Western policymakers and corporate
executives believe, on both moral and economic grounds, that the needs of the global
poor should not go unaddressed. Solutions include the manufacture of low-cost
generic drugs and medical devices, and innovations that overcome the infrastructure
and environmental barriers that prevent solutions from traversing “the last mile” to
reach the world’s poorest.
For example, several water purification devices have been developed that use solar
power to produce potable water from contaminated water for a home or for a village.
The challenge is funding their manufacture, distributing them, and training people
in their use and maintenance, often in remote locations. The need to refrigerate most
vaccines and many drugs from the factory to the point of use adds significant cost. In
addition, the unreliability of the cold chain in developing countries means that many
vaccine doses go to waste and others that are administered are ineffective. Vaxess is
one company that seeks to economically heat-stabilize vaccines in the production pro-
cess, removing the need for refrigeration and increasing the odds of access and afford-
ability for last-mile consumers.
As with any innovation, the adoption of such new technologies depends on their
relative advantage, their complexity, their compatibility with existing practices, the
ease with which their benefits can be understood, and the ease with which consumers
can try them out at minimal risk. These five criteria were identified by Everett Rogers
in his 1962 book The Diffusion of Innovation. The five diffusion criteria can be applied
across all stakeholder groups to assess the likelihood of new product adoption. The
benefits of non-refrigerated vaccines, for example, must be seen clearly not only by
consumers but by the vaccine manufacturers, by the regulators who must approve
them, by the international organizations like UNICEF that buy them in large volumes,
by the insurance companies and payers in the developed world, and by the hospitals,
doctors, and nurses who administer them.
Access and affordability present important ethical and practical challenges in
developed countries as well. Disparities exist even in countries with single-payer,
taxpayer-funded national health systems that provide care to all citizens. Rural areas
may not be well served by doctors, and specialized help may be limited. The poor
may find even modest copayments unaffordable and a deterrent to using health ser-
vices, perhaps resulting in more expensive emergency room treatment later. A major
criticism of single-payer systems is that governments focus on controlling healthcare
expenditures with unfortunate results. They may ration care, causing patients lengthy
waiting times to see a specialist or to receive a non-emergency surgery, or they may
limit their citizens’ access to new drugs and expensive or discretionary treatments.
In the United States, around 40 million people had no health insurance prior to
the passage of the Affordable Care Act in 2010. Many were unemployed or underem-
ployed and therefore had no access to an employer health plan. Others were unable to
obtain health insurance due to preexisting medical conditions. Many healthy young
adults viewed themselves as invincible and saw health insurance as a grudge purchase.
They chose not to buy it even if they could afford it; their non-participation in the risk
pool raised costs for everyone else.
The Affordable Care Act established minimum standards for health insurance plans
and set up an electronic marketplace in each state where private insurance companies
 xx Introduction

could offer qualifying plans that varied in pricing and benefits. Consumers were able
to comparison shop, and many received government subsidies toward their annual
premiums based on their incomes.
Yet, despite two years of marketing efforts, the number of uninsured was reduced
by only around 10 million. Many people simply found health insurance too difficult a
subject to deal with and continued to use public hospital emergency rooms—at great
cost to the system—when they were unwell. Others were philosophically opposed
to participating in any “big government” program. Undocumented immigrants were
afraid to sign up. Many young people chose to remain uninsured. Understanding the
consumer mindset of these various population segments is essential to crafting mes-
sages, incentives, and regulations to bring them into the ranks of the insured.
Access to expensive new drugs that target serious diseases with limited preva-
lence presents pharmaceutical manufacturers with financial, marketing, and ethi-
cal challenges. In 2013, 19 of 28 new drugs approved by the US Food and Drug
Administration were specialty drugs with an average development cost of $2.6 bil-
lion. The higher prices of these drugs, especially those targeting diseases with lower
incidence, were highlighted when Gilead Sciences charged $80,000 for a single treat-
ment course of Solvadi for hepatitis C patients. While justifiable on a value pricing
basis (Solvadi cured rather than controlled the disease), many insurers and employers
balked at covering the cost of the drug for their members. Gilead offered lower prices
for needy patients in the United States, charged less in other developed countries
with single-payer government agencies that leveraged their procurement clout, and
licensed generic production at a fraction of the US price in developing economies.
A generic version priced at $10 emerged in Bangladesh in 2015.
By responding in this way, Gilead followed a common pattern of price discrimina-
tion for drugs and vaccines, whereby prices in developing countries are set well below
those in developed countries. This is one reason that 18% of US GDP is spent on
health care, compared to 10% worldwide; the US consumer cross-subsidizes the drug
and vaccine purchases of consumers in other countries.
The major pharmaceutical companies continue to allocate most of their funds
on research and development of new blockbuster drugs. Few funds are devoted to
improving access and affordability. Yet the manner in which a drug has to be taken
(e.g., by vaccine, pill, or patch), the frequency of dosage, the duration of the treat-
ment, and the availability of the drug in remote areas all bear upon the new drug’s
ability to influence healthcare outcomes. Even when they add value, important inno-
vations that improve patient access and adherence take a back seat to the new prod-
ucts. The reality is that there is no Nobel Prize in Medicine for improving access or
distribution.

CONSUMERISM AND PATERNALISM

From online shopping to managing financial assets, increasingly large segments of
consumers are willing, indeed eager, to gather information and make decisions, largely
unassisted by others. They have sufficient experience to be confident in their judg-
ments, and these judgments can be reversed; products bought online can be returned,
mutual funds can be sold.
 xxi Introduction

Healthcare decisions are not so easy. In emergencies, there is no time for shop-
ping around and price comparisons are not high on the agenda, especially if an insur-
ance company is paying. Some comparative performance information on doctors and
hospitals is available, but it is likely incomplete and possibly out of date. Sampling
alternatives is often impractical, and some decisions (e.g., elective surgery) cannot be
reversed once implemented, while others (e.g., non-adherence to a prescription) can.
Most important, the consumer cannot do it all herself: doctors, hospitals, and insur-
ance companies all must be selected and worked with.
Nevertheless, there is a myriad of new web-based sources of health information
to interest the engaged consumer. The British National Health Service publishes per-
formance ratings of all its hospitals on multiple dimensions. There are websites such
as WebMD that provide information about disease symptoms and treatments or drug
side effects. Other websites, including Patients Like Me, organize communities of
patients who share information about the efficacy of drugs and other treatments for
various diseases, often providing comfort and hope as well as empowering patients
and their caregivers.
Some consumers, often those more interested in prevention, soak up this infor-
mation and feel empowered by it to the point of raising questions with their doctors.
Others try to avoid the information overload and are comfortable viewing their doc-
tors as superiors rather than equals. For their part, doctors are also divided. Some
welcome patients who take an interest in their health, conduct research online, and
ask intelligent questions in office visits. Others find that over-curious patients detract
from their efficiency and worry that patients may become confused by the informa-
tion or may try to treat themselves in ways that could be harmful.
John Stuart Mill objected to paternalism, the curtailment of freedom of choice,
unless free choice harms others. In the case of health care, consumers unprotected might
make choices that cause themselves harm. But, in causing such harm, they may consume
services that might be better allocated to others and diminish their ability to be produc-
tive members of society. As such, the consumer who doesn’t exercise, eats unwisely, and
doesn’t adhere to prescribed medications is causing financial harm to others.
In late 2013, the Food and Drug Administration prohibited 23andMe, a
direct-to-consumer genetics testing company, from continuing to provide
disease-risk information to its paying customers. The FDA contended that 23andMe
was marketing a medical device and that the analytical and clinical validity of the
algorithms underlying the disease-risk assessments were unproven and risked mis-
leading consumers into taking harmful medical action. Many of 23andMe’s 450,000
consumers defended the right to know their DNA and to purchase information that
interpreted it.
This case highlights the mindset contrasts between healthcare regulators and
entrepreneurs. Regulators are naturally conservative and write rules to protect all citi-
zens, including the most vulnerable and those unable to look out for themselves. Their
worst nightmare is to approve the sale and marketing of a drug or medical advice,
only to find that it causes injury or death, to however small a minority of users. The
entrepreneur, by contrast, often embraces a Benthamite philosophy of greatest good
for the greatest number; if a drug cures a severe illness but one in a thousand users
dies, the entrepreneur might push ahead. Finally, the entrepreneur is used to target-
ing her product at the market segment that most needs it. The regulator, however, has
 xxii Introduction

to regulate for all citizens and must consider the possibility that the product may be
acquired by some for whom it is not appropriate.
Public health policymakers often think they know what is best for people and
rarely make a move without believing that they have science on their side. The
problem is that they often investigate insufficiently the various consumer behavior
responses and underestimate the messaging necessary to motivate behavior change.
When Mayor Bloomberg tried to cap at 16 ounces the serving size of sugary drinks
sold in New York City restaurants, he may have presumed that all consumers who
previously ordered 24- or 32-ounce servings would knuckle under. But surely there
would be some who would order two 16-ounce servings, especially if the soft drink
manufacturers priced this option attractively? Giving consumers a nudge is not quite
the same as limiting their freedom of choice. When consumer protection morphs
into paternalism, some citizens respond with defiance, often counter to their own
well-being.

EMERGING MARKETS, CONSUMER

BEHAVIOR , AND PUBLIC HEALTH
Despite an ever-increasing mountain of scientific evidence regarding the deleterious
effects of tobacco smoking, cigarettes continue to be sold. For 50 years, the tobacco
industry has steadfastly resisted all efforts to curtail its marketing activity. The industry
has compensated for the decline in smoking in developed economies by promoting
cigarette consumption in emerging markets such as China and India, where the taxes
generated on tobacco sales often reflect the interests of the finance ministry overriding
those of the health ministry.
In Western countries, public health officials have used the complete arsenal of
available measures to gradually curtail the incidence of tobacco consumption. These
include messaging from public service announcements to warnings on packaging and
in advertising; restrictions on where and how tobacco products can be sold to man-
age the “choice architecture” presented to consumers; pricing nudges in the form of
higher taxes to dampen consumption; and, in some jurisdictions, outright bans on
where smoking can occur or on the sale of some or all tobacco products. Objections
to paternalism and in defense of individual freedom fall short since the health costs
to address the harmful consequences of tobacco smoking largely fall on taxpayers as a
whole, not on the individual smoker.
The tobacco companies have worked hard to improve the efficacy of filtered ciga-
rettes in catching carcinogens before they are inhaled. They have also focused their
promotion on menthol and “lite” cigarettes. In other words, they have shaped their
product portfolios and their allocation of marketing effort across products in response
to declining consumer interest and pressure from public health officials.
The accelerating emergence of the markets for e-cigarettes and recreational mari-
juana use both offer substantial opportunities for the survival of the big tobacco com-
panies. E-cigarettes offer consumers the opportunity to smoke without inhaling the
carcinogens that accompany the burning of tobacco. Not surprisingly, big tobacco
companies interested in diversifying their risk have been purchasing fledgling, inde-
pendent e-cigarette brands, catapulting them rapidly to national distribution and
increased sales.
 xxiii Introduction

For public health policymakers, e-cigarettes present a difficult dilemma. On the

one hand, they represent a potential path away from cigarettes for smokers trying to
quit. Though exposure to nicotine remains an important medical concern (and there
is insufficient research on the consequences of nicotine addiction), it is preferable that
the traditional cigarette smoker who switches will no longer be ingesting carcinogens
into her lungs. On the other hand, many are concerned that e-cigarettes will become
a halfway house in the opposite direction on the road from not smoking to smoking
cigarettes, with the cool technology of vaping attracting young people who would have
otherwise eschewed the by-now dirty habit of cigarette smoking. These two approaches
can be seen in the marketing of different e-cigarette brands, with some aiming to help
the intelligent cigarette smoker to quit and others focusing on vaping pleasure.
Worldwide, public health officials have been scrambling fast to regulate the marketing
of e-cigarettes and to place some limits on the permissible nicotine content. Legalization
of marijuana for recreational as well as medicinal uses has also proven controversial,
not least because of medical evidence of pain relief benefits being offset by evidence of
reduced IQ among young people who smoke regularly. Add to this the fact that mari-
juana remains an illegal drug in the United States under federal law; the market is devel-
oping slowly, one referendum in one state at a time. In Colorado, recreational marijuana
sales became legal on January 1, 2014. Through the licensing of retail dispensaries and
the electronic tagging of individual plants, the market remains tightly controlled. There
are, in fact, four submarkets, each characterized by different consumer behaviors; the
preexisting medicinal market involving frequent users who are loyal to a particular strain
or supplier that relieves their pain; the recreational market involving occasional users
(including tourists) who are less price sensitive and value a “Starbucks-like” retail experi-
ence; the individual grower market, consumers growing for themselves but perhaps ille-
gally selling their surplus privately to others; and the illegal market, which continues to
exist because of high recreational marijuana prices stemming from greedy state and local
governments imposing high sales and excise taxes. Meanwhile, public health officials are
scrambling to regulate the new product categories of marijuana edibles and drinkables
that can be tempting to non-users and children, as well as attractive to current users who,
in some circumstances, do not want to be seen smoking.
It will be perhaps 5 to 10 years before a sufficient number of states legalize recre-
ational marijuana to attract the direct investment interest of the big tobacco compa-
nies. At present, the market size is too inconsequential and federal law prevents the
legal movement of marijuana across state lines. But for sure, the major tobacco com-
panies are plotting their strategies to maintain shareholder value in their companies
by investing in both marijuana and e-cigarette brands. Public health officials must be
cognizant of such emerging markets and plan their future responses rather than scram-
bling to react once the genie is out of the bottle.

CONSUMER POWER IN SHAPING PUBLIC HEALTH

Healthcare and education are two issues in which citizens around the world, rich
and poor, are passionately interested. It has long been appreciated that the way that
a society treats its youngest and oldest members says much about its moral matu-
rity. Economic development specialists also attest to the importance of health care
 xxiv Introduction

in determining productivity. The connection between child health and nutrition and
readiness to learn in school is also well established. Forthcoming revisions to the
Millennium Development Goals are expected to again highlight the importance of
disease prevention and health care to the global community.
Nevertheless, the pressures of commercial competition all too often still result in
decisions that take scant account of public health and whether the health of individual
citizens is being advanced. When worker safety is jeopardized by unenforced build-
ing codes or exposure to harmful industrial chemicals, that becomes a public health
issue. Bangladesh garment factory owners engaged in cutthroat price competition to
secure orders from Western manufacturer and retailer brands. These brands conve-
niently sourced their requirements at arm’s length through third-party intermediaries
to avoid any responsibility for workplace conditions. Then, the Rana Plaza disaster
that killed over 1,000 factory workers in Bangladesh in 2013 highlighted to Western
consumers the challenging conditions faced by the workers who made their clothes.
Consumer pressure on Western retailers worked its way back up the supply chain to
force improvements in workplace conditions. In this case, Western consumers were
taking responsibility not for their own health but for the health and safety of workers
in a foreign land thousands of miles away.
Consumer power has not been that evident a criterion in shaping the financial
decisions of major multinationals. Merger and acquisition activity in the healthcare
sector invariably occurs with scant regard for the impact on public health or the end
consumer. Pfizer’s attempted takeover of the British company, AstraZeneca, in 2014
was criticized widely for being motivated by financial engineering; the combined
company would be headquartered in England in order to achieve a lower corporate
tax rate. The British government favored the merger as it would boost the high-priority
life sciences sector, but little attention was paid to whether the integration of the two
company research groups would delay the development and commercialization of
important new drugs to the detriment of consumers. Interestingly, though, at pub-
lic hearings, the AstraZeneca chief executive championed the interests of patients in
opposing the proposed merger.
Consumers worldwide are increasingly taking charge of their health. As popu-
lations age, there are more consumers than ever before suffering from chronic
conditions. Most no longer see disease and the timing of their death as inevitable.
Supported by the Internet, many actively seek out information to increase their
odds of staying alive. Aided by family and friends, they research their conditions
and possible treatments, often sharing their experiences with others in online com-
munities. They are more inclined to question authority, and to raise issues with
their doctors, care providers, and pharmacists. Some providers view such patients
as wasting their time, but most recognize that patients know themselves better than
anyone and therefore value their insights. Of course, not everyone is interested in or
capable of engaging in the management of his or her own health. Some are fatalistic;
others avoid doctors and hospitals at all costs; still others are simply too sick to help
themselves. Any public health system must respect the reality of these consumer
differences and not withhold care from people simply because they do not engage
and do not speak up. As Atul Gwande has stated elegantly, “Patients are pleased
to have their autonomy respected but exercise of autonomy includes the right to
relinquish it.”
 xxv Introduction

Consumer empowerment is perhaps more evident in the United States than

other developed economies served by single-payer national health systems. In the
United States, most citizens see each month on their paystubs a significant dol-
lar sum deducted for health insurance. Every year, they have to review alternative
health insurance plans, make risk-return tradeoffs, and choose the ones they pre-
fer for themselves and their families. In Japan and Western Europe, most citizens
receive their health care “for free” through a national health system, funded by
taxpayers. The result can sometimes be a less empowered, more quiescent patient
population. Interestingly, many developing countries operate more like the United
States. Lacking the resources to fund meaningful national health programs, indi-
vidual consumers are left to fend for themselves, seeking private treatment that they
and their families can afford. In poor countries, consumers are best advised to keep
their own medical records since nothing approaching an electronic record-keeping
system is available.
As a result, enormous innovation in the delivery of good quality but low cost health-
care services is taking place from Asia to Africa. In India, the Avarind Eye Hospital
provides routine eye surgeries to the highest quality standards at perhaps a tenth of the
developed country price. A mass production approach to other routine surgeries, such
as hernia operations, provides similar savings. In the area of prevention, the spread of
ever-cheaper mobile smart phones enables citizens in remote rural areas to receive
online medical consultations, treatment suggestions, and prescriptions. Readings on
diagnostic machines in clinics can be taken by nurses or community workers, trans-
mitted electronically and interpreted by specialist doctors working in city hospitals.
When the time from data collection to treatment can be cut thanks to mobile health
care, lives can be saved.
Mobile health is gaining traction in developed economies as well. The Fitbit
and other wristband products that enable consumers to self-monitor exercise lev-
els, sleep patterns, and blood pressure have sold briskly. Despite Google Health’s
failed effort to facilitate patients’ collecting their medical records electronically in
one place, there were around 40,000 health apps available by 2015 for 1.6 billion
mobile smart phones, and the advent of Apple’s Healthkit, also deployed in the new
Apple Watch, promised to stimulate broader use and more innovation. Many of
these products, sometimes faddish in nature, appealed to a younger generation of
healthcare enthusiasts or to the worried well—those who are basically fit but who
make an effort to look after themselves. The importance of consumers working to
preserve their health through sensible, preventive measures cannot be underesti-
mated; these consumers are reducing or at least postponing their eventual burden
on the healthcare system.
For those already sick, mobile health adds equally important benefits. From
remote monitoring to in-body sensors, mobile health innovations enable patients
to spend fewer expensive and less than pleasant days in hospitals and more days
getting better or managing their illness in the comfort of their own homes. The
temptation to undertake continuous rather than snapshot monitoring can, in some
cases, be unproductive and costly, and risks turning patients into hypochondri-
acs. Mobile health innovations should be adopted widely only after controlled
consumer experiments have demonstrated their value added in terms of improved
patient outcomes.
 xxvi Introduction

CONCLUSION
Demographic changes are powerful forces. Equally powerful are the dramatic improve-
ments in public health over the last century that have lengthened life expectancies and
so contributed to the aging of populations and deteriorating dependency ratios. The
invisible hand of the market responds to such shifts by reallocating resources and cre-
ative efforts to take advantage of new business opportunities. At the same time, there
are many poor and vulnerable citizens whose income levels are not that attractive to
the private sector. Humanity requires that their health needs be addressed but, in an
era of resource constraints, both rich and poor can be part of the solution by taking
care of themselves, living a lifestyle that promotes rather than challenges good health,
and availing themselves of medical care when needed but receiving that care from the
correct providers.
For those consumers who are not self-motivated, who is in the best position to
nudge them to make the right choices? Is it the family doctor or the front-line team of
doctors and nurses who are employed by the hospital where they are being treated? Or
the insurance companies that are motivated to lower the costs of their care by persuad-
ing patients to take preventive measures? Or perhaps the pharmacists who can influ-
ence consumers to stick to prescribed drug regimens? Who does the consumer trust
more? The public health policymaker who is simultaneously trying to improve patient
outcomes and lower costs has many private-sector allies to influence patient behavior if
she knows how to engage them. While philosophical and stylistic differences between
public and private sector executives in the healthcare sector may remain, mutual
understanding and partnership-driven solutions can always be advanced when both
groups focus on the common theme of consumer needs, consumer decision-making,
and better consumer health outcomes.
 PART I

Corporate Strategy
and Public Health
Another random document with
no related content on Scribd:
he wrote, and he had kissed her as his thanks. Evidently she had been
mistaken; he would prefer to be alone. And why, oh why should he choose to
find a room in his mother's house? It would be the beginning of seeing far less
of him than ever. Of course his mother would persuade him to stay to dinner
with her if his next duty was near her rooms; and it would be only human
nature for her to discuss his wife with him and to hint that she was incapable.
But she put this thought away from her at once. She was so certain that Luke
would not discuss her with anyone, even with his mother.

Her perfect silence made Luke look round, and the expression on her face
perplexed him. He covered the hand that lay on the back of his chair with his
own, saying remorsefully:

"I'm afraid, dearest, I was a little sharp just now. You must forgive me. You
were perfectly right to tidy away my papers; but you will understand that it
would be easier for me if I had a room where I could leave them about and
find them easily. Besides," he said, "I want more time for private prayer and a
place where I cannot be interrupted. My work is suffering for want of this."

"I see," said Rachel. She tried to smile, but failed. "I so love being with you
when you write your sermons," she added.

"And I have loved to have you. But the work must come first; and I am
convinced that for every reason it will be better to have a room quite to
myself." He turned round again to finish sorting his papers.

Rachel came to a sudden determination.

"You won't engage that room till you have thought a little longer about it," she
pleaded.

"I shall engage it to-morrow if possible," he answered with decision.

And Rachel said in her heart, "You shall not engage it to-morrow."

Then she went out to find Polly.

"Polly," she said in a soft voice, "do you think your father could come round
this evening and bring a man with him. I want to give Mr. Greville a surprise
and make the spare room into his study. He will be out at a meeting till nine
o'clock. Could you just run round do you think? I will get the tea."
The little spare room had been arranged with the hope that her sister Sybil
would soon be able to come and pay them a visit. It was dreadfully
disappointing that now she would not be able to take her in. She would have
to get a room out for her which would not be nearly so nice. But anything
would be better than for Luke to rent a room in his mother's house. She could
not endure that. If he did that she would see less and less of him, and she did
not think it could be good for a husband to get used to being a long time away
from his wife. In fact she simply could not bear it. Sybil's little room at the top
of the stairs must be turned into a study; and all the time Rachel was
preparing the tea she was planning where to place the furniture and his
books. The very idea of giving him such a surprise had the effect of sending
away all melancholy thoughts, and Luke, who had been as startled to see
such a look of melancholy on his wife's face as she had been to hear his
somewhat irritable tone of voice, was relieved to see her as bright as usual,
and determined never to allow any irritability to find its way into his heart
towards her again.

At ten o'clock that evening Rachel sat by the open window in the drawing-
room listening for her husband's footstep. She was very tired, as though
Polly's father had, with the help of another man, taken up Luke's writing table
and book shelves, etc., and moved other furniture into the spare room. Rachel
and Polly had between them moved the books and had arranged them as
near as possible in the same order in the shelves, as Luke had arranged them
himself in the dining-room. She had taken out of the dining-room two of his
favourite pictures and had hung them over his table; and she had placed a
large armchair by the window so that he could read in comfort.

And now she sat wondering if Luke would be pleased, or if the very careful
moving of his papers would again vex him. Her heart beat as she heard him
open the door and she ran to meet him. She drew him into the drawing-room,
saying:

"I have such a surprise for you."

But Luke hardly seemed to hear her. His face was radiant, and Rachel saw at
once that something had happened to make him very happy and to engage all
his thoughts.

"I have such good news to tell you," he said, as he sank rather wearily into a
chair.

"What is it?" asked Rachel. After the excitement of the evening his
preoccupation rather damped her spirits. That it was not the time to spring her
surprise upon him she felt at once, so she took up her needle work and sat
down. She could not but notice the expression on his face. She could not think
of any other word by which to describe it to herself, but radiant, and a longing
that he did not live quite so up in the clouds, as she would have expressed it,
took possession of her; he had evidently not heard her remark as she had met
him at the door; or if he had heard it, it was to him of such infinitely minor
importance than the news he was about to communicate to her, that he had
ignored it.

As he was silent before answering her question Rachel said again, and he
didn't notice the faint tone of impatience in the voice.

"What is your wonderful news? Do tell me."

"That's just it," he said looking joyfully at her. "It is wonderful. A man who has
been the ringleader of a lot of harm in the parish, has to-night made the great
decision; in other words, he has been converted."

"Oh Luke, how beautiful," said Rachel.

Rachel knew what this news meant to her husband. For a moment the study
was forgotten.

"He has only twice been to the class;" continued Luke, "and the first time he
made himself troublesome by arguing with me. But he came again to my
surprise, and to-night, well, it was wonderful. It only shows what God can do. It
was just a word of Scripture that struck him and would not let him rest. He was
quite broken down."

Rachel's work had dropped on to her knee and she sat looking at her
husband. His face reminded her of the parable of the lost sheep and of the joy
in the Presence of God over one sinner that repented. Even in the days of
their perfect courtship, even on that wonderful moonlight night on the sea at
Southwold, she had never seen such joy on his face. His love for his Lord,
and His work, exceeded, evidently, every other love and interest. Rachel
looking into her own heart and remembering how comparatively little
communion she experienced with her Lord, compared to Luke, felt inclined to
weep. She had been wholly taken up with her husband and his home and with
the determination of keeping him all to herself. She had not given much time
to prayer; and even in those moments in which she had knelt down night and
morning she found her thoughts wandering away to Luke, and revolving round
him. Her conscience accused her loudly.
"I will bring in your cocoa," she said rising, "Polly has gone to bed."

It was after drinking his cocoa, that she told him again that she had a surprise
waiting for him.

They ran upstairs together, his arm round her. He was in such buoyant spirits.
Then Rachel opened the study door.

For the first moment he was silent from astonishment. Then he took her face
between his hands and kissed her.

"But I don't approve of the surprise at all," he said, laughing. "What about
Sybil?"

"Sybil will have a room out. I would a hundred times rather that you should
write your sermons in your own home and near me than that you should get a
room elsewhere. Do you like it?"

"Like it? I should think so." Then his face became grave. "But where are my
letters and papers?" he asked anxiously.

"Perfectly safe. I have put an elastic band round the letters and they are in
exactly the same order as you left them, and so are your other papers which
you will find in the long top drawer. Then I have told Polly that she is never to
come into the study, but that I will see to it. So you can leave everything about,
dear; or lock the room up when you are out."

Luke busy among his papers looked up with a smile.

"Are you sure you would not mind me doing that? I can't tell you what a relief it
would be to me to know that nothing has been moved."

"I will dust it early in the morning before your letters come," said Rachel, "and
then you will be sure that you can leave everything about and it won't be
interfered with."

His smile of pleasure was enough reward for Rachel.

 CHAPTER VII.
RACHEL CONFIDES IN THE BISHOP.

The Bishop was in his garden, surrounded by the Clergy of his diocese and
their wives. He was a grey-haired man, upright and spare of build. His face
was full of kindness and love as he went among his guests, entering into their
difficulties and encouraging them in their work.

It was his annual garden party, and he looked forward to it almost as much as
did his clergy. Being a widower, had it not been for his work he would have felt
the Palace lonely. It was an old and hoary building, and lay in the shadow of
the cathedral; but the greater part of the garden was full of sunshine, and
wherever the Bishop was, there was brightness and the atmosphere of love
and fellowship.

He now stood glancing around as if looking for someone; then he caught sight
of Rachel who was making her way swiftly towards him, her face alight with
love and eagerness.

The child is happy, he thought gladly, and stretched out both his hands in
welcome.

"I was looking for you," he said, "and was hoping that you and your good
husband were not going to play me false. Where is he?"

"He's coming by the next train, in half an hour's time, but I was so impatient to
see you that I told him I could not wait. Some parishioner has been taken ill
and he had to go and see him. But I simply had to come."

"Now," said the Bishop, "I want to know all about your dear mother, and about
your new life. We will go towards the nut walk where we shall not be
interrupted. I also want to show you the Palace. I promised to do that in the
old days I remember."
"It's perfectly delightful to talk to anyone who remembers those old days," said
Rachel, with a slight catch in her voice, "and specially with you of all people.
How father loved you."

"He was my best friend," said the Bishop, "and the world for me is the poorer
for his absence. But tell me about your new life. Are you getting used to it?"

A slight cloud crossed Rachel's face which was not unnoticed by the Bishop.

"It's just a little difficult," she answered. "Luke's parishioners are quite different
from any people I have met; some of them are nice, and they adore Luke. But
oh they are so funny! They take offence at such small things. I don't think they
like me much. You see I was labelled as young and incompetent before they
saw me. But after all it does not much matter, as I have Luke. Perhaps if it
were not for a few worries I should be almost too happy."

"You have a good husband in Greville."

Rachel looked up into the Bishop's face. Her look was enough to convince him
of her happiness.

"He's much too good for me," she said, "I'm not half worthy of him, and of
course his people can't help seeing that, specially his mother."

"She does not live with you, does she?"

"No. She turned out for me, but she lives very near."

The Bishop detected a shade of bitterness in the little laugh that escaped her
lips.

"Is it difficult?" he asked kindly.

"I think you had better not ask me," said Rachel. Then unable to restrain her
feelings, she added, "She just spoils everything, and I am so afraid of Luke
finding it out; he is so devoted to her."

The Bishop was silent.

"The worst of it is," said Rachel, after a slight pause, "I can't talk it over with
Luke, so there is a secret always between us. Don't you think it was horrid of
her to tell people how incapable she thinks me? The result is that I can't help
Luke in his work; people don't believe in me."
"How do you know this?"

"Someone let it out by mistake when she called," said Rachel. "There are
always, I suppose, people like that in a place who talk more than they mean
to. This person is a regular gossip, and I learnt more about the people in half
an hour from her than I should have learnt in a year from Luke. Luke never
tells me anything. I wish he would."

"No, I don't think you should wish that. A man who does not talk over his
people is a man to be trusted with the secrets of their souls. That is just the
one disadvantage in my eyes of a man being married. It is difficult for some
wives to tolerate their husbands not telling them what should be kept sacred.
For every other reason I am a great advocate of married clergy. A wife may be
of the very greatest help to a man. But in order to be so she must be a woman
of high ideals, and one who understands what is due to his position. But my
dear child, why did not you try to turn the conversation of this parishioner?
Take my advice and don't listen to criticisms of yourself."

"I am not sure that I have high ideals," said Rachel with a little laugh, "but I'm
afraid I do like being appreciated. I am sure the people as a whole don't like
me, and I can't think why."

The Bishop laughed.

"I expect you are mistaken about that," he said, "It's very easy to get fancies of
that sort into one's head."

"Oh no it is not fancy. Anyhow the older people do not like or appreciate me.
They think I am no help to Luke; but he won't give me any work to do. I expect
it's his mother's fault as she thinks I am incapable. It worries me very much, as
I want them to like me for Luke's sake. Then I sometimes wonder if it is
anything to do with my dress. I see Mrs. Greville's face change sometimes
when I put on one of my specially pretty dresses."

The Bishop held her at arm's length and looked at her. Certainly she was one
of the best dressed women in the palace garden that day, but it was all very
pretty and becoming.

"Perhaps you are a little smart for the wife of the Vicar of Trowsby," he said
reluctantly. "It is very pretty, but in a parish where there are so many poor, it
might be wise to dress in a somewhat less luxurious fashion."
"It's part of my wedding trousseau," said Rachel regretfully, "and I do love
pretty clothes; perhaps they are my temptation."

"Perhaps they are," said the Bishop, smiling kindly.

"Anyhow when these are worn out the temptation will be over as I shall have
no money to spend on clothes. I am not sure that we shall not be eligible for
Gifts from the 'Poor Pious Clergy Society'," she added laughing. "Mrs. Greville
does not seem to think we have a penny to spare. I hate having to think of
every penny; it makes one inclined to be miserly and mean."

"No; it's the poor who are most generous. Don't wish to be rich; by far the
nicest people are those who are not endowed with this world's goods. It is far
harder to persuade the rich man to give of his wealth than the really poor
widow of her mite. I am glad that you have not too much of this world's
goods."

"I should love to be rich, or quite comfortably off as we were at home. I never
thought of taking care of the pence in those days, nor indeed of the pounds
either. Now I am always thinking 'can we afford it,' and find myself choosing
the thing that costs threepence rather than threepence halfpenny. It seems to
me horrid and cramping."

"Not nearly so bad as if you spent five pounds carelessly, when your poor
neighbour had only five shillings to spend. You will find that if you do not allow
yourself to grow miserly, you will be the richer for being poorer."

They had reached the door of the Palace by this time and the Bishop led the
way up the winding stone steps which led to the drawing-room. It was a long
low panelled room with large windows looking over the garden.

"How charming," said Rachel. "I hope you are going to ask us to stay with you
one day. I can imagine sitting here and dreaming all kinds of pleasant dreams.
Don't you love it?"

"If my dear wife was living and we had a houseful of children I should
appreciate it. But except when I have visitors, or when the house is full of
clergy, I have no use for this room. Come and I will show you my study."

That the study was a room in constant use Rachel saw at a glance, and
wondered if the Bishop was as anxious over the many papers and letters that
were arranged neatly on his writing table, as Luke was.
The sight of the papers brought to Rachel's mind the sudden panic that had
arisen in her heart at the idea of her husband renting a room in his mother's
house, and she told the Bishop of her fears as she moved about looking at the
pictures on the walls. Then suddenly turning round and facing him, she asked:

"Do you think all this is very small of me? I can't tell you how trying Luke's
mother is. She simply has no tact whatever and I can't help thinking that she is
a little jealous of me."

"Come and sit down," said the Bishop. Then he looked at her gravely. "I am
going to say something that I fear will hurt you. But I do it as your father's
friend and as your Bishop. Will you let me tell you the truth?"

Rachel's eyes filled with tears.

"I only want the truth," she said. "And I could never mind anything you said.
Indeed I want help."

"I will try to help you. And first let me tell you that you have the most splendid
opportunity of growing into a noble strong woman. This mother-in-law of
yours, instead of being a hindrance to your soul's life, may be a stepping
stone to a higher life. It depends a great deal upon yourself which she
becomes, a hindrance, or a stepping stone."

"I don't see how," said Rachel.

"She will be a tremendous hindrance if you give way to your present feelings
about her. You must forgive me, my dear child, but I am perfectly certain from
all you have told me that you are suffering from a terrible enemy. Let me call
him by his right name: his name is jealousy."

"Oh no," said Rachel shrinking. "I despise jealous people, I don't think it is
that."

"In the depths of your heart you are afraid lest your influence over your
husband should be undermined by his mother; lest he should grow more
dependent on her than on you. You do not like him to spend time with her
which you think ought to be given to you. In fact you generally suspect him of
being with her when he is late home, and all this makes it impossible for you
to like her. Is it not so?"

Rachel was silent. She knew he was telling her the truth.
"But you must remember that his love for his mother is the most natural thing
in the world. You would not really have it otherwise. If he did not remain
faithful to her now he has married you, you would have cause to doubt if he
would always remain faithful to you. You should encourage this filial love in
him."

"But you don't know her," said Rachel.

"Yes, I have met her; and though I can understand that she may not have
much tact, and may be lacking in sensitiveness, in fact is rather a rough jewel,
nevertheless she is a jewel, and I think you should be grateful rather than
otherwise to her for the beautiful influence she has had over her son, which
provides you with such a husband. And do not you think that possibly she has
more cause for jealousy than you? Remember, she has had to turn out of her
home, to give up her son, to see him wrapped up in his love for you. I own I
feel a little for Mrs. Greville."

Rachel looked up at him with her eyes still full of tears. "I know you are right,"
she said, "and I think I have been horrid. Somehow I have selfishly been
thinking of my own trials and have forgotten hers. But I don't know how I can
be different."

"Unless you get the victory over this sin, it will get the victory over you and
embitter your life. Jealousy becomes a kind of obsession, if given way to. It
has wrecked many a life."

"It is just that, an obsession. I can't sleep sometimes for thinking of her, and
my first waking thoughts are of how I can circumvent her."

"Then let me give you a receipt for jealousy. Whenever you find yourself
thinking of Mrs. Greville, pray, and then resolutely turn your thoughts away
from her."

"It will be very difficult," said Rachel, looking down. "She has got quite on my
mind."

"With God all things are possible."

"I sometimes wonder if I am really a Child of God," said Rachel. "I am so very
far from being like the Lord Jesus Christ."

"You must not let the great enemy of souls tempt you to despond," said the
Bishop. "That is the kind of atmosphere in which he delights to do his work.
You gave yourself to God at the time of your confirmation, I remember. Don't
listen to the doubts that the Devil suggests. You are a Child of God, but just at
present not a very happy or good one."

"I ought to be happy," said Rachel looking up with a smile, "with such a
husband as Luke. I only hope I do not love him too much."

"I don't think so. I doubt if it is possible to love a husband too much; but it is
very possible to love God, Who gave him to you, too little."

Rachel looked up again into the Bishop's face.

"I do want to be good," she said, "and really I have everything to make me
happy; if I am not happy it is my own fault, I quite see that." Then she looked
at her watch.

"Luke's train must be in by now and he will be hunting for you. I ought not to
keep you any longer; but I am so glad that you are my Bishop and my father's
best friend. I feel just as if I had had a talk with him. He, I know, would agree
with every word you have said."

Then finding it was so late they hurried into the garden where they discovered
Luke among a crowd of clergy, and Rachel, feeling as if a weight had been
lifted off her shoulders, left them together.

Luke's eyes rested lovingly on the retreating figure of his wife, and as he
turned to the Bishop the question in his eyes was so evident that the latter
answered it.

"Yes," he said laughing, "I know what you want me to say—that there never
was a sweeter girl in the world; I congratulate you Greville on your marriage."

"It is an ideal marriage," said Luke. "She is all I could possibly wish for."

"Knowing her father I'm not surprised to hear you say so. What does she do in
the parish?"

For a moment Luke was taken aback. He suddenly realized the fact that she
did nothing but keep his home for him.

"I don't encourage her to work in the parish," he said. "She is much too young,
I feel, as yet; I consulted my mother about it and we both came to the
conclusion that it was best at present for her to do nothing in that line."
"But is not that rather a pity? For the Vicar's wife to be a nonentity is not good
for a parish, surely there is something she can do."

"I can't tell you the state of the place," said Luke. "It would not really be fit for
her to go among the people. I could not endure for her to learn of all the awful
sin that abounds. It would be such a terrible shock to her."

"But, my dear fellow; you married her to be a helpmeet for you. I don't think a
man has any right to marry a girl and then to keep her entirely to himself just
to make his home comfortable, when there is God's work to be done. I think
you should trust her with God. It is no good keeping people blissfully ignorant
of the sin that abounds. Besides, ignorance is not innocence. It is almost as if
you were leading her about blindfold."

"My mother felt very strongly about it," said Luke. And yet for the first time a
suspicion crossed his mind that possibly he was denying to Rachel from
selfish motives, the wonderful privilege of working for God in the Parish. He
could not bear that his sweet wife should touch pitch even though it was in
God's service. He remembered saying to her what a rest it was for him to
come home and be with someone who knew nothing of the awful matters with
which he had come in contact during the day. Might not this be a subtle form
of selfishness on his part?

"Do you suppose that the women who go as Missionaries," added the Bishop
"have the faintest idea of the horrors they will see and learn about? Yet you
would not urge them to stay at home. Help her to work for her God regardless
of the consequences. Leave these with God. Besides you may not always
have your mother who I suppose is as good as a curate to you."

Luke determined to think the matter out when alone, and was soon pacing the
nut walk with a fellow clergyman discussing the attitude of the modernists in
the Church of England.
 CHAPTER VIII.
THE BISHOP COMES TO LUNCH.

The opinion of his mother weighed with Luke more than that of his Bishop.

After the sudden suspicion that he had been unconsciously giving way to
selfishness in not encouraging Rachel to work, he made up his mind that he
must talk the matter over.

"My dear boy," said Mrs. Greville, "Rachel is no more fit to work in a parish
than a child of five years old, and particularly in this parish. She has been
buried in the country all her life and is absolutely incapable of doing any good
till she has had anyhow a little experience."

"But I don't see how she can gain experience without working," said Luke.

"Well if you are so bent on it let her come with me to the mothers' meeting and
watch how things are done. In fact she might undertake the reading, that is to
say if she reads well."

"I have never heard her read, but no doubt she does. She does everything
well," he added laughing.

"In fact she is perfect in your eyes," answered his mother amused at her son's
blindness. "Well, let her come to the mothers' meeting to-morrow. She can't
anyhow do any harm."

"Harm! No indeed. The mere look of her must do good."

"She is certainly very pretty," was the answer.

And Luke left her in good spirits, quite unconscious that his mother did not
agree with his views of his wife, and that when she made the statement that
anyhow Rachel could do no harm she did not intend it for a joke.

He was however disappointed that Rachel did not seem to take kindly to the
idea of going to the mothers' meeting. To his surprise he had actually seen her
face fall at the suggestion.
"Don't go dear if you would rather not," he said quickly, "but I fancied you
might be glad of the experience. You are always telling me you want to work in
the parish."

"I want to help you," she said, "but I don't see that sitting and watching your
mother would be exactly a help either to you or to me." Then suddenly
remembering her talk with the Bishop, she added, "But of course it is very kind
of your mother to propose it. Perhaps I had better go. I should not like to
appear ungrateful to her."

And Luke left her, thinking to himself, "After all I don't believe she wants to do
that kind of work. Anyhow, she does not seem very keen about it; we may
have been right in not encouraging it before."

Rachel, as she took her place at the table at the mothers' meeting, and
opened the book she was given to read, felt nervous. She was quite sure that
the mothers were full of curiosity to see how she would conduct herself at this
first appearance at their meeting, and she was still more convinced that in her
mother-in-law she had a severe critic. She was so nervous that she found
herself even wondering how to pronounce some of the words. The book was
about Missionary work in India and in places of which she had not heard
before. Her mistakes were never passed over but were corrected at once by
Mrs. Greville. She felt like a child at school and decided that this was the last
time she would ever come to the mothers' meeting so long as Mrs. Greville
was present.

But she was determined not to let Luke know how her pride had suffered that
afternoon. She laughingly told him that she did not read well enough to be of
any good; the words were too long for her to master, and too difficult. Her
education, had evidently been neglected and she believed that every one of
the women present could have read better than she could. She was so merry
about it that Luke took it all as a joke and told her he would have to give her
reading lessons.

But when the next week came she thought of the "stepping stones" of which
the Bishop had talked, and felt that the remembrance of his words might help
her to grow into a noble strong woman worthy of Luke, if she mastered her
pride. And after the effort was made she was glad that she had gone. Her
mother-in-law was evidently pleased, and thanked her for her help, and
Rachel felt inclined to sing. She noticed too that when Mrs. Greville smiled the
expression of her face changed, she looked kind and motherly. Rachel felt
happier than she had done for some time.
The following week the Confirmation took place. The Bishop was coming to
lunch after the Confirmation. Rachel was overjoyed at the prospect.

She was busy the day before making every corner of the house look as pretty
as possible, and so imbued Polly with her excitement that she forgot her
manners and went singing about the rooms. Rachel was too happy to reprove
her. In fact she was quite glad to have someone who seemed almost as
excited as herself.

"Polly," she said, "the Bishop must have the best of everything, so our cooking
won't do for him. I'm going round to Evesham's to order a veal and ham pie
and other things; so if they arrive you will understand that they are all right."

"I shall give him a lunch regardless of expense," she thought, smiling as the
remembrance of Mrs. Greville's injunctions to economise crossed her mind.
"For once I shall not count the pennies. He shall have a lunch like he used to
have at home."

On the counter in the window of the confectioners she saw the exact thing. A
small veal and ham pie, the crust of which was baked to a golden brown and
the edges of which were frilled. It looked dainty and good. So Rachel made up
her mind she would order one to be made exactly like it, and with it were to be
sent some rissoles and a jelly.

She thought that possibly she and Polly between them could provide the
puddings.

She went home quite satisfied with her purchases and determined, should
Mrs. Greville hear of her extravagance, to brave it out. Besides, her mother-in-
law was not coming to lunch so there was no need to tremble at the
consequences of her morning's shopping. Luke would be quite oblivious as to
whether they had boiled mutton or a dainty veal and ham pie. He never made
any remark about his food; nor indeed, was he apparently conscious when his
wife provided him with something specially nice for a treat.

It was at the early dinner that the bomb fell. "I have asked my mother to lunch
to-morrow," said Luke.

"Oh Luke!" For the moment Rachel was off her guard and did not restrain the
bitter disappointment that his news gave her. Then seeing a surprised look on
her husband's face, she added quickly, "It is such a small room for four big
people."
Luke laughed.

"Four big people! I don't think any of us answer to that description. Certainly
you don't. I wish you did."

Rachel was too disappointed to be able to laugh.

"I had so hoped that you and I would have him to ourselves," she murmured.

"But it was only natural that we should ask my mother," said Luke. "And you
need not worry about the food. She will send round something suitable."

"There will be plenty," said Rachel, a little stiffly.

Luke glanced across the table at his wife. He had never heard her speak in
that tone of voice before. What could possibly have upset her, he wondered.

"He was father's greatest friend," continued Rachel, "and I had such a lot to
talk to him about. It will just make all the difference having a third person."

"Yes, I can understand that, if it were a stranger, but after all it is only my
mother. She need make no difference."

He was just a little surprised at his wife, and could not understand why she
should make a trouble of it.

Rachel did not speak. Her heart was hot within her. How blind Luke was! Were
all men like him? Surely he must have noticed how impossible it was for her to
be her best in his mother's presence, being conscious, as she was, of her
critical spirit.

Then she glanced across at her husband. He was looking perplexed and a
little worried. And had she not registered a vow that he should never be
worried with her smallnesses?

"O well, it does not really matter," she said with a faint laugh. "I am apt to
make mountains of molehills I expect. Don't look so grave Luke. Of course
you were quite right to ask your mother. She would no doubt have been
pained if you had not done so, and it will be all right. As for food there will be
plenty. I have been quite reckless on the Bishop's behalf. But you must not
blame me for my extravagance."

"He won't expect a spread," said Luke.

"I know. And probably would be quite happy with only bread and cheese. But I
love to give him of the best." Her laugh made her husband forget that his
news had worried her, and the faint surprise he had experienced disappeared.

In the evening as Luke was out Rachel told Polly to bring in all the silver and
she would give it an extra rub.

"Everything must shine as brightly as possible to-morrow Polly," she said.

At nine o'clock there was a ring at the bell, and a man handed in a large
basket which Polly brought excitedly into the drawing-room.

"It's from Mrs. Greville, Ma'am," she said. Remembering that Luke had said
that his mother was sending in something towards the lunch, Rachel had no
doubt that the basket contained her gift.

She lifted the cloth that covered the contents of the basket, and groaned.

It was a pie! but not a dainty pie such as she had ordered. It was large and
ungarnished, and might have been intended for a school treat rather than for a
dainty luncheon table.

Polly stood looking at her mistress's perturbation with surprise; in her eyes the
pie was lovely, and yet as her mistress was not pleased there must be
something wrong about it.

"Ain't it good, Ma'am?" she asked anxiously.

"Oh yes, it's good, but oh so much too large and clumsy for our table. Besides
I've ordered one, and it is to come early to-morrow morning. You'll see the
difference when it comes Polly. I can't think what I am to do. I'm afraid I shall
have to go round to Evesham's, late though it is, and counter order mine."
Then a sudden determination made her add: "No, I won't, I'll keep to my
original plan. This pie will do very nicely for another day. It is of course very
kind of Mrs. Greville to send it," she added for Polly's edification.

When Luke came home she said nothing to him about what had happened,
and he did not notice that she was not quite in such gay spirits as usual. Mrs.
Greville arrived early in the morning next day.

"I thought you might need my help," she said to Rachel who tried to smile a
welcome. "Is the silver brightened? And have you remembered to get out the
best cloth? I provided one or two extra good ones for such occasions." She
was full of excitement and anxious to help.

"Now would you like me to lay the table for you?" she said. "I see you have
some flowers. That's right, I wondered if you would think of them."

"Thank you," said Rachel. "I can quite do everything myself. Yes, I know the
Bishop is particularly fond of flowers and notices them more than anything
else."

"Well, then you can arrange them while I lay the table," said Mrs. Greville
drawing off her gloves. "I know where everything is to be found, and you need
not pay any attention to me, my dear."

Mrs. Greville in the kindness of her heart was perfectly unconscious that her
services were neither required nor wished for, and busied herself about the
house. When Rachel, who always felt a puppet in her hands, mildly suggested
that it might be better to let Polly arrange the table, as it would disappoint her
not to do so, Mrs. Greville remarked:

"The great thing is that it should be laid correctly and Polly will have to get
over her disappointment. Perhaps next time she will be able to do it. But this
first time it is as well that some one who really knows should undertake it."

Rachel supposed that Mrs. Greville had never entertained a Bishop before, as
she was in such a state of excitement over it, and evidently was nervous lest
her daughter-in-law should disgrace her and her son. Rachel understood now
how her husband could scarcely have helped inviting her to lunch under the
circumstances. It would, without doubt, have pained her and disappointed her
terribly to have been left out.

But to Rachel it was almost more than she could bear. She had looked
forward to a quiet happy time with her father's best friend. To make such a
fuss over him was perfectly unnecessary. She wanted to show him her little
house, and to assure him that she was trying to follow out his fatherly advice.
Now she felt that all was altered.

She saw that even Polly felt the hurrying and exciting influence in the house.
The girl was looking worried and disappointed as Mrs. Greville called her
hither and thither telling her to do this or that, and not leaving her a moment's
peace. Her face was crimson and its expression one full of anxiety. She was
no longer enjoying running about at her mistress's behest, and entering into all
the pleasure shown by her at the coming of her father's best friend, (for
Rachel had informed Polly of many things about her home life that she knew
would interest her faithful and devoted little maid), but she was straining every
nerve that things should be properly done for the arrival of a very grand
gentleman who would notice every little mistake she made.

Besides, what worried the girl was the fact that her own dear Mistress seemed
to have lost her good spirits since the early morning. The sun had gone out of
her face; and disappointment and chagrin had taken its place.

Mrs. Greville had a very kind heart and if she had had the faintest idea of the
disappointment she was giving to her daughter-in-law, she would have put on
her gloves and disappeared at once. But she was not sensitive to her
environment. Though she noticed that Rachel was graver than usual, she
supposed the gravity was caused by anxiety that all should go well, and
congratulated herself that she had come in to help so early in the morning, as
her daughter-in-law seemed rather helpless and worried.

The more Mrs. Greville bustled about, the more lifeless Rachel became. All
her energy had evaporated. She felt there was nothing for her to do as all was
being done by her competent mother-in-law.

Even the arranging of the flowers was not left entirely to her. Having placed
them gracefully with their long stalks in the flower vase, she put them in the
centre of the luncheon table and was admiring them, when Mrs. Greville came
into the room, her hands laden with dishes. Putting them on the sideboard she
turned and looked critically at Rachel's flowers; then quick as thought lifted
them out of the water and breaking their stalks put them again into the vase
on the table, pressing them down so that the blossoms might all be even.

"There! they look better so and more tidy," she said, whilst Rachel stood by
too astonished and taken by surprise even to expostulate.

But no sooner had Mrs. Greville left the house having done everything to her
satisfaction, than Rachel slipped on her hat and ran round to the florist. Even
if her mother-in-law had her way in everything else she was determined that
her flowers should be an exception. The Bishop should anyhow see
something to remind him of her old home, and the flowers were those he
particularly loved. They were a fabulous price, but Rachel was reckless.

Happily the pie did not arrive from Evesham's till her mother-in-law had
disappeared. Rachel found Polly regretfully contemplating it as it lay on the
kitchen table.
"It's such a beauty!" she said to Rachel as she came in. "It's ever so much
nicer than the one Mrs. Greville brought. It has such a pretty edge, and is
varnished like, and there's a piece of parsley sticking out of the top. The other
looks ever so plain by its side."

"Go and fetch the other back from the table Polly," said Rachel. "We'll put this
one in its place."

Polly wondered how her mistress dared to do such a thing, and fervently
hoped that Mrs. Greville would not scold her too much, but she fetched it
gladly with an inward thrill of excitement.

Rachel went to the Confirmation Service in no devout state of mind. She felt
out of touch with all good things. She knew she was indulging in wrong and
unworthy feelings towards her mother in-law, as she was not blind to the fact
that all she did was done in pure kindness, and because she had a false
preconceived idea of her daughter-in-law's incapability. It was a case of
misunderstanding. But what had happened this morning had made her feel all
on edge. However, the sight of the Bishop, the sound of his voice, and still
more the Charge he gave to the Confirmation candidates, filled her with a
feeling of shame. How badly she was keeping the resolutions she had made
at her own Confirmation. How half-heartedly she was fighting the world, the
flesh, and the devil; what an unsatisfactory soldier of the King, under whose
banner she had promised to fight unto her life's end.

She felt so ashamed of herself and so full of repentance, that she hurried
home as fast as she could after the service and told Polly to put Mrs. Greville's
pie on the table again. It was more necessary for her to be good and for her
mother-in-law to be saved pain, than for the Bishop to partake of a pie with a
frilled edge and, as Polly had expressed if, "all varnished like."

Then with an easier mind she was able to welcome her friend and even to
smile at Luke's mother. It must be confessed however, that the smile was
difficult to maintain, as she could scarcely get in a word edgeways with the
Bishop. Her mother-in-law entirely engrossed his attention. Even Luke had to
sit and listen, which made Rachel every now and then feel furious.

The Bishop, who was a much more sensitive man than Luke, saw at once that
Rachel was feeling tried, and did what he could to turn the conversation in a
direction that Mrs. Greville could not participate in for a short time, but before
a few words had been exchanged with. Rachel or Luke, Mrs. Greville chimed
in and again monopolised his attention. She felt that Luke and Rachel were
silent and so did what she could to help to make talk, quite oblivious of the