Why isn’t our current healthcare creating health? (Part I)
How historical successes led to a system that no longer serves us.
Today we begin a series on a common question I hear about healthcare. We spend a lot on medical care (18% of US GDP and at least 10% in the EU), yet it doesn’t seem like we’re getting much healthier. Life expectancy has stalled over the past 20 years, and modern end-of-life can be heartbreaking years upon years of low-quality health. Often, frustrated patients know preventive care is important, but it doesn’t seem to be covered. Why isn’t all our spending creating health?
To understand why, we’ll walk through the current system’s misaligned financial interests and the disconnect between prevention and reaping its benefits. But first, this may not be the fault of the current system, but instead that our historical successes have created new needs which the old system is not set up to address.
1. From there to here: making medicine a science
Medicine for a long time was more of an art than a science, simply because of meager understanding about disease and its causes. However, around the 1880s, new tools such as microscopes led to the discovery of bacteria and other microorganisms, which revolutionized and standardized medicine. Thus began the modern painstaking but radically successful campaign against infectious disease.[1] This first phase of medicine changed the way we interact with an environment that, turns out, is out to get us. Handwashing, sterilization, and improvements in public sanitation dramatically curtailed infant mortality and increased life expectancy. Medicine made structural changes to our physical environment to radically decrease our chances of contracting illnesses.
With infection taken care of (and the handy discovery of penicillin by the 1940s), the second phase of improving health began in the mid 20th century by turning inward to acute problems in the body itself, rather than external attacks from infection. Scientific knowledge of the human body accelerated with steadily increasing funding. Between 1946 and 1960, the once singular entity of the National Institute of Health (NIH) multiplied into 10 agencies, starting with agencies for mental health, dental diseases, and heart diseases, followed by institutes focusing on arthritis, metabolic disease, and allergies. The 1950 NIH budget was $52 million. In 2023, the National Institutes of Health now numbers 27 institutes and centers and has a research budget of 47.6 billion.[2] [3] The past 70 years of spending has greatly expanded our knowledge of the physical body and its functions, but much of what we learned concerns acute conditions over short-term analysis.
2. Yesterday’s vanquished reveal today’s adversaries
Ok, infectious disease: conquered. Fine, there are some exceptions like COVID-19, but even here, our well-established medical research infrastructure was quickly able to knock out our adversary. Unfortunately, today’s top causes of death are not rock-em-sock-em attackers any longer, but a more pernicious villain that creeps in over time. The top killer in the US in 2023 was heart disease, followed by cancers, strokes, Alzheimer’s and diabetes.[4] And this isn’t just a US healthcare problem- Alzheimer’s and dementia were the leading causes of death in the UK, followed by heart disease and stroke.[5] Heart disease and cancer also top the list in the EU.[6] All these countries have different approaches to healthcare, yet the health challenges are the same. This isn’t just a case of tweaks to the existing system, but instead structural difficulties of where medicine has landed.
Today’s top causes of death are different than those we have defeated. They are not acute attacks, such as an opportunistic infection, but develop over long periods. Medicine could potentially intervene at several points, but a long period of development means there are many potential causes to sort out. What’s more, many of these causes are not from the environment acting on the body, but from the body’s interaction with both the external environment and an internal environment we create through our choices of care for our bodies. Stress, nutrition, and exercise are not fully external adversaries- patient choice is a significant component in their defeat.
3. New needs need: A new system
Why don’t second phase strategies work against these third phase health challenges? First, one of our best tools of 20th century medicine, clinical trials, are not well-suited to long term research. Diabetes onset or heart disease risks accumulate over 20-30 years. Clinical trial lengths have been increasing in the past 15 years, but they still average about 40 months- just over 3 years.[7] Second, because the nature of medicine has been to intervene only for well-defined acute conditions, our current interventions enter in a way that likely doesn’t match the nature of the disease. For example, pharmaceuticals are prescribed only after blood cholesterol crosses a specific threshold or a heart attack occurs. We lack information on how interventions could be timed earlier, or spaced along a 30-year period, or even what biomarkers to track which could predict improved outcomes.
In the next parts of this series, we will examine how the institutions that grew up around these first two phases of medicine may no longer be serving us well into our next phase and then examine the role of a newly important, but disenfranchised, medical player- you! As always, keep me updated on what you’re up to or reach out to chat with me about these issues!
Best,
TMD
Read Part II in this series and learn how insurance is like Costo or Part III where healthcare goes to Prevention Camp!
[1] I say radical compared the Black Death’s elimination of a third of Europe’s population to even deadly COVID, with over 2 million deaths out of 746.4 million people, or 0.2 percent of the population. Statista, “Cumulative number of deaths of coronavirus deaths in Europe”. Jan 13, 2023.
[2] The NIH Almanac. “Historical Appropriations” November 2023.
[3] NIH, Office of NIH History and Stetten Museum “A Short History of the National Institutes of Health”
[4] CDC, National Center for Health Statistics, FastStats “Leading Causes of Death” COVID ranked #10 in 2023. Let’s hope it gets fully knocked off for 2024!
[5] UK Office for National Statistics, “Deaths registered in England and Wales: 2022”
[6] Eurostat, “Causes of Death Statistics” March 2023.
[7] Martin, L., Hutchens, M. & Hawkins, C. Clinical trial cycle times continue to increase despite industry efforts. Nat Rev Drug Discov 16, 157 (2017).
In the case of the car body shop, individuals who drive inexpensive cars carefully can end up saving money. Under universal insurance coverage, or post-ACA US coverage people can't be charged differently based on their health status. This means the benefits of prevention are now more muted for individuals. This is especially true with people moving to publicly-funded Medicare post 65 in the US. Of course this is a good thing if we want protection against un-preventable disease or accidents, but harder for the preventable component of chronic disease. Perhaps a system which addresses chronic illness needs through different tracks, i.e. you've chosen lifestyle interventions with low payments or you haven't with accompanying higher costs. Somehow we need stronger ability for individuals to reap the benefits of preventive choices.
Thanks for your insight. Ask 100 body shop and auto mechanics, how many would feel responsible for how people drive? They get paid to fix the car. Kaiser differs in making more money if people don’t use the health care system. So their incentive would be to reduce health care use but that’s not the same as promoting health. But that’s a whole another story. E.g. Palliative care would be very profitable but not necessarily “health-promoting.” Unfortunately, in a sci-fi world, individual people would have to be responsible for their weight, blood pressure and HbA1C (diabetes measure), subjecting themselves to regular testing and receive payment for improvements and penalties for worsening. Isolated from the immediate consequence, they face only long-term effects at which time they find themselves in the body shop. Too late for driving lessons.