Healthcare and the Quality of All Life
Human health depends on all human systems, plus nature’s systems. But we seldom think of health care that way. We define it as intervention when things go wrong – as curative care to restore health. And its costs seem to be rising out of sight. That’s what concerns us, but perhaps we should worry about the healthcare of all life, or the quality of all life.
In the US, debates about both ACA (Obamacare) and AHCA (Trumpcare) largely avoid discussing how we actually care for our health, now or in the future. Instead, we debate financing curative care — access, insurance plans, taxation – and who pays, although no financial restructuring so far has stemmed the rising cost of curative care. Perhaps neither Congress nor anyone else can resolve such deep issues alone. Better ideas may not come exclusively from health system experts. Ideas to intervene in the system depend on how we mentally frame the issues. Perhaps if we can collectively reframe the issues, we will evolve a new social contract about health. But how do we do that?
Intellectually, we all agree that good health reduces curative care, but reasons for poor health explode in all directions. “Everything” affects our health, including our own attitudes. We persist with poor diets, lack of exercise, and abuse of substances. We tolerate poor sanitation, toxic substances, and social customs that let pathogens spread unchecked.
Questioning why we need so much curative care dredges up excuses, blame games, systemic paradoxes, and perverse psychology. (A former secretary said that all she had to live for was enjoying smoking and drinking because she “owed It to herself.”) Many studies have shown that low income and low social status correlate with poor health, poor access to curative care, and shorter life spans.
The present and future health of Americans deeply concerns health authorities, not least leaders in the U.S. military. In recent years, reports are that up to 75% of all Americans of draft age cannot meet the standards for induction into military service. About a third are too obese. Other notable deficiencies are functional illiteracy, mental instability, and substance abuse.
At the beginning of WWII, 45% of all draft eligible men could not meet induction standards. Obesity was not formally measured, but “flabbiness” was a subjective criterion. And 100 years ago most inductees rejected in WWI were underweight or tubercular; overweight was a limit only for sitting on a horse (180 pound max).
Since WWII, obesity has steadily grown as a health concern in the general population. Physical debilitations now treated were ignored or impossible to treat 100 years ago, and in the future, health officials worry about care of obese, diabetic people as they age. The explosion in the costs of curative care is from an aging population, medical technology advances, and curative care becoming a “business” (see the review of An American Sickness). People live longer, coping with conditions hopeless to treat in the mid 20th century.
In 1940, a doctor with a little black bag couldn’t do much, but was affordable; that’s just how it was. Antibiotics were barely known, and a disease like cancer killed almost everyone who got it. Then public expectations of medical miracles began to skyrocket. Miracles became routine, with new ones appearing so fast that only leading edge specialists can keep up and harried general doctors can’t. But miracles cost big time bucks, and specialists have difficulty communicating with each other. Curative care burgeoned into a much more complex system, with bureaucratic messes not seen before.
Medical research and technical advances are coming faster than we can assimilate. The Medical Futurist, Dr. Bertalan Mesko, posts 20 technical trends coming fast (and microbiome research isn’t even on his list). After 19 whiz-bangs, his 20th is simple – Patient Empowerment. Leading edge or back edge, we have to take more responsibility for our own health – and Mesko bets that digital technology will empower us.
The Medical Futurist site also has a button labeled Grand Challenges. All four of them suggest that each one of us must learn to take more responsibility for our health, rather than rely blindly on experts. The coming system he envisions should:
- Embrace disruptive technologies (keep up).
- Put patients at the center of healthcare.
- Digitize healthcare information (so non-physicians can see it and can interpret it).
- Shift focus from treatment to prevention.
By contrast, Dr. Gilbert Welch is a technophobic campaigner against over-diagnosis, over-treatment, and under-proven technology. But he too advocates more patient involvement and responsibility, and less medical intervention. So do many other health professionals. The existing health care system is near peak spending; financial re-engineering can’t fix it; fundamental perspectives and practices have to change. Since health care relates to almost everything else, a big social shift has to sweep in – soon.
Substantially shrinking the health care system would be an economic implosion – maybe trillions of dollars and millions of jobs. Nonetheless, we have little choice but to go for it. The revolution has to yield better quality from much less quantity. But the real revolution is changing basic beliefs about life, quality of life, and medical intervention – subjects that we don’t like to talk about. They invoke taboos and provoke clashes. Here are four crucial health care issues:
- When should life end? Many of us have experienced ethical dilemmas about end-of-life treatment. In the US, social agreement is that the patient’s preferences when capable of expressing them should be respected. Many of us now have advanced directives on “when to pull the plug,” but in practice end-of-life decisions are still complex and emotion laden, as medical ethicists describe.
Most people incur a surge of medical treatment (and expense) in the final year of life. This is sometimes attributed to medical adventuring despite a dismal prognosis. However, according to a University of Michigan study this is mostly myth. By far the priciest end-of-lifers are elderly people with on-again, off-again bouts that slowly degenerate into multiple system failure. Almost half of the Medicare decedents surveyed are in this category, likely to experience feeding tubes, respirators, or dialysis – not high tech by current standards, but requiring expensive professional attention. At some point this may become excessive and painful, but deciding when recovery is hopeless doesn’t reduce to a standard protocol. Better technology may diminish the uncertainty, but not the anguish of the decisions.
- When should life begin? Instinct tells us to do everything to start a life – or does it? About 10% of births are premature, and the earliest births tie our gut instincts in ethical knots. A third of all infant deaths are preemies. Nearly half of all infants entering preemie care don’t survive. Many of those that do have lifelong problems. For instance, 45% of all children with cerebral palsy were preemies.
A hundred years ago, little could be done for a preemie. It was beyond human control, so ability to care for preemies using the best medical technology presents new ethical issues, quality-of-life decisions as well as life-death decisions. They are too emotional for cost-benefit calculus or regulatory codes. And we do not yet have a social consensus for ethical guidance.
- Is treatment effective? Much evidence points to ineffective treatment that could have been avoided, interventions touted as effective that are later shown not to be effective. By post-op second opinions, between 10 and 20% of all surgeries are unnecessary. Data are hard to collect and doctors don’t like to talk, but it is significant. Ineffectiveness of pharmaceuticals now has a well-documented history, and a causal factor is clinical trials.
Carried to completion, clinical trials are expensive, $1 billion on up, if numbers are to be believed, and many critics don’t. Only 10% of drugs entering clinical trials are approved, and of those that finish clinical trials, the FDA approves only half. The ability to predict performance is rapidly evolving, but drug development remains a high-stakes, dicey business. Companies want to maximize revenue from each approved drug, so development costs plus heavy marketing costs drive up drug prices.
The system of development needs work, excluding cases like Martin Shkreli and his 5,500% price hike, considered blackmail because patients with toxoplasmosis (and their insurance companies) had little choice other than Shkreli’s Daraprim. However, the outrageous cases mask a more widespread pressure to maximize pharma income, perhaps to prop up stock prices in an industry that is slipping.
Technology aims to rescue this unsustainable situation. One initiative is patient specific prediction, designing treatments for exactly what ails each individual. Right now this is a Big Data dream, threading through DNA, proteomics, microbiome, and other patient characteristics to pinpoint a magic key.
This magic key should hit a perfect score of 1 on “number needed to treat” (NNT). That is, it would “cure” an individual with no observable bad effects. NNT is sometimes, but far from always used for scoring drug effectiveness. Its counterpart is “number needed to harm” (NNH) when observing downsides. For those interested, Wikipedia has a good run down on NNT statistics.
If a drug has modest positive effects accompanied by bad side effects, NNT can be over 100, meaning that to help one patient, you would have to treat 100. Cost per patient helped is obviously high, and you have only padded the bill and wasted time and money with the rest. However, this NNT-NNH effect, and the consequences of false positives and false negatives on tests are hard for patients wanting the “very best” to understand.
But concepts of normal health or perfect health are elusive. Many of us live a long time flawed with various disabilities, and over time, our physical and mental states change. That is, we are an ever-changing system, interacting with other systems. To address this, one of several approaches is Functional Medicine – evidence based allopathic medicine concentrating on a whole person and their environment over time. It’s also preventive medicine, guiding us how to live to reduce chronic “industrial” diseases. That is, Functional Medicine is mainstream medical technology melded with systems thinking.
- Should we attempt to biologically improve our “natural” condition? Enhancements range from drugs like steroids, to implanted electronics, to babies “designed” by genetic modification (now roundly denounced). The physiological branch of the Transhumanism movement concentrates on improving humans into superhumans, and the artificial intelligence branch concentrates on improving computing until it surpasses human powers.
Intervening to improve ourselves attracts opposition of course. For example, Elizabeth Parrish, CEO of BioViva, extended her telomeres with experimental gene therapy and claims that her body cells are 20 years younger. Skeptics and ethicists are howling. However, compare the sci-fi objectives of transhumanism to some of the near-term projections of The Medical Futurist and they start to blend. It’s hard to forecast what we will accept 10 years from now. For example, plastic surgery is quite common in Brazil (are you really that good looking all by yourself?)
And health authorities commonly recommend vitamins, vaccinations, orthodontics, eye surgery, and other procedures to make us better than nature and our own abuse leaves us. At what point may we experience unintended side effects?
Even if we ameliorate the pressures driving up costs, “health care” appears to be evolving into a tiered system, although how it will split is uncertain. Will we have one tier of curative care for those with big money and another for the rest of us? Will some insiders transform into physical and mental superhumans, while the rest of us remain ordinary wimps?
Some things futurists agree on: In whatever tier of health care attention that we land, all of us have to learn how to knowledgeably interact with professional doctors, and they with us. We have to adopt more preventive lifestyles. Whether measured by money or by life satisfaction, we cannot enjoy living a long time constantly hobbled by medical interventions.
In any case, health is an element in our overall quality of life, which is our longevity plus our vigor over that lifetime. And health is related to the environment in which we live. Therefore, it is related to the health of a lot of other life on the planet. Thinking of our health as connected to all other health puts a broader perspective on it. Since it is interrelated, perhaps our desire for quality of life should be broadened into a concern for quality of all life. But that is for another time.