More than Medicine: The Broken Promise of American Health

MORE THAN MEDICINE

the broken promise of american health

Robert M. Kaplan

Cambridge, Massachusetts

London, England

2019

Copyright © 2019 by the President and Fellows of Harvard College

All rights reserved

978-0-674-97590-3 (hardcover : alk. paper)

978-0-674-98918-4 (EPUB)

978-0-674-98919-1 (MOBI)

978-0-674-98920-7 (PDF)

The Library of Congress has cataloged the printed edition as follows:

Names: Kaplan, Robert M. (Robert Malcolm), 1947– author.

Title: More than medicine : the broken promise of American health / Robert M. Kaplan.

Description: Cambridge, Massachusetts : Harvard University Press, 2019. | Includes bibliographical references and index.

Identifiers: LCCN 2018024768

Subjects: LCSH: Medical policy—United States. | Preventive health services—United States. | Medicine, Preventive—United States. | Public health—United States.

Classification: LCC RA395.A3 K353 2019 | DDC 362.10973—dc23

LC record available at https://lccn.loc.gov/2018024768

For the family that questions: Margaret, Cameron, Seth, Ashley, Oscar, and Rose

contents

Introduction

1

Let’s Be Average

2

Research Promise and Practice

3

Mistaking the Meaning of Health

4

Making Health Care Safe and Effective

5

Social Determinants of Health

6

The Act of Well-Being

7

A Way Forward

Appendix

Notes

Acknowledgments

Credits

Index

Introduction

Apparently, nothing is more important to Americans than good health. That is why we are willing to spend so much to achieve it. Health care now accounts for the biggest sector in the biggest economy in the history of the world. In 2017, the United States spent $3.2 trillion, or about 18 percent of the gross domestic product (GDP), on health services. Most countries that Americans consider our economic competitors spend less than 11 percent of their GDP on health care. If the US health care system were an independent country, it would have the fifth-largest economy in the world, behind only China, Japan, Germany, and the United States itself.¹

One reason the United States spends so much on health care is that it is deeply invested in the most expensive variety of that care: biomedicine. Advocates for this sort of care have a compelling argument on their side: more investment means more medicine, and more medicine, the argument goes, means more cures, greater longevity, and increased quality of life. The validity of this argument is obvious to Americans, and why shouldn’t it be? We know that diseases result from malfunctioning biological systems—infections, organ system dysfunctions, toxic exposures, accidents, and genetic abnormalities. To identify aberrant biological systems, we need biological tests. To fix these systems, we need pharmaceutical interventions, medical devices, and other therapeutic techniques directed at the biological system. The faith on which American health care is built is that basic science can be translated into miracle cures, rescuing patients from the grip of life-threatening illness. Indeed, we hear stories of such patients frequently. They inspire us to not give up hope—and to spend without limit.

The narrative of miracle cures surfaces everywhere. It is in advertisements for pharmaceutical products and hospital services. Charities push it in solicitations for contributions. Doctors and patients talk about great new scientific accomplishments and those on the horizon. Researchers justify their budgets by promising curative medical technologies. For instance, in 2014, National Institutes of Health director Francis Collins told the Senate Appropriations Committee that NIH scientists had brought down the US death rate from coronary disease by 60 percent and stroke by more than 70 percent compared with the three previous generations. Credit went to their work on heart attack and stroke prevention, cholesterol-lowering drugs, blood-pressure-control therapies, and innovative strategies for dissolving blood clots. Collins closed his testimony with the story of Nic Volker, a 6-year-old from Monona, Wisconsin, who survived a mysterious, life-threatening intestinal disease with the help of NIH-funded biomedical research.²

It is no wonder, therefore, that biomedicine dominates federal research expenditures. In 2017 NIH spent about $33 billion on biomedical research. By comparison, the National Science Foundation spent just $7.7 billion to support basic research in all other areas of science combined. The cure narrative also shapes decisions about how biomedical-research budgets are spent. Grants identified with the search terms genome, stem cell, and regenerative medicine—all research areas associated with disease detection and therapy—consume 57 percent of the NIH budget. Between 1974 and 2014, the number of indexed biomedical research articles grew 410 percent; the same period saw a 2,127 percent increase in articles identified with genome research.³ Meanwhile, faith in cures, and the large budgets thereby justified, attracts young minds to biology and medicine, starving other fields of talent and financial resources. That same faith fuels runaway prescription drug prices: only because we believe we need them are we willing to pay so much for them.

In this book, I ask an unusual question that would be much more common if we were not so invested in the status quo: Is it worth it? Medical science has undoubtedly made great advances. As a medical researcher and science administrator working in academia and government, I have been fortunate to witness and take part in these advances. I have seen the injured healed and the sick made well. But are we getting the return our investment demands? In the chapters that follow, I argue that we are not.

A Critical Look at Biomedicine

We need to rethink our basic approach to biomedical research and health care. As practiced today, our approaches are too expensive and too often fail to make good on the promise of providing cures. They also rely on a fundamentally mistaken, mechanistic view of the human that diverts attention from the kinds of research and intervention that would be most useful in improving Americans’ health.

At this point it would be folly to deny that American health care is enormously expensive. What we don’t often recognize, though, is that spending the most doesn’t necessarily make for the best outcomes. Americans have shorter life expectancies and higher infant mortality rates than the people of most other developed nations, and the gaps are widening. The disparity is present even among the most privileged: the death rate for US white non-Hispanics between the ages of 45 and 54 is nearly twice the average for whites in that age group in Sweden or Australia.⁴ On the whole, the United States ranks last among rich nations on key indicators including life expectancy and probability of surviving to age 50.⁵

Of course, some Americans can afford excellent, cutting-edge health care, but even this is often less impressive than it seems. Recall NIH director Collins’s claim that biomedical research investments are responsible for dramatic declines in death from heart disease over the course of generations. Although new medications have helped, a review of more than fifty studies indicates that at least 50 percent of the mortality reduction is attributable to nonmedical factors.⁶ For instance, a major source of the drop in heart disease deaths is declining tobacco use.⁷ The course of the heart disease epidemic closely follows that of cigarette smoking’s popularity. Smoking was relatively rare in turn-of-the-century America; its incidence began increasing around 1910, plateaued in 1945, held steady, and declined in the 1970s. Similarly, incidence of heart disease began rising in 1910, plateaued in 1945, and fell after 1970.⁸ The rapid decline in deaths from heart attacks and strokes began well before patients had access to modern heart medicines such as cholesterol-control drugs.

Indeed, there is little evidence that advances in drug therapies have saved people from heart disease. In the past twenty years, the most credible major randomized clinical trials to evaluate treatments intended to reduce premature deaths from heart disease were sponsored by the National Heart, Lung, and Blood Institute. Their studies have high credibility because they monitor conflicts of interest and they require the highest standards of transparent reporting. Of the twenty-five treatments tested in these high-quality studies, just one was associated with significantly increased life expectancy.⁹

And yet, testifying to the power of the cure narrative, Americans believe we have the world’s best health care. A 2013 YouGov public opinion poll for the Economist asked Britons and Americans, How do you think the US compares with other wealthy countries, such as Britain, Canada, France, and Germany?¹⁰ Respondents were asked to compare the United States and these other countries in terms of life expectancy, infant mortality, obesity, and homicide rates. As I explore in Chapter 1, the United States has lower life expectancy, greater infant mortality, and significantly higher prevalence of obesity than these other countries. The number of homicides in the United States is also far greater. But US respondents told poll-takers the opposite for each category. In response to each question, US respondents reported that their country had superior outcomes. In other words, Americans downplay poor outcomes and fail to account for public-health concerns that can’t be solved by cures.

Our tendency to impute great power to a system driven by medical interventions, and to deemphasize the effects of social and behavioral risk factors such as obesity and homicide, reflects widespread misunderstanding of the people being cared for. Medical science in America today treats people like auto garages treat cars. Is your oil low? Add some. Is your hemoglobin low? Add some by taking medicines that raise it. Just as mechanics remove and replace malfunctioning parts, surgeons remove malfunctioning organs and sometimes replace them with transplants. This find it and fix it philosophy works for some health problems, but not for all. Treatments may improve some physiological measure while having no effect on longevity or overall health. They may be harmful as well, producing serious side effects.

Meanwhile, over-focusing on biological mechanisms directs attention away from the many social and behavioral determinants of good and ill health. Current biomedicine recognizes the quality-of-life and longevity effects of violence, poverty, racism, workplace policy and stress, and poor education. But the current practice of medicine pays very little attention to these influences: they cannot be easily addressed with medicines or surgeries.

Taking Control from the Dead Men Ruling

Effecting change in public policy is daunting. Citizens often clash over spending priorities, whether they want more funding for schools, infrastructure, law enforcement, health care, or any other public project. Many citizens also want spending cuts and lower taxes. And lobbyists push for their industry’s bottom line, heedless of governance philosophies or the greater good.

Yet it is not just good-faith disagreement and bad-faith profiteering that are to blame for unwise spending—too much for things we don’t need, too little for things we do. As the economist Eugene Steuerle shows, many of our investments are just continuations of previous ones.¹¹ Programs, once established, develop lives of their own and can be hard to dislodge. Spending priorities set in one year often persist to the next, and the next, and so on down the line. Although these programs live on, they often represent the priorities of people who are no longer alive. In other words, Steuerle explains, dead men rule.

The ideas governing current scientific research spending are mostly those of dead men such as Vannevar Bush, the engineer and public administrator who pressed for the creation of the National Science Foundation. Once programs are funded, advocacy groups form to keep them in place. Scientists in nearly every discipline lobby hard to assure funding for their research area will grow, or at least stay the same.

The rule of dead men has not encouraged us to be stingy, but it has directed expenditure narrowly toward biomedical research and intervention. Compared with countries that enjoy better health outcomes, the United States spends significantly more on medicine and significantly less on other human services.¹² This is not to suggest that spending on biomedical research and health care is always wasted, but there is reason to believe that a different allocation of resources, toward social services and away from medicine, would produce better health outcomes.

The Science of Better Health

In many parts of the world, scientists and citizens concerned about rational, well-developed policies must contend with challenges from pseudoscientific and anti-science forces. The United States is no exception. Highly organized and richly funded pressure groups contest well-established evidence of evolution, the causes and effects of human-generated climate change, the benefits of vaccination, and the contributions of social science. It is obvious that risky sexual behavior increases the chances of serious infectious problems including HIV and hepatitis. Yet, serious efforts have been organized to block funding for research on sexual behavior. And, during an epidemic of deaths associated with guns, restrictions have been placed on the Centers for Disease Control for studying firearm-associated deaths.¹³ One might worry that challenging the cure narrative, and the value it assigns to biomedical research and medical care, is just more science bashing.

But what I have in mind is not science bashing at all, but science practice. I use evidence reported in mainstream peer-reviewed biomedical literature to inform hypotheses and policy ideas. My arguments are not outlandish. In fact, most physicians and public-health scientists are familiar with the position I take throughout this book; they discuss related matters in journals and at professional meetings.

I hope you will see no disconnect between my arguments and the science you can find regularly reported in the leading medical and public-health journals. Instead, the disconnect is between professional and lay understanding. My goal, in part, is to help the public appreciate what many scientists appreciate already: that the dominance of biology and medicine in American approaches to health care is a source of dysfunction. Faith in cures costs us massively in terms of direct expenditure and in terms of opportunity. By sucking up resources and diverting attention from social and behavioral factors, the cure-driven biomedical system hollows out our ability to provide human services, leading to worse health.

In fact, it is our current course of action that lacks empirical rigor and method. To continue would be to engage not in science but in insanity, according to the definition famously attributed to Albert Einstein: doing the same thing over and over again and expecting to get different results. In the chapters that follow, I explore why this is so, showing why public faith in cures is misplaced and indeed dangerous—and how nonmedical investments can do more to improve the health of all Americans.

1

Let’s Be Average

The year 1945 marked the beginning of America’s war on disease, an idea dear to Vannevar Bush, who originally proposed the development of the National Science Foundation and who led American science efforts in the 1940s. Bush proposed to further the remarkable progress in life expectancy witnessed between 1900 and 1940.¹ That period saw large declines in the incidence of yellow fever, dysentery, typhus, and other diseases. Bush attributed these achievements to the biological engineering ongoing at the time, which gave us vaccines, penicillin, and the insecticide DDT. Even more remarkable was the 0.5 percent annual increase in life expectancy reported each year between 1940 and 1945.²

Many of the treatments that lowered mortality rates in the first half of the twentieth century are now regarded as primitive, even harmful. And there wasn’t much access to care during that heady first half of the 1940s, because about half of physicians were involved in the war effort. Yet the increase in life expectancy during the first fifty years of the century was greater than that of the second fifty. Between 1900 and 1930, when essentially no modern medicine was available, US life expectancy increased by about 3.1 years per decade. Over the past thirty years, it has continued to increase, but at a much slower rate of about 1.5 years per decade.³ And for some demographic groups, life expectancy is now declining rather than lengthening.⁴

One might point out that initial gains tend to be easiest: early on, there is a long way to go, and, once the basic problems are taken care of, every marginal improvement is harder to achieve. But this does not exonerate Americans’ faith in—and spending on—biomedicine, because the biomedicine we have today was not responsible for the early gains that so impressed Bush and his contemporaries. And if there is some limit to human longevity that can be approached only asymptotically, at ever-escalating cost, then we must at some point question whether that cost is worth paying.

Even so, the war-on-disease narrative that began with Bush and his ilk remains attractive, and it appears that Americans are ready to continue the fight no matter the sacrifices necessary. Here and in Chapters 2 and 3, I take up evidence that raises questions about our trajectory. First and foremost, we need to seriously interrogate the fundamental assumption underlying the commitment to finding and deploying cures: that doing so makes Americans healthier at reasonable cost.

Americans Aren’t Healthier

A few years ago, I was a member of a committee for the Institute of Medicine, a component of the National Academies of Science.⁵ The committee’s job was to recommend ways to use resources to improve public health, and, after years of effort, we offered several. Our first recommendation was shocking to many. The secretary of HHS should set national goals on life expectancy and per capita health expenditures that by 2030 bring the US to average levels among other countries, we said.⁶ That’s right; we recommended that the United States, the world’s richest and strongest power, strive for average. How could that be?

We made our recommendation because, in spite of its enormous capabilities, the United States is below average when it comes to health outcomes per dollar spent. Way below average. Data from the Organization of Economic Cooperation and Development (OECD) show that the United States is an extreme outlier in terms of expenditures (Figure 1.1). Per capita, the United Kingdom spends about $0.40 for each dollar spent in the United States; Belgium and Denmark spend about $0.50 for each dollar spent in the United States; Spain spends about $0.33.⁷ Nevertheless, life expectancy is lower in the United States than in any of those countries. The populations of most member nations of the OECD are healthier than the population of the United States, according to this all-important measure.

Figure 1.1. Relationship between percent of GDP spent on health care and female life expectancy in OECD countries. Missing life expectancy data estimates were imputed from prior year. Country abbreviations: AT: Austria; AU: Australia; BE: Belgium; CA: Canada; CH: Switzerland; CL: Chile; CZ: Czech Republic; DE: Germany; DK: Denmark; EE: Estonia; ES: Spain; FI: Finland; FR: France; GR: Greece; HU: Hungary; IE: Ireland; IL: Israel; IS: Iceland; IT: Italy; JP: Japan; KR: South Korea; LU: Luxembourg; MX: Mexico; NL: Netherlands; NO: Norway; NZ: New Zealand; PL: Poland; PT: Portugal; SE: Sweden; SI: Slovenia; SK: Slovakia; TR: Turkey; UK: United Kingdom; US: United States.

Data from the US National Research Council backs up the OECD conclusions. The NRC considered current life expectancy for 50-year-old women between 1955 and 2010.⁸ Current life expectancy is the median number of years of life remaining after a milestone age—as in, how many years can a woman expect to live after her fiftieth birthday? In 2016, that number was 33.15 years, according the US Social Security Administration, but the number varied considerably depending on demographic variables. In 1955 the United States was twelfth in the world on this indicator. By 2006 it had slipped to twenty-sixth, just below Malta. In a life-expectancy comparison of ten wealthy countries, US women were third out of ten in 1955 but ninth out of ten in 2006. Among the many countries with more rapid increases in life expectancy were Japan, France,