Let us begin by pointing to some unpleasant realities, starting with infectious disease. Forty years ago, it was commonly assumed that infectious disease had all but been conquered, with the eradication of smallpox taken as the great example of that victory. That assumption has been proved false—by the advent, for example, of HIV as well as a dangerous increase in antibiotic-resistant microbes. Based on what we now know of viral disease and microbial genetics, it is reasonable to assume that infectious disease will never be eliminated but only, at best, become less prevalent.
Then there are chronic diseases, now the scourge of industrialized nations. If the hope for eradication of infectious disease was misplaced, the hopes surrounding cures for chronic diseases are no less intoxicated. Think of the “war on cancer,” declared by Richard Nixon in 1971. Mortality rates for the great majority of cancers have fallen slowly over the decades, but we remain far from a cure. No one of any scientific stature even predicts a cure for heart disease or stroke.
Now let me make a few comments:
1. In a 1942 Internal Medicine text and earlier I find almost 30-40% of the book about infectious disease. On the other hand there is a paragraph on prostate cancer basically saying by the time it is noticed you might just as well forget it. In the current volume of Harrison's the focus has changed, we can handle most infectious diseases and even most prostate cancer.
2. As to their claim that we assumed to have solved the infectious disease problem, well we have, just look at AIDS, we managed to turn it into a chronic disease in almost zero time. The dealing with AIDS was and is a medical triumph, and the authors downplay it. Well one is a surgeon.
3. Chronic disease, well, yes there are major problems, say with obesity and Type 2 Diabetes and their sequellae. How to solve that, less medial research, hardly, just change diet, at least in almost all cases. Cancer, great progress here, and we keep taking steps forward. The cell, its pathways, its microenvironment, cancer provides a window to understand that. Hopefully we can learn not to cut but to cure.
They continue:
In light of the fact that we are not curing most diseases, we need to change our priorities for the elderly. Death is not the only bad thing that can happen to an elderly person. An old age marked by disability, economic insecurity, and social isolation are also great evils. Instead of a medical culture of cure for the elderly we need a culture of care, notably a stronger Social Security program and a Medicare program much more heavily weighted toward primary care. Less money, that is, for late-life technological interventions and more for preventive measures and independent living. Some people may die earlier than now, but they will die better deaths.
The issue is cultural not governmental or medical. Advance Directives are typically prepared by those who have looked ahead. People died of heart problems or pneumonia, while having a more serious underlying disease. We are now often forced by the law and yes by families to extend the care to overcome the first cause and to then deal with the expensive and much more painful second cause.
The authors reveal their true selves with the statement:
Finally, we need a health care system that is far more radically reformed than the system envisioned by the Affordable Care Act (ACA). Should the ACA be successful down to the last detail, it is still unlikely to succeed in bringing the annual rise in health care costs down to the annual GDP increase. In their 2011 yearly report, the Medicare program trustees project insolvency by 2024. The only reliable way of controlling costs has been the method used by most other developed countries: a centrally directed and budgeted system, oversight in the use of new and old technologies, and price controls. Medicine cannot continue trying to serve two masters, that of providing affordable health care and turning a handsome profit for its middlemen and providers.
Yes, they want that obese GS5 with an attitude telling us what to do and what we can do with ourselves! Imagine that GS5 telling the surgeon, after all I rarely met a surgeon who took orders from anyone, no less than a GS5 over a telephone.
So what is the alternative? Central control or individual choice. The market does have a way of selecting priorities. Having to pay something does force the individual to choose. The real only reliable way to paraphrase the authors is to have a more market driven system. If you want unending care for chronic and debilitating old age, beyond a reasonable level, then you must be prepared to pay for it. It is amazing to see what happens when the relatives are presented with the bill.
The issue is not affordable care as they say above. The issue is excessive care. CAT scans are great for identifying strokes, but the incidental findings all too often send us down the rabbit hole. Lots more tests and at great cost. It is the burden of the overhead of litigation, patient demands without understanding costs, and Government that got us here. More of the same will not get us out.
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