Medical care can diagnose illness and injury, but a lack of medical care is not the cause of illness or injury. Medicine is more an art than a science. State-of-the-art care changes over time. When I was in medical school in 1972, a professor of medicine began his lecture by informing us that, "In 10 years' time you will discover that half of what I am telling you is wrong. I just don't know which half."
We didn't give aspirin to someone having a heart attack until after 1980, but it's now routinely administered even before the victim gets to the hospital. Until the 2000s, post-menopausal women were given estrogen to replace the hormones they no longer produced, with one study finding slight gains in life expectancy from the use of that therapy. Most now consider this practice to be harmful.
Consider medical care comparisons across nations for conditions that should be responsive to care. Although for many conditions medical care has little to offer, there are many others for which it is beneficial: bacterial infections, diabetes, heart attacks, HIV/AIDS, hypertension, maternal bleeding during delivery, and leukemia in young people. The U.S. performs badly even for those problems: repeated studies show we have considerably higher mortality for treatable conditions than other rich nations. Although deaths from these situations are decreasing overall, the improvements are unfortunately shameful in the U.S. Comparing avoidable deaths and 10-year mortality reduction (2009-2019) among rich countries, the Commonwealth Fund shows the U.S. as the worst.
Why are the deficiencies of medical care not stressed? Because they would compete with the victories of healthcare.
We doctors pride ourselves on "saving lives." I recall attending my first emergency code as a medical student at Stanford. Someone's heart stopped beating and a physician-in-training administered a defibrillating shock that restarted the heart. After the chief resident arrived, he asked who shocked the patient. A hand motioned, and he said solemnly, "You saved a life." Saving lives, seeded in my mind as a child, is the metaphor of medical care.
But is it true? In too many cases, it isn't medical care that does the saving.
As a medical intern one evening in 1973, I looked at an issue of the Journal of Infectious Diseases, containing an article by Edward Kass, MD, PhD, a renowned infectious diseases doctor at Harvard. In that article "Infectious Diseases and Social Change," Kass presented data on deaths from various infectious diseases since the 1850s in England and Wales, where reliable records had been kept. He noted that poorer people were consistently more likely to succumb to infections. Considering tuberculosis, diphtheria, scarlet fever, measles, and whooping cough, he then presented data demonstrating that deaths from these problems dropped profoundly even before the advent of antibiotics or immunizations. Kass argued that this decline in deaths resulted from improvements in socioeconomic circumstances and standards of living, not medical care. He called it "the most important happening in the history of the health of man." It took a few decades for the concepts I read that day to sink in, but Kass' article prompted me to start asking important questions. One of those questions was: how can we distinguish medical care's benefit from threat?
Consider giving two groups of people different levels of medical care, with one group receiving as much free care as they want and the other having to co-pay part of the cost. In the Rand Health Insurance Study, over 4,000 adults were randomly assigned to one of these two groups. Those who had to pay part of the cost of their care used a third fewer services and had a third fewer hospitalizations than those who had free care. The result? Essentially no differences in mortality rates.
A more extreme version of this approach considers what happens to death rates when doctors go on strike. A review of the literature suggests mortality actually declines when doctors don't go to work. One study of people receiving less treatment because of a doctor's strike was done for the month-long anesthesiologists' 1976 strike in Los Angeles County. County coroner death rates fell during the strike. Deaths then increased afterwards as elective surgeries had been postponed.
This unexpected finding -- that less care is not always less health -- has been confirmed again and again, but the reasons behind it are not clear. One possible explanation is that whenever medical care itself has been considered as a possible cause of death, it is always one of the leading factors.
The first major study on medical harm was published in 1991. Investigators from Harvard Medical School reviewed a sample of charts from New York hospitals for 1984, documenting "adverse events" that resulted from the care provided. Common problems were reactions to prescribed drugs and surgical wound infections. There were complications from technical procedures, such as leaving an instrument in the body during surgery, or a device not functioning correctly. Adverse events were found to be common, with a substantial proportion ending in death.
Since then, many studies in different countries by different investigators have found medical harm to be common. A key finding: being admitted to a hospital can result in a substantial risk of dying from treatment alone, and the sicker you are and the longer you stay, the greater the risk.
People die in their quest for medical care. The numbers of these deaths vary. In the 2015 issue of Best Hospitals from U.S. News & World Report, an article on patient safety disclosed that one analysis "put the number of preventable deaths alone each year at 440,000." In 2016, a study by surgeons at Johns Hopkins University presented medical error as the third leading cause of death in America. The New York Times reported in 1998 that over 100,000 people die each year from adverse drug reactions.
Yet, media attention to the roughly 500,000 treatment-related deaths a year in the U.S. is scant. But it deserves much more media attention than it receives.
All this is not meant to discredit access to needed healthcare. Universal access to appropriate medical care is a benchmark of a healthy society. Millions in this country lack such access. The U.S. has a long journey ahead to reach this goal.
This excerpt was adapted from the forthcoming book, Inequality Kills Us All: COVID-19's Health Lessons for the World (Routledge, November 11, 2022, Paperback), by Stephen Bezruchka. Used by permission. All rights reserved.
Stephen Bezruchka, MD, MPH, is associate teaching professor emeritus in the Department of Health Systems & Population Health and the Department of Global Health at the School of Public Health, University of Washington.
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