By Jonathan Jimenez, M.D.
Health is created in the places we live and work — in community. Yet U.S. health care, an industry the size of the French economy, tasked with caring for the nation’s health, remains focused only on the therapies that can improve health for individual patients rather than the for whole communities.
As a health care system and medical profession we have many formidable forces keeping our eyes on a small porthole window of biomedical care. The result is, by now, a cliché: America pays more for health care and gets less health.
Our collective myopia has taken and continues to take too many patient lives. Physicians must reclaim their professional lineage as protectors of population health to transform our health care system into a health system and safeguard our patients’ health from the strongest forces determining their health.
‘Medicine is a social science’
Physicians have a rich tradition of examining and treating a patient’s context as well as their body. Rudolf Virchow (1829-1902), the German physician and the father of pathology, in his “Report on Typhus Epidemic in Upper Silesia,” prescribes “full and unlimited democracy.” He was elected to Prussian House of Parliament where he advocated for the rights of workers and the poor. He was thus named the founder of social medicine, but he did not see his work as a subset or alternative medical discipline. He affirmed, in theory and practice, that “medicine is a social science.”
Others searching for the root cause of illness came to similar conclusions. John Snow, a physician, studied the patterns of the 1854 cholera outbreak in London discovering that the cause was a cesspit too close to a water pump. During their lifetimes, medicine and public health (then inseparable) were important parts of social movements to improve sanitation, housing, working environments and water and milk quality in the United States and other nations. All were interventions which dramatically improved the length and quality of life of entire populations affected by these reforms.
At the turn of the century, however, in an effort to professionalize medicine, and urged on by the germ theory, the Flexner Report recommended medicine be rooted in a biomedical undergraduate and graduate education. The paradigm shift from miasma theory to biomedicine had many benefits, to be sure. For decades, antibiotics, vaccines and surgeries were developed that made once terminal diseases into routine illnesses. Overall, life expectancy rose steadily, and over time the top causes of mortality became heart disease, cancer and chronic lower respiratory diseases.
U.S. health care system
New medical technologies and the growing middle class demand intertwined with this paradigm shift to grow the role of money in medicine. Hospital use from the civil war to the civil rights movement increased 200-fold, although the U.S. population increased only fivefold during the same time.
While western nations were developing national health insurance programs, private health insurance companies in America spread to every state. Meanwhile, physicians, led by the American Medical Association, and the rest of the health care industry, road-blocked every attempt at health care reform. As a result, no one entity is responsible for the health of Americans from birth to death. In our fee-for-service payment system, everyone is paid to treat disease, but no one, except the patient, is compensated if it is prevented.
That arrangement has been good for business, bad for patients and equivocal for physicians. In 1960, national health expenditure (NHE) made up 5.2% of GDP; by 2010 NHE made up 16.4% of GDP. Hospitals are the economic engines of most counties. Americans have not seen the bulk of the benefit. Americans, as the Institute of Medicine report “US Health in International Perspective: Shorter Lives, Poorer Health,” put it, have shorter lives and poorer health compared to other high-income nations, and even some middle and low income ones. Although physicians enjoy unemployment rates of 0.8 percent and average incomes in the top 5 percent of earners, they are increasingly asked to see more patients in less time. Burnout rates remain dramatically high across specialties, from 37 to 52 percent (“Medscape 2015 Physician Lifestyle Report”).
Physicians, however, unlike other high-income earners, watch social circumstances bear out every day in their patients’ lives, for better and for worse. In the “County Health Rankings & Roadmaps” in 2009, we see how adjacent counties across the nation can have a 10 year difference in life expectancy. Although we are not trained to pay much attention to those “social issues,” and we are certainly not given the time to, we suspect those may be the most important ones. Our work, narrowly focused on treating what is paid for, loses meaning. Over time, physicians develop an earned nihilistic view that the progression of disease and the eventual outcome, an early death, is inevitable for patients from certain zip codes. Empathetic, compassionate doctors exclaim “we are not trained.”
If our commitment as a profession were to health, not a paradigm, then we should have been. Twenty percent of premature death in America is due to social circumstances and environmental exposures (“We Can Do Better — Improving the Health of the American”). Another 40 percent is due to behavioral patterns (e.g. smoking, diet, exercise) of which a large proportion could likely be attributed to a combination of poverty, structural racism, adverse childhood experiences, (“Adverse Childhood Experiences Study”), and the physical environment. Only 10 percent of premature death is secondary to medical care.
A transformation is underway
Elizabeth H. Bradley, professor of public health at Yale University, has shown that percentage of GDP spent on health care was not a predictor of population health outcomes (i.e. life expectancy, infant mortality), the percentage spent on social services was. All the same we spend 10 percent of GDP on social welfare services, compared to Scandinavian nations spending 16-21 percent of GDP on the same. Their citizens are healthier for it.
Mercifully, a transformation is already underway. Although the Affordable Care Act did not fundamentally fix the system, it created opportunities to start the fixing. Many CMS experiments moving us toward value-based payment inevitably redistribute health care money to direly needed social services. The Duke University Health system recently changed its branded name from Duke Medicine to Duke Health and is embracing population health, including the portion of the population who are not-yet patients.
Duke Health, looking to the future, is excited to invest in the health of a whole population, not just those that signed up for Duke insurance, says A. Eugene Washington, M.D., MSc, chancellor for health affairs at Duke University, in “Academic Health Systems’ Third Curve: Population Health Improvement.” But, our health care institutions are still depending immense revenues from overused medical technologies and there will be struggle to hold on to that revenue and pretend like further investment in health care can realize the gains in health we need.
Social needs are health needs. The nation needs a generation of physicians that will embrace the tradition of Virchow, Snow, and many others. As Virchow wrote, “If medicine is to fulfill her great task, then she must enter the political and social life.” Let us fulfill our great task promptly, ours and our patients’ lives are at stake.
Editor’s note: Duke Family Medicine residents guest blog the second Friday of every month.