Medical care can diagnose illness and injury, but a lack of medical care is not the cause of illness or injury. Medicine is more of an art than a science. Cutting-edge treatments evolve over time. When I was in medical school in 1972, a professor of medicine began his lecture by informing us that “In 10 years, you will find that half of what I tell you is wrong. I don’t know which half . “
We didn’t give aspirin to a heart attack victim until after 1980, but now it’s routinely given even before the victim arrives at the hospital. Until the 2000s, postmenopausal women were given estrogen to replace the hormones they were no longer producing, with one study finding small gains in life expectancy with the use of this therapy. Most now regard this practice as harmful.
Consider comparisons of medical care between countries for conditions that should respond 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 childbirth and leukemia in young people. The United States fares poorly even on these issues: repeated studies show that we have dramatically higher mortality from treatable diseases than other wealthy nations. Although deaths from these conditions are decreasing overall, the improvements are sadly disgraceful in the United States. Comparing avoidable deaths and mortality reduction over 10 years (2009-2019) in rich countries, the Commonwealth Fund shows that the United States is the worst.
Why are deficiencies in medical care not highlighted? Because they would rival health wins.
We doctors pride ourselves on “saving lives”. I remember attending my first emergency code as a medical student at Stanford. Someone’s heart stopped beating and a doctor-in-training delivered a defibrillation shock that restarted the heart. After the chief resident arrived, he asked who had electrocuted the patient. A hand waved, and he said solemnly, “You saved a life. Saving lives, sown in my child’s mind, is the metaphor of medical care.
But is it true? In too many cases, it is not medical care that saves money.
As a medical intern, one evening in 1973, I watched an issue of Journal of Infectious Diseases, featuring an article by Edward Kass, MD, PhD, a renowned infectious disease physician at Harvard. In this 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 showing that deaths from these problems had dropped dramatically even before the advent of antibiotics or vaccinations. Kass argued that this decline in deaths resulted from improved socioeconomic status and living standards, not medical care. He called it “the most important event in the history of human health.” It took a few decades for the concepts I read that day to sink in, but Kass’s article made me start asking some important questions. One of these questions was: how can we distinguish the benefit of medical care from the threat?
Consider giving two groups of people different levels of medical care, with one group getting as much free care as they want and the other having to pay part of the cost. In the Rand Health Insurance Study, more than 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 one-third fewer services and had one-third fewer hospitalizations than those who received free care. The result? Essentially no difference 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 that mortality actually decreases when doctors are not at work. A study of people receiving less treatment due to a doctors’ strike was done for the month-long 1976 anesthesiologists’ strike in Los Angeles County. County coroner death rates plummeted during the strike. Deaths then increased afterwards as elective surgeries were postponed.
This unexpected discovery – that less care is not always less health – has been confirmed time and time again, but the reasons behind it are unclear. One possible explanation is that whenever medical care itself has been considered a possible cause of death, it is always one of the main factors.
The first major medical harm study was published in 1991. Harvard Medical School investigators reviewed a sample of New York City hospital records for 1984, documenting “adverse events” resulting from the care provided. Common problems were reactions to prescribed medications and surgical wound infections. There were complications due to technical procedures, such as leaving an instrument in the body during surgery or a device not working properly. Adverse events were found to be frequent, with a substantial proportion ending in death.
Since then, numerous studies conducted in different countries by different researchers have found that medical harm is common. A key finding: Being admitted to a hospital can carry 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 search for medical care. The number of these deaths varies. In the 2015 issue of Best Hospitals from US News and World Report, an article on patient safety found that an analysis “put the number of preventable deaths alone each year at 440,000”. In 2016, a study by surgeons at Johns Hopkins University listed medical error as the third leading cause of death in America. The New York Times reported in 1998 that more than 100,000 people die each year from adverse drug reactions.
Yet media attention to the approximately 500,000 treatment-related deaths per year in the United States is low. But he deserves a lot more media attention than he gets.
None of this is intended to discredit access to necessary health care. Universal access to appropriate medical care is the benchmark for a healthy society. Millions of people in this country do not have that access. The United States has a long way to go to achieve this goal.
This excerpt has been adapted from the forthcoming book, Inequality is killing us all: health lessons from COVID-19 for the world (Routledge, November 11, 2022, Paperback), by Stephen Bezruchka. Used with permission. All rights reserved.
Stephen Bezruchka, MD, MPH, is associate professor emeritus in the Department of Health Systems and Population Health and the Department of Global Health at the School of Public Health at the University of Washington.