Overdosed America (9 page)

The low ranking of Americans’ health reported in this article was so disparate from what I had believed that I started to look for other sources of comparative data to see if this was right. An extensive comparison of the health of the citizens of industrialized countries done by the Organisation for Economic Co-Operation and Development (OECD) confirmed the conclusions presented in Dr. Starfield’s article. The
United States again ranked poorly
, with 18 industrialized countries having greater life expectancy.
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One of the best single indicators of a country’s health was developed by the World Health Organization (WHO); it is called “healthy life expectancy.” This measure represents the number of years that a child born now can expect to live in good health (i.e., total life expectancy minus years of illness adjusted for quality of life). Children born in the United States today can expect to live the equivalent of about 69.3 healthy years of life, while children born in the other 22 industrialized countries can expect an average of 2.5 additional years of healthy life. And children born in Japan can expect almost six more years of good health than Americans. Americans’ healthy life expectancy ranks 22 out of 23 industrialized countries, better only than the Czech Republic.

The World Health Organization also developed several broader
measures of health system performance
, providing more in-depth comparisons between countries. On “overall achievement,”
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the health care system in the United States ranks 15 in the world. “Overall performance” measures the efficiency of a health system by taking into account the per-person health expenditures required to reach its level of achievement. On this measure the U.S. health care system ranking falls to 37. Finally, “performance on the level of health” measures the efficiency with which health care systems improve their citizens’ overall health. On this measure, the United States’ ranking drops to a lowly 72 in the world.

Despite the poor performance of the American health care system, our health care costs are simply staggering. In 2004,
health expenditures in the United States are projected to exceed $6100
for every man, woman, and child. How does this compare with other countries? The United States spends more than twice as much per person on health care as the other industrialized nations. Even taking into account our higher per-person gross domestic product, the
United States spends 42 percent more on health care
per person than would be expected, given spending on health care in the other OECD nations. The excess spending on health care in the United States is like a yearly tax of more than $1800 on every American citizen. (And still the United States is the only industrialized country that does not provide universal health insurance, leaving more than 43 million Americans uninsured.)

The U.S. health care system is clearly alone among the industrialized countries. The following chart shows that Japan and Switzerland stand out for their good health, and the Czech Republic stands out for its low cost and poor health. The United States, however, is almost off the chart with its combination of poor health and high costs (see Fig. 4-1).

FIGURE 4-1.
HEALTHY LIFE EXPECTANCY AND PER PERSON MEDICAL EXPENDITURES FOR 23 OECD COUNTRIES

Notwithstanding the tremendous progress and the enormous cost of American medicine, over the last 40 years the health of the citizens of the other industrialized countries has been improving at a faster pace. According to researchers from Johns Hopkins, “On most [health] indicators the
U.S. relative performance declined
since 1960; on none did it improve.” One of the most telling statistics is the change in the years of life lost below the age of 70, before death due to natural aging starts to become a factor. In 1960, Americans ranked right in the middle of 23 OECD countries on this measure. But despite all of the extra money being in spent on health care in the United States, the
health of the citizens in the other OECD countries is improving more quickly
. By 2000, men in the United States were losing 21 percent more years of life before the age of 70 than men in the other OECD countries, and American women were losing 33 percent more.

All this does not add up. The United States’ emergence as the world leader in medical research, combined with seemingly bottomless pockets when it comes to health care, does not square with the comparatively poor health of Americans.

One explanation for this paradox is that the United States foots the bill for a disproportionate share of medical innovation, from which the rest of the world then benefits. And indeed, this argument is often used to explain why brand-name
prescription drugs cost about 70 percent more in the United States
than in Canada and western Europe. But at least with respect to pharmaceutical innovation, the facts tell a different story. From 1991 to 1999,
pharmaceutical companies in the United States
did not develop more than their share of new drugs on a per capita basis compared with western Europe or Japan. Furthermore, according to the U.S. Food and Drug Administration,
of the 569 new drugs approved
in the United States between 1995 and 2000, only 13 percent actually contain new active ingredients that offer a significant improvement over already available drugs and therapies.

Another reason why Americans believe they get better health care than any other nation may be that it
appears
as though we do. According to surveys done by the World Health Organization for its
World Health Report 2000,
patients in the United States
are provided with the best service in the world. These surveys evaluated seven nonmedical aspects of health care—dignity, autonomy, confidentiality, prompt attention, quality of basic amenities, access to family and friends during care, and choice of health care provider. The WHO aggregated these results into a measure called “health system responsiveness,” on which the United States ranks first.

The myth of excellence is also sustained by the assumption that advances in medical care are responsible for most of the gains in health and longevity realized in the United States during the twentieth century. I admit that I was dubious when I first read that this was not the case. According to the U.S. Centers for Disease Control and Prevention,
“Since 1900, the average lifespan
of persons in the United States has lengthened by greater than 30 years; 25 years of this gain are attributable to advances in public health.” These include improvements such as sanitation, clean food and water, decent housing, good nutrition, higher standards of living, and widespread vaccinations.

The CDC’s report was based on a 1994 article in the prestigious
Milbank Quarterly,
written by researchers from Harvard and King’s College, London. They found that
preventive care as recommended
by the U.S. Preventive Services Task Force report—including, for example, blood pressure screening, cancer screening, counseling about smoking, routine immunizations, and aspirin to prevent heart attacks—adds only 18 to 19 months to our lives. Medical care for illness (heart attacks, trauma, cancer treatment, pneumonia, appendicitis, etc.) increases our life span by 44 to 45 months. The overall effect of medical care, then, has been to increase longevity by only about 5 years and 3 months during the twentieth century. (It is also important to remember that many medical interventions—like joint replacement and cataract removal—can produce benefits in the quality of life without improving longevity. These improvements are included in the World Health Organization’s calculation of
“healthy life expectancy,”
discussed above.)

By looking at the leading causes of death during the twentieth century, we can see just how limited the role of advances in medical care has been in extending life expectancy. In 1900,
tuberculosis was the leading cause of death
in the United States. Over the next 50 years, the death rate from TB fell by 87 percent.

This dramatic decrease in the tuberculosis death rate may appear to be a great triumph for American medicine, but in truth it was entirely due to improvements in the social and physical environment, such as healthier living and working conditions, better nutrition, more education, and greater prosperity. The
first effective
medical
therapies for tuberculosis
, the antibiotics isoniazid and streptomycin, were not even introduced until 1950, well after death rates for tuberculosis had plummeted. Throughout the twentieth century, similar patterns occurred in the death rates from many other infectious diseases, such as measles, scarlet fever, typhoid, and diphtheria. As with tuberculosis, the vast majority of the decline in mortality occurred before the introduction of effective medical therapy, antibiotics, or vaccines—polio and HIV/AIDS being the notable exceptions.

Rene Dubos, a French-born microbiologist who discovered the first two commercially manufactured antibiotics, wrote in his classic book
The Mirage of Health
, “The introduction of
inexpensive cotton undergarments
easy to launder and of transparent glass that brought light into the most humble dwelling, contributed more to the control of infection than did all the drugs and medical practices.”

Our experience with cancer during the twentieth century proves the point in reverse. Despite an enormous investment in cancer research, the age-adjusted
death rate for cancer in the United States
actually
increased
by 74 percent from the beginning to the end of the twentieth century. And by the end of the twentieth century, the age-adjusted death rate for cancer was the same as for tuberculosis at the beginning of the century:
it had become the number one killer
among people below of the age of 75.

In 1971 Congress launched a war on cancer by passing the National Cancer Act.
President Nixon boasted
, “This legislation—perhaps more than any legislation I have signed as President of the United States—can mean new hope and comfort in the years ahead for millions of people in this country and around the world.” In 1984 the director of the National Cancer Institute told Congress that the death rate from cancer could be cut in half by 2000. But two years later, an article published in
New England Journal of Medicine,
coauthored by a statistician from the National Cancer Institute, concluded just the opposite:
Cancer death rates were going up
, and “we are losing the war against cancer.”

There have been a
few tremendous successes in this war
, notably with some of the childhood cancers, testicular cancer, Hodgkin’s disease, and leukemia. Notwithstanding the barrage of news about major breakthroughs in the diagnosis and treatment of cancer, the
overall death rate from cancer was exactly the same
in the year 2000 as it had been in 1971, when “war” was declared.

In 1998, the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry provided a concise statement of the
proper goal of a nation’s health care system
: “The purpose of the health care system is to reduce continually the burden of illness, injury, and disability, and to improve the health status and function of the people of the United States.” About 70 percent of the health care in the United States is directed toward meeting this goal.
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The other 30 percent is commercially driven health care activity without demonstrable health benefits. The problem for doctors and the public is that there is no clear line of demarcation between these two fundamentally different health care activities, and as the commercial influence on medical practice grows, the line between the two becomes ever more blurred.

This brings us back to the decision about how to treat Ms. Fletcher’s advanced breast cancer. It turns out that in 1996, when I had the conversation with Ms. Fletcher’s oncologist, only one small randomized trial, done in South Africa, showed that women who received high-dose chemotherapy and bone marrow transplants did better than women who received conventional therapy. Nonetheless, bone marrow transplantation had become an accepted therapy (covered by insurance), and big business. A superb article in the
New York Times
explained that at
$80,000 to $200,000 per procedure
, the service was a great lure for doctors and hospitals. A for-profit chain of cancer treatment centers, Response Oncology, grossed $128 million in revenues in 1998, mostly from bone marrow transplants. For-profit hospitals were advertising, competing for patients, and even offering to reimburse patients for their transportation costs. Academic medical centers got in on the action. One breast cancer expert told the
New York Times,
“Bone marrow transplanters are kings. They usually get a higher salary, they usually get more money. And more important, they have security and power.” Even community hospitals started offering the procedure. All this when nobody really knew whether the more aggressive treatment was worth the additional suffering and cost.