To Overhaul the System, ‘Health’ Needs Redefining

The Canadians haven’t figured it out. Neither have the Japanese, the French or the British. No health care system has seriously grappled with the question most fundamental to its task: what constitutes health?

As the United States contemplates an overhaul of its system, maybe we should take a stab at it.

For years the question has been deferred to those with a financial interest in the answer — health professionals entwined with pharmaceutical companies, biotechnology firms, manufacturers of medical devices and diagnostic technologies, free-standing diagnostic centers, surgical centers, hosptitals and academic medical centers — a group aptly labeled some 30 years ago by the editor of The New England Journal of Medicine as the “medical-industrial complex.”

It’s an industry that has learned a lot over those years. I know, because I’ve been part of it. And increasingly it has settled on a most convenient answer: health is the absence of abnormality.

In the past, people sought health care because they were sick. Now the medical-industrial complex seeks patients. It encourages those with minor symptoms to be evaluated and urges those who feel well to get “checked” — just to make sure nothing is wrong.

So, if health is the absence of abnormality, the only way to know you are healthy is to become a customer.

But healthy people aren’t great customers; they’re like the people who pay off their entire credit card balance each month. The money is in those in whom an abnormality can be found.

The medical-industrial complex has made that relatively easy to do.

It develops diagnostic technologies able to find smaller and smaller abnormalities. So more and more of us are found to have damaged cartilage in our knees, bulging discs in our backs, and narrowed blood vessels throughout our bodies. And far too many are also found to have “spots” or “shadows” that are seldom significant but are said to be “worrisome.” So more and more of us have knee surgery, back surgery, angioplasty and more diagnostic investigation.

And the medical-industrial complex has another way to find more abnormalities: it simply narrows the definition of normal. Take blood pressure. In the past, relatively few were said to have abnormal blood pressure. Now a normal blood pressure is said to be below 120/80. This means that well over half the adult population of the United States is abnormal. The same is true for cholesterol. And although it involves a smaller portion of the population, narrower definitions of normal are expanding the number of people said to have diabetes and osteoporosis. So more and more of us are treated for these conditions.

Finding more abnormalities has been a great strategy for our industry. But it has been a disaster for health-care costs.

Some believe that finding more abnormalities is the right strategy to improve the nation’s health, but how much it reduces death and disability is open to debate. The new abnormalities being found are generally not severe, but mild: they are not life-threatening, and in many patients they won’t ever produce symptoms. When the benefit of treatment is known, it is known to be small — so small that many people, sometimes hundreds, must be treated for one person to benefit. But more often than not, the value of treating these mild abnormalities is simply not known.

What is known is that others are invariably harmed in the process. Admittedly, the harms are often mild — lightheadedness or fainting from too much blood pressure medication, for example. But occasionally they are more severe, even fatal; last year, for instance, a major study of intensive diabetes treatment was stopped because it caused more deaths.

But while these harms are rare, so are the benefits— if they exist at all. Nevertheless, the medical-industrial complex has systematically exaggerated the benefits and minimized or ignored the harms. The reality is more nuanced: whether a strategy does more good than harm is often a much closer call than is ever advertised.

And then there is a larger question. How does “absence of abnormality” affect our perception of health? This construct is both too narrow and too broad. It’s too narrow because there is more to being healthy than striving to avoid death and disease. Health is more than a physical state of being; it’s also a state of mind.

And it’s too broad because all of us harbor abnormalities. The construct drives the system to look for things to be wrong — a search that will be successful in most of us. We then feel more vulnerable. This induced vulnerability undermines the very sense of well-being and resilience that in many ways defines health itself. Viewing health as the absence of abnormality thus conflicts with the desire for a healthier society.

Furthermore, the strategy has created a host of other problems: doctors who are overwhelmed by the number of ailments their patients allegedly have (and who are often distracted from the most important ones); doctors in training who are increasingly confused about who is really sick and who is not; lawyers who increasingly have a field day with the charge of “failure to diagnose”; patients who get too much treatment or lose health insurance because they been given a new diagnosis; and a frazzled, fearful public adrift in a culture of disease. Oh, and did I mention that it has been a disaster for health-care costs?

If you are one of the millions of Americans adversely affected by the unrelenting growth of health costs — an employer that can’t afford insurance or a patient who can’t afford prescription drugs or can’t find insurance at all — you have to take back responsibility for deciding what health really means, not surrender that decision to “experts” with strong financial incentives.

And even if you are one of the few who doesn’t need to worry about money, you still need to take back this responsibility. Your health may depend on it.