Thursday, December 27, 2007

Looking back, Part II

As with yesterday's page, this is not about something that is contained in the year just ending, but it is something that has come into particularly sharp focus in that time. The "something" is the developing health-care crisis.

Let us take note that insurance coverage, while it has been the chief facet of the issue being talked about, is just that: one facet. If we ask why so few people are covered at all, and why so many who are "covered" have mediocre to poor coverage, we get at the deeper problem: that health care is very, very expensive, and getting more so every day. If we project out current trends, in the not terribly far future health care is all we'll be paying for, as individuals and as a nation.

Obviously--as is well known--one cannot project out any given trend to some logical absurdity: there is always some limitation that arises to preclude the absurdity (which is why it's absurd). But what is the limiting factor in considering health-care costs? What it would seem to be limitation on the amount of health care the average person can receive.

The reasons health care is expensive, and growing more so, are several and various. In the United States, we pay doctors far more than other "first-world" industrialized nations do, and that is one reason health care is delivered so much better in virtually all of those nations: it costs less per quantum of care, so more quanta can be supplied for a given cost. But their costs are rising, too, and the U.S. is only a harbinger of the problems that eventually all nations will have to face.

Another matter is that medical knowledge, like all knowledge, is an ever-expanding sphere; that means (without straining the analogy too far) that the surface--the border between the known and the unknown--increases geometrically faster than the radius, the scope of our knowledge in any one direction, which is to say aspect of medicine; moreover, the volume within that sphere, the sum of our knowledge, increases faster yet. Ever more diseases and conditions shift from being untreatable to being something we can treat, or something we might (with further expenditure) be able to treat. And the treatments are expensive.

But, in a sense, the "cure" is more knowledge yet. As the science essayist Lewis Thomas elegantly points out (Thomas is always elegant) in his essay "The Technology of Medicine" (collected in The Lives of a Cell), medical technology falls into three classes.

First is what he calls "nontechnology", the methodology of what is best described as "caring for". But, while essential, it is nonetheless "not technology in any real sense, since it does not involve measures directed at the underlying mechanism of disease." But it is what most doctors spend the largest part of their time doing. Also, it is very costly, in good part because of the great chunks of time it takes from physicians and other skilled medical personnel.

Second is is what Thomas calls "halfway technology". This, he says, "represents the kinds of things that must be done after the fact, in efforts to compensate for the incapacitating effects of certain diseases whose course one is unable to do very much about." It includes such things as organ transplants and artificial organs, radiation and chemotherapy. To the public, it is all very gee-whiz, and seems to signify the pinnacle of medical science. But while in one way it is very sophisticated, in another way it is quite primitive: we still aren't doing anything about the actual problem. All the high-tech stuff is simply cleaning up after the disaster. This type also is stupendously expensive, to devise and to effect.

The third level is "the kind that is so effective that it seems to attract the least public notice; it has come to be taken for granted. This is the genuinely decisive technology of modern medicine, exemplified best by modern methods of immunization . . ." It consists of the means to prevent or cure conditions based on a substantial understanding of their basic nature. And it is by far the cheapest. And it is typically simple and readily delivered.

As Thomas remarks, "I cannot think offhand of any important human disease for which medicine possesses the outright capacity to prevent or cure where the cost of the technology is itself a major problem." There is much food for thought there--though it was written a third of a century ago now, before the drug companies had fully realized how readily they could squeeze money out of human pain and suffering.

Thomas sums up: "If I were a policy maker, interested in saving money for health care over the long haul, I would regard it as an act of high prudence to give high priority to a lot more basic research in biologic science."

But "policy makers" today aren't interested in "the long haul": they are interested in whatever is the upcoming election cycle. Where is the presidential candidate whose "health-care policy" mentions major investment in basic science research? Where is the presidential candidate any of whose policy statements includes the very word "science"?

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