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How America’s Health Care Fell Ill
As modern medicine has grown ever more powerful, our ways of providing it and paying for it have gotten ever more wasteful, unaffordable, and unfair. An explanation and a possible first step toward a solution.
May/June 1992 | Volume 43, Issue 3
Physicians in the United States at the turn of the nineteenth century had hardly more at their disposal than the Greeks had had.
McMahon —On Saturday, January 2 , at half-past six P.M. Mary F. McMahon, the beloved daughter of William and Sarah F. McMahon, after a painful illness, aged 2 years, 10 months and 6 days.
Darling —Suddenly, on Friday, January 1 , Clarence A., second son of A. A. and G. W. Darling, aged 11 years and 2 months.
Reilly —On Friday, January 1 , Margaret R., the beloved wife of James W. Reilly, in the 21st year of her age.
Then finally, in the 1850s and 1860s, it was discovered that many specific diseases were caused by specific microorganisms, as was the infection of wounds, surgical and other. The germ theory of disease, the most powerful idea in the history of medicine, was born, and medicine the science was born with it. For the first time it became possible to study individual diseases systematically, and one by one their etiologies and clinical courses came to be understood.
Still, while there was now a solid scientific theory underpinning medicine, most of its advances in the late nineteenth and early twentieth centuries were preventive rather than curative. The fact that serum from the relatively harmless disease cowpox could immunize a person against the disfiguring and often deadly smallpox had been empirically discovered in the eighteenth century by Edward Jenner. Now Louis Pasteur and others, using their new knowledge of microorganisms, could begin developing other vaccines. Rabies fell in 1885, and several diseases once the scourges of childhood, such as whooping cough and diphtheria, followed around the turn of the century.
Pasteur also demonstrated that heating milk and other liquids to a little below boiling for a certain period killed most of the microorganisms present in them and helped protect against a number of diseases, including tuberculosis. When the pasteurization of milk was widely mandated, beginning around the turn of this century, the death rate among young children plunged. In 1891 that rate for American children stood at 125.1 per 1,000. By 1925 it had been reduced to 15.8, and the life expectancy of Americans began a dramatic rise.
In 1900 a newborn child could expect to live only 47.3 years. By 1920 it was 54.1 years, in 1940, 62.9, and by 1950 the average American lived to the age of 68.2 years. Life expectancy rose more than 44 percent in fifty years. Still, in the first three decades of this century, the two great victories over disease were, first, the increasing understanding of “deficiency diseases,” illnesses caused not by microorganisms but by diets lacking in what are now called vitamins—a word coined only in 1912—and, second, the discovery of insulin, in 1921. Juvenile diabetes had once killed swiftly, but with regular injections of insulin it was possible for patients to live for many years and lead near-normal lives.
Then a revolution in medicine began, changing it beyond recognition in less than two decades. This revolution continues, and there is no end in sight. Actually it is really four revolutions at once, each having a powerful, synergistic effect on the other three.
The first is the pharmaceutical revolution. Sulfa drugs, introduced in the 1930s, and ever-proliferating antibiotics, which began appearing in the early 1940s, were able to attack pathogenic organisms within the body. For the first time doctors had weapons to use against infectious disease itself, not just against the symptoms such diseases produced. Dreaded ills like pneumonia, once one of the leading killers of young and old, now could often be controlled.
Vast new categories of drugs, including cortisone, psychotropic drugs, and synthetic hormones, became available in ensuing decades. Today such new technologies as recombinant DNA assure that the pharmaceutical revolution will continue with undiminished vigor. Antibiotics remain the most important drugs of the new medical era, however. They not only have had a major impact on medicine but have transformed surgery as well. Although the antiseptic surgical procedures pioneered by Joseph Lister in the 1870s greatly reduced the incidence of postoperative infection, they by no means eliminated it. Surgery, while it advanced rapidly after Lister, remained to some extent a measure of last resort.
But now any postoperative infection could be dealt with promptly, and antibiotics could be given prophylactically to surgical patients to assure that no infection started. Thus surgeons became much more willing to operate, and the number of medical conditions that could be cured or ameliorated by surgery grew swiftly.
The heart-lung machine, first used in 1953, opened a great new territory to surgeons, while lasers, miniaturization, fiber optics, and such advanced materials as resins, plastics, and ceramics revolutionized surgical technique, making it far less traumatic for the patient. The surgeon had once been among the lowest on the totem pole of medical science (English surgeons to this day are called mister, not doctor), but the new weapons of surgery changed everything, and they swiftly became the dashing heroes of modern medicine.