The State Of Medical Care, 1984


There’s no doubt that we are seeing an awful lot of hand-wringing about our aging population. Some gloomy souls tell us that chronic disabling conditions are going to be ever-increasing and that we are going to have to spend our whole gross national product caring for those eighty and over, who will be largely mindless and infirm. But I do not think there is cause for such despair. As others have pointed out, there’s a big misunderstanding here. When we say life expectancy is increasing, we don’t mean that we are extending life. In fact, the maximum duration of life for most humans probably has not changed much in a hundred thousand years: it averages somewhere around eighty-five years, maybe eighty-six or eighty-seven. Nothing medicine has done has moved that figure up one bit. What we have done is to protect different groups so that more and more people have a chance of reaching that classic age. And of staying healthy and vigorous almost to the end.

Are you saying not only that more people reach old age but also that fewer of them get senile?

Percentagewise, yes. What we are shooting for is a system in which we will have the answers to cancer, to the rotting of your arteries, to the aging of your brain, and to other mysteries, so that you have every chance of taking care of yourself and surviving soundly to eighty-five or so, at which point you can just take to your bed one day and be dead shortly thereafter. If this could be accomplished, the care of our elderly would not be such a disproportionate expense to society. And the point is, I believe we are getting closer and closer to that ideal.

But how are these elderly people going to support themselves?

The honest answer is, I simply don’t know. Perhaps they’ll work longer. Already the retirement age of sixty-five is being pushed up, although many people are electing to retire as early as sixty-two. According to legend, retirement age was set generations ago by Bismarck of Germany, at a time when very few people lived to sixty-five. It doesn’t seem very logical anymore. Many people can work well into their seventies. For those who cannot, clearly we must design a system to care for them with respect and dignity.

But what of the cost of medical care? It is punishingly expensive now and getting more so. It is everyone’s major worry, or at hast every patient’s.

I have to take issue with you on that last point. Most patients, if they are really sick, don’t care about the cost. “Doc, I don’t care what it costs,” they say. “I want the very best. ” What we have here is a massive public concern about total cost, and appropriately so. Society, or more accurately our public officials, are looking at the enormous amount of the gross national product that health care is taking and saying it’s too much. However, the public views here are schizophrenic. While they feel medical care is too expensive for them personally, polls show that most Americans would actually like to see the nation spend more, not less, on health care.

How did it happen that the cost went up so steeply?

The root cause is the technological revolution that has transformed medicine in the last fifty years. The revolution not only helped improve everyone’s health but changed for all time the ways you are treated, the kinds of doctors you see, and the nature of what has become the central institution in the system, the hospital. Historically medicine was a modestly paid, profession. Doctors made about what teachers did and certainly less than lawyers. That was partly because they couldn’t do much. As late as the 1920s there wasn’t an awful lot a doctor could do to influence the course of many diseases other than providing reassurance and hand holding.

Which everyone now misses.

Which everyone misses, and for good and proper reasons: but, back then, we were only beginning to get some of the incredible advances that changed everything. We had insulin, so that we could take one dreadful disease, diabetes, and prevent death from it; we could treat pernicious anemia with liver extract and malaria with quinine, and we could give heart patients digitalis; but that was about it. Tuberculosis was our number one killer, and hospitals were full of people with other diseases that really couldn’t be treated. Starting in the 1930s, with the discovery of the sulfanilamides and subsequently penicillin and other antimicrobials—what people refer to generally as antibiotics—doctors found that they had the weapons with which they could actually cure an impressive number of human illnesses. The changes were accelerated by our experience in World War II when we found that if you apply a lot of money to a problem, you get substantial results. So the American people turned to the medical profession and said, “Find the answers to those things that are troubling us.” The result was the march of science-based medicine, which is continuing at an accelerating pace.

And this was happening even before the Russians’ launch of Sputnik focused our attention on the need for greater funding of scientific research?