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Healthcare Research Today and Tomorrow

This essay is a reprint of the afterward, "A Choice for the Future: Our Health or Our Wealth?" from the book Scientists Greater than Einstein: The Biggest Lifesavers of the Twentieth Century

By Billy Woodward


Modern medicine is remarkably new. The reason doctors made house calls until the 1940s is that they couldn’t fix much and could fit most of their medical tools into a little black bag. 
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In practice, doctors were more like hospice workers than healers. Outside of setting broken bones, most of what they did was to provide comfort in the form of painkillers until nature took its course, for better or worse. Baby boomers were the first generation to grow up with modern medicine that could actually cure many diseases.

The book Scientists Greater than Einstein is a celebration of the accomplishments of ten scientists.  Five of them made their discoveries in the first half of the twentieth century. And what a fifty-year period it was, pushing American life expectancy from 45 years to 65 years. The impact of the other five scientists occurred in the latter half of the century. Four of their discoveries primarily affected the developing world, so it might be concluded that the major breakthroughs have all occurred, and only incremental advances are left. Yet the incremental advances add up in many ways to just as remarkable a revolution - one that could be called The Silent Miracle. With few monumental, well-publicized breakthroughs, deaths have continued to decrease dramatically.

The Silent Miracle

Since 1950, life expectancy from birth has increased by 12 years to 77 in the United States. Between 1950 and 1994, even the life expectancy of the average 45-year-old increased by 4.5 years. Think of being middle-aged and someone giving you four and a half more years of life. Furthermore, they will likely be good years – since 1980, the percentage of the elderly that have difficulty living independently has decreased from 25 percent to 20 percent. Just in the last ten years, deaths from heart disease, the biggest killer of Americans, have decreased by 25 percent.

Across every age group an unheralded revolution has occurred. Check out how relevant these innovations have been to your own life in the following table. The death rate in every age group has dropped by 29 percent or more.

29% to 66% Fewer Deaths!

The Silent Miracle Revolution
Annual death rate per 100,000 people in the following age ranges:
Your Age    1970      2000    Change
0-1               2142     729       -66 %
1-4                   85       33       -61 % 
5-14                 41       19       -54 %
15-24             128       82       -36 %
25-34             157     108       -31 %
35-44             315     200       -37 %
45-54             730     431       -41 %
55-64           1659   1004       -39 %
65-74           3583   2428       -32 %
75-84           8004   5688       -29 %


Why Did the Greatest Advances in Saving Lives Occur

While We Were Lucky Enough to be Alive?

scienceword

What is so Powerful about Science?

History has demonstrated over and over again that as soon as scientific methods are applied to a field, prodigious new knowledge emerges that replaces the dogma that existed before. Thanks to science:
astrology became astronomy
dynamics became physics
alchemy became  chemistry

Life sciences like medicine were slower than the physical sciences to adopt empirical methods, primarily because living systems are so darn complex. It was only after chemistry had become a mature science that researchers such as Landsteiner, Florey, Müller, and Endo could move the life sciences so dramatically ahead.

Science Is Much More Than a Collection of Knowledge

– It Is a Way of Thinking

Specifically, science is a form of reasoning that relies on evidence. Knowledge used to be passed down from generation to generation, resulting in rote memorization of whatever the authorities taught. Science refuses to defer to authority; instead it insists upon demonstrable evidence that allows anyone who wants to look, to verify the truth for them self. For example, instead of believing an authority who insists that Jesus cared more about war than the sick, a scientific approach can be taken by using statistics to count the number of times the sick were mentioned in the gospels as compared to war: 
jesuscommentssickwar

Science revolutionized medicine by insisting that a treatment had to be demonstrable in repeatable experiments before it could be claimed to be a cure.


Medicine without Science -

The Death of George Washington.

washingtonwpclipartdotcom1231448715One snowy day in December of 1799 the sixty-eight-year-old George Washington came in from riding his horse around his farm. That evening he complained of a sore throat. Over the next two days he became hoarse, and began to have trouble breathing. Three doctors saw him, and following the textbooks of the day, each decided the best treatment was to bleed him in the hopes that doing so would stop the inflammation in his throat. At that time, the proponents of bleeding thought the body had twice as much blood as the twelve pints it actually has, so the doctors removed almost half the blood in Washington’s body. George Washington died the next evening.

The problem was that Washington’s treatment was not based on scientific evidence. Three hundred years ago about the only double-blind experiments were when a doctor treated both eyes of a patient with the wrong salve. Washington’s doctors had learned from other doctors the accepted treatment, and earnestly practiced what they had been taught, but there had never been any controlled experiments proving that bleeding worked, or didn’t work. The doctors’ reliance on knowledge passed down from authorities prevented them from properly analyzing the problem. The real danger was that Washington’s inflamed throat was obstructing his air passage - most likely Washington suffocated. Today’s prescription -- putting a tube down the throat to prevent suffocation -- was not used successfully until almost 100 years later. But don’t miss the point – it is not to blame Washington’s doctors, who were performing as they had been trained to do. What is important is to understand why their treatment failed. It wasn’t an irresponsible mistake. It was a systemic mistake due to the pre-scientific reasoning the medical community had traditionally used.

Dr. David Eddy, a leading critic of traditional medicine and founder of the evidence-based medicine movement, claims that when he was trained in the 1970’s, only 15 percent of what doctors did was backed by scientific evidence. Even today some in the movement claim that doctors use scientific evidence for only 25 percent of their treatments. Some doctors have characterized this as a battle between evidence-based medicine and cookbook medicine, a nice descriptive term for the rote retrieval of treatments out of textbooks or medical school lectures. All of the life-saving advances of the past century were due to this primary characteristic of science – examining evidence.

Unfortunately, Making Scientific Arguments Based on

Evidence Does Not Come Naturally to Most People

A 1993 study by Deanna Kuhn showed that only 40 percent of adults in America could even make an evidence-based argument. Furthermore, only 20 percent of those without a college education could do so. Using evidence in an argument is something most humans have to learn.

normal_kid_01 40%! That many?








Premature Death

Since we will all die someday, what we are really talking about when we speak of saving lives is stopping premature death. One of the most common responses people have with respect to death is fatalism. Since death is inevitable, it is easy to think that living a full life or living longer is not a choice, but is a matter of genetic or environmental luck. However, the evidence presented in the book of well over one billion lives saved strongly suggests that premature death is not a matter of fate. Mankind, with the power of science, has the ability to reduce mortality from many more causes of premature death.

These causes range from violence to accidents to disease.

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16,242 deaths in 2003




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44,757 deaths in 2003



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525,405 deaths in 2003

 





With disease, premature death is sometimes defined statistically as dying prior to the age of 65. About one fifth of all the disease deaths in the United States are premature. In 2003, disease caused 520,405 premature deaths – about 1,440 a day. Vehicular accidents caused 44,757.  Murder caused 16,242.

One reason more people do not celebrate the monumental medical advances is the fear that even if individuals’ lives can be saved, the cost to do so will drain society’s economic resources. So it is reasonable to ask if saving lives is cost-effective.

owes_moneypdclipartdotorg














Is Spending Money on Healthcare a Good Investment?

The media often create the impression that spending on healthcare will eventually bankrupt the country. A similar concern is that allowing people to live into old age will sap the incomes of young people. If we use scientific reasoning and look at evidence, the complete opposite becomes apparent. As David Cutler, Professor of Economics at Harvard, points out, the reason medical care was 4 percent of a much smaller GDP in 1950, and is 16 percent now, is that doctors couldn’t actually treat many conditions in 1950. Now however, when many diseases can be cured, people quite rationally spend more of their money on medical care.

In order to assess the effect of healthcare on the country’s economy, over the past decade several economists have done groundbreaking studies to calculate the value of lives saved economically. Their conclusions, some of which will likely garner a future Nobel Prize, is nothing short of amazing. It is summarized in the book Measuring the Gains from Medical Research: An Economic Approach, edited by Kevin M. Murphy and Robert H. Topel, both of the University of Chicago. They found that, “Improvements to life expectancy alone added about $2.6 trillion per year to national wealth between 1970 and 1998. By comparison, average GDP over this period was about $5.5 trillion.”  William D. Nordhaus, a Professor of Economics at Yale, found that, “Growth in longevity since 1950 has been as valuable as growth in all other forms of consumption combined.”
normal_money_bagspdclipartdotorg
As hard as it is to believe, the great economic advances over the past three decades are not primarily the result of the computer revolution or the advent of the Internet. Evidence demonstrates that economic gains due to increased health and lives saved over the last half of the twentieth-century dwarf any other industry’s contribution.

These numbers are huge, for one because a disease eliminated no longer consumes resources. The United States used to spend hundeds of millions of dollars trying to keep people with smallpox from coming into the country. Now that smallpox no longer exists, such spending is no longer necessary. Secondly, preventative measures such as vaccines abolish disease. If millions of people never get a disease like measles, no money is spent trying to cure it. Thirdly, and most importantly, every single person whose life is saved continues to produce and consume. Think of an infant saved. He or she may grow up to be another Steve Jobs and run one of the most innovative companies in the world – Apple.

A simple statistic demonstrates the effect of saving lives on the economy. In 1960, when the population of the United States was about 200 million, the number of deaths each year was 2.7 million. In 2000, a comparable population of 200 million, adjusted for a similar age distribution, had 1.7 million deaths – one million less. Over decades the numbers of lives saved add up to the tens of millions, each of whom actively participates in the economy, producing goods and services and paying taxes. Economists also recognize a multiplier effect. Every dollar produced or consumed by a person whose life has been saved affects other people, who sell that person goods, and who then also produce and consume more, which causes other people to produce and consume more, and so on. In addition, there are intangibles. Would globalization, considered by many to be the economic story of the decade, even be possible without the defeat of smallpox, allowing unrestricted travel throughout the world?

Increasing longevity is the greatest economic tool our culture has produced. No other investment has had such high rates of return. Yetsack_o_cashpdclipartdotorg1 most of what the media report is that we have a financial crisis in healthcare. They are right; we do have a financial crisis. From an economic point of view we aren’t spending too much on healthcare -- we are investing way too little!



What Can Scientific Evidence Teach Us

About Investing in Research to Save Lives?


We live in a nation where we each have a say in how our resources are used. As a society we can decide if we build huge monuments like those on Easter Island, or if we add more and more square footage to our homes. One of our choices is how much to spend on healthcare research. Charity accomplishes much, but it can play only a small role in healthcare research because research is so expensive. In 2004, charity contributed about 2 percent of the $101 billion spent in the United States on healthcare research, and half of that 2 percent came from the Bill and Melinda Gates Foundation. The 60 percent of all healthcare research funding that corporations – primarily the drug companies – contribute is significant. But corporations only spend money on big problems, where there are big profits to be realized, and on relatively focused problems, where a profitable solution can be achieved relatively quickly. Funding for basic, untargeted research, and research on less common health problems, must come from the government. And as much as some people are loath to contribute, the government gets its money from taxes.

Are we basing our decisions on how to spend our tax money using evidence, as science has taught us? If we are, what should we choose to spend our tax money on, if we want to save lives?

Taxes Spent on Researching How to Save Lives
2004 Federal Government Research Funds Spent to Save Lives
$ 69 Billion       Defense
$ 38 Billion       Disease
$     58 Million  Vehicle Safety

To be clear, $69 billion is not the defense budget, which for 2004 totaled $380 billion and for 2008 will total $481 billion (not counting what is spent on the wars in Iraq and Afghanistan). The figure we are discussing is only the defense research budget. The budgets have changed since 2004. In 2008 the outlay for defense research increased to $81 Billion, while federal funding for healthcare research has been unchanged.

If this spending were rational, it would be based on the evidence of need. Here are the numbers of deaths caused by each of the above categories.

Deaths by Category per year
520,405 Disease prior to age 65 in 2003
44,757 Vehicle Accidents in 2003
277  Yearly average war and terrorism deaths for the past 30 years thru 2007.

Let's look at this visually:

Yearly Deaths from War and Terror (past 30 years through 2007)


deathsyearly

deathsyearly2a

deathsyearly3a

We can calculate the amount spent on each individual life:

2004 Federal Research money spent per life lost by:
War and terrorism                   $249,000,000
Disease prior to age 65                    $ 73,000
Vehicular Accidents                            $1,300

A Visual Presentation May be More Meaningful
U.S. Federal Research Funds Spent to Save Lives per lives lost from:
Vehicular Accidents ¢
Disease ¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢¢
War and Terrorism $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
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Yes, those are cents for the accidents and disease research, but dollars for war and terrorism research. Let’s use a military analogy: medical triage. If a MASH unit with 3,401 doctors is confronted with 1,879 wounded soldiers, how would they allocate the doctors? Would they assign 3,400 to one wounded soldier and one to all the rest? That is the way we are allocating our research funds. For every war death there are 1,878 disease deaths, yet we are spending 3,400 times as much on preventing a war or terrorism death as we are on preventing a death -- perhaps your child’s -- from disease. We are spending 190,000 times as much to prevent a war or terrorism death as we are to prevent a traffic death.

Our Declaration of Independence states that it is a self-evident truth that all people are created equal. The Golden Rule implies that everyone should be treated equally. Obviously, our government officials do not follow either in allocating research funding.

Some people might argue that war may not be the biggest threat to life now, but historically it has been the biggest threat. That argument ignores the evidence. In the twentieth century, one and a half times more people died from one disease – smallpox – than died in all the wars in all the countries combined (300 million to 188 million – these war deaths include combat and noncombat deaths, as well as those resulting from politically caused famines and genocide). Every single day in the United States 1,440 non-elderly people die prematurely. That is one per minute – like a 9/11 terrorism attack every two days. Is it because there are no television cameras on their pale, sad faces that we think less about these than about those who die in war? Is it because they die with less drama?

The evidence indicates that we are not spending our resources on researching what is really killing Americans!


Still Believe War is the Gravest Danger?

More than twice as many people have died in vehicular accidents in the United States than have died in all the wars the United States has ever fought. (The highest count of war deaths in all of the wars in U.S. history, including both combat and non-combat deaths, is 1,541,650. Total vehicle deaths through 2005 are 3,393,806).

Don’t think health insurers should cover mental health?

More people have died from suicide since 1940 than have died in all the wars the United States has ever fought (1,582,266).

Against providing health insurance to those who can’t afford it?

More people die each year due to having no health insurance than are murdered.

Believe healthcare providers should cut corners to save money?

More than two times as many people die each year from medical errors than are murdered.


 

If You Had a Child, How Would You Choose to Invest Your Research Dollars?

Let’s do a thought experiment. Let’s imagine that you and your spouse are going to have a baby and you have a certain amount of resources in the form of taxes that you are willing to pay and you want to use those resources to protect your child from deadly harm over his or her lifetime. First you will determine what your child will most likely die from.

Probability of your child dying
Before the age of 65 due to disease 1/6
Lifetime due to auto accident            1/84
Lifetime due to suicide                       1/116
Lifetime due to murder                       1/217
Lifetime due to war or terrorism        1/13,000

Your child is 2,000 times more likely to die prematurely from disease than from war or terrorism, and more than 100 times more likely to die from an auto accident or suicide than from war or terrorism. It is our choice, how we spend our taxes for research.

 


Our society is vastly under educated in probabilities.  Let’s examine more statistical evidence, in order to understand what the real threats to our children are.

 

  • 1,440 non-elderly people a day die prematurely from disease in the United States.
  • More than twice as many people have died in vehicular accidents than in all the wars the U.S. has ever fought (the highest war count that includes both combat and non-combat deaths is 1,541,650 – total vehicle deaths through 2005 are 3,393,806).
  • One and a half times more people died from smallpox than in all the wars in all the countries in the whole world in all of the twentieth century (300 million to 188 million – these war deaths include combat and noncombatant deaths, as well as those resulting from political famines and genocide).
  • 1 non-elderly person dies prematurely each minute from disease in the United States.
  • Your child is almost twice as likely to commit suicide as to be murdered. (2003: 31,484 suicides to 17,732 murders) Still don’t believe in insurance companies paying for mental care?
  • More people have died from suicide just since 1940 than died in all the wars the U.S. has ever fought.
  • In three years more non-elderly people will die prematurely from disease than in all the wars our country ever fought (1,561,215 by disease vs 1,541,650 by war).
  • More people die due to having no insurance each year than are murdered (20,000 to 17,732). Why do we become emotional (rightfully so) that three thousand people die from an act of terrorism but not that 20,000 die every year from something we absolutely can prevent?
  • Two and a half times more people die each year from medical errors than are murdered. (44,000 to 17,732).
  • Someone died prematurely from disease while you read these stats (you can change that).

This is a Real Life or Death Decision

One day you may be in a hospital, holding the hand of a loved one. He or she will die. You will walk out of the hospital alone, tears streaming down your cheeks, your loved one dead. You will get into your big, new shiny car and drive home to your house, which is $100,000 more expensive than the one you bought in 1990.  You will walk through the house, not wanting to sit down, alone without your loved one, and you will find yourself in a back bedroom. You paid extra for the back bedroom, for more carpet and drywall.  You chose to spend your money on the fancier car, the bigger house, rather than pay more taxes. And now you stand alone in a room no one will live in. Was your choice made using scientific evidence?

The Irony is that the United States is the

Best in the World at Research!

This is not a harangue to make you wring your hands, and lament that the United States of America can never do anything right. What does the evidence say about the United States? Based on a Chinese university’s study, the United States has 17 of the top 20 universities in the world.  The United States leads the world in money spent on healthcare research by private firms. The United States leads the world in healthcare research funded by the government. Europe doesn’t come close, nor does any other country. The truth is that the U.S. has done more right than any other country in the history of the world – ever!  We excel.  Medical research is a stream of successes. Half of our ten heroes were born and educated in the U.S., and the whole world owes them an enormous debt of gratitude. And while globalization may take manufacturing jobs or even service jobs overseas, our nation is far out front in scientific research. We can be the nation that cures the world.  We can be the nation that all others look to, to heal their loved ones, to model their research spending after. We can be the nation that teaches the rest of the world that scientific evidence is the answer to mankind’s problems.

Scientific evidence indicates that we could save tens of thousands more lives with a few policy changes.

Policy Change No. 1 -

Cut Vehicular Deaths to 10,000 by the Year 2015

A NASCAR vehicle flips thirteen times and the driver gets out grinning from ear to ear. We have the technology and scientific auto_crashpdclipartdotorg1intelligence to drastically cut the probability of death in an automobile accident to much less than 1/6,500 each year. How can a parent in his or her right mind spend money for GPS systems and engines with much higher horsepower than necessary when their child’s car is not designed to be safe?








Policy Change No. 2 - Reform Health Insurance

Studies have shown that 20,000 non-elderly people a year die from not having health insurance. Those without health insurance often sad_girlpdclipartdotorgdelay going to the doctor, even in emergencies, due to concern about the cost of treatment. For a nation as wealthy as ours to allow 20,000 people a year to die from not having health insurance is shameful. Perhaps a new way to conceptualize the problem the working poor have in paying for health insurance is needed to help wealthy people in power empathize with them. If everyone should have health insurance, and since everyone who does have health insurance pays for the treatment of those without health insurance either through taxes or higher insurance premiums, health insurance, even if privately purchased, can be viewed as a tax. If health insurance is viewed as a tax, then for the forty percent of workers whose employers do not provide health insurance, it is a draconian tax. A health insurance policy for an average family of four now costs over $10,000 a year. This equals a 52 percent tax on a household at the 20th percentile of income and a 20 percent tax on a household at the 50th percentile. This is why one in three non-elderly Americans go periods of time with no health insurance.

Policy Change No. 3 –

Enhance the Jobs of Those Who Provide Medical Care


When we have a sick child or loved one, where would we be without those who provide us with healthcare? Upon visiting any doctor’s normal_baby_doctorpdclipartdotorgoffice or hospital, it is immediately apparent that healthcare providers work hard and care about those who are ill. In fact, the average doctor works 50 hours a week. Evidence indicates that healthcare professionals do more for the economy than capitalists, yet they pay much higher taxes. Doctors currently pay a top rate of 35 percent on their income. The top rate capitalists pay is 15 percent. Economists have shown that healthcare professionals and researchers are more important for the economic success of the country than capitalists, so they should have a top income tax rate no higher than the capitalists’15 percent rate. By reducing their taxes, doctors can take on fewer patients and still make as much money as they do now, thereby using their extra time to provide better care to their patients and to study new advancements in medicine. With a reduction in their taxes, more of our brightest students will be drawn to medicine and research, which could solve the looming shortage of doctors and other healthcare professionals that is expected in the coming decades, as well as finding more ways to save lives.

Primary Priority -

Increase Healthcare Research to $153 Billion

A drug company’s CEO who refused to invest a portion of their company’s profits in researching and developing new drugs would be considered irresponsible and fired. Government should be held to a similar standard. What have our government officials done? The 2008 federal budget increased defense research funding to $81 Billion, an increase of 17 percent since 2004. The primary medical research agencies in the government are the National Institutes of Health. The NIH’s budget has not even kept up with inflation over the past four years. Evidently, our government officials care a lot more about creating weapons that kill people than creating weapons that save people.

Kenneth G. Manton and his colleagues at Duke University have analyzed the amount of medical research the federal government should moneypdclipartdotorg1be funding, taking into account the contribution of past medical advances obtained through research, the economic benefit of such research, the aging of our population, and other factors. In a paper published in 2007, they suggest that the federal government should be spending four times its current amount on health research – $153 billion a year. (This is about the amount that the government has invested in AIG, an insurance company). If enacted, this would increase spending to almost $300,000 per disease death, still 1,000 times less than that spent on each war/terror death. Currently less than 20 percent of scientists who request a grant to study disease are being funded. How many scientists greater than Einstein are not being funded? Will your child have a disease that could have been studied by one of the 80 percent of grants that are now denied funding?



Buttonhole Your Congressperson

The evidence is clear, and there is ample academic research to prove that our nation needs to drastically change our research priorities. openclipart_people_people_04bpdclipartdotorgIn the end, however, there is only one person who can ultimately decide to save more lives – your openclipart_people_people_07apdclipartdotorgcongressperson. To be sure, entrenched lobbyists will fight any increase in medical research funding. Your congressperson is paid by these lobbyists to listen to them and ignore you, but he or she also knows that if enough people care about something, they can be removed from office. So shake your congressperson’s hand, look him or her in the eye, and with your other hand give them a picture of a loved one who has died prematurely, or one who is alive and whom you don’t want to die early. Tell your congressperson:
“Only you can prevent premature death.”


Sources

1. Centers for Disease Control and Prevention. http://www.cdc.gov/nchs (Accessed December 2006 through January 2008).

2. Cutler, David M. 2004. Your Money or Your Life: Strong Medicine for America’s Healthcare System. New York: Oxford University Press.

3. Kuhn, Deanna. 1993. Connecting Scientific and Informal Reasoning. Merrill-Palmer Quarterly 39 (1): 74-103.

4. Manton, K.G., Lowrimore, R.L., Ullian, A.D., Gu, X., Tolley, H.D. 2007. Labor force participation and human capital increases in an aging population and implications for U.S. research investment. PNAS 104 (26):10802-10807.

5. Moses, H. III, Dorsey, E.R., Matheson, D.H.M. Thier, S.O. 2005. Financial Anatomy of Biomedical Research. JAMA 294 (11): 1333-1342.

6. Murphy, Kevin M., and Topel, Robert H. 2003. Measuring The Gains From Medical Research: An Economic Approach. Chicago: The University of Chicago Press.

7. Wallenhorn, White McKenzie. 1999. George Washington's Terminal Illness: A Modern Medical Analysis of the Last Illness and Death of George Washington. The Papers of George Washington.
http://gwpapers.virginia.edu/articles/wallenborn.html (accessed December 10, 2006).

8. 2007. Bible Study Tools. Crosswalk.com http://bible.crosswalk.com/ (accessed January 11, 2008).

9. 2007. Odds of Dying From… National Safety Council. http://www.nsc.org/NSC%20Picture%20Library/News/web_graphics/Injury_Facts_37.pdf 
http://www.livescience.com/3780-odds-dying.html

(accessed January 12, 2008).

10. 2008. Health Insurance Coverage. National Coalition on Health Care.
http://www.nchc.org/facts/coverage.shtml.