Is Population Health a Reasonable Medical Problem? Historical and Geographic Variation in Disease, Mortality and Infrastructure, Part I

Is Population Health a Reasonable Medical Problem? Historical and Geographic Variation in Disease, Mortality and Infrastructure, Part I

The Questions

Could 21st century medicine have dampened population afflictions caused by epidemical and endemic diseases during the 17th-19th centuries?  For that matter, are the tools and treatment models of 21st century medicine adequate for the current infectious and parasitical diseases of Sub-Saharan Africa?   Modern medicine works away steadily in that area of the world, yet it is a location where pestilences are still the principle causes of death. [1] Put differently, does what doctors do have a positive effect on population health?  After all, it might be that physicians fail to help, harm, or kill as many people as they heal. [2] Or, medical “reach” into a population may be insufficient to have any significant effect on the major diseases of a given time. [3]

I do not believe there is any evidence that, as a healing force, modern medicine could carry the day against the disease density of populations, historical or current.  Historically, population health is a matter of separation from insalubrious conditions and of increased resistance to infection due to improved nutrition.   Such health is achieved by degree when people are protected by a thick wall of sanitary infrastructure (see Blog dated February 8, 2016).  This is to say, the great 19th century epidemiological transition in the west was not a function of medicine, vaccines, modern medical ideas or medical activism.  That vast waning of infectious diseases in western countries began before the widespread application of vaccines, before antibacterial medication and before the profession of medicine had put aside the humoral theory of disease.  In a word, “development” turned the tide against disease. [4]

The carefully observant Rene Dubos said every disease has it time and place.  The plague came and went (mostly) long before modern medicine.  Leprosy horrified humanity and left.  Smallpox died out in places where there was little to no inoculation/vaccination and declined in others despite inoculation/vaccination.  That biggest killer of children, diarrheal diseases, was literally flushed out of populations.  Erysipelas stopped killing and was forgotten.  The great decline in tuberculosis occurred (a passive verb); it was not achieved.  And the decline in tuberculosis began long before its pathogen was identified, and certainly before successful treatment with streptomycin became available.  In the U.S. and elsewhere, twentieth century polio arose when sewage in urban and newly suburbanized areas mixed too frequently with daily life, and polio waned as sewage treatment improved and was better separated from play areas and drinking water.  (And of course, conversion to the far more stringent diagnostic criteria of 1955 was exceedingly important to the rapid decline of “polio” incidence – at the exact time the Salk vaccine was introduced.  Polio was defined away!  Unsurprisingly, this medical legerdemain ledsani-dump-sign to diagnostic substitution.  As cases of poliomyelitis declined, there emerged an immediate, concomitant rise in diagnoses of aseptic meningitis, transverse myelitis, enteroviral encephalopathy and non-polio acute flaccid paralysis (NPAFP), etc.  All of these diseases (and more) bring about the sudden onset of paralysis and would have been diagnosed as “polio” prior to 1955. [5] And so on…)

That was history.  Looking at the U.S. as a modern, western society, we are faced by our status as a world leader in obesity.  That is the new-style epidemic, one of the morbid outcomes of the epidemiological transition former and current (developing world).   Relatedly, the U.S. is nearly at the top of diabetes prevalence among OECD nations, we are above the OECD average in mortality by ischemic heart disease, and our life expectancy is much lower than our overall wealth would predict. [6] Our maternal [7] and infant mortality [8] rates are embarrassing.  This is our societal status now.  This is our population health now.  Would it be reasonable to imagine enough bariatric surgery, liposuction and prescription weight loss medication to fix obesity and the serious health concerns that flow from it?  Certainly not!  Medicine can make a lot of money from these conditions, but there are economic and cultural causes at root, not health issues to be positively altered by medical intervention.  Some forces – many, actually – that deeply influence our health are far bigger than medicine.

Supposedly a champion of health, the medical profession could at least try to advocate for environmental change.  If the base causes are environmental, where is the medical activism at all levels of government, seeking health and pressuring our leaders to change our regulatory structures?  Talking directly to patients about diet and exercise, or promoting them on a few websites does not leverage change in causal, structural economic parameters.

Healing Power

Historically, Western medicine was not bolstered by massive public health agencies, infrastructures and secular technologies.  Neither did it have the advantage of adequately nourished populations.  Without these societal, material supplements, even 21st century medicine could not have prevailed against urban conditions extant in the 17th to early-20th centuries, though modern palliative care could have eased much suffering.  We see the truth of this judgment in the various WHO world-regions and across low to high income nations.  In the economically worse off areas, medicine itself may be less ubiquitous than in the richer regions, but medical reach via vaccination is considerable.  Sparse ranks of medical personnel notwithstanding, medicine’s pervasiveness is perhaps as great, or greater, than its European counterparts in the 17th-19th centuries, and its functional resources far more substantial.   In the poorer regions of the world, infectious diseases, parasites, and malnourishment keep some populations weakened to a shocking degree, no matter how they are plied with pharmaceutical products. [9] These considerations make it altogether improbable to count medicine as the chief cause or even as one of several principal factors behind of the decline of infectious diseases and the rise of the disease epidemics associated with industrialization and urbanization in the west.   The empirical examination in Part II of this writing will show, furthermore, that in controlled analysis of World Health Statistics 2013 data, increasing physician density and increasing vaccination rates are strongly associated with increases in mortality, while sanitary measures and nutrition decrease mortality.

 

Endnotes and References Cited

[1] GBD 2013 DALYs and HALE Collaborators, “Global, regional and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 199-2013: quantifying the epidemiological transition”.  The Lancet, published online August 27, 2015, http://dx.doi.org/10.1016/S0140-6736(15)61340-X, Vol. 386, pp. 2145-91.

[2] See for example:  J. Lenzer. “Unnecessary care: are doctors in denial and is profit driven healthcare to blame?” BMJ, 2012; 345 (October 02 3): e6230 DOI: 10.1136/bmj.e6230.  Medical errors in U.S. hospitals kill about 440,000 per year (about the population of Atlanta, GA) or 1205 deaths per day.  This makes hospital errors the third leading cause of death in the U.S.  Hospitals cause from 4.4 million to 8.8 million serious but not lethal harms to patients per year, or about an average of 18,000 day.  See J.T. James.  “A new, evidence-based estimate of patient harms associated with hospital care”, Journal of Patient Safety, 9(3), 2013, pp. 122-128.  Annually, about 4.5 million Americans visit their doctor’s office or the emergency room because of adverse prescription drug side effects; 2 million other patients who are already hospitalized suffer the ill effects of prescription medications. “Few know that systematic reviews of hospital charts found that even properly prescribed drugs (aside from misprescribing, overdosing, or self-prescribing) cause about 1.9 million hospitalizations a year. Another 840,000 hospitalized patients are given drugs that cause serious adverse reactions for a total of 2.74 million serious adverse drug reactions. About 128,000 people die from drugs prescribed to them. This makes prescription drugs a major health risk, ranking 4th with stroke as a leading cause of death” (see:  http://ethics.harvard.edu/blog/new-prescription-drugs-major-health-risk-few-offsetting-advantages).

[3] Medical “reach” is defined as the degree to which, in a given society, the medical profession can effect its protocols on individuals, and thereby influence public health.  “Reach” thus varies across societies and across protocols.  Typically, vaccination offers the longest reach.

[4] Development means the power to build an artificial world for a large population that separates those people from the natural-physical world.

[5] See for example:  Neil Z. Miller, Vaccine Safety Manual, 2nd Edition, New Atlantean Press, pp. 52-53; Douglas Kerr, MD, PhD.  Pp. xv, Foreword in Donna Jackson Nakazawa, The Autoimmune Epidemic, Touchstone Books, 2008; Neetu Vashisht, et al., “Trends in Nonpolio Acute Flacid Paralysis in India 2000 to 2013”.

[6] OECD. Health at a Glance: OECD Indicators, 2011, http://dx.doi.org/10.1782/health_glance-2011-en.  U.S. life expectancy ranks 41st in the world.

[7] The U.S. maternal mortality rate ranks 60th in the world, and has been increasing absolutely since at least 1990.  See Kassebaum, et al. Lancet, 384(9947), 2014.

[8] The U.S. infant mortality rate ranks 58th in the world.  See CIA World Factbook, 2015 est.  Perhaps most shocking:  the U.S. infant mortality probability starts out 116% higher on ‘day one’ than the rate in Austria, for example, but the cumulative probability of death increases by 41% to 157% higher by ‘one year’.

[9] See World Health Organization, World Health Statistics, 2013.  Imbedded in the United States are poverty areas with disease conditions like those of poor, developing nations.  In these places, modern medicine is not winning because there is so very little infrastructural support for public health measures.  See, P. J. Hotez.  “Neglected Infections of Poverty in the United States of America”, The Causes and Impacts of Neglected Tropical and Zoonotic Diseases:  Opportunities for Integrated Strategies:  Workshop Summary, 2011, The National Academies Press, 2011, A8, pp. 237-263.