#21 - 14 February, 2024
CONTENTS
➡️ LEAD ARTICLE: The "Four Noble Truths" of modern healthcare delivery
➡️ Early bird - how early should you be?
➡️ Second helpings - good reading from the web
The "Four Noble Truths" of modern healthcare delivery
The Buddha's "Four Noble Truths" of life are universally known and preached. I am no Buddha, but 40 plus years of active practice have led me to believe that there are four truths (undoubtedly less noble) that we have to face in our encounters with modern healthcare systems.
Truth 1: We are living longer and paying a price for it.
Consider this chart, easily the cornerstone of this essay.
Just a hundred years ago, life expectancy at birth was about 45 years on average. For poor countries like India, it was even lower—somewhere in the high 20s. One of mankind's greatest triumphs has been the huge increase, doubling in some countries to an average of almost 70 years. Absolutely remarkable but poorly recognised victory.
How did this happen? It's not doctors.
Most of us will automatically credit this longevity bonus to advances in Medicine. Guess again. Increases in life spans occur when a society is able to give its citizens two public services.
Infections, which were the major cause of early mortality, drop away in importance.
There is a close relationship between life expectancy and gross domestic product (GDP). As countries get wealthier, their citizens enjoy the two conditions listed above, and people live longer.
There's a name for it. Swapping of infectious and nutritional diseases for NCDs, seen as a consequence of economic growth, has a scientific name: "The epidemiological transition of societies."
It's interesting to note that the transition occurred in "advanced societies" decades before the advent of antibiotics, immunisation, and the wonders of modern medicine.
Paying the piper
Good things often come at a price. Yes, infections are no longer a bogey, but as we live longer, the body shows evidence of wear and tear—degenerative disorders, collectively called Non-Communicable Diseases (NCD). Here's a chart listing the 10 most important NCDs today in order of the number of people affected.
Taking it in terms of these diseases being the cause of death, here's what it looks like.
Cardiovascular disorders and cancer account for the lion's share of deaths.
Don't get too caught up in the numbers. The list is what healthcare delivery is all about today. This is good news for the healthcare industry, particularly the for-profit corporate sector. We'll see why.
What's up?
The disorders are wide-ranging and affect different body systems, but they have two underlying characteristics in common.
The myth of regular health checks.
Based on what we just saw, we have been sold the fable that regular checks and measurements of a variety of bodily functions can detect NCDs early in their course. Effective treatment can be given early and will mitigate the damage.
Wrong again. There is no hard evidence in support of this strategy, and a lot of it shows a lack of value. Still, the health check business is a hugely profitable industry that continues to grow in size and complexity.
To all intents and purposes, there are just a handful of routine tests that could deliver value.
Lipid profiles and liver function tests are of dubious value. The decades past have witnessed a ding-dong battle between fats and carbs as the bad guys in heart disease. Fats have now gained the upper hand again after many years of cholesterol bashing. Carbs are out. Wait some more time to see the pendulum swing back.
ECGs, X-rays, and scans of any sort are a waste of time and money for those who have no symptoms or have not been previously diagnosed with a NCD. False positives are common and can lead you down a trail of further investigations, to say nothing of the emotional turmoil encountered in the pursuit of these red herrings. Even cancer follow-up testing seems to show no real value.
By now, I think you will get the message about the first truth. Let's move on to the remaining three, which follow as a sequence.
Truth 2: You will inevitably need the services of the healthcare delivery system and won't be happy with them.
With the very rare exceptions, you will succumb to one or more of the NCDs listed earlier. When you do, you will need the services of care givers. Encounters can be acute events such as heart attacks and strokes or continuing care for monitoring the progress of the disorder. This is usually lifelong. Patients don't like this situation.
The NCDs have no cure. On one hand, we hear about the near-magical advances in Medicine but are told to reconcile with the fact that there is no permanent cure for the underlying problem.
Complementary Medicine is equally ineffective. Patients commonly fail to accept this and look at other systems: the AYUSH (Ayurveda, Unani, Siddha, Homoeopathy) bodies of knowledge. Although the claims are loud and dramatic, none of them can do better. When subjected to the scientific method (which many of them sneer at), they don't pan out.
The godlike status of doctors is a thing of the past. Doctors were the unquestioned centre of the process for a very long time, with all other services revolving around them. Although still the pivotal point, the intensity with which their role is played has diminished over recent years. The internet has empowered patients to the extent that we now talk about the "Dr. Google" phenomenon. The doctor's word is no longer unassailable. Indeed, quite often, patients could well have a deeper understanding of their specific problem than their doctor, who has to deal with hundreds of different disorders. Even with the best of intentions and efforts, it's impossible to keep up with the tsunami of information that drowns us today. Doctors become defensive when their authority is eroded.
Defensive medical practice. When outcomes are unsatisfactory, patients often seek recourse through litigation. Doctors become defensive and tend to do a lot of tests and investigations to avoid being accused of inadequate standards of care. No one is happy—neither doctors nor patients.
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Worldwide, there is a deep sense of dissatisfaction with the medical profession. Caregivers are blamed for a problem that is deep-seated and complex.
Truth 3: Modern healthcare is expensive.
I don't think anyone needs to be told this. Not only is it expensive, but costs keep rising at rates that are much higher than general inflation. We have the ability to defer or postpone the purchase of consumer items, but when it comes to healthcare, we have no choice.
Four factors are at work in bringing about this relentless rise.
As countries get richer, healthcare costs mount and show no signs of plateauing.
Catastrophic health expenditure. Acute illnesses strike without warning. Patients may have to fork out large sums of money without any preparation. At the end of it all, outcomes can be unsatisfactory, sometimes even ending in the death of the individual. Catastrophic health expenditures usually occur in the last years of a patient's life. In India, it is one of the leading causes of families being driven below the poverty line.
Privatisation of health care. Almost two-thirds of overall health care in India is delivered by the private sector. The figure is larger for in-patient care. The profit motive and the need for providing returns to investors and share holders go well before the interests of patients. The government's share of expenditure for healthcare in India is less than 20% of the overall amount. This is one of the lowest figures for any country.
Truth 4: There's no free lunch.
Someone has to pay for the costs involved in medical care. There are 3 payers.
It is estimated that almost half of India's population of 1.3 billion has to pay out of pocket for health care. No other country in the world has such a large figure.
I am basically a person with a positive outlook on life, but I have watched healthcare delivery in India for over 40 years with a deep sense of despair. Health and education are easily the first two responsibilities of any society. Sadly, they have been handed over on a platter to self-serving interests. I run the risk of being branded as a leftist, but I am not. I prefer to examine issues on my own and come to conclusions. This is what I see.
As a doctor, I am expected to provide solutions. The problem, however, is well beyond the reach of my profession to solve. It needs societal action—a mass movement involving intelligent and concerned people from all strata of our population. I am watching and hoping.
Early bird - how early should you be?**
The "Snooze" button on alarm clocks is one of mankind's great inventions - high on the list, which includes staplers, safety pins, paper clips, and Post-it notes. You get those additional minutes (often more than that) before waking up to face what Lennon-McCartney called "just another day." It irks me to read about super-successful people who are up at absurd hours like 3 and 4 in the morning.
Good news. It seems like these early birds are the exception. Over two-thirds of CEOs report waking up around 7; a mere 5% get up at 4. Sleep specialists (whose opinions, I trust, are derived from first-hand exposure to long hours of their subject of study) aver that what matters is getting 7 to 9 hours of good sleep every day. If you shortchange yourself on this number, productivity will drop.
I am a "night owl." I go to bed around 11 to midnight. The post-dinner hours allow me to work without the interruptions of the day.
My wife and I are longstanding fans and watchers of Mark Cuban's "Shark Tank." Here's what he does to start his day. I bet he has one of those bedside tables that you see in hospitals or a lap desk to help him along. I have both, and it allows me to work not just from home but from anywhere within my house.
Sauer M, CNBC Make It. February, 2024
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"The specific benefits of waking up early mostly center around gaining some alone time, which can provide space to set goals, exercise or complete personal tasks without distractions."
SECOND HELPINGS
Good reading from all over
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