October, 2002

Editorial, unpublished

If the present discussion about health care reform continues as it has been, we will all be losers in any reform that might happen. We will lose if the Democrats prevail, we will lose if the GOP prevails, and we will lose if progressives prevail.

This loss will not happen because reform is unneeded. It most certainly is. The loss will happen because the discussion is entirely focused on reform, with virtually no discussion about health. The discussion of reform focuses on questions such as Who pays? and How do we reduce costs? and Should/shouldn’t Medicare cover a particular treatment?

Republicans answered the reform question in a predictably Republican way. Bush has proposed “drug cards” that will subsidize the pharmaceutical industry by using Federal money to pay some percentage of the outrageous prescription costs.

Democrats have countered in a typically Democratic way. They propose even greater Medicare coverage of prescriptions, more NIH research funding, and greater access to the health care system for those currently unable to get adequate treatment.

Progressives have always cast themselves as the true champion of the people, and when the topic is health care the situation is no different. Long-time advocates of a universal health plan such as Sen. Bernie Sanders and Ralph Nader have articulated a vision in which every man, woman and child in the US is able to walk into a hospital or doctor’s office and receive any health care they need, free of charge.

The assumption behind all of these plans – from Republican to Progressive – is that our current medical system delivers a set of services that actually advance something called “health.” But how is health defined in order to make that assumption correct? How do patients’ future ability to avoid disease and their long-term quality of life get valued in the assessment of the present health care system?

The most frequently used treatment within the context of a visit to a physician is drug therapy. According to information from the National Center of Health Statistics, over 60% of visits to a physician include some form of medication being prescribed (in 1999, the most recent year available). Medications are the primary tool used to advance health within our system, and lowered costs or greater access ultimately means easier access to medications, in addition to other less prevalent therapies. As a comparison, there are approximately 2.5 billion prescriptions written annually in the US, compared to 20 million surgeries, or 125 prescriptions written for every operation.

In what sense, though, is heath being measured such that taking medications is a valid tool for health care? One example will help illustrate the importance of the answer to that question.

For millions of people with indigestion, gastric reflux, ulcers and heartburn, a class of drugs called H2-blockers are prescribed regularly. These include brand name drugs such as Tagamet and Zantac. Overall, this class of medication was the largest-selling class in 1998, totalling over $6 billion in sales in the United States that year. The function of H2 blockers is to lower stomach acidity, thereby alleviating the burning pain caused by stomach acid.

There is controversy over whether these drugs significantly reduce the overall death rate or diseases associated with ulcers. There is good evidence that these drugs significantly reduce or eliminate the symptoms for which they are prescribed. However, in this context, “health care” means only that the experience of symptoms has been lessened or removed. But at what cost?

Because they lower the acidity of the stomach, H2 blockers have a number of other effects in the body:

· Stomach acidity regulates bacteria growth in the digestive tract. Use of H2 blockers leads to overgrowth of both stomach and small intestine bacteria, including E. coli, Candida albicans, Pseudomonas, enterococcus, Bacteroides vulgatus and several others. Intestinal overgrowth of any of these bacteria have health consequences of their own, not the least of which is further indigestion and digestive discomfort.

· Stomach acidity is necessary for the breakdown and assimilation of dietary protein. The lowered acidity caused by H2 blockers inhibits protein digestion, consequently inhibiting protein absorption by the body.

· H2 receptors (the molecules that are blocked by H2 blockers) are found not only in the stomach, but also in the brain. There is growing evidence that H2 blockers affect a number of chemicals known as neurotransmitters in the brain. Neurotransmitters, including serotonin, dopamine and others, have an impact on everything from moods and sleep to movement, cognition and sensation.

· Largely due to their effects on the acidity of the digestive tract and intestinal bacteria, H2 blockers have been shown to deplete vitamin B-12, vitamin D, and folic acid, and the minerals iron, zinc and calcium. Depletion of each of these has significant health consequences.

In what sense, then, do these common medications used by the present health care establishment actually promote health? All the currently proposed health care reforms will make drugs such as these easier to obtain, but how has health been advanced as a result? While H2 blockers were used as an example, the same analysis of virtually any tool currently used in the present health care system would be just as instructive.

Determining whether any given tool employed by the health care industry advances health is no simple task. How are the documented and very real detriments to health caused by just this one common class of medication to be accounted for when we talk about health care reform? If there is someday health care reform that makes these drugs more accessible to those who cannot now afford them, can it be said with confidence that the reform advances health in any meaningful sense of the word?

A 1999 study found that individuals over the age of 60 are now prescribed, on average, between 5 and 6 medications concurrently, with some taking as many as 22 different medications at one time. Each medication no doubt makes the experience of some set of symptoms more tolerable, but are we all willing to forfeit the goal of meaningful health advancement for the sake of enhancing access to only disease and symptom management? If advocating more research means development of more of these same tools, does that research work toward the promotion of health?

Therapies that are used to advance health should not only make today’s complains more tolerable, but should enhance, rather than compromise, an individual’s overall functioning. Treatments that help one problem while at the same time making a host of other problems more likely in the future simply continue the cycle of disease and the dependency on more treatment.

Before we advocate reform, we first need a national discussion about health and what it means. The tools employed by the present medical system need to be evaluated not in the extremely limited manner of a clinical trial; such trials look almost exclusively at the impact of one treatment in relation to only one symptom, complaint, or even one laboratory value. Instead, the tools used by the health care system should each be evaluated for their ability to advance health today while at the same time not compromising the overall health in the future for those who use them.

Some critical steps toward formulating and advancing meaningful health care reform include:

• Defining what we mean by “health” in the national discussion about health care. A definition that moves beyond the simplistic notion of health as the suppression of symptoms and includes recognition of proper overall physiological functioning would allow for a meaningful evaluation of the tools used for health care.

• Advocacy of medical research into treatments that supports this new definition of health. If, in order to be judged as useful, new medical treatments had to promote both short-and long-term normal functioning of the body rather than compromise it in the process of relieving symptoms, research into new treatments would move in radically new directions.

• Systematic re-evaluation of current therapies commonly used within the health care system. This examination should rate efficacy of a given treatment not simply by its ability to ameliorate the experience of discomfort. Therapies must be evaluated in much more broad terms, so that any negative impact on overall physical function is considered side-by-side with its short-term effects.

• Public investment into research without regard for the profit potential of the outcomes of those investments. Theoretically, Federally-funded health care research should have no concern whether research findings and product development have profit potential, at least not as a greater motive than the desire to promote the general health of those using health care services. Removal of this profit motive from publicly financed research would allow for a more comprehensive assessment of new therapies and products. The overall health benefits and risks of each treatment can take precedence over the limited assessment based on single symptoms or complaints. Profits thrive on this limiting of the scope of assessment, such that virtually any treatment can be defined as beneficial within some context.

• Advertising for pharmaceuticals should be more strictly regulated, so that the potential long-term consequences of their use are made explicitly clear both to physicians and to the public. For example, stating that H2 blockers have indigestion as a possible side effect is inadequate when there is considerable evidence that impaired protein absorption, intestinal bacterial overgrowth and specific nutrient deficiencies are also potential consequences. These aren’t currently listed as side effects because they are not experienced as physical symptoms. However, this only illustrates that the present definition of “side effect” is far too limited to encompass all negative consequences of a given therapy.

• Assessment of treatments should not be limited only to pharmaceuticals. All manner of procedure and therapy should be re-evaluated. Even basic public health measures such as vaccinations must be examined in light of all information available. For example, there is growing concern about the rising tide of autism, autoimmune diseases and neurological diseases and their possible correlations with the enormous increase in vaccinations over the past 40 years. These concerns are no longer found only in the fringes of alternative medicine, but increasingly within the scientific mainstream. The progressive community would do well to educate itself about these issues, rather than leaving all decisions about scientific matters to professionals. Surely progressives are well aware of the ways professional authority can be used – intentionally or unintentionally – to protect the interests of the social institutions that grant it a voice.

No one should be blamed for wanting relief from their mental and physical discomforts, and if there is a medical treatment to accomplish that goal it should be available. However, we should be aware of the detrimental impact of the medical services we receive, and we should formulate a program of health care reform that recognizes the importance of protecting and even promoting long-term health even while addressing more immediate complaints.

Universal access to health care is undoubtedly a worthy cause, and progressives should not waver from that goal. However, it is worth being careful what we wish for. Access to therapies for today’s complains that compromise our abilities to remain complain-free tomorrow is a step backward, not forward, in the campaign for meaningful health care reform.