Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS9 2PR, UK.
It is a dull fact that where polarized positions exist either there is no single truth, or the truth lies somewhere between the fortified positions of the key protagonists. McKeown's presentation of historical mortality patterns1 and Illich's nihilistic polemic2 came as refreshing antidotes to both the heroic history of past therapeutic triumphs and breathless optimism about the capacity of post-war science to conquer common chronic diseases in the way it appeared, then, to have conquered the major communicable diseases. Works of that sort, with the added spice of Cochrane's iconoclastic view of the scientific foundations of clinical activity,3 became the tracts that assuaged the public health doctor's lowly medical status, rather as the Bible may ease the daily humiliation of Jehovah's Witnesses as doors are slammed in their faces. The comfort that these works offered was, however, not without cost, as the implicit or explicit assertion that the medical care of the later 20th century did not contribute to health improvements was so counter-intuitive that this view may have contributed to the increasingly marginal position of public health.
The fact that major improvements in health status occurred prior to the availability of effective measures does not mean that a significant proportion of recent improvements cannot be ascribed to medical care. Mainstream opinion responded to the view that medical care can take no credit for health improvement largely by ignoring it. John Bunker has been the main authority to take on this debate in its own terms. Over many decades he has performed two major services that reflect his balanced view of the merits of medical treatment. First he was a key pioneer of the critical, quantitative analysis of the benefits of medical treatment through the study of treatment variations. Second, he offered the formal counterbalance to the views of McKeown and others. This review brings up to date his ideas on the relative importance of medical care in explaining 20th century increases in life expectancy, and outlines their policy implications.4
He highlights the two difficulties with ascribing major health improvements to medical care. First he considers, fairly, the matter of iatrogenic disease and death. Second he explores, with less balance, the impact of socioeconomic influences upon mortality. While acknowledging a 91/2-year difference in life expectancy between men in professional and unskilled occupations, he neutralizes this issue on the grounds that where the very rich and the very poor comprise only a small proportion of each population, such inequalities can have only a small effect upon overall population trends. His estimate of 11/22 years net effect on life expectancy is probably an underestimate, given, for example the 4-year life expectancy difference between the highest and lowest septile for English health authorities for 19921994.5 Such differences are a serious underestimate of the true attributable health effects of socioeconomic disadvantage, since they do not take into account lifetime social circumstances and are based on comparing large heterogeneous areas, and thus substantially misclassifying individual experiences of deprivation.5 But the main problem here is the assertion that ... improvements in public health (are) essentially complete ..., with the clear recommendation that medical care must be the overriding priority for national policy. This overstates the case, and serves to distract from the fact that the environmental effects seen in 19th century mortality patterns are still available to deprived populations within industrialized countries. Modelling the wider determinants of health is also complicated by the proper absence of trial evidence from randomized individuals on the effects of population measures; the idiom of evidence-based medicine is now being applied inappropriately to the consideration of the merits of broader investments in health.6 The view that income redistribution can be justified outside any technical discussion of health status is not considered. The suggestion that government commitments to reducing suicide deaths can be met through medical care is surprising, given the uncertain effectiveness of relevant interventions and uncertain access to those who may be at risk of suicide.7
What is the effect of making the assertion that medical care accounts for a high proportion of increased life expectancy and quality of life? The case is here made for more medical care. But what does this mean? Medical care is not a unitary activity where having more is unequivocally beneficial. The reasonable case is for more benefits of health care, rather than more health care per se.8 In some instances there is no doubt that more is better. For example, there is little doubt that there is underprovision of cataract extraction in the UK, with consequent unnecessary disability; we can therefore feel confident that more cataract extraction is desirable. Many other instances are more complex. The major discrepancy between the rates of coronary revascularization procedures between the US and UK is amongst older people; amongst those aged 7584 the difference is over tenfold. The question is then, are older people in the UK being deprived of an unequivocal benefit, or are older people in the US being exposed to unwarranted risks? It is important to stress that there are no formal answers to this question at the moment as the trial evidence that exists is based upon outcomes amongst younger people. This is a specific example of the general problem in reconstructing the population effects of medical care where participants in trials differ from the population experiencing conventional services in terms of age and other characteristics, including multiple pathology. Not only do international studies not show any mortality benefit from higher levels of coronary revascularization, there is some evidence that countries with the most aggressively interventionist approach have higher rates of other adverse events, such as stroke.9 The issue is therefore as much a matter of what approach to the morbidity of declining years individuals in different cultures may favour; implicit assumptions that more is better are therefore unhelpful.
The time has probably passed when the simple opposition of medical care and other determinants of health has any value. The more interesting questions concern which components of medical care and which influences upon other determinants of health justify investment. However, the discourse in health policy has been dominated by the idiom of the health economist where choices are always hard and costs represent opportunities forgone.10 If we have to express these complex issues in terms of a continuum between increasing investment either in the wider determinants of health or in medical care, the truth, for the UK at least, lies at both ends.
References
1 McKeown T. The Role of Medicine. Oxford: Basil Blackwell, 1979.
2 Illich I. Medical Nemesis. London: Calder and Boyars, 1975.
3 Cochrane AL. Effectiveness and Efficiency. London: The Nuffield Provincial Hospitals Trust, 1971.
4
Bunker JP. The role of medical care in contributing to health improvements within societies. Int J Epidemiol 2001;30:126063.
5 Shaw M, Dorling D, Gordon D, Davey Smith G. The Widening Gap. Bristol: The Policy Press, 1999.
6
Davey Smith G, Ebrahim S, Frankel S. How policy informs the evidence. Br Med J 2001;322:18485.
7
Gunnell DJ, Frankel SJ. Prevention of suicide: aspirations and evidence. Br Med J 1994;308:122733.
8
Frankel S, Ebrahim S, Davey Smith G. The limits to demand for health care. Br Med J 2000;321:4044.
9 Yusuf S, Flather M, Pogue J et al. Variations between countries in invasive cardiac procedures and outcomes in patients with suspected unstable angina or myocardial infarction without initial ST elevation. Lancet 1998;352:50714.[ISI][Medline]
10 Davey Smith G, Frankel S, Ebrahim S. Rationing for health equity: is it necessary? Health Econ 2000 (in press).
|