The following is the sixteenth essay in Lewis Thomas’s book, Lives of a Cell: Notes of a Biology Watcher, published in 1974.
Your Very Good Health
We spend $80 billion a year on health, as we keep reminding ourselves, or is it now $90 billion? Whichever, it is a shocking sum, and just to mention it is to suggest the presence of a vast, powerful enterprise, intricately organized and coordinated. It is, however, a bewildering, essentially scatterbrained kind of business, expanding steadily without being planned or run by anyone in particular. Whatever sum we spent last year was only discovered after we’d spent it, and nobody can be sure what next year’s bill will be. The social scientists, attracted by problems of this magnitude, are beginning to swarm in from all quarters to take a closer look, and the economists are all over the place, pursing their lips and shaking their heads, shipping more and more data off to the computers, trying to decide whether this is a proper industry or a house of IBM cards. There doesn’t seem to be any doubt about the amount of money being spent, but it is less certain where it goes, and for what.
It has become something of a convenience to refer to the whole endeavor as the “Health Industry.” This provides the illusion that it is in a general way all one thing, and that it turns out, on demand, a single, unambiguous product, which is health. Thus, health care has become the new name for medicine. Health-care delivery is what doctors now do, along with hospitals and the other professionals who work with doctors, now known collectively as the health providers. The patients have become health consumers. Once you start on this line, there’s no stopping just recently, to correct some of the various flaws, inequities, logistic defects, and near-bankruptcies in today’s health-care delivery system, the government has officially invented new institutions called Health Maintenance Organizations, already known familiarly as HMO’s, spreading out across the country like post offices, ready to distribute in neat packages, as though from a huge, newly stocked inventory, health.
Sooner or later, we are bound to get into trouble with this word. It is too solid and unequivocal a term to be used as a euphemism and this seems to be what we are attempting. I am worried that we may be overdoing it, taxing its meaning, to conceal an unmentionable reality that we’ve somehow agreed not to talk about in public. It won’t work. Illness and death still exist and cannot be hidden. We are still beset by plain diseases, and we do not control them; they are loose on their own, afflicting us unpredictably and haphazardly. We are only able to deal with them when they have made their appearance, and we must use the methods of medical care for this, as best we can, for better or worse.
It would be a better world if this were not true, but the fact is that diseases do not develop just because of carelessness about the preservation of health. We do not become sick only because of a failure of vigilance. Most illnesses, especially the major ones, are blind accidents that we have no idea how to prevent. We are really not all that good at preventing disease or preserving health–not yet anyway–and we are not likely to be until we have learned a great deal about disease mechanisms.
There is disagreement on this point, of course. Some of the believers among us are convinced that once we get a health-care delivery system that really works, the country might become a sort of gigantic spa, offering, like the labels on European mineral-water bottles, preventives for everything from weak kidneys to moroseness.
It is a surprise that we haven’t already learned that the word is a fallible incantation. Several decades of mental health have not made schizophrenia go away, nor has it been established that a community mental-health center can yet maintain the mental health of a community. These admirable institutions are demonstrably useful for the management of certain forms of mental disease, but that is another matter.
My complaint about the terms is that they sound too much like firm promises. A Health Maintenance Organization, if well organized and financed, will have the best features of a clinic and hospital and should be of value to any community, but the people will expect it to live up to its new name. It will become, with the sign over its door, an official institution for the distribution of health, and if intractable heart disease develops in anyone thereafter, as it surely will (or multiple sclerosis, or rheumatoid arthritis, or the majority of cancers that can neither be prevented nor cured, or chronic nephritis, or stroke, or moroseness), the people will begin looking sidelong and asking questions in a low voice.
Meanwhile, we are paying too little attention, and respect, to the built-in durability and sheer power of the human organism. Its surest tendency is toward stability and balance. It is a distortion, with something profoundly disloyal about it, to picture the human being as a teetering, fallible contraption, always needing watching and patching, always on the verge of flapping to pieces; this is the doctrine that people hear most often, and most eloquently, on all our information media. We ought to be developing a much better system for general education about human health, with more curricular time for acknowledgment, and even some celebration, of the absolute marvel of good health that is the real lot of most of us, most of the time.
The familiar questions about the needs of the future in medicine are still before us. What items should be available, optimally, in an ideal healthcare delivery system? How do you estimate the total need, per patient per year, for doctors, nurses, drugs, laboratory tests, hospital beds, x-rays, and so forth, in the best of rational worlds? My suggestion for a new way to develop answers is to examine, in detail, the ways in which the various parts of today’s medical-care technology are used, from one day to the next, by the most sophisticated, knowledgeable, and presumably satisfied consumers who now have full access to the system –namely, the well-trained, experienced, middle-aged, married-with-family internists.
I could design the questionnaire myself, I think. How many times in the last five years have the members of your family, including yourself, had any kind of laboratory test? How many complete physical examinations? X-rays? Electrocardiograms? How often, in a year’s turning, have you prescribed antibiotics of any kind for yourself or your family? How many hospitalizations? How much surgery? How many consultations with a psychiatrist? How many formal visits to a doctor, any doctor, including yourself?
I will bet that if you got this kind of information, and added everything up, you would find a quite different set of figures from the ones now being projected in official circles for the population at large. I have tried it already, in an unscientific way, by asking around among my friends. My data, still soft but fairly consistent, reveal that none of my internist friends have had a routine physical examination since military service; very few have been x-rayed except by dentists; almost all have resisted surgery; laboratory tests for anyone in the family are extremely rare. They use a lot of aspirin, but they seem to write very few
prescriptions and almost never treat family fever with antibiotics. This is not to say that they do not become ill; these families have the same incidence of chiefly respiratory and gastrointestinal illness as everyone else, the same number of anxieties and bizarre notions, and the same number–on balance, a small number-of frightening or devastating diseases.
It will be protested that internists and their households are really full-time captive patients and cannot fairly be compared to the rest of the population. As each member of the family appears at the breakfast table, the encounter is, in effect, a house call. The father is, in the liveliest sense, a family doctor. This is true, but all the more reason for expecting optimal use to be made of the full range of medicine’s technology. There is no problem of access, the entire health-care delivery system is immediately at hand, and the cost of all items is surely less than that for non-medical families. All the usual constraints that limit the use of medical care by the general population are absent.
If my hunch, based on the small sample of professional friends, is correct, these people appear to use modern medicine quitedifferently from the ways in which we have systematically been educating the public over the last few decades. It cannot be
explained away as an instance of shoemakers’ children going without shoes. Doctors’ families do tend to complain that they receive less medical attention than their friends and neighbors, but they seem a normal, generally healthy lot, with a remarkably low incidence of iatrogenic illness.
The great secret, known to internists and learned early in marriage by internists’ wives, but still hidden from the general public, is that most things get better by themselves. Most things, in fact, are better by morning.
It is conceivable that we might be able to provide good medical care for everyone needing it, in a new system designed to assure equity, provided we can restrain ourselves, or our computers, from designing a system in which all 200 million of us are assumed to be in constant peril of failed health every day of our lives. In the same sense that our judicial system presumes us to be innocent until proved guilty, a medical-care system may work best if it starts with the presumption that most people are healthy. Left to themselves, computers may try to do it in the opposite way, taking it as given that some sort of direct,
continual, professional intervention is required all the time to maintain the health of each citizen, and we will end up spending all our money on nothing but that. Meanwhile, there is a long list of other things to do if we are to change the way we live together, especially in our cities, in time. Social health is another kind of problem, more complex and urgent, and there will be other bills to pay.