- The structure of today’s medicine: key players, their interests and problems
- Development of medicine over the last 100 years: successes and failures
- Mid-term forecasts for medicine: critical analysis of different viewpoints
- Obvious and hidden hurdles that impede progress in medicine
By definition, the objective of medicine as the corner stone of healthcare system is to preserve and restore human health.
According to the WHO (the World Health Organization) definition, health is the state of physical, mental and social well-being of humans – i.e. health has three dimensions.
The main tools that today’s medicine uses to influence the state of health are medications (‘ethical drugs’) and surgical methods of treatment. Majority of medical tools are applied to the person’s physical body. At the same time, according to the official position of the WHO, the major health determinants are related not to the physical body but the lifestyle and the state of society. Hence the real practice is in discrepancy with the official declarations.
There are four major groups of players involved in the activities of medicine:
1) patients as end consumers;
2) doctors and other medical professionals that make medical tools work;
3) the state (government) as the warrantor of the patients’ rights, the regulator, the major source of infrastructure, the major customer and payer (in some countries, insurance companies also fall in this category);
4) developers, manufacturers and distributors of medical “tools”: pharmaceutical and medical device companies, manufacturers of laboratory equipment and disposals, pharmaceutical distributors, and pharmacies.
Most interests of patients and state (government) generally coincide with the declared objectives of medicine. Patients need access to affordable, effective and safe medical aid. The state (the government) concerns about cost effective medicine (reasonable relation of costs and benefits), and also about long term sustainable solution of the patients’ health problems: health of individual citizens influence labor resources and taxes, the pressure on social aid institutions, demographics, etc.
Medical professionals need a stable income and activity where they could realize their creative potential. However, the income of doctors depends not on the patients’ health but on the amount of services provided. That’s why the long term goals of medical professionals generally differ from the objectives of patients, of the government and of the medicine in general. Another important problem is that most medical professional can only use the instruments developed and provided by the ‘fourth player’.
The objective of the fourth player which can be generally determined as ‘health-related businesses’ is MAXIMUM PROFIT from sale of the medical instruments they develop or provide. This objective is in direct CONTRADICTION with the objective of medicine in general and the goals of other key players.
1) Patients: lack of access to medical aid; low efficacy and safety, high cost of available medical aid.
2) Doctors: lack of effective and safe tools, most importantly, for treatment of chronic diseases.
3) The state: 90% of expenses are used ineffectively (for the treatment of chronic diseases), lack of effective prevention; mismatch of medicine’s organizational structure and today’s needs (prevalence of chronic over acute diseases).
4) Business: increasing consumers’ demands and low scientific productivity (obviously exhausted opportunities for development of novel effective products, with cost of developing a new product reaching as much as $2 billion).
Determinants of long-term progress
In the long term, the progress of medicine is determined by relatively slow economic, social and technological processes, including but not limited to:
— changes in the quality of human resources (doctors and experts),
— development and introduction of new technologies,
— changing rules of interactions between the major players (the system of financing and provision of medical aid).
The most influential player able to shape the state policies in the listed fields is large business (primarily, large pharmaceutical companies). This influence is exerted through financial mechanisms and control over the expert community.
In this way, the long-term state policies in health care are actually shaped by the player that has mid- and long-term interests contradictory both to the interests of other players and to the objectives of the medicine itself. That is, the state policies in medicine are formed under obvious conflict of interests.
The current solutions for problems in medicine are basically reduced to the following two approaches:
1) Infusing more money – increasing health care spending, and
2) Putting the costs and responsibilities on the end consumers – in particular, replacing free access to medical help by ‘voluntary’ insurance.
Even brief analysis points at the most probable major source of problems in today’s medicine for end consumers and the state: the conflict of interests in shaping the long-term state policies in health care, since the policies are designed to serve the interests of business with prejudice to the interests of end consumers and the state. Due to the conflict of interests the actual objectives and tasks of medical institutions contradict with the declared objectives of medicine and with the interests of end consumers.
The conflict of interests is maintained owing to the business’ financial opportunities to influence the state policies – primarily, through the expert community.
- The significant drop in mortality seen in developed economies over the 20th century (as exemplified by the USA) was rather due to improvement in social wealth (better nutrition, housing, etc.) and wide introduction of sanitation and hygiene than to development of new medical technologies like new drugs and vaccines.
- This is very much in line with today’s official position of the WHO on the determinants of human health.
- The steep rise of health care expenditures in the second half of the 20th century (as exemplified by the USA) had only minor influence on the objective indices of public health.
- The role of vaccination and wide use of antibiotics in reduction of mortality from infectious diseases is not supported by facts.
- Out of all medical breakthroughs of the 20th century only two survive critical review: progress in surgery and introduction of technologies from other branches of science.
- Despite the huge investment in development of new drugs, over the last 50 years pharmacology has failed in relieving the burden of chronic diseases.
- Drugs, the major instrument of today’s medicine, remain ineffective, unsafe and expensive. Most of them, >90%, work in only 30-50% of patients. They don’t treat chronic diseases but only temporarily relieve certain symptoms.
- In developed economies iatrogenic factors (related to wrong medical interventions) are among major causes of mortality.
- Thus, over the last 30-50 years medicine has been demonstrating very poor cost effectiveness: increasing investments are giving smaller returns in the form of benefit for health.
- In analyzing the promising medical technologies, one has to bear in mind the existing pressing problems, the available solutions for them, and the context of progress in medicine over the recent decades.
- Mid-term forecasts for medicine are made primarily by the representatives of the state and the business community, and these forecasts are made from the standpoint of the corresponding player’s interests. The end consumers have their own opinions that reflect their unsolved problems (ineffective-unsafe-expensive); and this opinion translates into choosing particular affordable and accessible methods, including those of alternative medicine.
- The forecasts related with the use of digital/information/big data technologies in medicine are quite realistic. However, these technologies cannot enable breakthrough solutions for the main problems in medicine, because the content of the information used in these technologies is rooted in inadequate practical understanding of health as ‘normal physiological parameters’ of the body.
- Most of the optimistic forecasts related with already existing or emerging “breakthrough” medical technologies (gene therapy, personalized and ‘smart’ drugs, etc.) represent wishful thinking and fail to consider the systemic nature of both human diseases and the problems of today’s medicine. Bearing in mind the socio-economical context (recession and numerous global challenges), active development and wide use of expensive technologies seems very doubtful.
- In-depth systemic forecasts for the EU are mostly pessimistic in terms of new medical technologies; they rather rely on optimization of health care structures. They all suggest a higher role of prevention and ‘do-it-yourself’ technologies of health control.
- The example of USA is very useful in the following way: the liberal model of healthcare demonstrates very low cost effectiveness and even doubtful overall benefit for the consumers (just recollect the rate of iatrogenic deaths in the USA). Financial injections, decisive for technology progress, are of very little use in overcoming the drawbacks in healthcare; adequate organizational solutions are much more effective.
- In the context of liberal healthcare model, when healthcare is actually replaced by health industry, businesses see a promise in the model of “owning the disease” which enables attaining the business goals – maximum financial profits. However, this business model cannot remove the conflict of interests from healthcare, and thus it will hardly be useful to the end consumers and the society in general.
As we have found, there is a lot of unsolved problems in today’s medicine, and most attempts taken over the last 50 years to tackle them have been ineffective. Under ‘progress in medicine’ we will mean effective (including cost-effective) solution for the problems presented by the players that medicine is actually designed for – namely, patients (end consumers) and the state (as the structure representing the society in general).
System analysis of the situation has revealed the following three in-depth hurdles for progress in medicine.
- The ECONOMIC HURDLE. The goals of healthcare itself are poorly compatible with profits, the objective of the mostly powerful players in healthcare. All decision making, experts’ opinions, standards of education and medical care are easily controlled and manipulated with tremendous financial resources. In this way, pharmaceutical business that had originally emerged as a tool of medicine, has become the full-fledged master of health care.
Profit as the goal #1 is gradually removing health preservation from the goals of health care. Or at least it is moving health far down in the list of the actual priorities. As a result, health in its original meaning (recall the WHO definition) is no longer understood, considered and treated as a priority anywhere, with a handful of exclusions. At the level of people and organizations, this problem demonstrates itself as the conflict of interests. This is the major ECONOMIC hurdle for progress in medicine (medicine, not the health business). This factor is the most “tangible”, visible – that’s why the beneficiaries cannot rely on it alone.
2. The IDEOLOGICAL HURDLE. Close examination of the fundamental axioms forming the basement of today’s biomedical science reveals a curious finding. The ideological structure of the medical science has an in-built brake, restraint that makes it impossible to develop and introduce novel medical technologies which
a) cannot be controlled by a monopoly,
b) are not profitable, and/or
c) cannot be monetized (are difficult to turn into a large-scale business).
This brake is a false assumption of how the body is regulated. The cornerstone on today’s biomedical science is the following axiom: “regulation of physiological processes can be reduced to chemical signals”. This axiom gives rise to all prevailing concepts of both disease mechanisms and approaches to diagnostics and treatment. This axiom directly implies that without introducing in the body some chemical compound (the source of chemical signal) one cannot influence diseased regulation in the body. HOWEVER, chemical signals hardly account for more than 10% of the mechanisms that body uses to regulate itself; the rest are signals of physical (biophysical) nature. This is a complex issue deserving a separate detailed discussion.
This axiom has the following practical implications for the beneficiaries:
a) the use of pharmaceuticals can be controlled by a monopoly (through patenting);
b) development and wide promotion of “unscientific” competitive methods can be reduced through limited financing;
c) the developers and followers of “unapproved” methods can be suppressed.
As a result of the described brake, the effectiveness of biomedical sciences is very limited: essentially, the research can only be done in the “approved” fields, and not in the fields where solutions can be found. This tacit ban on the studies of biophysical regulatory mechanisms is backed up by certain ideological restrictions in physics.
- The METHODOLOGY HURDLE. Finally, progress in medicine as the major science about health is impossible due to the actual rejection of systemic approach to a human as a trinity of physical, psychological and spiritual elements. The whole system of knowledge about human is split into unrelated and contradicting disciplines (physiology, psychology, sociology, etc.), and the representatives of each given discipline are unaware of the conceptual framework of the others. Due to this split both the fundamental science and applied sciences fail to consider and use the principles of living systems – the principles common for all the levels of human organization.
The systemic approach to human has been replaced by individualism – the position “self comes first” which contradicts both the principles of healthy living systems and the systemic understanding of the human nature. This replacement is especially devastating within the elites where decision making takes place in all fields including medicine.
Therefore, the source of problems in today’s medicine is triple:
- At the level of world outlook of the professional and expert communities: Individualism (and liberalism) as the system of beliefs contradictory to the principles of healthy living systems and incompatible with systemic and holistic understanding of the human nature.
- At the level of dominating scientific concepts, theories, and models: At the level of the scientific ideology, the expert community demonstrates an artificially introduced false understanding of how the body is regulated. This false scientific model prevents the search of effective solutions for medical problems and guards the economic interests of a small group of key players in health care.
- At the level of organizations and healthcare economy: Prevalence of individualism results in неразрешимый conflict of economic interests across the key players of health care. The only possible result of this conflict in individualistic persons is that drive for profit (enrichment of minority) prevails over the benefit for society in general. The conflict can only be maintained with dominance of the false scientific ideology.