Vicissitudes of health care


We sometimes forget how lucky we are to be living in the first decades of the 21st century rather than two or three centuries back or even a century ago. Our expectation of life has in many cases more than doubled over the last 150 years.

Surgery before anti-sepsis and anesthetics led to almost unbearable pain and frequent death. Cholera, typhus, typhoid, plagues killed whole communities. Tuberculosis (or consumption as it was popularly called) took away many men and women of promise. Influenza after the First World War added millions to the casualties of that horrendous conflict.

Until quite recently a diagnosis of cancer was a death sentence. Now, while many cancers are still difficult to treat and no panacea has been found, overall survival rates are continuing to improve.

Today we can be immunized not only against smallpox and polio but also against a swath of diseases that were either killers or cripplers not so many decades ago. A recent epidemic of measles in Britain could have been avoided if parents had ensured that their children were immunized. Heart attacks and strokes can still be lethal, but many of us have at least managed to postpone such events if not avoid them altogether, thanks to modern medicine.

We face other problems that some of our predecessors avoided by dying in young or in middle age. As we get older we have to cope not only with the running down of the machinery that controls our bodily functions but also with the deterioration of our mental faculties. Alzheimer’s disease and senile dementia are clinically different but they pose similar problems to the sufferers and to their carers.

The advances in medicine and health care are not confined to developed countries. They are fortunately spreading to developing countries through aid agencies and charities such as the Gates Foundation, but there are still countries where for instance simple developments in hygiene or precautions against the spread of malaria by mosquitoes can lead to significant improvements in health and well-being.

The most difficult issue facing the developed and the developing world in relation to health care is that of rising costs.

The United States spends a greater proportion of its GDP on health care than any other developed country, but despite Obamacare there are still sections of the U.S. population that do not have free access to adequate medical facilities. Other developed countries in Europe, and Japan in Asia, have developed systems that provide differing standards of universal health care at varying costs. No system is perfect, but it’s a huge improvement on what was available not so many years ago.

The role of pharmaceutical companies and their research departments in developing medicines and treatments can hardly be exaggerated, but governments also have an important function. Pharmaceutical companies, being commercial organizations, are not geared to undertake the sort of fundamental research that does not lead to immediate commercial results. Governments in developed countries need to maintain their funding of such basic research.

Governments also need to fund research into diseases that have not attracted commercial funding either because they have proved particularly difficult or because the number of sufferers is relatively small and therefore do not constitute a commercially viable market. Lung, pancreatic and prostate cancers are examples of diseases for which research has been comparatively underfunded.

Governments also have an important regulatory function through the issuance of patents and the licensing of new drugs. The safety of new drugs is of paramount importance as was shown by the thalidomide scandal some decades ago that left thousands disabled.

But safety must also be balanced by the possibility that a new drug could relieve symptoms and save lives.

Governments especially in Western countries, and Japan, can also exercise a direct influence on pharmaceutical companies through the procurement policies of their health services. If they try to force down the prices of patented drugs too far or too fast, they are likely to deter research and development. The Japanese system of licensing, procuring and prescribing drugs has been much criticized and will, many observers hope, be a priority for fundamental revision under the reform agenda of the Abe government.

The Japanese insistence that all new drugs must first be tested on Japanese as well as on other people has led to significant delays in the adoption of new drugs. The way in which the Ministry of Health and Welfare funds the costs of medicines is thought by many to have led to overprescribing by doctors and hospitals.

As people live longer and as research leads to the development of more effective drugs and improved surgical methods, costs are bound to go on rising, but electorates in democratic countries generally prefer that cuts be made in provisions for services other than health care.

There is increasing recognition that, not least because it would reduce long-term costs, more emphasis should be placed on prevention. Many of the diseases of the modern world are the result of our lifestyles. A reduction in the number of road accidents would save lives and reduce disability. Smoking bans would lead to a decrease in the number of cases of lung cancer and of circulation problems associated with smoking. Better diets and more exercise would lead to less obesity.

There is a limit in a free society to which lifestyle prescriptions can be legally enforced. Education and information campaigns are useful tools in encouraging change, but the fundamental need is a radical alteration in social attitudes.

Drinking and driving, which at one time was socially acceptable in Britain, is no longer so. Smoking at social functions is now generally unacceptable and junk food, thought to be a major cause of obesity, is frowned on by educated people.

There is much still to be done to improve health care, to reduce costs and to alter lifestyles for the better.

Hugh Cortazzi served as Britain’s ambassador to Japan from 1980-1984.