This interesting Lawrence Altman/NY Times article examines the theory that that an undiagnosed melanoma contributed to the death of President Franklin Delano Roosevent in 1945.
Of course, regular readers of this blog know that another killer disease — the dire implications of which were not well-known in 1945 — was probably the main cause of FDR’s death.
But despite the historical curiosity, the most important point to glean from FDR’s demise is the importance of continued investment in clinical and scientific research.
We sometimes forget that it was the generation of doctors and researchers who came of age after World War II who embraced the optimistic view of therapeutic intervention in the practice of medicine, which was a fundamental change from the sense of therapeutic powerlessness that was taught to these men by their pre-WWII professors. In short, it has not been that long since medical science has understood that it could cure disease and prolong life.
For example, if FDR’s doctors had known in 1945 what specialists in hypertension discovered in the two following decades, then those doctors would never have allowed FDR to be subjected to the stress of the Yalta Conference that doomed Eastern Europe to almost 50 years of totalitarianism and economic deprivation.
Stated simply, earlier discovery of the research into the implications of hypertension could well have changed the course of human history.
In fact, we all tend to under-appreciate the advancements in medicine since World War II. For male babies born in the U.S. in 1960, the life expectancy was about 66.5 years and for female babies a tad over 73 years. By 2005, the live expectancies had increased to over 75 and 80 years respectively. Although medical advances don’t account for all of those gains, newly-discovered drugs and medical devices — as well as enhanced understanding of disease — have had an enormous impact on improving the quality of life of most Americans.
Thus, as Congress considers reforming the U.S. health care finance system, it is important for citizens to understand that American medical care and research remains the hope of the world. The current health care finance system has generated enormous investment in that medical innovation, which has been a crucial and treasured export of America to the rest of the world.
Let’s think hard before radically changing a system that generated the investment that produced those benefits for us and the rest of the world.
The following comment is from Daniel Goldberg,a health policy & ethics fellow in the Chronic Disease Prevention & Control Center at Baylor College of Medicine. Daniel blogs at the Medical Humanities Blog :
You say:
“In fact, we all tend to under-appreciate the advancements in medicine since World War II. For male babies born in the U.S. in 1960, the life expectancy was about 66.5 years and for female babies a tad over 73 years. By 2005, the live expectancies had increased to over 75 and 80 years respectively. Although medical advances don’t account for all of those gains, newly-discovered drugs and medical devices — as well as enhanced understanding of disease — have had an enormous impact on improving the quality of life of most Americans.”
The second sentence is deeply disputable; in fact, I think it is downright dubious. There is very little evidence that advances in acute care services, including drugs and medical devices, have had an enormous impact on health outcomes either over the last fifty years, or over the last several hundred years. The largest recorded gains in life expectancy in the Western world occurred roughly between 1700 and 1940. The transition was so immense it is often referred to by demographers and public health historians simply as “the health transition,” or “the epidemiologic transition.” Now, as you no doubt know, the clinical efficacy of most medicine practiced during these periods was not particularly good. The first truly efficacious drugs with the sulfa drugs of the 1930s. Thus, there is no serious argument, to the best of my knowledge, that the single largest recorded gains in life expectancy in the Western world had much if anything to do with medical care, drugs, or devices. The work of Thomas McKeown alone has been indispensable to dislodging the cherished maxim that medical care itself is largely responsible for gains in health on the population level in the Western world.
While there is very poor evidence that technical acute care innovations have a substantial impact on population health, there is very good evidence that activities often deemed to be within the purview of public health such as clean water, sanitation, and occupational health and safety have a pronounced effect on population health. There is even better evidence that amelioration of poor social and economic conditions, including compression of socioeconomic disparities, is far and away the best means of improving population health.
In contrast, there is good evidence that increased technical innovation is actually a major driver of both health care expenditures and health inequities, and, as you yourself have pointed out, a painfully large proportion of the techniques and technologies we do use are either untested or turn out to have no benefit when actually tested (the proliferation of medical imaging procedures being only the latest example). Finally, even if we were to ignore the extensive evidence that acute care techniques, products, and services are not prime determinants of population health, the fact remains that evidence penetrance into clinical practice is extremely low, with estimates tending to hover in the low percentages of a 10-40% range. Even the techniques we do have that we have good reason to believe are useful and significant often do not get translated or used. This implies that if we ceased innovating TODAY, we would have all the modalities we need to make both our populations and the populations of the developing world substantially healthier then they are today.
Instead, the research imperative dominates, and we are constantly searching for the next fancy tool, the next magic bullet, when the evidence is compelling that the latter are not likely to substantially improve population health and reduce inequities.
I am frequently disturbed by the ubiquitous assumptions of the importance of innovation to population health. That such contributions are typically assumed rather than argued for is a very serious problem, IMO, and says much about the technological imperative in the U.S., our love of innovation and technology for its own sake, independent of any actual analysis of the good it provides in terms of health.
In any case, Happy New Year!
Best,
–Daniel