"Value" in the healthcare industry is misaligned with the true goal of providing healthcare.
We all agree that the ultimate goal of healthcare is to eliminate illness and untimely death from humanity. It is a self-defeating goal, since the need for healthcare no longer exists without illness and premature death.
But rest assured that the healthcare industry will never be able to snuff itself out. Just look at the completely new diseases that evolved into existence just in the past half-century: AIDS, Ebola, MERS, SARS, COVID-19... We also have to count the myriad diseases that were probably always there but have only been defined as such in the last century, e.g. PTSD, ADHD, Autism Spectrum, all sorts of cancer subtypes etc. We yet to eradicate the plague (Y. pestis) or anthrax and heck, we are still re-writing anatomy and physiology textbooks even to this day with new discoveries! Human limitations and the sheer scale and speed of natural evolution ensures that humanity will never truly master illness or death.
So I point out the obvious that people will inevitably get sick and die. Fulfilling that basic instinct of self-preservation as a demand is the fundamental "value" created by the healthcare industry. And it's a whole lot of value. Take a look:
Healthcare services market (2019): $7.1 trillion USD
Pharmaceutical market (2019): $1.25 trillion USD
Medical devices market (2018): $425 billion USD
That sum of nearly $8 trillion is greater than the national GDP of every country in the world except the United States and China (Source: IMF). The reason this industry is so big? Demand is essentially unlimited, as I explained above. The principles of normal market economics cannot apply to this type of grossly distorted mismatch of supply and demand. That's partly why many governments got the hint and have set up some type of system to regulate the pricing and distribution of healthcare.
(I plan to elaborate on the merits and drawbacks of various governmental healthcare regulation models in a future bit, so keep tabs on the site or follow me on LinkedIn for updates.)
But upon closer observation, we discover there is a chasm between the fundamental demand for healthcare and what is actually being supplied. Let's take a closer look at market sizes:
Pharmaceutical market (2019): $1.25 trillion USD
Vaccines market (2019): $46.88 billion USD
In vitro diagnostics market (IVD; 2020): $61.2 billion USD
Preventive healthcare market (2017): $177.2 billion USD
Vaccines (which most are prophylactic), IVD and preventive healthcare markets combined (disregarding overlaps) is about 23% the market size of pharmaceuticals, the latter of which is basically treatment after you get sick. Are we not putting our money where our mouth is?
Actually, the market is doing the best it can. (Sorry to burst your bubble, pharma conspiracy fans)
The lack of understanding of pathogenic mechanisms for most of human history (miasma anyone?) along with the myriad diseases that were actively killing more people than guns and bombs warranted a furious focus on prioritizing treatment development. But even then, the problems were so unmanageable that since the 1900's prevention strategies were aggressively promoted in parallel - think penicillin and condoms with sex-ed during WW2 or subsidized ARV treatment programs and anonymous HIV testing since the mid-1990's.
Indeed, we have made incredible strides in the past century especially with elucidation of the germ theory led by Louis Pasteur and Robert Koch in the mid-1800s. More people live longer and healthier than ever before. Top killers have shifted from influenza and pneumonia, tuberculosis and gastroenteritis in 1900 to ischemic heart disease, cancer and COPD.
And let's not kid ourselves. Without the mad money to be made in the modern capitalist economic framework, there was no way that medicine advances as quickly and robustly as it did. We all know incentives motivate, and a $8 trillion market is quite the motivation.
But as I previously wrote we still have tuberculosis, pneumonia, diarrheal diseases and neonatal conditions all stubbornly lodged in the Top 10 list, collectively claiming millions of lives year after year.
<Source: WHO; License: CC BY-NC-SA 3.0 IGO>
Also, take a look at this stunning graphic from Science (link provided to respect copyright). Although the primary takeaway message is that vaccines are very effective, you may also notice that even after decades of vaccine availability, half of those diseases have still not disappeared completely in the most developed nation in the world. Why?
To add insult to injury, antimicrobial resistance like antibiotic resistant Gonorrhea ("Super Gonorrhea"), multi-drug resistant tuberculosis (MDR-TB) and methicillin-resistant S. aureus (MRSA) are also very real problems that will creep up and bite us in the ass sooner than you think to the tune of a projected 10 million deaths a year by 2050. Most of you reading this will still be alive when this happens. And to think the world is collectively losing its mind right now over a mere 2 million COVID-19 deaths. (Hyperbole, people. Please.) But the lament of lack of economic incentives preventing new antibiotic development is so old it's becoming a trope. When will we ever learn?
And global warming is causing all sorts of problems including the rapid increase in tick-borne diseases that will only get worse. Take a look.
<Picture: Change in Lyme Disease case distribution from 2001 to 2018; Source: CDC>
So. Many. Dingleberries. (And I haven't even mentioned prions)
This, my friends and colleagues, is the point where the market fails and the dissonance in values is exposed. Because the goal of market economics is to arrive at the point of "good enough" compromise, the inherent unlimited demand for perfect health leads the industry down the endless rabbit hole of chasing never-perfect solutions for money ("value" provided), while our inseparable instinct as living beings to be always well ("value" demanded) will lament the tattered imperfection that is the perpetual state of healthcare - especially when inevitability will eventually claim a near and dear life to disease.
It's already hard enough that new shit is seemingly popping up once every decade. Not going that last mile to stamp out pathologic embers due to lack of financial return will just continue to add pages to pathology textbooks instead of enriching history books. One day, medical textbooks will balloon enough to literally kill someone with their sheer heft. Or more seriously, a misdiagnosis may do the mortal deed, not because of physician incompetence, but simply because there will come a point where there is too much information for a single human being to memorize.
Make no mistake: we are all complicit in this gross perpetual failure. On a government level, there is seldom policy before disaster. On an individual level, a whole lot of people simply need to get "punched in the mouth" before realizing their plan was, well, bad. Not many people really, truly cares what happens to a bunch of people they don't know half way around the world. A nephew with a broken arm gets more attention that a child with Ebola in the DRC bleeding out to death. It's human nature.
The incredible speed and acceleration of advances in biotechnology and healthcare that we are currently living through means that we will continue to increase our ability to understand the underlying causes of diseases. But having a complete understanding of a disease does not equal automatic eradication. These are complex problems that take an extraordinary amount of effort. The difficulty is highlighted by the fact that only one human disease - smallpox - has been officially eradicated thus far, and a large part of that was the good fortune of the disease having no non-human reservoir.
We already show a strong affinity to stay healthy and avoid sickness. The $123 billion USD dietary supplements market is a clear reflection of this desire. But thanks in no small part to unscrupulous snake oil peddlers and the many idiots in the industry refusing to invest in producing serious evidence, dietary supplements have sadly been relegated to pseudoscience and wishful thinking in the view of a large swath of the public. Almost everybody I know (and myself included) takes some form of dietary supplement, but how come we still get cancer? I digress...
The most beautiful feature of humanity is that we are capable of learning and improving. And the great part about unlimited demand is that there is equally unlimited opportunity for sustainable problem-solving.
I think I have sufficiently established that market economics alone cannot sufficiently meet the true demand for healthcare since business boils down to a simple equation of investment in, profit out. Once a given healthcare solution cannibalizes a disease niche to a point where that niche demand is no longer profitable, investors will demand abandonment of said niche, regardless of how many bodies will be left in the wake. And think about it: It's much quicker and cheaper to see if something cures a disease than wait around for months or years to see if a healthy person will eventually develop a disease. Hence a natural propensity towards treatment development. Follow the money. That's the definition of financial investment and how the game is played.
But if we flip the game on its head, this means that innovations in business structure can sustain a healthcare solution and take it further down the path of pathologic extinguishment. Pharmaceutical (especially biologics) manufacturing methods far less sensitive to economies of scale, innovations for low-or-no-cost last-mile distribution, breakthroughs in formulation technology for ambient temperature distribution of everything... These are just a few ideas that can accomplish the dual goal of profitability and fulfilling unmet demand in healthcare. The only problem is that they just don't sound sexy, and most definitely will not be enough to cover all bases.
Governments play another game which is accounted by different metrics. Economic indicators of GDP, unemployment, consumer sentiment etc. and health indicators of average life span, DALYs and QALYs etc. are all metrics that sway votes and therefore dictate policy decisions. Even the healthcare industry is affected by these numbers, not the least because of pricing and reimbursement mechanisms.
This two-degree separation from the pure money-in-money-out framework affords governments with a longer-term wider view of unfinished disease issues and could feasibly provide a means to prepare a pool of funds that are cost-benefit positive. This not only includes primary actions of public diagnostic, treatment and vaccination programs but also secondary preventive measures of health education policies. It is literally cheaper to buy a decent treadmill or stationary bicycle for every household in the US than the economic burden imposed by cardiovascular disease ($320 billion USD) every year. Yes, I know it won't be that simple but the fact that I failed to find a separate budget line item for "(public) health education" in every developed nation's budget report I could find should tell you how neglected this best form of prevention - behavior modification - is.
It would also be great if philanthropic efforts could divert more attention to help extinguish niggling issues that still claim lives but are out of the incentive scope of both the market and government realms. I'm not saying neglected tropical diseases aren't a serious issue (they are, and I am actively participating in helping address some of those diseases), but a life is a life, no?
I have to make absolutely clear that I am in no way discounting or disparaging the industry which I am proudly a part of and make a living in. I humbly stand on the shoulders of great scientists and business people that came before me who have worked tirelessly to get us to the standard of health and wellness we collectively enjoy. But it is precisely because I have so much affection I feel that I should voice my opinion on where we should be headed, based on observations of where we stand and what is still needed to be done. Again, this is a serious and complex issue that calls for a never-ending concerted effort.
Will we ever manage to eliminate human disease? No.
But can we do better? Oh yeah. Probably much, much better. As we have always done.
Disclaimers:
Reference to specific commercial products, manufacturers, companies, or trademarks does not constitute its endorsement or recommendation by the U.S. Government, Department of Health and Human Services, Centers for Disease Control and Prevention or the World Health Organization
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