Confronting the Christmas of our health care discontent
=======================================================

* Steven Lewis

This is the season of licensed excess, of endless parties, of cash-register orchestras chiming the Allelujah Chorus. In the health care systems of the world's richest nations, Christmas comes year round. An appealing notion, at first glance: the world would surely be a better place if good will and largesse were permanent contagions. But alongside these beneficent virtues looms the 3-headed Hydra of comparison, envy and ever-increasing expectations. It is an old lament that the festive season has become less a celebration of love and humility and more a homage to retail sales. Has the gift of medicare, designed to express civic solidarity and compassion, likewise mutated into a profane caricature of its founding ethos? Can we have too much of a good thing?

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/171/12/1449/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/171/12/1449/F1)

Figure. Photo by: Earthlore

There is abundant evidence that medicare has become the perpetual season of conspicuous consumption. Total health care spending in Canada has reached $4000 per capita per year. Beyond about $600 to $800 per capita, there is no correlation between a nation's life expectancy — a good proxy for health status — and spending.1 Use of diagnostic imaging has skyrocketed, even though we lack systematic evidence of impact on health outcomes or cost-effectiveness compared with other technologies.2 Health care has become decoupled from its central purpose of improving health status. There are now 2 competing concepts: health care as a public good, and health care as a market commodity. As with Christmas, marketization has gained the upper hand.

Health care at its best is about science, hope and compassion. Providers want to help their patients, and patients want to be helped. Hence we tolerate and even encourage doing more in the face of long odds and admire those who tilt at nature's windmills. But we learn distressingly little from the many optimistic, aggressive and costly forays that fail to do good, or even cause harm. A mighty coalition of doctors, industry (and advice columnists) have touted PSA screening as a life-saver, and thousands of men have subjected themselves to a surgically induced plague of impotence and incontinence, unaware that the state of medicine cannot distinguish between lethal and nonlethal variants of the cancer.3 Elderly Americans living in Miami consume twice as much publicly funded health care as those living in Minneapolis, with no difference in baseline health status, outcomes or satisfaction, but nothing seems to change when these and similarly perplexing results are published.4 Entrepreneurs hawk whole-body “preventive” scans as the latest prestige once-over,5 despite the risks of invasions occasioned less by demonstrable pathology than by a surfeit of uninterpretable patches on an image.

Many excesses are merely the product of bad luck that thwarts the well-intentioned. Many others are spawned by deceit and greed, assisted by unvigilant providers, ill-informed patients and relentlessly effective marketing. The tale of the COX-2 inhibitors is a current and sobering example. Vioxx and its sister drugs were never found to be more clinically effective than the older standbys;6 their therapeutic claim was a decrease in gastrointestinal side effects. Vioxx became a US$2.5 billion annual sales windfall for Merck before the company withdrew the drug in October 2004. The company has already been hit with a number of class-action lawsuits alleging that it knowingly withheld evidence that the drug may cause heart attacks.6 If this is true, Merck is by no means unique; industry is wont (some would argue obligated) to behave in such ways when confronted with a choice between sales and the public interest.

Health care follows a unique business model: never treat cheaply what you can treat expensively, especially where public or third-party insurance will pony up the cash. Everyone is getting in on the game. You can even buy a patient advocacy group to lobby for your product.7,8And scientists are at times startlingly complicit. For example, a study that showed aspirin to be just as effective as warfarin in reducing the risk of recurrent ischemic stroke, death or major hemorrhage concluded that either was a reasonable therapeutic alternative.9 On this logic, it is as reasonable to have your morning newspaper delivered by FedEx as by the teenager down the block. Canadian researchers have chronicled the factors that account for steep increases in drug spending that appear incommensurate with the added therapeutic value delivered.10 These and countless other examples of waste and harmful practice betray a weakness for anything new and a default position that more is better. Even Barnum would shake his head in wonder.

Perhaps none of this would matter if everyone agreed to pool the costs and pick up the tab for universal excess. But everyone does not agree. The anti-tax lobby declares the waste as yet another example of the fatal weakness of the public sector. Scolding think-tanks extrapolate 5-year trend-lines into 40-year projections and declare the system to be terrifyingly unsustainable.11 Citizens still seem willing to have governments fork out more of their money for health care, despite the lack of evidence that the now 7-year-old experiment with super-sizing the Canadian health care budget has durably solved any problem whatsoever. But they are beginning to connect the dots between massive health care spending and their kids' rising tuition fees and the unfixed potholes that put their cars in the repair shop.

Nor would it matter so much if Canadians had uniformly excellent health status. But we do not. The disparities are large and persistent.12 If we spend more and more on health care, insist on balanced government budgets and resist higher taxes, the first casualty will be investments that just might, over time, integrate marginalized, hope-deprived people into the mainstream economic and civic world — an achievement that, unlike health care at the margins, actually produces better health. Viewed from this perspective, health care spending may actually now be one of the causes of poor health. It is a virtual certainty that evidence-based reductions in health care spending combined with evidence-based investments in other areas of social spending would, over time, produce superior health status returns compared with the status quo.

Can we afford a perpetual Christmas in health care? Perhaps we can: we are a rich nation, and about 10% of us — not just the doctors and nurses, but administrators, device manufacturers, academics and consultants like me — owe our increasingly prosperous livelihoods to the extended festive season. The question is whether we should. The answer to that should be obvious. If we continue on this unreflective course, with the public, providers and government all partners in the race to *more* without evidence of positive impact (or in the face of evidence of neutral or negative impact), we will have created a false economy. In the wake of corporate scandals and in response to long-overdue heightened vigilance about public spending, we will put in place a Potemkin village of accountability to create the appearance of prudence. But unless we are prepared to confront some hard truths about the growing disconnect between health and health care, we may simply be creating a system that knows the price of everything and the value of nothing. 

Common sense also tells us that Christmas isn't Christmas if it comes every day. Gifts are no longer special. Voluntary acts of generosity become obligations. In a futile effort to recapture the magic, all are caught up in the pursuit to outdo last year's pyrotechnics. Millions of people fear they are in a state of permanent underdiagnosis. Perhaps we need a new measure of contemporary health: the WALY, or worry-adjusted life year.

If the true spirit of Christmas risks corruption by material fixations, the health of both individuals and society may be compromised by excessive dependence on and preoccupation with health care. Let us celebrate true scientific breakthroughs but recognize that hype is not reality. Let us not delude ourselves that health care is exclusively about altruism and free of stupidity and greed. And let us accept the gift of effective health care with gratitude and wonder, but remember that not needing it is the greatest gift of all.

## References

1.  1. Leon DA, Walt G, Gilson L. International perspectives on health inequalities and policy. BMJ 2001;322:591-4.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEyOiIzMjIvNzI4Ni81OTEiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTcxLzEyLzE0NDkuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  2. Canadian Institute for Health Information. *Medical imaging in Canada*. Ottawa: The Institute; 2003.
    
    

3.  3. Hernandez J, Thompson IM. Prostate-specific antigen: a review of the validation of the most commonly used cancer biomarker. Cancer 2004;101:894-904.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1002/cncr.20480&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=15329895&link_type=MED&atom=%2Fcmaj%2F171%2F12%2F1449.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000223458600003&link_type=ISI) 

4.  4. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med 2003;138:288-98.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.7326/0003-4819-138-4-200302180-00007&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=12585826&link_type=MED&atom=%2Fcmaj%2F171%2F12%2F1449.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000181019400002&link_type=ISI) 

5.  5. Kalish GM, Bhargavan M, Sunshine JH, Forman HP. Self-referred whole-body imaging: Where are we now? Radiology 2004;233(2):353-8.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=15459320&link_type=MED&atom=%2Fcmaj%2F171%2F12%2F1449.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000224650400009&link_type=ISI) 

6.  6. Singh D. Merck withdraws arthritis drug worldwide. BMJ 2004;329:816.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjE0OiIzMjkvNzQ3MC84MTYtYiI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xNzEvMTIvMTQ0OS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

7.  7. Batt S. *Breast cancer advocates and pharmaceutical industry funds*. Montreal: Breast Cancer Action Montreal. Available: [www.bcam.qc.ca/news/advocates.html](http://www.bcam.qc.ca/news/advocates.html) (accessed 2004 Nov 5).
    
    

8.  8. Guyatt G. Patient advocacy groups are often not what they seem. Originally published in *Winnipeg Free Press* 2003 Nov 23 with title, Take pill ads with a grain of salt. Available: [www.hwcn.org/link/mrg/guyatt.2003.html#Patient\_advocacy\_groups\_are\_often\_not](http://www.hwcn.org/link/mrg/guyatt.2003.html#Patient\_advocacy\_groups_are_often_not) (accessed 2004 Nov 5).
    
    

9.  9. Mohr JP, Thompson JL, Lazar RM, Levin B, Sacco RL, Furie KL, et al; for the Warfarin–Aspirin Recurrent Stroke Study Group. A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 2001;345(20):1444-51.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1056/NEJMoa011258&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=11794192&link_type=MED&atom=%2Fcmaj%2F171%2F12%2F1449.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000172132700002&link_type=ISI) 

10. 10. Laupacis A, Anderson G, O'Brien B. Drug policy: making effective drugs available without bankrupting the healthcare system. Healthcare Papers 2002;3:12-30.
    
    

11. 11. Robson WBP. Will the baby boomers bust the health budget? Demographic change and health care financing reform. *C.D. Howe Institute Commentary* 2001;148:1-29. Available: [www.cdhowe.org/pdf/rob-18.pdf](http://www.cdhowe.org/pdf/rob-18.pdf) (accessed 2004 Nov 5).
    
    

12. 12. Canadian Population Health Initiative. *Improving the health of Canadians*. Ottawa: Canadian Institute for Health Information; 2004. Available: [www.cihi.ca](http://www.cihi.ca) (accessed 2004 Nov 5).