The Medical Crisis and the Coming Age of Health Care
— The future direction of medicine and health care
(I) Background
Contemporary medicine faces a contradiction: on the one hand, medical science has made huge advance; humans have rich results in knowing life and diagnosing-and-treating disease; governments and societies invest more and more in health services. On the other, the mode and quality of those health services is far from meeting people's needs.
Society too has changed greatly: the environment is worsening; the elderly population grows; lifestyles shift; competitive pressure intensifies. Under these conditions, if the health-care pattern is not greatly adjusted, the future will be hard — a medical crisis is possible.
The US has world-leading medical technology and equipment; most modern medical high-tech came from there; US doctors per capita are top; US medical costs are vastly above other countries. 1993: US health expenditure $900 billion, 14% of GDP, $3,500 per capita — 1.5× other developed countries. By 1994 US health expenditure topped $1 trillion; uncontrolled, by century-end it would eat 19% of GDP. Yet over 40 million Americans still lack basic medical coverage. In 1990 US public satisfaction with the health system was only 10% — far below Canada (56%), Switzerland (32%), Germany (41%), Japan (29%), UK (27%). The supply-demand contradiction and the high cost vs. low benefit contradiction are urgent, treated by President Clinton as a top domestic issue.
The US medical crisis is a miniature of the world's medical crisis. The crisis of contemporary medicine exists in all countries to some degree, but is sharpest in the US. As the Hastings Center said: "The US is in major medical crisis; it will take many years of effort to overcome. Developing countries should learn from modern medicine's strengths, and the more so avoid modern medicine's mistakes."
(II) Manifestations of the Medical Crisis
1. Modern health service focuses too much on rare and difficult diseases, ignoring the broader health needs of people, and so cannot escape the contradiction of supply-short on one side and supply-over on the other.
2. Unrealistic hopes in conquering certain refractory chronic diseases; bound by traditional treatment ideas, always seeking a miracle drug — and so unable to truly serve these patients.
3. Treatment is the focus; prevention is ignored. Preventive medicine and clinical medicine grow apart. For modern civilization diseases and affluence diseases, prevention matters most.
4. Understanding of health and disease is one-sided: medical service is taken as diagnosis-and-treatment by drug, surgery, and other material means; the role of care and concern — non-material means — is ignored; psycho-social services are weak.
5. Service organization over-favors big medical centers; ignores community service and primary care; gives too little attention to family care and self-care — so the rapid growth of big medical centers runs counter to health for all.
6. Investment rises, but unfair distribution and improper use produce the sharp contradiction of high investment and low benefit.
(III) Conditions in China
In central and western regions, especially rural, the chief threats to health are infectious diseases and parasitic diseases; the chief problem is too few doctors and drugs.
In southeast and large/medium cities, however, conditions like those of Western developed countries appear. Disease patterns differ from the central-west and rural regions; the service model is moving along the Western high-equipment, big-center, treatment-heavy path, falling into high cost, low benefit and many contradictions.
If health service in China continues along the path of treatment-heavy, in-hospital-heavy, focusing only on the ill and difficult — the difficulties will grow; a medical crisis becomes hard to avoid. Worse: in the transition and market-tide medical units, the single medical-house-interest model worsens the crisis. Medical-house-interest model: running hospitals and pharmacy businesses for maximum profit — making money the sole aim. Such hospitals and doctors reduce the doctor-patient relation to bare money.
Conclusion: the medical crisis Western developed countries face and we soon will face reflects the contradiction between modern medicine and the multilevel, multifaceted health needs of the public. Health service's current state does not meet them.
In fact, medical crisis or recognition error — both reflect the confusion in this age, from medical world to common person, in thought and action. All this makes us reflect: are the goals modern medicine pursues reasonable? Where is it going?
(IV) History and Reality
Looking back through human history, each era had its era-diseases or common diseases. In primitive and agrarian eras, low productivity meant chief causes of death were hunger, malnutrition, accidental injury, infection, infectious disease. After the Industrial Revolution, especially the last century, medicine in immunization, public health, and antibiotics greatly controlled infectious disease. Today's main causes of death are cancer, cerebrovascular disease, immunological and endocrine disorders, and age diseases like osteophyte, prostate disease, senile dementia — the so-called change of disease spectrum.
These diseases differ in cause and treatment from the previous century. Generally no single pathogen, no single cure-all drug or specific surgery. They are deeply tied to our environment and lifestyle. And, more seriously, once started, most are not curable; the patient lives long with disease. With aging, their incidence rises.
Faced with such new diseases — different in cause and method from before — traditional medical systems and services are showing weakness: 1) the biomedical model offers only specific therapies; for these diseases, prevention, yangsheng, and lifestyle change are more crucial; 2) the model cannot meet individual health needs — it stays at the general level of diagnosis-and-treatment of disease, neglecting attention and guidance to the concrete person's psychology, spirit, and society. This is the deeper cause of medical crisis.
(V) The Future Road
In 1994 the Hastings Center put forward basic questions on medicine's goals: in the coming decades, how should we understand medicine? What is medicine's ultimate goal? How should medicine serve the public?
Asking medicine's goal is not only to solve medical crisis; the crisis brings the question to the fore. Deeper questions follow: how should humans face birth-old-illness-death? How improve life's quality? Through these we can rationally allocate resources, putting limited funds and effort first to priority items, ensuring medical reform's right direction. This is the strategic root.
In 1997 the Fourth International Health Promotion Conference in Jakarta — held at a critical moment of international health-development strategy — said: health promotion is the process by which people can grasp and improve their own health; through investments and movements affecting health determinants, people gain the greatest health return, sharply reduce health inequalities, secure human rights, and increase social resources. The core of the health strategy: increase individual capacity, give individuals the knowledge and skills; change lifestyles to affect health determinants. It also emphasized the public's participation in health learning.
In 1998 the WHO, setting its 21st-century goals, stressed: "Change health behavior and determinants by promoting and using health-supporting lifestyles and changing health-damaging ones." Hence: stress self-care, healthy and scientific lifestyles — a key part of global health strategy. The WHO report: health and longevity depend on — self-care 60%, genetics 15%, society 10%, medical conditions 8%, climate 7%. Strengthen health promotion, advocate self-care. The new view asks us to shift focus from treatment to active prevention and care, from doctor-dependence to grasping our own health and fate. This individual responsibility for health, individual participation in health trend is now an important feature of global health work. Some scholars say modern medicine moves toward prevention-care-treatment-rehabilitation integration, with self-care awareness rising — the age of self-care is dawning.
(VI) Coming Opportunity
Self-care medicine differs from ordinary self-care; not just spontaneous use of medical popular knowledge for yangsheng.
Self-care medicine is a new science. With modern basic medicine, sociology, psychology, behavior science as theoretical base, with raising life-quality as main aim, it studies human life activity, health needs, individual and group self-care behavior, and social activity patterns. Through medical staff doing self-care diagnosis and writing self-care prescriptions, it implements the health-promotion project, bringing individual and group self-care into the orbit of medical science. We call this health management.
Health management features: 1. Strengthen self-regulation and adaptation. The superior physician treats what has not yet become illness — prevention first. 2. Value control of daily-life health determinants; stress lifestyle change. 3. Individualized health plans covering physiological-psychological-social levels. 4. Health promotion through life — from young, through middle, to old.
Health management's advantages: people-centered, valuing self-defense and disease-resistance; active participation, grasping one's own health; early investment, low cost, lifetime return; close to life, fit for modern society. Most importantly, implementing self-care and health promotion can keep humans in dynamic balance with disease-causing factors — so it is the root solution to personal health risks and the social medical crisis.
(VII) The Role of TCM
TCM's view of body, disease, and health: the body's right qi and inner regulating ability are the inner cause. In health, right qi held within, evil cannot encroach; in illness, where the evil gathers, the qi must be empty. Disease cannot be eliminated; humans and disease and bacteria stand in dynamic balance; over- or under-regulation in the body brings illness. Health is the relative balance of human, nature, and outer environment.
Through millennia TCM has held the superior physician treats what has not yet become illness as its first principle, exploring many yangsheng theories and cheap-and-effective techniques. In doctor-patient relations especially, the physician first rights himself — every doctor must know yangsheng and know spirit-treating, keeping himself in high health, so as to regulate the patient's jing-qi-shen with his own. Data show TCM doctors' lifespan and health quality are above other professions.
Look at China's medical investment: China uses 3% of national income — 1/8 of America's — to maintain the health of 1.2 billion; the US uses 14% for 200 million. TCM's contribution is part of that. Using TCM serves the aim of spend less, do more — and can greatly ease medical-cost-driven crisis.
But: by the limits of the system, environment, and old big-medicine views, TCM today is limited to prescription, needling, tuina; the patients are mostly already-ill or, after Western failure, trying their luck terminal cases. Many strengths of TCM's treasure-house are not fully shown; this limits TCM's positive role.
(VIII) Closing
Facing the next century's needs, medicine will see new change and chance. Continuing the technology road serves traditional health-industry interests; though crises and complaints have appeared, inertia will not stop at once and may, for interest, temporarily confuse and intervene in policy.
Human health and happiness are the ultimate goal of medicine. Medicine is not technology, not money, not habit, still less a tool for some individuals or groups to grab private gain. It is the blood and tears of millions of years of human courage against pain and death; the crystallized wisdom of the kind-hearted; the effort of all humanity to escape suffering and seek the bright tomorrow.
For this we need more concern and reflection; we need more awakeners and innovators.
Article by Li Fan.