the controlled trials of evidence-based medicine are the answer to medicine's problems rather than being taught that they are a first step on the road to an answerâjust as John Snow's isolation of the Broad Street Pump as a source of the cholera epidemic in London in 1856 was the first step on the road to an answer rather than itself the answer. It was Robert Koch's discovery of bacteria rather than Snow's researches that explained the cluster of events in Broad Street. Koch's work opened the way to a raft of inputs from the laboratory sciences into medical care that flourished in the work of clinicians like Richard Cabot a few years later.
THE FUTURE OF MEDICAL CARE
The juxtaposition of markets and health produces shudders, jolts, and every so often quakes as the tectonic plates of production, efficiency, equity, and choice collide. Americans embrace markets because they want choiceâthey don't want to be dictated to. Europeans have steered away from markets in medicine, seeing both equity and strength in the musketeer's one for all and all for one.
James Lind opened his treatise on scurvy in 1753 with the statement that âarmies have been supposed to lose more of their men by sickness, than by the sword.â Perhaps aware that empires and economies have been more likely to be destroyed by plagues and pestilences than by losses on the battlefield, Europeans have placed greater emphasis on ensuring the production of health by making it free and if necessary compulsory. 27 But the development in our day of biological interventions, from cosmetic surgery to risk management medicines, that have the appearance of medical treatments but far from enhancing productivity and well-being almost certainly reduce it, parasitize universal health care to the point where it may not survive. No one would ever have thought to include the proprietary medicines of the nineteenth century in a universal health care system, but this is close to what is happening now. And as a consequence, universal healthcare is also today under threat in Europe, where healthcare costs are rapidly rising toward American levels.
Americans meanwhile have seen the market deliver extraordinary developments in technology. They have seen transformations in living standards happening globally, and they believe that to some extent these developments have hinged on responses to consumer demand. Even within the health domain, consumer demand, for better or worse, has led to rapid developments in, for instance, cosmetic surgery. Pharmaceutical company executives lead the queue to say that if the same forces were unleashed more widely within the rest of medicine, we would solve all our healthcare problems. 28
If, as commonly believed, both markets and science deliver progress, it seems inconceivable to many that the domain in which markets and science interact to the greatest extent would be one characterized by decline rather than progress. But when it comes to pharmaceuticals, because of prescription-only arrangements, the current operation of patent laws, the sequestration of trial data, the ease with which medical experts can be seduced by junk epidemiology, and the extent to which bad data has driven out good data, this is not a market that can respond to patient pressure. It is a market where patient pressure is perverted by pharmaceutical marketing campaigns, where outcomes can get worse with no apparent consumer (medical) concern, a market in which the mental sets of consumers (doctors) have been captured so that it is difficult for them to conceive of alternatives to those being sold to them, a market in which there is almost no possibility of discrepant data emerging to trigger a thought that might be unwelcome to a pharmaceutical company, a rigged market that operates in terms of five-year plans. Indeed, it is a polity, rather than a market, that in its control of information is perhaps best described as totalitarian.
Hitherto one of the major
THE FUTURE OF MEDICAL CARE
The juxtaposition of markets and health produces shudders, jolts, and every so often quakes as the tectonic plates of production, efficiency, equity, and choice collide. Americans embrace markets because they want choiceâthey don't want to be dictated to. Europeans have steered away from markets in medicine, seeing both equity and strength in the musketeer's one for all and all for one.
James Lind opened his treatise on scurvy in 1753 with the statement that âarmies have been supposed to lose more of their men by sickness, than by the sword.â Perhaps aware that empires and economies have been more likely to be destroyed by plagues and pestilences than by losses on the battlefield, Europeans have placed greater emphasis on ensuring the production of health by making it free and if necessary compulsory. 27 But the development in our day of biological interventions, from cosmetic surgery to risk management medicines, that have the appearance of medical treatments but far from enhancing productivity and well-being almost certainly reduce it, parasitize universal health care to the point where it may not survive. No one would ever have thought to include the proprietary medicines of the nineteenth century in a universal health care system, but this is close to what is happening now. And as a consequence, universal healthcare is also today under threat in Europe, where healthcare costs are rapidly rising toward American levels.
Americans meanwhile have seen the market deliver extraordinary developments in technology. They have seen transformations in living standards happening globally, and they believe that to some extent these developments have hinged on responses to consumer demand. Even within the health domain, consumer demand, for better or worse, has led to rapid developments in, for instance, cosmetic surgery. Pharmaceutical company executives lead the queue to say that if the same forces were unleashed more widely within the rest of medicine, we would solve all our healthcare problems. 28
If, as commonly believed, both markets and science deliver progress, it seems inconceivable to many that the domain in which markets and science interact to the greatest extent would be one characterized by decline rather than progress. But when it comes to pharmaceuticals, because of prescription-only arrangements, the current operation of patent laws, the sequestration of trial data, the ease with which medical experts can be seduced by junk epidemiology, and the extent to which bad data has driven out good data, this is not a market that can respond to patient pressure. It is a market where patient pressure is perverted by pharmaceutical marketing campaigns, where outcomes can get worse with no apparent consumer (medical) concern, a market in which the mental sets of consumers (doctors) have been captured so that it is difficult for them to conceive of alternatives to those being sold to them, a market in which there is almost no possibility of discrepant data emerging to trigger a thought that might be unwelcome to a pharmaceutical company, a rigged market that operates in terms of five-year plans. Indeed, it is a polity, rather than a market, that in its control of information is perhaps best described as totalitarian.
Hitherto one of the major
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