End of the Road

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‘If something cannot go on forever, it will stop’. This statement might seem blindingly obvious, but it was coined in 1986 by the economist Herb Stein and is formally known as Stein’s Law. Herb was describing economic trends, but it is surely a general truth. It certainly applies to the current model of health care in which cost, supply and demand are locked in a mortal combat which cannot go on for much longer.

On one hand, the West is moving into recession and thence, probably, depression. On the other, the average cost of biological drugs is currently anywhere from $10,000 to $500,000 a year1 and rising; Zolgensma, a gene therapy for spinal muscular atrophy and currently the most expensive drug ever, costs $2.1 million for a one-off application2. On the third hand, the demand for biologicals and other drugs is increasing relentlessly.

Why the third hand? Because, according to the Rand Corporation, and many others, public health is in substantial decline3. (There is a fourth hand attached to this, which we’ll come to later).

A team from the US Department of Health and Human Services4 came up with broadly parallel findings. Between 2006 and 2010, the percentage of people with chronic conditions increased from 49.7% to 51.7% and the percentage of people with multiple chronic conditions increased from 27.5% to 31.5%. 

Two more damning sets of data points.

Between 2000 and 2020, the number of American adults with at least one chronic disease grew from 45%5 to 60%6. Children are increasingly affected; according to the CDC, more than 40 percent of children and adolescents now have at least one chronic illness7. 

This alarming trend can be traced further back in time. In the National Health Survey of 1935/1936, the first national survey to focus on chronic disease and disability, the incidence of chronic conditions was recorded at a mere 10%8-11.

Comparing 1935 to 2000 / 2020 is not exactly straightforward. Screening technology was less sophisticated back then and underdiagnosis more likely, particularly of borderline  and pre-clinical conditions. Treatments were less effective, and it is reasonable to assume that those with chronic conditions did not survive as long as their equivalents do today. For comparative purposes, let’s double the reported 1935 tally and bring it up to 20%. 

If we double the 1935/6 rates, then the ‘real’ incidence of chronic degenerative disease since 1935/6 has ‘only’ risen by 150%. The delta documented in the Rand and the USDHHS data3, 4 suggest that a 150% increase might be somewhat conservative, but it is probably not too far wrong. 

This large increase in degenerative diseases is claimed by some to be due to our increased life expectancy, but this is a difficult argument to make. Between 1980 and 1990, for example, life expectancy rose by 20 months (circa 2.5%) but the prevalence of major chronic diseases such as diabetes, heart disease, and high blood pressure increased by between 40% to 150%12. 

The change in public health really starts in the early 1950’s, when chronic degenerative diseases first became the dominant causes of death. This general point is illustrated below by the crossover of death rates from infectious (acute) and noninfectious (chronic) lung disease13. Tends in deaths due to diseases of the gastrointestinal and genitourinary tracts show the same pattern.

Those negative trends have continued. Chronic diseases are now the leading cause of disability14, and currently responsible for 7 out of 10 deaths15. As the frequency of these diseases increases and their latency decreasesie16, life expectancy is inevitably forced down17 and costs up. According to the Milken Institute18, the direct and indirect costs of chronic disease conditions now amount to 19.6% of the USA GDP.

Demographics make the problem worse. Even as oldsters are being culled earlier at the far end of the old age range, more are entering at the younger end of this range and the 65+ year old group – who have multiple pathologies – are growing the fastest19.

The above stats are derived from the USA, whose unhappy citizens take pole position in the international ultra-processed food (UPF) stakes20. 73% of the all-American diet is ultra-processed21. As such a diet correlates with higher risk of metabolic syndrome, diabetes, angina, elevated blood pressure, biological age20, cancer21, 22 and depression23, you can see why Yankees are increasingly going home, if only in the biblical sense.

One should take composite statistical measures with several modal pinches of salt. Notwithstanding, the USA, which in 1950 scored 12th in the international table of life expectancy, has now fallen to 53rd place24 and ranks 69th in overall national health25, far behind Monaco, Singapore, Japan and South Korea. 

The UK follows its US master slavishly, with 57% of its calories from UPF’s26, 27 and a similarly falling life expectancy28. It will only get worse from here; British children consume 65% of their daily calorie intake as ultra-processed foods, which is the highest level in Europe29. 

By 2035, and on current trends, two-thirds of British adults aged over 65 are predicted to be living with multiple health conditions30, 31. Seventeen percent will be living with four or more diseases, double the number in 2015. One-third will have a mental illness – although, in a futile attempt to appear fair, I would suggest that neo-liberalism and gender politics are likely contributing to this32.

The Brits appear to be on the same dire trajectory as the Americans, but in some ways these papers30, 31 are overly optimistic. The authors predicted an increased life expectancy of three years for men and women, and warned that people will spend longer living with multi-morbidity. The good news is that currently falling life expectancy means that more people will likely develop multi-morbidity earlier in life, but will not have to spend longer living with it.

From a medeconomic perspective this is entirely positive as it reduces the impact of a fourth driver of medical costs, namely the average duration of the generally progressive illnesses which develop in our declining years. This has been increasing, due in substantial part to our progressively degraded diets and consequently, the earlier age of onset of many chronic conditions.

In the 1980’s and ‘90’s, men and women could expect to spend the last 10% of their sentence in a state of progressive illness and medical dependency33. There has been a deterioration in the manner of our ageing34-37, with many diseases emerging earlier16, to the point where we are now typically ill for the last 20% of our lives38. (The tools used in these last calculations are not identical but they are broadly similar.)

There is one more fatal structural problem, namely the ongoing increase in the ratio of elderly and generally non-productive citizens to those of working age, who generate the revenue needed to fund the over-priced healthcare needs of their elders. The graph below38 describes the situation in the USA, but is applicable almost everywhere except Africa.

Neither the state nor its subjects can afford this. Every day in the exceptional USofA, 1,500 Americans experience bankruptcy due to medical bills. This equates to 530,000 individuals and families made destitute every year, with numbers bound to rise as the economy declines39. 

The erosion of health and life expectancy, the spiraling costs of healthcare40, the declining relative workforce and the resulting collapse of healthcare systems41, 42 are most marked in North America, where the pharmaceutical model has reached a terrible apogee and the drug companies have become so powerful that they have coopted and corrupted medical science, the regulatory system and health care policy and practice43, 44. But the crisis is universal.

The last best hope of the Pasteurian model, the use of accumulated SNPs to determine Polygenic Risk Scores for the chronic diseases, has failed. It is insufficiently effective to justify its use in mass screening and medical allocation45-47. 

This failure should not surprise anyone, because public health isn’t so much about genes. Physicians may continue to blindly graze on Pasteur’s green (48), but livestock veterinarians know that environmental factors are far more important. It is our unhealthy diet and lifestyle that are making so many of us so ill.

In summary, prevailing negative environmental factors will continue to push medical costs up, but the economy and the workforce will not be there to sustain them. We won’t, therefore, have to change our financial and dietary environment, because it will be changed for us. 

Stein was surely correct. What cannot go on forever will stop. The pending medeconomic collapse will force a much-needed shift from reactive to preventive medicine, despite the increasingly criminal holding behavior of the pharmaceutical industry49, 50, 51.

I believe this will be just one of a series of transformations, because we cannot continue to run the world the way we have run it for the last 50 years. Change is coming, despite our inherent laziness and fear of the new, because the crises driven by the stupidity and cupidity of the ‘elites’ are becoming exponential. 

These crises will galvanize those who survive the Fourth Turning to seek and create change. That will mean medical disintermediation and a wholesale shift to preventive health. Parallel moves to a flatter world may come from blockchain, decentralised business models and devolutionary political systems.

In the crowded theatre we inhabit, it is time to shout ‘Fire’. This is neither illegal nor unethical52, as the stake holders and silencers of free speech would have us believe. Once the theatre is alight, it is a profoundly moral action53. 

The estimable Professor Martin McKee believes that decreasing public health foreshadows political instability54. As declining public health is an indicator of decaying social systems, his thesis seems very reasonable – and in the USA, very apparent.

The supermercado is on fire, and it’s past time to head for the exit. Leave via the produce aisle, grab some pharmaconutrition for the road.

Endnote. I occasionally play 4-deck spider on my mobile phone, and the app comes with ads. This morning a medi-tech company tried to sell me a wide-bore MRI scanner, designed to accommodate larger patients and a snip at $1.2 million. If this is not a sign and portent of the end of (current) times, I don’t know what is.

Next week: Automatic immunity.

References

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  2. Nuijten M. Pricing Zolgensma – the world’s most expensive drug. J Mark Access Health Policy. 2021 Dec 29;10(1):2022353.
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