End of the Road

‘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 data^{3, 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.