More money is not the answer

The amount of money which is being demanded for the provision of health care continues to grow. Here in the UK the various political parties compete with each other to increase expenditure on health services.

On the other hand, there is little convincing evidence that the standards of public health are improving. If anything they are deteriorating. While it is indisputable that life expectancies in many countries are increasing, this does necessarily mean better health.

Public health is deteriorating

Here in Great Britain, the incidence of type 2 diabetes (T2D) in both men and women has more than doubled in the last 15 years. It is likely that there will be 5 million cases by the year 2025 in the UK (1). The position is similar in most other countries. In the USA, in 2014 it was estimated that 29.1 million people had diabetes (2). As many as one in three people could be affected in 2050. Effectively T2D is the tip of the iceberg because it is associated with increased risk of many other diseases including heart disease, cancer and Alzheimer’s Disease (AD).

Cancer is a leading cause of death but despite the resources ploughed into research the progress is not encouraging. A recent article in the Lancet states quite bluntly:

“Current strategies to control cancer are demonstrably not working. Already one of the world’s leading causes of death, the annual death toll from cancer has risen by almost 40% since 1990 and this rate of increase is set to continue. WHO predicts deaths from cancer will rise from the current level of around 8 million lives a year to more than 13 million by 2030” (3).

Dementia is a major cause of disability and is getting progressively worse, especially as people are living longer. In the USA between 2000 and 2010, the incidence of autism in young children doubled. According to the National Institutes of Health (NIH) in the USA, about 10% of the population has autoimmune diseases. The American Autoimmune Related Diseases Association claims that the incidence is much higher because the NIH only includes those diseases for which good epidemiology studies were available (4). These diseases are amongst the 10 leading causes of death in girls and women in all age groups up to the age of 64 years.

On top of all this mental health issues affect many people which in the USA can be as high as 25% of the population.

Expenditure on health

This is an appalling state of affairs. The information in Table 1 which has been collected by the World Health Organisation (WHO) shows how expenditure on health varies between selected countries (5). The most striking feature is the USA which spends 17.1% of GDP. This is almost double that of some other developed nations. As the USA is a wealthy country, this represents a staggering amount. Even so, the USA ranks only 42nd in the life expectancy league table, lagging well behind Japan, Singapore, Australia and Norway (6). On infant mortality the USA ranks only 55th in the world with a rate which about 3 times that of those countries which are at the top of the list (7).

Table 1. Expenditure on health care as a % of GDP (5).

Country Expenditure in 2013, % GDP
Australia 9.4
Brazil 9.7
Canada 10.9
China 5.6
Ireland 8.9
Malaysia 4.0
Morocco 6.0
Netherlands 12.9
New Zealand 9.7
Peru 5.3
South Africa 8.9
Tanzania 7.3
Tunisia 7.1
UK 9.1
USA 17.1

 

It is evident from this information that spending money does not guarantee a high standard of public health. Therefore it follows that much of the resources are not achieving the expected results and are effectively being wasted. There are many reasons why this happens but in this blog I will limit myself to a few aspects of government policy with some examples from the UK which apply equally to many other countries.

Failure of government

At the end of May 2015, I sent this Daily Mail article to my MP who forwarded it to the Department of Health (DoH).

http://www.dailymail.co.uk/health/article-3096634/Why-butter-eggs-won-t-kill-Flawed-science-triggers-U-turn-cholesterol-fears.html

The headline was:

“Why butter and eggs won’t kill us after all: Flawed science triggers U-turn on cholesterol fears”

Essentially the message was that the Americans were having a re-think on the dietary guidelines and in particular on the role of cholesterol.

About a month later, there was a reply from Jane Ellison who is a junior Minister in the DoH. This included the statement that:

“There is good evidence that saturated fat consumption influences serum cholesterol levels and thereby increases the risk of cardiovascular disease. On this basis, the PHE will continue to advise people to consume a diet that is low in saturated fat”.

Defending the indefensible

Anyone who has taken an active interest in recent developments will understand that this is the justification in official recommendations to reduce the intake of saturated fat (SFA) and increase that of polyunsaturated fat (PUFA) in many different countries. However there is now overwhelming evidence that this rationale has been totally discredited and that there was never any foundation for making the recommendations in the first place. This is explained in a recent blog which summarized the extensive range of research which demonstrates convincingly that the cholesterol level in the blood is not a reliable risk factor for all-cause mortality (ACM)(8). In fact what emerges is that those with the lowest values for blood cholesterol and for LDL-Cholesterol have the highest death rates. This rather ironic since these are the people who actually comply with the official targets and many of them will be on medication (eg statins) because they have been told they need to “reduce their cholesterol”! Clearly this means that there are lower death rates at higher cholesterol levels and for men there is no changes as the cholesterol increase but for women the higher the cholesterol the greater the life expectancy. So all of this blows any case for lowering cholesterol out of the water.

Hence it is obvious that the policy is flawed and it is no surprise to find that it is not effective. If we are to make progress it is important to try to understand how and why things have gone so badly wrong. Here are some suggestions:

  • Government advisers may be fairly rigid in their thinking, not receptive to new concepts and unwilling to admit that their advice has been wrong in the past.
  • There are definite conflicts of interest in the sense that many of those who are involved in advising governments have financial links with companies which benefit from the status quo and would therefore be adversely affected by a radical change. Here is one example
  • http://www.dailymail.co.uk/debate/article-2543052/Obesity-tsars-sugar-firms-paying-fortune-VERY-unhealthy-relationship.html
  • There are powerful commercial interests such as the drug companies which depend on the cholesterol theory to justify the use of statins. There is absolutely no doubt that these companies devote huge resources to support this rationale and to throw doubt on any evidence to the contrary. The blunt truth is that institutions including government has been corrupted by the activities of these companies (9).

Conclusion

Although one might expect that the over-riding objective of any national health policy is to ensure the best possible health for the citizens, the reality is very different. There are all sorts of other factors and influences at work. In practice we have been badly let down by the politicians who whether by accident or design allow themselves to be manipulated by other forces and seem incapable of exerting any kind of authority to ensure that the highest standards of public health are achieved.

References

  1. https://www.diabetes.org.uk/Documents/Reports/State-of-the-Nation-2012.pdf
  2. http://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html
  3. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60059-8/fulltext
  4. https://www.aarda.org/autoimmune-information/autoimmune-statistics/
  5. http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS/countries?display=default
  6. https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.htm
  7. https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html
  8. http://vernerwheelock.com/179-cholesterol-and-all-cause-mortality/
  9. http://vernerwheelock.com/113-can-we-trust-the-drug-companies/