For the two decades of my career since earning a medical degree in 1999 the system has plodded along with minimal structural change in how we provide healthcare. The very term we use for the system is a misnomer. Strictly speaking, we don’t actually have a “healthcare” system, rather we have a very expensive sickcare system with two critical problems.
The first is that the epidemics of our time only continue to worsen: Chronic diseases are increasing in incidence in all three major categories (cardiovascular disease, cancer, and neurodegenerative diseases), and all are being fueled by the steady rise in obesity. The addiction epidemic continues to take a tragic toll on our population with someone dying of an opiate overdose every 7 minutes (in addition to the impact of alcohol and the other drugs of abuse). For the first time in a century, life expectancy has fallen for three years in a row (the last time coinciding with WWI and the flu pandemic of 1918). And virtually all measures of despair are moving in the wrong direction (anxiety disorders, depression, suicide, and a general sense of meaninglessness).
The second critical problem is that these simultaneous cataclysms are worsening despite the massive resources being spent at ever increasing rates in vain attempts to fix them. How much do we spend on our medical system? To put it into perspective, the total amount of revenue collected by the IRS last year amounted to $3.4T. Yet we spent more than that on healthcare (about $3.5T), which is more than double of most other western countries and includes $1T of spending on administration, which proportionally is also double of most other countries. Within less than 10 years (even without any new Medicare expansion policies) the projected cost of Medicare and Medicaid alone will be $3T, or about 80% of current total annual federal revenue.
Although our sickcare system is laudable in many ways, we are caught in a double bind. Not only can we not afford it for much longer, but even if we passed a massive tax hike to somehow finance this incessant spending binge, we have little evidence to suggest it would actually slow any of these epidemics. We are utterly failing to get at the root causes of these crises, and most of the organizations and individuals who are proposing course-correcting strategies are either part of the medical industrial complex that got us to this point in the first place, or believe that “Medicare for all” will solve this crisis. They’re missing the point. This problem is self-terminating. It simply cannot continue without imploding upon itself and basic math suggests this will happen not happen sometime in the distant future, but likely in single-digit years. Furthermore these issues are so complex and so intertwined with all of the other pillars of our society (education, economics, governance, food production, energy production, etc.) that any solution will require a wholesale reconsideration of not only the very foundation of our medical system—but also deep questions about the kind of society that we envision for our children in the future.
A common criticism that we hear from folks describing the conventional model as they transition to ours is some version of, “I almost never used it, and when I did I was loathe to do so. It was there for me in case I broke a leg or got cancer, but otherwise it had little or nothing to offer me. I was paying a massive premium every month and basically just waiting until something really bad happened to me and my health.” Such comments are to be expected in an unaffordable sickcare system.
So what is the basis of our current medical system? It is built upon a singular fundamental concept: pathogenesis. Virtually everything we know and study and do in conventional medicine is based upon our understanding of patho (disease) genesis (generating) factors and their treatment. The system evolved from the original miracle drugs of modern industrial medicine which brought a rapid end to so much death (via antibiotics, etc.) and suffering (via anesthetics, etc.) with “silver bullet” approaches, and what a gift this has been to humanity! But the “pill for any ill” approach, unfortunately, is poorly suited for the epidemics of our time.
We are very good at understanding how things go wrong. Ask any medical student in the country to list 20 or 30 ways in which your liver can get sick and they’ll have no trouble quickly rattling off the list. But ask them to explain how to heal or nourish or support your liver and you’ll likely get a blank stare.
Even our titles represent hallmarks of a system based upon pathogenesis. My diploma states “doctor of medicine,” which implies that I have some knowledge of prescribing medications and pharmacological drugs for the various ailments which can befall us as human beings. Im very grateful and proud to have such knowledge, to whatever degree it may serve my patients. But if we are to build a true healthcare system, we doctors (the original meaning of which is “teacher”) must also become guides toward building and supporting health, not merely aiding in recovery from illness. Most of us, thankfully, spend a large portion of lives when we aren’t patients at all. We’re not necessarily clinically sick, we’re just people living our lives, moving along various points on the spectrum of well-being. A real healthcare system would leverage those periods in life when we could all benefit from relevant and updated information, guidance, tools, techniques, programs, and protocols by which to evaluate and elevate our state of of health regardless of our baseline.
In the 1950’s, Aaron Antonovsky coined the term which points the way forward. It provides the necessary counterpart and complement to our model of pathogenesis, but the word died along with him. He was interested in studying how we heal, how we recover, and how we become more resilient. He named this concept salutogenesis—saluto (health) genesis (generating). It is time to resurrect Antonovsky’s potent word and begin to embed this concept into our system as efficiently, effectively, and economically as possible. What would a healthcare system which incorporates the concept of salutogenesis look like? And how would this influence the overall well-being of our society? (Part II will be posted in April)