(April 20, 2005)

Cristina Grasseni
Let’s start with a question that is relevant to the aims and interests of the FGB, which is discussing responsibility in innovation. How would you relate it to your own interests?

Daniel Callahan
I have long had a fascination with technology and particularly its power to change the way we live our lives, whether we want the changes or not. Medical technology is particularly interesting, because we use it to deal with illness, suffering, and death. It is one of the main ways medical progress moves forward. Like everyone else I am prone to seek and buy the latest technologies, even if I recognize they may not do me much good.

Do you think that in the health sector there’s a case for irresponsible innovation?

I can think of few instances of irresponsible innovation. Most individual technologies make considerable sense, and are by themselves not at all irresponsible. The problem with technological innovations usually comes from their over-use (too many automobiles now in many countries), their cost in the aggregate (thousands of people making use of hundreds of expensive medical technologies, many of them making little actual contribution to health), and their tendency to introduce a social bias of one kind or another (spending too much on medical innovation at the cost of needed innovation in the teaching of children). The state of California will spend $3 billion on stem cell research, which may not result in important medical innovations, but not spend the same amount educating the estimated 2.5 million people in that state who are illiterate and thus doomed to poor jobs and poverty.

You discuss the issue in term of sustainability. In our cfc some of the comments were asking, isn’t this just a problem of reallocating resources? If there is a priority for health, shouldn’t we look at the ways costs are generated? Or just find more money for it?

Economists have long pointed out that there is a direct correlation between money spent on health care and the economic affluence of different societies. But at present even affluent societies are having trouble paying for constant and often large annual increases in health care costs. It is unsustainable for a society to allow its health care costs go up each year at a rate faster than the general cost-of-living increases. The most common response is to attempt to eliminate inefficiencies in the health care system. But this has been tried for many decades now with only moderate success. The main reason for the cost increase is that of new technologies, ever new medical innovations. I believe that is where the effort at change and reform must be directed. But that is hard for many people to accept. Of course taxes can be raised to keep up, but there is finally a limit to what taxpayers will put up with, even it might mean better health services. I believe many countries have already reached that point. The importance of the concept of sustainability is to force us to understand we need to find a long-term solution to the cost problem, and that will mean finding a way to limit excessive cost increases over the long run.

What about the profits of the pharmaceutical industries? Public spending in the health sector is going up because someone is making such high profits as 15.5%

The multinational drug companies complain, often bitterly, about the price controls placed on drugs in Europe–and Americans often complain that our high prices are paying for the research that Europeans (and Americans of course) benefit from. Drug companies have been immensely profitable, but that has changed over the past 2-3 years. I am not sympathetic to the drug company complaints about efforts to control the prices paid for drugs. Many other industries have flourished–such a computers–with a much smaller profit margin. Moreover, many drug company costs come from developing new drugs that are only marginally, if at all, better than the old ones.

Sure, that comes out very clearly from your book. But let’s take an example. Let’s take infertility treatments. You say clearly in your book that there shouldn’t be a priority of public spending to make infertility treatments available to all. That is one thing. Another thing altogether would be not to do a type of research that makes this treatment available, at least potentially, at all.

I don’t think we can stop this kind of research. It will get funding somewhere because there is market for it. But I think we need to get people to have a better understanding of why they need infertility treatment in the first place. One cause is late procreation: too many women over 35 trying to have their first baby. If we got women to get babies at 21 or 22 we would not have infertility problems. The other one is sexually transmitted diseases. Both of these make it a public health problem. which we have unfortunately turned into a medical problem. If you want to have delay having babies till 40, you may need infertility treatment. I think this is a very interesting example, in fact, because sometime there are expensive medical interventions due to people having poor health behaviour. Expensive lung cancer treatments mainly come about because of unhealthy smoking habits. We need to stop the smoking and not depend upon medicine to find a cure for lung cancer.

Yes but, the alternative to infertility treatments is to change the social conditions by which women find themselves choosing between a career and having babies. Would that cost less than infertility treatments?

It’s very difficult to change the whole society, securing support to women, childcare, etc. It’s an endless in debate in every country I have been in. But I guess it’s still a question to what extent you encourage the continuation of such behaviour by supporting it. If the government said ‘we are sorry for you, and we understand you need to get a degree before you have your babies. But you made that choice; you did not have to pursue that career. If this is a lifestyle choice that gets you to have babies with great difficulty at age 40, we should not pay for it’. You still have a lot of women who have their babies after higher education, they are less educated when they have their babies but they are happy with it. In Southern Italy you still have a lot of women getting their first babies at 21, with many fewer needing infertility treatment.

It seems to me that the kind of reform of medicine and of health care that you advocate actually require a radical rethinking of our society. It’s not a question of appeasing one lobby or another. Who should decide how to do it? The medical professions? A committee of people like you?

In the US we have three ways people get their health care paid for. Mostly it is our employers that pay for your health care; about 60% of people get health care this way. Medicaid is a government programme for the poor, in which case it is the state that decides how much to spend for their health. At the federal government level, Medicare programme is for people over 65. If it’s the state that pays, it decides how much to spend and on what. If it’s the employers, they have to make decisions about what they are prepared to cover–and if it is the government it has to make the same kind of decision. We have debates at the moment because, due to cost pressure, the employers are reducing benefits. Here your health care system is mainly supported by taxes and there’s some private health care available. So it should be the state that decides how much it is going to support e.g. infertility treatments, how many cycles of in vitro fertilisation etc. It is an interesting example because it is a very expensive and not very successful treatment. Maybe 25% succeed. And it costs 10 to 20 thousand dollars per treatment cycle (at least in the US), and sometimes 3-4 cycles are necessary for success.

I have a question about educating people. In your book you talk about investing more on public health. What do you mean by that?

I am referring to what is often called a “population perspective”on health; that is, what can we do to improve the general health of society, not simply helping individuals?.We know, for instance, that organ transplantations work exceedingly well on a small minority of people but the impact overall on a nation’s mortality rate is minimal. We should invest money in what makes the most difference statistically, particularly when the cost is worn by the entire society. This is a public health and population perspective.

There’s a strong educational aspect to it…

A lot of behavioural changes come about from educating the public about public health, but for a lot of these issues education doesn’t work very well. It’s worked moderately well on smoking, but in most countries it has taken the additional force of law to get at those smokers who do not respond to education programs. I notice there’s no smoking in restaurant here, I don’t see anyone smoking here?

It’s a new law…

Smoking is an easy case, but how would you pass laws on eating to reduce obesity or on exercising? How are you going to convince people to jog every day?

Would you recommend that some specific agency take the reins on these aspects?

In the US now, some companies are taking a leadership role. For instance, in some cases if an employee is overweight, he can lose his job. In case of seriously overweight employees, they will provide employees with help to lose weight but if you haven’t succeeded after 6 month you can get discharged. This is happening in few companies. In most companies it’s forbidden to smoke at work, but in a few cases they even test people to see if they smoke at home, in which case they are going to fire you. It’s a small minority of course, about 1% of companies, but there’s a lot of attention on them, especially because of the court case they are going to attract and the controversy they have engendered. But the employers have good evidence that smokers cost them more in terms of health costs–so if smokers cost a company 20% more than everybody else, they feel they should not bear those additional costs. Unfortunately, just lecturing people won’t always change their habits.

There’s such an obviously political side to this. The debate takes a different shape according to the political model of citizenship you take. You talk about market and solidarity models of health care. And you talk about the differences about Americans and Europeans, the latter thinking of public health as solidarity. If anyone thought pragmatically about implementing the reforms you advocate, don’t you think it would create such political unrest that they would be non implementable?

That’s true with any other revolutionary ideas. You have to wait for the right moment. In the US, the number of uninsured people, 45 million, is rising. You need a moment of great crisis. In our country only some very serious crisis will make people, particularly the middle classes, prepared to change radically. 85% of Americans are well insured. They don’t care too much about the 45 million uninsured, who are near-poor people. They are not going to change the entire system to help that 15%. But more people are amenable to the idea of taking more drastic steps to control smoking because they realize that cancer and heart problems from smoking add to everyone’s health care costs.

How would you combine the private and public sector then?

In our society, nobody can agree on the right mix. They don’t like government to take the guide. The net result is no one gets anywhere. It’s a stalemate. For that reason I much prefer the European systems, which gives the government considerably more control of the health care system.

What would be your model for a virtuous relationship?

I have just finished a new book on the impact of the market on health care and what I say is the European healthcare systems and Canada’s are infinitely superior to the US. Everybody is covered, and you get better health care for less money. The average American believes they have the best system in the world. We do have the best hospitals but that does not make it good for the average person, particularly if they do not have much money. If you don’t have good coverage and you go into the emergency room with a broken leg they’ll just send you a 5000 dollar bill and put you on drugs for the rest of your life that cost 300 dollar a month. But the European system is in trouble because of the cost pressures. My picture is that the US is struggling to climb up the mountain of universal health care, and the Europeans are trying to hang on, to keep up there. The market gets very attractive in Europe because this way the government gets rid of some of the costs. It’s a very interesting drama unfolding, interesting for me to see how you all keep it and to see what we get.

But about the strategy of privatisation to cut costs, if health care provisions were more geared towards long term strategies as you suggest, these would not be attractive to the private sector…

There’s no money to be made in prevention. The perfect drug for companies is for arthritis: if you get at 45, it does not get away, and you need to increase doses to relieve the pain. They certainly don’t make their money by stopping you smoking or decreasing adolescent smoking. There’s no profit in prevention, and it does not excite people to get to think about what may happen to the in 25-40 year’s time. A cure for cancer is much more attractive.

It seems to me whichever way you approach the problem, one reaches the same conclusion: the privileged, the rich, get the best…

The rich always win. They get the best cars, the best hospitals and so on. I knew a very wealth NY layer who got leukaemia and discovered there was an experimental treatment in Israel. For one year he flew once a week to Israel by Concord (at $8000 dollar per leg) to get the treatment; and it saved his life. The issue is how big is the gap between rich and poor. I live in NYC on the Hudson River, every night there is a stream of helicopter that a few rich people use to avoid traffic jams. That does not bother me. It is when the gap between rich and poor gets too big, with the poor hurting that the real problem emerges.

And what about the developing countries?

There’s a chapter about it in my new book. By the 1980s most of them had a certain primitive level of universal care that worked reasonably well at an affordable price for the countries. Then they shifted to a market model, often spurred on by the World Bank. That meant in great part privatising the health care systems–but in the process often all but destroying the government system The private system would siphon off the better doctors from the public system, as well as the interest of the more affluent in the public system, which they ceased to use. Take China, where they had the barefoot doctors providing primary care. They had a good public system, but they dropped the whole thing especially in rural areas.

Just a few questions that were raised in the call for comments and during the debate online. How would you preserve informed consent and the right of patients? What role should the doctors play?

The doctor-patient relationship is an important one. Usually people like to choose their own doctor, though there’s no research that says you get a better health care that way. The doctor should also get to practice medicine the way he wants without too much interference. If you have the state in charge you are going to have some limitations and control on how much technology is going to be available in your region. I think you should allow a fair amount of free choice, though not too much otherwise patients will want all sorts of expensive treatments that the government will not be able to pay for. In many countries there’s a gate keeper in primary health, usually a primary care doctor who controls access to specialist treatments. Many patients do not like that limitation, but it does help to hold down costs.

In the environmentalist debate, ‘sustainability’ is a word applied to limited resources. Is it applicable to things we produce ourselves, like technology?

You can measure how much air we need to breath, but how much health care do we need? People’s aspirations for better health are potentially infinite. They don’t want to die, they don’t want to get sick. Progress keeps raising the standards of good health. We keep wanting more, and more, and more. Infertility relief was something unthinkable 40 years ago, you simply could not have children.
I think the crucial question in the environmental movement is that of “limits to growth”. I believe we have a similar problem with health care: we need to find a way to limit the development of new and expensive technologies as well as educate people to know that, however important health is to them as individuals, societies will have to set limits to what it can pay to satisfy our infinite desires.

Are you aware of experimental forms of discussing with the citizens what should be done and deciding democratically? What do you think of them?

The public, which ultimately pays for health care, must have a role. The best method I know of is to work with samll groups, giving them good information, allowing time for discussion and analysis and then, in the end asking for their judgment. It is an expensive method, but nothing else seems to work as well with the complexities of health care.

Do you really think that the European systems are the result of communitarism and of a solidarity frame of mind, and not, for instance, of political results of a history of social struggles?

Well, you have much better welfare programmes than we do, all sorts of welfare programmes in fact. You are much more prepared to take care of each other. Americans don’t feel badly enough about poor people. If people get sick and don’t have jobs, Americans tend to l think they should just have worked harder. should the taxpayers support them? But even in Europe there is now a lot of agitation about welfare policies, including health care. The European value of solidarity has been important as a foundation for health care systems. But I sense that, unless the European countries find better ways to control costs, solidarity will weaken as a value, and could bring a greater use of market practices. The ultimate problem is that, in developed countries we have an infinity view of medical progress, that is, the view that we should always seek more and better health whatever the costs. That view is now being challenged by the cost problem, and every country will be forced to reconsider it. There is no other future option.

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