We Need Bold People to Change the Way Health Is Run
From the new leadership in US health institutions to the crisis of affordability in Europe, change is coming in how health is run. It will be uncomfortable and some of it will be destructive, but a lot of it is needed. It may be that only leaders who are willing to break things can take full advantage of new technology and remedy longstanding deficiencies.
The highest-profile controversies are about the areas that need the least change. Vaccines, for example, have brought extraordinary benefits at very low cost and risk. Even here, we could do better. Vaccine companies have often left it to doctors and governments to sell the benefits of preventing polio, measles, whooping cough and cancer. In some countries, they are not permitted to talk directly to the public, but they don’t need to. Look at Dr Mike (almost 13 million followers) on YouTube to see what can be done and ask yourself why industry doesn’t help (or get out of the way) so it’s done more.
Change threatens vested interests
We do, though, need change. The respected British think tank, the Institute for Public Policy Research, said in November of 2024 that the British National Health Service was getting more and more money as productivity fell. “If productivity [in 2023/24] had matched 2019/20 levels, the NHS could have delivered an extra £19 billion worth of care. This would’ve been enough to build 900 new health centres. The new Labour government has announced a major uplift to NHS spending in the 2024 autumn budget, taking the planned daily expenditure budget to £192 billion by 2025/26…The NHS aims to improve productivity growth to 2 percent per year by 2029/30. This goal next year could deliver an additional £3.8 billion worth of care — enough to more than triple the numbers of MRI and CT scanners in the NHS.”
Doctors say productivity is declining because they are so stressed. Yet, in the same month, the doctors’ trade union, the British Medical Association, called unanimously for an end to high blood pressure checks in pharmacies because, in part, the work was “traditionally and contractually the remit of general practice.” There are fewer GP hours available in England (the four UK nations run separate health services) now than in 2015, mostly because male GPs are reducing the number of hours they work weekly. So, the BMA is calling for part-time doctors, who are already often unavailable, to be the only professionals who can measure high blood pressure, which kills about 75,000 people a year.
This is a preview of battles to come. The rules of acceptable discourse require us to say that British GPs work part-time because they find their job, where the BMA recommends that they see no more than 25 patients a day, stressful and they need their free time to do paperwork. The less polite would say that GPs are now paid so much that they do not need to work full-time — a professor of general practice threatened to make sure that I never worked again when I said this a few years ago, so I’m careful not to say it now.
It will get much nastier very fast. A relatively small study in October 2024 found that CHAT GPT outperformed attending and resident US physicians in internal medicine, family medicine, and emergency medicine. These doctors were mainly young, but they came from Harvard, Stanford, and the University of Virginia. In a randomised trial, the doctors and the AI were presented with clinical vignettes based on actual patients and with information available on initial diagnostic evaluation. The doctors got the diagnosis right about 74 percent of the time; the doctors using AI about 76 percent of the time; and the AI alone about 90 percent of the time. In short, doctors reduced the effectiveness of AI. Remember, this is the early days of AI.
By 2030, most screenings may be done online by AI, and nearly all treatment choices and monitoring may happen that way, too. Doctors and pharmacists will still need to supervise and may need to take overall legal responsibility, although a senior Google official argued earlier this year that AI should be licensed on the same basis as health professionals currently are, which seems to be laying the groundwork for those systems to take responsibility for their actions.
Taking advantage of AI in clinical settings will require a very thick (emotional) skin. So much so that middle-income countries will do it before high-income ones do. There is a precedent: East Africa had contactless payment long before we did because the big payment processors spent less time fighting it. They got a much firmer rejection by national governments too.
The most significant advantage of AI may, though, come in R&D. The speeding up and rationalising of early-stage medicines development will be uncontroversial but the displacement of traditional clinical trials will have the richest and most powerful academic institutions howling. Suppose we can track efficacy and adverse events in real-time. In that case, the laborious process of vastly-expensive phase 3 trials will become redundant, especially in life-threatening cancers and neurological and auto-immune diseases. The process started after the AIDS activism of the 1980s and has been dogged by criticism ever since. We should expect those who run large trials to become more and more vocal and only the bravest regulators to embrace the full value of big data.
History suggests that needed change will be avoided
Our health systems are full of unaddressed dangers alongside make-work systems that serve no purpose.
Look at which medicines require a prescription and which don’t, for example. Americans are often surprised that paracetamol/acetaminophen (they are the same substance) and codeine combination tablets are available from pharmacies without a prescription in Canada and most of Europe. In fact, the codeine is less of a worry than the acetaminophen, which can be bought in tubs of 500 in almost every supermarket in the USA. The minimum effective dose of codeine is 15mg, roughly the dose from two tablets in most pharmacy packs, which rarely contain more than 24 tablets; the maximum safe dose is about 16 times what is found in those two tablets. The codeine in an entire pharmacy pack would probably not kill you; the acetaminophen might. The two tablets typically contain about 1000mg of paracetamol/acetaminophen — 12 doses of that would kill many of even the biggest and strongest of us. In fact, twice the maximum recommended dose of paracetamol/acetaminophen for five days may be enough to cause fatal liver damage. It doesn’t even work very well: one of the few modern studies found that it is about 20 percent better than a placebo in reducing pain from headaches.
By contrast, cholesterol-lowering medicines require a repeat prescription, for which someone has to pay a doctor, and dispensing by a pharmacist, for which someone has to pay a fee. It takes 5 grammes of simvastatin (over 60 times the recommended maximum daily dose) to kill a rat; there are only a tiny number of documented cases of simvastatin killing a human at all (although I’m not recommending anyone take 60 tablets at once because the likelihood of severe muscle pain and other damage is quite high).
Throughout the world, a highly toxic and not very effective drug is in every supermarket because it has been there for over 70 years and changing it would cause all kinds of ripples; a life-saving and very safe chronic medicine is not because doctors and pharmacists have fought every attempt to reclassify it tooth and nail. Fixing this requires a willingness to upset many groups of people.
We have an example of how things could be done better. Since 2006, pharmacists in the Canadian province of Alberta have been able to adapt or renew prescriptions for diagnosed conditions and renew them. Most can also prescribe any medicine except narcotics and controlled substances. They document their assessments, rationale, and plans in patient charts or through medication clarification notices. Predictably, the Alberta Medical Association claimed that this was driving doctors to think about leaving the province or retiring because the increased scope of pharmacy prescribing threatened their financial viability. However, the grumbling has reduced over time. Alberta was, in 2006, virtually a one-party province, and its right-wing government pushed through a variety of controversial health reforms.
The causes of ill health are mostly unaddressed
Progressives find one thing more uncomfortable than anything else about the nominee to be US Secretary of Health and Human Services: he is willing to take on the underlying causes of ill health in a way that few progressives anywhere in the world are.
Canadians who got more calories from ultra-processed foods (UPFs) were found to have 31 percent greater odds of developing obesity, 37 percent higher odds of diabetes and 60 per cent increased risk of high blood pressure compared to those who got the fewest calories from such foods. “Not only do ultra-processed foods not contribute to a healthy diet, but they displace other healthier foods that do,” said report author Jean-Claude Moubarac of the University of Montreal. However, most of the restrictions on marketing these foods, even in saintly Canada, are voluntary and the worst that can happen to offenders is that they are ordered to withdraw offending advertising.
Things are worse in the USA, where UPFs account for 57 percent of daily calories for adults and 67 percent of daily calories for children and teenagers, according to a November 2024 release from the American Medical Association. The same release quotes Dr. Stephen Devries of the Gaples Institute in Chicago: “Ultra-processed foods are the perfect storm to promote overconsumption and weight gain: they are laboratory engineered to maximise appeal, are calorie-dense, and have little or no fibre or other healthful nutrients. The problems are even more acute for individuals who are food insecure, as constraints of limited access and affordability of nutritious food lead to especially high consumption of ultra-processed foods.” Yet, in the US, the only restrictions on promotion relate to deceptive advertising.
Robert F Kennedy Jr wants to ban hundreds of food additives and chemicals and change regulations, research topics, and subsidies to reduce the dominance of ultra-processed food. Convenience stores, which often have similar pricing structures to supermarkets, reported gross margins of 51.84% on candy as of 2022. Banana margins are typically around 10% to 15% for stores. He will have his work cut out.
That, though, is the relatively easy part.
What if I told you that I had discovered how to delay the average onset of Alzheimer’s by five years? I have. All you have to do is bring up your children bilingually and you’ll probably confer this gift on them. If you become bilingual as an adult, the benefits are less pronounced, but if you learn more than one language, you’ll do even better than someone bilingual. Yet, the number of English school children who took an exam in French at age 16 has more than halved since 2005 — despite it being a short train ride to a country where they can practise their French. And they are no longer required to do so.
I can halve your risk of dying of cancer, too. Cycling to work is associated with a 47% lower risk of early death from any cause compared to non-active commuters. Bike commuters also have a 51% lower risk of dying from cancer and a 24% lower risk of being hospitalized for cancer-related issues (suggesting that those who do contract cancer are more likely to survive). Although the Scottish researchers who reported this finding did note that “cyclist commuters have twice the risk of being a road traffic casualty compared with non-active commuters.” If governments were serious about improving health, they would copy Denmark’s cycling infrastructure and increase fuel taxes radically. But they don’t.
I accept that causation is not this simple: cyclists tend to smoke less, and obese people tend to cycle less. While we may argue about the size of the causal relationship, the overall principles are clear. If we are serious about tackling chronic disease, we need to rethink education, town planning, workplaces and much else besides healthcare and prevention.
The brave know how to make health affordable and accessible now and in the future
Increasingly, we select to have unaffordable and inefficient health systems because it avoids upsetting vocal vested interests. We need bold people who are not afraid to be unpopular. Ideally, they will not be people who believe in conspiracy theories about vaccines and fluoride. In the meantime, we will courageously work with the voices of power who are the gatekeepers to people’s care.