Contrary to the nineteenth century, whose Zeitgeist could be captured in the proactive idea of ‘progress’, we live in an age centred on sensible ‘security’. Admittedly, the state has retained a melioristic outlook. The foremost social task, however, is now perceived to be: (a) preventing, (b) reacting, and (c) building or rebuilding rather than creating eutopia on the Aare (see The Independence of South Sudan: The Role of Mass Media in the Responsibility to Prevent by Walter C. Soderlund and E. Donald Briggs).
From progress to prevention
In theory, one may agree with such a precautionary stance. In practice, things look quite different. Health policy is a good example of this discrepancy. These preventive strategies have given rise to what one might call the medical-industrial complex (MIC) – a phenomenon likely to have a profound impact on our future.
The choice of this term is deliberate. It evokes its military precursor, with which it shares the goals of ‘prevention’ and ‘security’, and which arguably shaped the development of the hegemonic state since WWII. President D. Eisenhower warned in 1961 about the dangers of the ‘military-industrial complex’. He feared that once the preventive logic of the defence system was embedded, it would become self-perpetuating and undermine his country’s democratic processes.
Eisenhower’s fears were not misplaced: defence expenditure ballooned to levels of madness. Surprisingly, it retained staying power despite major shifts in the strategic security environment – a textbook example of a ‘path-dependent outcome’. The complex expanded chaotically and even erratically during the Cold War in response to perceived (and often overstated) threats (see Command and Control: Nuclear Weapons, the Damascus Accident, and the Illusion of Safety by Eric Schlosser). After the fall of the Berlin Wall, it transformed from a mechanism of reciprocal deterrence between states into a system for preventing asymmetric warfare. Today, we live in a permanent ‘quasi-war’ environment. ‘National security’ is now a domestic as well as international concern, encompassing global communications surveillance and the militarisation of police forces.
When care becomes control
Now back to healthcare. Post-WWII, the ability to cure illness and injury took a leap forward with the advent of powerful anaesthetics and antibiotics. Demand for health services skyrocketed. Healthcare provision became a priority for both states and markets. Today, the USA spends 17.9% of its GDP on healthcare (the outcomes in the USA do not seem to justify the overhang of expenditures as compared with other OECD countries), followed by numerous developed countries, many spending over 10% (the EU as a whole spends less than 10%). By 2050, OECD countries could spend 14% of GDP on both health and long-term care. End-of-life care alone consumes a significant share. Healthcare expenditure already dwarfs military spending (<5% of GDP) and education (5–7% of GDP, although the data are fragmentary).
Even more than medical innovation, improvements in public health policy have driven the global trend of population ageing. ‘According to the UN Population Division, 1 in 5 people are expected to be 65 or older by 2035. This dramatic growth in numbers and proportions, increased life expectancies, and energetic lifestyles, now enables us to live 20 to 25% of our lives in active retirement’ – drawing on entitlements such as pensions and health insurance. Not only have we created a novel ‘rentier’ class – the elderly – we have also constructed a system where end-of-life care consumes an increasing share of societal resources. Atul Gawande argues (see Being Mortal: Medicine and What Matters in the End by Atul Gawande), ‘We’ve created a multi-trillion-dollar edifice for dispensing the medical equivalent of lottery tickets – and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win.’
Given the size of the health sector, one might justifiably ask whether the ‘medical-industrial complex’ now surpasses its military cousin in societal impact. They share defining features.
Like security from war, health is a basic societal aspiration: we are willing to spend ‘whatever it takes’. While war can (hopefully) be prevented, death is inevitable. There comes a point where continued treatment leads only to a serious decline in quality of life. Identifying the transition from curative to end-of-life medicine is difficult. Interventions often continue far beyond what is reasonable.
Information asymmetries. As with military expertise, medical knowledge is highly specialised. Few are equipped to assess diagnoses, treatments, or palliative options. Society has shifted from an authoritarian model (‘doctor knows best’) to an informational one (‘the patient chooses best – if informed’). Perversely, this has led to ‘doctor- and therapy-shopping’ (A good example is the increase in C-sections. While no ‘optimal percentage’ may be ascertained, it is doubtful that medical necessity underlies the fact that in Italy C-sections are four times those in the Netherlands. Huge regional disparities also exist within Italy, with Naples exceeding 50%), denial of one’s prognosis, and escalating end-of-life costs. A related issue is adversarial or defensive medicine, which drives up costs further (Development of ubiquitous ‘best practice’ standards and procedural documentation leads to increased costs. Litigation adds another significant layer).
Third-party payor system. As in warfare, where costs are socialised, healthcare expenses are shouldered collectively. Insurance-based models underlie all health financing. The demand for ‘the best’ is widespread. Since neither doctors nor patients bear the cost directly, complex interventions are often favoured over simpler, more appropriate ones. Overspending is systemic.
Fixed-cost-driven care provision. Healthcare as an industrial sector demands massive investment in infrastructure and personnel. These represent sunk costs to be recouped over decades. Once made – often competitively – these investments create pressure to maximise usage regardless of necessity (Particularly in surgery, doctors are under pressure to meet operating room and bed occupancy ‘targets’. For example, in the Canton of Bern, hospitals were located by law to ensure that no citizen was more than a 30-minute ride away. These hospitals remain and are still being expanded. The private sector has added more. Patients now often choose the ‘best’ rather than the nearest hospital).
Manias and panics. Given the speculative nature of preventive medicine, mass media act as key agenda-setters (do we talk about the issue?) and agenda-framers (which options are considered?) in public debate.
The very success of healthcare has created unintended consequences: people live longer in retirement, and end-of-life costs keep rising with no clear link to outcomes. Fixed-cost rigidity hampers strategic change. The financial burden on ageing societies may become unsustainable, especially if economic growth fails to keep pace. The ‘retired bloc’ vote, meanwhile, may resist attempts to renegotiate entitlements.
The ‘medical-industrial complex’ is no longer focused solely on the elderly. It is increasingly targeting rare or extreme conditions in younger populations, creating profitable niche markets (Examples include attempts to extend reproduction beyond physiological limits. Surrogacy is one route. Career pressures now lead many women to freeze eggs for later use.)
At the root of the extreme-cure economy is society’s refusal to develop a heuristic for valuing life itself (see Laws of Fear: Beyond the Precautionary Principles by Cass R. Sunstein). This emotional reluctance fuels absurd spending patterns. Millions die for lack of basic, inexpensive care, yet society awarded USD 89 million to the estate of a 38-year-old woman with advanced metastatic breast cancer after her insurer refused to cover further experimental treatment.
What lies ahead? Unlike military budgets, which are state-driven, individuals influence how they experience death. Many, having seen loved ones suffer in the ‘medical-industrial complex’, now seek the best possible quality of end-of-life. Economic concerns are often secondary. The hospice movement, which began in the UK in the 1960s, is gaining ground worldwide – including in the USA. Palliative care is a growing alternative (see Über das Sterben: Was wir wissen. Was wir tun können. Wie wir uns darauf einstellen by Gian Domenico B). Informal self-help networks are emerging. One perverse consequence of the ‘medical-industrial complex’ is a neglect of geriatric training – in the USA, new specialists are not replacing retirees at sufficient rates.
Once again, it appears that lived experience – not intellectual discourse – will determine outcomes. Moral and political leadership is emerging. Successful referenda show a growing popular consensus.
Cultural conservatism may delay change through rational discourse, but cannot stop it. However, the resulting polarisation may render certain widespread practices unspeakable. Aporia is nothing new. Birth control, for instance, was widely practised in the nineteenth century (see Conflicts in French Society: Anticlericalism, Education and Morals in the Nineteenth Century: Essays by Theodore Zeldin). It remained taboo until the pill normalised it, eliminating the need for public debate.
The post was first published on DeepDip.
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