Medical Care and Health Improvement: The Critical Link

What is the contribution of medical care to health improvement? For decades, this question has occupied and preoccupied countless professionals, researchers, politicians, and members of the public. Health care systems serve many secondary purposes, such as creating jobs or generating profits, but most people would agree that services should be primarily a means toward the end of improved health. However, there is sharp disagreement about the strength of this relation compared with other factors that determine health status. The implications of this discrepancy go beyond academic interest to include key policy matters.

The “In the Balance” papers in this issue deal with one of those matters, probably the most important one: What is the best strategy to reduce persistent inequalities in health? Andrulis [1] and Pincus and colleagues [2] draw up the lines of the debate with clarity. One side maintains that expanded access to medical care is essential to achieve that goal. The key assumption underlying this position is that health services are major determinants of health status, so that inequalities in the latter are largely the result of differential access to the former. The other side claims that medical services have a small effect on health status compared with socioeconomic determinants. Thus, progress in reducing health inequalities will be achieved not so much by increasing access to medical care as by changing the social conditions and lifestyles that account for the persistence of such inequalities.

Clearly, the question that lies at the heart of the discrepancy between the two articles has to do with the weight of medical services compared with other determinants of health status. This debate has a long history in medicine and public health. Throughout the evolution of this debate, two levels of analysis have produced different bodies of evidence. The first level, the “macro” level, deals with the aggregate effects of medical care on the health conditions of entire populations. The second level, the “micro” level, focuses on the effectiveness of specific medical interventions in achieving health outcomes for particular groups. Most of the evidence cited by both papers belong to the latter category. However, it is important to briefly examine their broader context.

The macro-level debate was triggered by the interest in accounting for the impressive reductions in mortality that have been achieved in the past century. Such reductions have benefited almost all countries of the world and all social groups, although with enormous disparities in the extent and pace of progress. The coincidence of this process with the multiplication of efficacious medical technologies led to the almost obvious conclusion that the latter had to be the cause of the reduction in mortality, but this certainty was not to last long.

In the 1950s, precisely when most countries were beginning to report important decreases in mortality, several influential criticisms were leveled against the conventional wisdom. In 1959, Rene Dubos published his now-classic book Mirage of Health [3]. In it, he demonstrated that mortality had begun to decline in the West much before the formulation of the microbial theory of disease and the availability of “magic bullets.” Almost at the same time, physician and demographer Thomas McKeown was beginning the series of studies that would make him one of the most controversial critics of the role of medicine [4]. According to McKeown, the main reasons for the decline of mortality were to be found in better living conditions, especially nutrition, housing, and environmental sanitation. This was certainly not the first time that the effect of social conditions on health had been noted; this observation goes back at least to the ancient Greeks and finds an eloquent exponent in Rudolf Virchow. The important point was that both Dubos and McKeown were specifically trying to refute the common notion that medical advances were responsible for major gains in health.

Medical intervention has always been accompanied by skepticism about its value. But what began to be expressed in this debate were not doubts about particular interventions but doubts about the entire medical enterprise, leading to what Paul Starr has called a new “therapeutic nihilism” [5]. This view implied a radical shift in public policy for health. Whereas a common policy goal throughout the world had been to achieve universal access to medical care, the notion of the relative irrelevance of medical care undermined the rationale for such a goal. As Starr [5] points out, if medical services make so little difference in health and life expectancy, “why worry about the poor-or, for that matter, anyone-not getting enough of them?” Ironically, therapeutic nihilism began as a critique from the left but was subsequently incorporated into the conservative justification for cutting health care budgets and tolerating socioeconomic inequalities in access.

This long-standing debate is now enriched by the “In the Balance” articles. Both offer instructive reviews of the recent literature, mostly about specific interventions and populations, which complement the more aggregate evidence of earlier discussions. While acknowledging the importance of other determinants of health, Andrulis [1] makes a case for achieving universal access to medical care. In contrast, Pincus and colleagues [2] argue that it is much more important to focus on broad social conditions and what they call “self-management” by patients. In support of this position, they cite several studies showing that socioeconomic differentials in health have persisted or even widened in many countries despite the elimination of financial barriers to care.

However, the existence of a health gap per se does not imply that access to care is irrelevant. As a result of universal access, poor persons might have made important progress in their health status, yet the gap might have widened if the better-off groups in society had experienced an even higher rate of improvement given all their other advantages. The authors do not consider the possibility that without such access, inequalities in health status might have been even worse than the observed ones. Furthermore, it is important that their call for more patient involvement in self-management does not mean that disadvantaged groups are left only with a low-grade substitute formal medical care. This would truly deepen inequities.

The point of these comments is not to deny the central importance of socioeconomic and behavioral factors in the determination of health. However, this recognition need not lead to the conclusion that medical care has little value. In fact, the contrary is true. As Andrulis underscores [1], a large part of the socioeconomic differentials in health stem from unequal access to medical services that have proven to be highly efficacious. The problem is that resources are often allocated to interventions of unproven efficacy. Under these circumstances, the aggregate value of medicine in producing health will be reduced. The solution is not to dismiss all medical care but to improve the allocation of resources by giving priority to effective services and assuring access to them. As Starr [5] has persuasively reasoned, critics have the point turned around when they argue that because medical care has had a relatively small effect on health, we should not be concerned about inequalities in access. If we wish to make medical care have a greater effect on health, we must be centrally concerned with eliminating inequalities in access to effective services. If we give up the cause for universal access, what is the point of advocating improved effectiveness, quality, and efficiency? Without recognition of the value of medicine, it becomes illogical to make proposals for improving health services.

Fortunately, Pincus and colleagues [2] avoid falling into an extreme position. Their paper repeatedly emphasizes the need to pay attention to social factors in addition to and not instead of access. In fact, the debate between medical care and socioeconomic development as alternative determinants of health represents a false dilemma. Health services are not disconnected from social conditions, as the debate often seems to suggest. On the contrary, the quality and coverage of health services are an integral part of the definition of development itself and constitute one of the main indicators of social well-being. Sustained health improvement seems to be the result of a process of development that includes access to high-quality services as one of its main components.

We must supersede false dilemmas if we wish to understand and act on the intricate causal web that determines the distribution of health status across social groups. Achieving better health is too complex a process to allow one-sided conceptions and prescriptions. Improved social conditions, promotion of healthy behaviors by individual persons, and universal access to medical care are not alternative but synergistic strategies in the pursuit of health.

• Copyright ©2004 by the American College of Physicians