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ABSTRACT: Health care costs represent the number one political issue in America today. The success of the 1992 Clinton campaign was credited, to a large extent, to James Carville, who brought into focus the urgent consideration of economy with the cliche, “It’s the economy…stupid!”
The title of this paper is predicated on this phrase by substituting the problem of medical care costs for that of the economy. The title is not new, since it has been used in “The Sciences,” the official organ of the New York Academy of Sciences.1 It has also been used in a publication of HMO.2
There is no question that one of the most overused words on the political and socioeconomic scene is health. We are deluged with debates about health care, costs, maintenance organizations (HMOs), reforms, benefits, principles, practices, and policies. Much of this is promoted by “health experts” in the National Institutes of Health (NIH), the Department of Health and Human Services (DHHS) and the World Health Organization (WHO).
Examination of randomly chosen issues of two major American medical journals, including the advertisements, book reviews, letters, and major communications revealed that the word “health” was encountered approximately twice per page in 150-170 pages per issue.3,4 In fact, the word “health” as used in these prestigious journals is so overdone that it has become meaningless. Health expenditures,3 health care,3 health problems4 and health care provider4 are typical examples. There is hardly a health policy expert who has not contributed unwittingly or otherwise to this semantic confusion. The well-written and penetrating discussion by Fuchs5 reveals the repetitive use of the word.
In every instance, the statements become more meaningful only when “health” is replaced by “medical.” Should it be medical insurance rather than health insurance? The same substitution can be made for expenditure, care or issues, all of which are discussed in relation to the word “health.” We can reduce the confusion simply by defining what health care really is. Put simply, it is the primary prevention of health deterioration or its preservation. Modern medicine provides clearcut reasons why costs are rising. It should be referred to as “disease care.”
Cesarean deliveries have accounted for nearly one out of four annual births in the United States,6 the third highest among 21 reporting countries and exceeded only by Brazil and Puerto Rico. The average hospital stay for all deliveries in 1991 was 2.8 days, whereas for a primary C-section it was 4.5 days. The mean costs for cesarean versus vaginal births was $7,826 and $4,720 respectively. It is medical care costs that are rising and there is no doubt that something needs to be done about it. A series of simple observations might clarify the true meaning of health preservation.
An Exercise in Common Sense
The human organism, like any other higher animal, depends upon the efficiency of the immune system. When it fails, we become sick and will die if the failure is severe enough. What can be learned about the immunologic picture from a healthy group subjected to a simple daily exercise program of 30 minutes of t’ai chi, versus control subjects?7 In those performing this simple, Chinese exercise there was a marked improvement in T-lymphocyte dependent immunocompetence. Here is a superb demonstration of health care in action with all its simplicity and total absence of cost.
There is plenty of evidence of health care from other equally simple and cost-free demonstrations. Regular exercise is a well-known health preserver, but it does not have to be athletically vigorous.8 For example, a 150-pound person expends 300-450 calories an hour gardening and 150-250 house cleaning, 435 playing tennis, and even walking at 3.5 miles an hour will burn 372 calories an hour. According to a theoretical model developed by the Rand Corporation, each additional mile a person walks or runs will yield an extra 21 minutes of life and save society an average of 24 cents in medical care. If an otherwise sedentary lifestyle is the rule, by walking at 3 miles an hour an individual can get back the investment with interest. Walking 1 mile a day for 20 years will add 106 days to such a person’s life and save society $1,752.
A Health Bargain
The incidence of otitis media was studied in 237 children in reference to the duration of breast feeding, with a follow-up from birth to three years of age.9 Recurrent ear infections were strongly associated with early bottle feeding. In contrast, prolonged breast feeding provided a 3-year protective effect.
A study of breast feeding was reported in relation to a possible connection to childhood malignancy.10 The survey compared 201 children with diagnosed cancer between the ages of 1.5 and 15 years of age and 181 controls. Children who were breast fed for more than 6 months were strikingly less likely to have cancer than those receiving it for lesser periods and fed by artificial formula. Hence, the fad of not breast feeding infants during the 1950s and 1960s may have been partially responsible for higher rates of cancer and other immunologic disorders.
The cost of bottle feeding as compared with breast feeding has also been studied.11 The average yearly price per bottle-feeding mother in North Carolina was $8,686. In contrast, the low-income nursing mothers required only $4,848 per annum for nutritional support. Hence, not only is bottle feeding more unhealthy but just about twice as costly.
Next to health care, education continues to be a big and important issue. By all standards of measurement, it is stated that American schools are in deep trouble. The solutions, we are promised, will come with more schools, more teachers, more books and increasing computers and other exotic gadgets. Very little attention has been directed to the possibility that the learning in children may be directly related to their health. The U.S. Environmental Protection Agency estimated in 1990 that approximately 3 million children in the United States had blood lead levels high enough to affect intelligence, attendance, dropout rate, behavior and development.12 What may be more important in the overall problem would be to identify and treat those children who have this kind of handicap.
The literature is replete with examples of the clinical devastation of the climacteric, the often ineffective and dangerous therapy and its high cost in dollars. There are, however, harmless alternatives. In a study of 94 menopausal patients,13 treatment consisted of 1200 mg of bioflavonoids and 1200 mg of ascorbic acid a day, compared with calcium carbonate, salicylate or estrogen. Each patient received a one-month course of each of these therapies. The vitamin combination was judged to be the most effective.
In another study of 33 menopausal women, their hot flashes were monitored by sophisticated skin electrode measurements.14 Treatment consisted of slow deep breathing, muscle relaxation or biofeedback. The hot flashes were reduced by 50% in the patients only when practicing deep breathing.
The pandemic nature of heart disease is well known. The fact that hypertension is the leading prodromal warning of serious cardiovascular problems is also unquestioned. The principal thrust in conventional medicine has been weight loss and drugs. We are beginning to learn now that specific dietary factors may play a significant role in therapy. According to McCarron and associates,15 of 17 dietary factors considered, they noted 4 which were significantly related to blood pressure, namely calcium, potassium, vitamin A and the ascorbates.
In a placebo controlled study of 20 adults with hypertension, 1000 mg of ascorbic acid was shown to lower the systolic pressure significantly. Wiley and associates17 studied the effects of isometric, hand exercises on resting blood pressure. Following such simple gripping exercises for two minutes three times a week for 8 weeks, the systolic pressure dropped from 134 to 121, and the diastolic pressure declined from 87 to 72. The matched control group showed no such changes. When the subjects stopped the exercises in the next 5 weeks the blood pressures went back to their original levels.
It is well known that the elderly are more susceptible to infections. Chandra18 studied the effect of vitamin and trace element supplements given in RDA doses compared with placebo. He monitored the occurrence of infection-related illness at the beginning and the end of a 12-month interval. Ninety-six independently living, presumed healthy, elderly individuals who were not taking any medications were randomly assigned to receive dietary fortification or placebo. Only the subjects in the vitamin-supplemented group demonstrated superior immune response as measured by various laboratory indices. The placebo group had 48 days of infectious illness, whereas the supplemented group had only 23, a reduction of over 50%. If this could be extrapolated to other forms of illness, medical care costs might actually be halved.
Nutrition and Timing of Meals
Aside from the quality of food, there are important lessons to be learned from timing.19 It is well known that lower animals like the rat nibble their food. In their pristine world, these creatures fare well. Less known, but equally true, is that the rat, when provided with 3 square meals a day acquires human traits. It becomes obese, blood cholesterol rises and there are blood glucose aberrations of a diabetic nature. What happens when man nibbles like the rat? From every reported study, obesity is muted, and carbohydrate and lipid metabolism are righted. If we were to eat 6 times a day instead of the ritualized number of 3, consuming one-sixth of the daily intake at each meal, there would be some real health benefits.
It is very clear that lung cancer has declined, not because of modern treatment, but because of a high-powered antismoking education crusade designed to modify lifestyle. Leigh and associates20 provided a group of retirees with a readily achievable health education curriculum. Their annual medical bills dropped by $300. Another study21 was reported on the effectiveness of an intervention program designed to modify behaviors which are hypothesized to be related to the future developments of cancer. Of 1,105 children in 15 institutions, schools were assigned to either an intervention or a non-intervention program. Subjects from 4th through 9th grades in schools in the experimental group received each year a teacher-delivered lecture for 2 hours per week, focusing on diet and prevention of cigarette smoking. After six years the rate of initiation of cigarette smoking was 73% lower among children in the experimental group. There was also a striking increase in reported intake of total complex carbohydrates and a concomitant decline in total and saturated fats.
Leaf22 reported that from 1978 to 1988 there was a 29.9% reduction in the age-adjusted death rate from heart attacks in the United States. This encouraging reduction in cardiovascular mortality has resulted largely from the public assuming more healthful living habits rather than from medical treatments. He pointed out that Blue Cross/Blue Shield and Medicare will pay $30,000 for coronary bypass graft operations and more than $100,000 for heart transplant surgery but not $1000 to $2000 for a rehabilitation program.
Summary and Conclusions
This article continues a series of essays on the subject of “Medical Ignorance: Myths and Magics in Modern Medicine”19,23-26 It is now time to try to resolve the myth of this monstrous medical muddle. The problem seems to be one of semantic correctness. Health and medical care, albeit interdependent, are not synonyms. Rarely is this recognized, but it was emphasized in a letter to the editor of the Journal of the American Medical Association that “Medical care is not health care”.27
We have the opportunity to price true health care by instituting the simple techniques described in this article, and others like them, rather than relying on the extravagance associated with disease as our modern system emphasizes.
It is apparent that the public knows better than the physician community what this really means. It was reported from a survey that one in three respondents used at least one unconventional therapy in the year of the survey.28 They made an average of 19 visits to eclectics during the year with a mean charge of $27.60 per visit, after they had already visited a traditional physician. Americans made an estimated 425 million visits to providers of unconventional therapy in 1990. This exceeded the 388 million visits to all U.S. orthodox care physicians. Health care costs are not rising. It is, in fact, our biggest bargain.
- A forum on the President’s proposals for reform: “It’s health care, stupid!” The Sciences 1994; 34:15-21.
- Noe T J. “Health care plus reform equals job restructuring.” HMO 1993; 34:34-43.
- JAMA 1992; 268:2607-2754.
- N. Engl. J. Med. 1993; 328:1-170.
- Fuchs V R. “No pain, no gain: perspectives of cost containment.” JAMA 1993; 268: 631-633.
- Office of Vital and Health Statistics Systems, National Center for Health Statistics, CDC: “rates of Cesarean delivery–United States, 1991.” JAMA 1993; 269:2360.
- Xusenq S, Yugi X, Yunjian X. “Determination of E-rosette forming lymphocytes in aged subjects with Taichiquan exercise.” Int. J. Sports Med. 1989; 10:217-219.
- Stamford B A, Shimer P. Fitness without exercise. New York, Warner Brothers, 1990.
- Saarinen U M. “Prolonged breast feeding as prophylaxis for recurrent otitis media.” Acta. Paediat. Scand. 1982; 71:567-571.
- Davis M K, Savitz D A, Graubard B I. “Infant feeding and childhood cancer.” Lancet 1988; 2:365-368.
- Freed G L. “Breast-feeding: time to teach what we preach.” JAMA 1993; 269:243-245.
- Binder S, Matte T. “Childhood lead poisoning: the impact of prevention.” JAMA 1993; 269:1679-1681.
- Smith C J. “Non-hormonal control of vaso-motor flushing in menopausal patients.” Chicago Med. March 7, 1964.
- Freedman R R, Woodward S. “Behavioral treatment of menopausal hot flushes: evaluation by ambulatory monitoring.” Am. J. Obst. Gyn. 1992; 167;436-439.
- McCarron D A, Morris C D, Henry H J, et al. “Blood pressure and nutrient intake in the United States.” Science 1984; 224:1392-1398.
- Osilesi O, Trout D L, Ogunwole J O, et al. “Blood pressure and plasma lipids during ascorbic acid supplementation in borderline hypertensive and normotensive adults.” Nutr. Res. 1991; 11:405-412.
- Wiley R L, Dunn D. L, Cox R H, et al. “Isometric exercise training lowers resting blood pressure.” Med. Sci .Sports Exercise 1992; 24:749-754.
- Chandra R K. “Effect of vitamin and trace element supplementation on immune responses and infection in elderly subjects.” Lancet 1992; 340:1124-1127.
- Cheraskin E. “The breakfast, lunch, dinner ritual.” J. Orthomol. Med. 1993; 8:6-10.
- Leigh J P, Richardson N, Beck R, et al. “Randomized controlled study of a retiree health promotion program: The Bank of America Study.” Arch. Int. Med. 1992; 152:1201-1206.
- Walter J H, Vaughan R D, Wynder E L. “Primary prevention of cancer among children: changes in cigarette smoking and diet after six years of intervention.” J. Nat. Cancer Inst. 1989; 81:995-999.
- Leaf A. “Preventive medicine for our ailing health care system.” JAMA 1993; 269: 616-618.
- Cheraskin E. “The name of the game is the name: revisited.” J. Orthomol. Med. 1993; 8:1-4.
- Cheraskin E. “The case of the invisible toothbrush: why some people can brush less.” J. Orthomol. Med. 1993; 8:176-181.
- Cheraskin E. “Will the real diabetic please stand.” J. Adv. Med. 1993; 6:185-192.
- Cheraskin E. “Primum non nocere: revisited.” J. Appl. Nutr. 1993; 45:115-121.
- Winkelstein W, Jr. “Medical care is not health care.” JAMA 1993; 269:2504.
- Eisenberg D M, Kessler R C, Foster C, et al. “Unconventional medicine in the United States; prevalence, costs and patterns of use.” N. Engl. J. Med. 1993; 328: 246-252.