[On May 18, the website of the Ludwig von Mises Institute ran a slightly edited version of this article. You can find it here.]
In its current usage, the phrase “dismal science” is a disparagement leveled against mainstream economics for its failure to provide a coherent account of economic activity.
According to Austrian school critics of the neo-Keynesian synthesis, this failure is in large part due to a foolish determination to bring into economics the mathematical precision of the physical sciences. To achieve this precision, neo-classical economists disproportionately focus their inquiry on global measures of economic activity: gross national product, aggregate demand, global supplies of money, goods, or labor, and other variables that lend themselves to quantification and numerical modeling. Lost in mainstream economic analysis is the attention due to the individual economic actor who, by virtue of his or her power of self-determination, is ill-suited for the equation or the graph.
A similar love affair with quantitative methods has rapidly taken over the medical field over the last several decades. As in mainstream economics, equations and predictions can only come about by turning one’s attention away from the individual patient to focus instead on the aggregated group, or population, as the prime target of analysis and intervention. Thus, population medicine is an apt term to describe the discipline that seeks to mathematize medical practice by caring not for the patient in particular, but for the patient on average, globally, or in the abstract.
For the promoters of population medicine, the individual clinical interaction is of no interest. It is dismissed as quaint, anecdotal, and inconsequential to a proper understanding of health issues. Instead, the data of interest are those garnered from large epidemiological studies and clinical trials. From such research, one can derive “risk factors” for disease, elucidate the “determinants of health,” and promote prescriptive measures in wide swaths.
Advancing the convenient fiction that whatever is good for the group must be good for the individual, population medicine has become an indispensable framework of analysis for the central planning of health care. Accordingly, government agencies can now avail themselves of the findings of this discipline to decide which services, drugs, and interventions should be paid for and promoted, and which must be deemed unnecessary or even fraudulent. The decisions can thus be rendered under cover of “scientific proof.”
An example of activities promoted by population medicine is the “risk calculation,” which doctors are expected to embrace, or else face penalties for practicing outside of the desired norm. Risk calculation involves inputting a handful of patient factors—e.g., age, weight, cholesterol, blood pressure, and the like—into a formula to obtain the patient’s “personal risk” of dying or suffering a specific outcome in the future. Based on this mathematical insight, an intervention is prescribed. A patient can thus enjoy the privilege of being treated like a number not just figuratively, but quite literally.
Needless to say, the architects of population medicine overlook that the concept of “personal risk” is rather devoid of meaning, as statistician Richard von Mises explained many decades ago. Willful or naive, this oversight is turning medicine into an enormous risk management enterprise aimed at solving an impossible game of health optimization.
According to the wisdom of population medicine, for example, to be healthy is to confine our weight, our blood cholesterol, or our blood sugar to an ever-more narrow range of “normal values” defined—and repeatedly revised—not on the basis of any physiological reality, but by the will of committees of medical technocrats. With each new revision in the definitions of what constitutes a “normal” blood pressure, blood cholesterol, or blood sugar, millions of hapless citizens whose numbers happen to fall outside the desired range are instantly turned into patients, to the great delight of the pharmaceutical industry.
And it’s not just anthropomorphic variables which are so narrowly defined. What we eat, how much we drink, how long we sit, and how fast we move are all of interest to population scientists eager to show us the narrow path to healthy living measured in precise servings per meal, ounces per day, hours per week, or miles per minute.
The scientific advice, unfortunately, does not always lead to a healthy outcome. A population-wide push to discourage consumption of saturated fats, for example, led to a population-wide increase in the consumption of carbohydrates, and thus may have unwittingly played a role in the obesity epidemic of the last 20 years. At the very least, lifestyle fads advocated through the bullhorns of population medicine are undoubtedly causing epidemics of food and exercise neuroses.
Population medicine ambitiously aims to improve the health of entire nations. To do so, it proceeds to sketch an ever-more quantified but all-the-more unrealistic portrait of the human being, to be analyzed by those who enjoy directing medical care from the remote comfort of their academic or governmental chairs.
The parallels between neo-Keynesianism and Population medicine can be summarized as follows:
- Neo-Keynesianism ignores the subjectivity of consumer decisions and the specific role of the entrepreneur in the economy. Population medicine ignores patient individuality and the personal role of the physician in health care.
- Neo-Keynesianism misunderstands money and promotes fiat currencies. Population medicine misunderstands health and promotes fiat diseases.
- Neo-Keynesianism embraces the central planning of the economy. Population medicine embraces the central planning of health care.
- Neo-Keynesianism contributes to booms and busts in the economy. Population medicine contributes to booms and busts of artifactual epidemics.
- Neo-Keynesianism favors the growth of government bureaucracies and corporate interests. Population Medicine acts similarly, favoring the growth of healthcare bureaucracies and giant healthcare corporations.
- Neo-Keynesianism reigns at the Federal Reserve. Population medicine reigns at the Institute of Medicine, the World Health Organization, the Center for Disease Control, the American Medical Association, among most healthcare organizations and among most medical school faculties throughout the nation and across the world.
The frightening core of population medicine was candidly made clear in a commentary by Dr. Harold Sox writing in the November 13,2013 issue of JAMA that is entitled “Resolving the tension between population health and individual health care”.
Particularly chilling is this paragraph :
“It will take several generations to realize the full benefit of investments in disease prevention . In the short run,the investments may draw resources away from tests and treatment for some sick people.In the long run, disease prevention and better low cost technology could reduce the outlay for treatment.In the interim, skillful clinical decision making can make the most of limited resources”
Dr. Sox continues and makes a Orwellian link to his proposed sacrifice of the individual to some alleged aggregate benefit and “patient centered care”. Wow! Sacrificing the individual for the statistical “good” of the group is now what we call “patient centered care”. 2+2=5.
Your description of the similarities of aggregate economics and aggregate medicine is brilliant. Thank you for putting into words something I have been fumbling with for some time . I will quote freely from your analysis.
James
James,
Thank you. I remember reading your analysis of Harold Sox’s comments on your blog. I also must give you credit for the Richard von Mises insight. I think I read it first on your blog, if I recall. (Interested readers should definitely check-out Dr. James Gaulte’s outstanding blog).
Amazing what one can do by conflating Keynesian economics, population health, and government planning and then combining them with a gargantuan dose of imagination. The result: a frightening, And mostly imaginary “boogey thing”.
First, don’t confuse population health with public health. The latter focusses on applying the same principle to everyone, whereas in population health the whole point is to make sure that every individual in a group receives the care they need, when they need it, and where they need it. My visits to many organizations that have embraced population health have convinced me that they have grasped what it means to provide care that understands the needs of the individual person better than our traditional approach. What makes our profession so wise as to think that the best care is that which requires someone to come to us only after they perceive an illness, especially one that might have been prevented in the first place?
And this thing about risk scores? The ones I see have nothing to do with this idea of “government planning”. No, they simply are used to help direct resources to people who might benefit from them. And the individual can choose to accept or reject those resources .
As for Hal Sox (disclosure: a personal friend for nearly 40 years), I admit that I am not sure what his comment meant. What I am sure of is that he has trained hundreds of physicians over his career, and he has trained them to be astute and caring clinicians. He has also trained them to be prudent in their use of tests and treatments, such that the ones that are employed actually benefit the patient.
I found this article very interesting because, at this time in the state of Utah, SelectHealth is promoting a new managed care product. SelectHealth is an insurance carrier that is at least partially owned by Intermountain Healthcare, a monopolistic behemoth in Utah, especially in areas with only one hospital for miles. In its promotion of SelectHealth Share, the carrier is talking about “population health,” which sounds like so much pablum to me.