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Health and Medicine

"A man ought to handle his body like the sail of a ship, and neither lower and reduce it much when no cloud is in sight, nor be slack and careless in managing it when he comes to suspect something is wrong."

Plutarch (46? - 120?)
Greek biographer and philosopher.
Moralia, "Advice about Keeping Well"

The World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being, and does not consist only of the absence of disease or infirmity". Though this is a useful and accurate definition, some would consider it idealistic and nonrealistic because using the WHO definition classifies 70-95% of people as unhealthy. This definition also overlooks the fact that several factors influence both the definition of health and standards of health.

What it means to be healthy can vary from culture to culture and is often connected with advances in technology. In some cultures, larger body sizes are seen as a sign of healthiness as it indicates an individual has a preponderance of food. In other cultures, largess is more closely associated with unhealthy lifestyles (e.g., lack of exercise, poor eating habits, etc.). Advances in technology have also expanded the idea of what it means to be healthy. What are understood today to be healthy practices were not emphasized prior to clear understandings of disease and the contributions of lifestyles to health.

A doctor conducting a pre-natal examination of a patient in El Salvador

Figure 1: A doctor conducting a pre-natal examination of a patient in El Salvador.

Health care (or healthcare) is an industry associated with the the prevention, treatment, and management of illness along with the promotion of mental and physical well-being through the services offered by the medical and allied health professions. Healthcare is one of the world's largest and fastest-growing industries, consuming over 10 percent of gross domestic product of most developed nations. In 2000, health care costs paid to hospitals, doctors, diagnostic laboratories, pharmacies, medical device manufacturers and other components of the health care system, consumed an estimated 14 percent of the gross national product of the United States, the largest of any country in the world. For the G8 countries (eight of the most developed countries in the world) the average is about nine percent.

Immunizations from various diseases have improved health worldwide

Figure 2: Immunizations from various diseases have improved health worldwide.

The sociology of health and medicine is concerned with the distribution of healthcare services globally, in particular inequalities in healthcare, and how conceptions of health have changed over time.

The Evolution of Health Care and Medicine

All human societies have beliefs that provide explanations for, and responses to, childbirth, death, and disease. Throughout the world, illness has often been attributed to witchcraft, demons, or the will of the gods, ideas that retain some power within certain cultures and communities (see faith healing). However, the rise of scientific medicine in the past two centuries has altered or replaced many historic health practices.

Folk Medicine

Folk medicine refers collectively to procedures traditionally used for treatment of illness and injury, aid to childbirth, and maintenance of wellness. It is a body of knowledge distinct from modern, scientific medicine but may coexist in the same culture. It is usually unwritten and transmitted orally until someone collects it. Within a given culture, elements of folk medicine may be diffusely known by many adults or may be gathered and applied by those in a specific role of healer, shaman, midwife, witch, or dealer in herbs. Elements in a specific culture are not necessarily integrated into a coherent system and may be contradictory. Folk medicine is sometimes associated with quackery when practiced as theatrics or otherwise practiced fraudulently, yet it may also preserve important knowledge and cultural tradition from the past.

Herbal medicine is an aspect of folk medicine that involves the use of gathered plant parts to make teas, poultices, or powders that purportedly effect cures. Many effective treatments adopted by physicians over the centuries were derived from plants (i.e. aspirin), and botany was an important part of the materia medica of professional medical training before the 20th century.

Increasing attention is being paid to the folk medicine of indigenous peoples of remote areas of the world in hope of finding new pharmaceuticals. Of special concern is the extinction of many species by the clearing of formerly wild rainforests. Such activity may lead to the loss of species of plants that could provide aids to modern medicine. Attitudes toward this type of knowledge gathering and plant preservation vary and political conflicts have increasingly arisen over ownership of the plants, land, and knowledge in several parts of the world.

Alternative Medicine

Alternative medicine describes methods and practices used in place of, or in addition to, conventional medical treatments. The precise scope of alternative medicine is a matter of some debate and depends to a great extent on the definition of conventional medicine. Positions on the distinction between the two include those who reject the safety and efficacy of the other, and a number of positions in between.

The debate on alternative medicine is also complicated by the diversity of treatments that are categorized as alternative. These include practices that incorporate spiritual, metaphysical, or religious underpinnings; non-European medical traditions; newly developed approaches to healing; and a number of others. Proponents of one class of alternative medicine may reject the others while much of alternative medicine is rejected by conventional medicine.

Many in the scientific community label all healthcare practices that have not undergone scientific testing (i.e., peer-reviewed, controlled studies) as alternative medicine. Yet, the boundary between alternative and mainstream medicine has changed over time. Some methods once considered alternative have later been adopted by conventional medicine, when confirmed by controlled studies. Many very old conventional medical practices are now seen as alternative medicine, as modern controlled studies have shown that certain treatments were not actually effective. Supporters of alternative methods suggest that much of what is currently called alternative medicine will be similarly assimilated by the mainstream in the future.

Criticisms of alternative medicine→ Due to the wide range of therapies that are considered alternative, few criticisms apply to all of them. Criticisms directed at specific branches of alternative medicine range from the fairly minor (e.g., conventional treament is believed to be more effective in a particular area) to incompatibility with the known laws of physics. Some of the criticisms of alternative medicine include:

• Lack of proper testing- Despite the large number of studies regarding alternative therapies, critics contend that there are no statistics on exactly how many of these studies were controlled, double-blind peer-reviewed experiments or how many produced results supporting alternative medicine or parts thereof. They contend that many forms of alternative medicine are rejected by conventional medicine because the efficacy of the treatments has not been demonstrated through double-blind randomized controlled trials. Where alternative methods provide temporary symptomatic relief, this has been explained as being due to the placebo effect, or to natural healing, or to the cyclic nature of some illnesses. Richard Dawkins, professor of the Public Understanding of Science at Oxford University, defines alternative medicine as "that set of practices that cannot be tested, refuse to be tested or consistently fail tests".

• Not proven to be an alternative- Some doctors and scientists feel that the term alternative medicine is misleading, as these treatments have not been proven to be an effective alternative to regulated conventional medicine.

 Safety issues- Some alternative practices have caused deaths indirectly when patients have used alternatives in attempts to treat such conditions as appendicitis and failed. Proponents of alternative medicine say that people should be free to choose whatever method of healthcare they want. Critics agree that people should be free to choose, but when choosing, people must be certain that whatever method they choose will be safe and effective. People who choose alternative medicine may think they are choosing a safe, effective medicine, while they may only be getting quack remedies. This issue is particularly important in the treatment of children and individuals whose capacity to evaluate the treatment is impaired.

• Delay in seeking conventional medical treatment- There is a concern that patients may delay seeking conventional medicine that could be more effective, while they undergo alternative therapies, potentially resulting in harm.

• Poor diagnosis- Medical doctors hold that alternative medical practitioners sometimes fail to correctly diagnose illnesses and therefore do not provide safe therapies. William T. Jarvis contends in a web article "How Quackery Harms Cancer Patients" that "Dubious therapies can cause death, serious injury, unnecessary suffering, and disfigurement" and gives an example of how an unlicenced naturopath caused severe disfigurement of a patient.

• Issues of regulation- In countries where healthcare is state-funded or funded by medical insurance, alternative therapies are often not covered, and must be paid for by the patient. Further, in some countries, some branches of alternative medicine are not properly regulated. As a result, there is no governmental control on who practices alternative medicine and no real way of knowing what training or expertise they possess. In the United States, herbal remedies, vitamins, and supplements are not regulated by the Food and Drug Administration (FDA). This means that companies are not required to prove that these supplements are either effective or safe. The failure to regulate supplements has lead to serious problems, including some deaths. Such problems did ultimately lead the FDA to ban the sale of ephedra, an herbal supplement implicated in several deaths.

• Testing and studies- The scientific community argues that many studies carried out by alternative medicine promoters are flawed, as they often use testimonials and hearsay as evidence, leaving the results open to observer bias. They argue that the only way to counter observer bias is to run a double-blind experiment in which neither the patient nor the practitioner knows whether the real treatment is being given or if a placebo has been administered. This research should then be reviewed by peers to determine the validity of the research methodology. Testimonials are particularly disturbing in this regard because, by chance alone, some people may see some improvement in the ailment for which they are being treated and will proceed to testify that the method helped them when the method was not the true cause of improvement.

 Lack of funding- Some argue that less research is carried out on alternative medicine because many alternative medicine techniques cannot be patented; as a result there is little financial incentive to study them. Conventional pharmaceutical research, by contrast, can be very lucrative. However, funding for research into alternative medicine has increased. Increasing the funding for research of alternative medicine techniques is the explicit purpose of the National Center for Complementary and Alternative Medicine (NCCAM). NCCAM and its predecessor, the Office of Alternative Medicine, have spent more than $200 million on such research since 1991.

Modern Medicine

Modern medicine has substantially improved quality of life around the world.

Figure 3: Modern medicine has substantially improved quality of life around the world.

The more generally accepted view of healthcare is that improvements result from advancements in medical science. The medical model focuses on the eradication of illness through diagnosis and effective treatment. In contrast the social model of healthcare places emphasis on changes that can be made in society and in people's own lifestyles to make the population healthier. It defines illness from the point of view of the individual's functioning within society rather than by monitoring for changes in biological or physiological signs.

Modern, western medicine has proven uniquely effective and widespread compared with all other medical forms, but has fallen far short of what once seemed a realistic goal of conquering all disease and bringing health to even the poorest of nations. Modern medicine is notably secular, indifferent to ideas of the supernatural or the spirit, and concentrating on the body to determine causes and cures - an emphasis that has provoked something of a backlash in recent years. Backlashes notwithstanding, modern, western medicine is clearly the most effective contributor to the health of humans in the world today.

Health Disparities

While technology has advanced the practice of medicine and generally improved health, not all people have the same access to health care or the same quality of health care. According to the Health Resources and Services Administration of the U.S., health disparities are the "population-specific differences in the presence of disease, health outcomes, or access to health care". Of particular interest to sociologists are the differences in health and quality of health care across racial, socioeconomic, and ethnic groups.

In an effort to dispel the stigma associated with HIV/AIDS testig in Ethiopia, Randall Tobias, U.S. Global AIDS Coordinator, was publicly tested

Figure 4: In an effort to dispel the stigma associated with HIV/AIDS testig in Ethiopia, Randall Tobias, U.S. Global AIDS Coordinator, was publicly tested.

In the United States, health disparities are well documented in minority populations such as African Americans, Native Americans, Asian Americans, and Hispanics. When compared to whites, these minority groups have higher incidents of chronic diseases, higher mortality, and poorer health outcomes. Among the disease-specific examples of racial and ethnic disparities in the United States is the cancer incidence rate among African Americans/blacks, which is 10 percent higher than among whites. In addition, adult blacks and Hispanics have approximately twice the risk as whites of developing diabetes. Minorities also have higher rates of cardiovascular disease, HIV/AIDS, and infant mortality than whites.

Age-sex-adjusted percent of persons of all ages who assessed their health as excellent or very good, by race/ethnicity: United States, 2004

Figure 5: Age-sex-adjusted percent of persons of all ages who assessed their health as excellent or very good, by race/ethnicity: United States, 2004

Causes of Health Disparities

There is debate about what causes health disparities between ethnic and racial groups. However, it is generally accepted that disparities can result from three main areas:

• From the differences in socioeconomic and environmental characteristics of different ethnic and racial groups. For instance, blacks and hispanics tend to live in poorer neighborhoods that are near to industrial areas and are older than new suburban subdivisions. Industrial pollutants and lead-paint, common in older homes, can both lead to increased incidents of disease.

• From the barriers certain racial and ethnic groups encounter when trying to enter into the health care delivery system.

• From the quality of health care different ethnic and racial groups receive.

Most attention on the issue has been given to the health outcomes that result from differences in access to medical care among groups and the quality of care different groups receive. Reasons for disparities in access to health care are many, but can include the following:

• Lack of insurance coverage. Without health insurance, patients are more likely to postpone medical care, more likely to go without needed medical care, and more likely to go without prescription medicines. Minority groups in the United States lack insurance coverage at higher rates than whites.

Age-sex-adjusted percent of persons of all ages without health insurance coverage, by race/ethnicity: United States, 2004

Figure 6: Age-sex-adjusted percent of persons of all ages without health insurance coverage, by race/ethnicity: United States, 2004

• Lack of a regular source of care. Without access to a regular source of care, patients have greater difficulty obtaining care, fewer doctor visits, and more difficulty obtaining prescription drugs. Compared to whites, minority groups in the United States are less likely to have a doctor they go to on a regular basis and are more likely to use emergency rooms and free or reduced rate, government subsidized clinics as their regular source of care.

• Lack of financial resources. Although the lack of financial resources is a barrier to health care access for many Americans, the impact on access appears to be greater for minority populations.

• Structural barriers. Structural barriers to health care include poor transportation, an inability to schedule appointments quickly or during convenient hours, and excessive time spent in the waiting room, all of which affect a person's ability and willingness to obtain needed care.

• The health financing system. The Institute of Medicine in the United States says fragmentation of the U.S. health care delivery and financing system is a barrier to accessing care. Racial and ethnic minorities are more likely to be enrolled in health insurance plans which place limits on covered services and offer a limited number of health care providers.

• Scarcity of providers. In inner cities, rural areas, and communities with high concentrations of minority populations, access to medical care can be limited due to the scarcity of primary care practitioners, specialists, and diagnostic facilities. In addition more private practices are putting limits on the number of medicaid and medicare patients that they will accept because these programs reimburse at a much lower percentage than private insurers. Finding physicians who accept Medicaid and Medicare is becoming increasingly difficult.

• Linguistic barriers. Language differences restrict access to medical care for minorities in the United States who are not English-proficient.

• Low Health literacy. This is where patients have problems obtaining, processing, and understanding basic health information. For example, patients with a poor understanding of good health may not know when it is necessary to seek care for certain symptoms. Similarly, they may not understand the medical jargon that is used by health professionals and, consequently, are unable to accurately follow medical instructions. While problems with health literacy are not limited to minority groups, the problem can be more pronounced in these groups than in whites due to socioeconomic and educational factors.

• Lack of diversity in the health care workforce. Cultural differences between predominantly white health care providers and minority patients is also often cited as a barrier to health care. Only 4% of physicians in the United States are African American; Hispanics represent just 5%. These percentages are much lower than these groups' respective proportions of the United States population.

• Provider discrimination. This is where health care providers either unconsciously or consciously treat certain racial and ethnic patients differently than they treat their white patients. Some research suggests that minorities are less likely than whites to receive a kidney transplant once on dialysis or to receive pain medication for bone fractures. Critics question this research and say further studies are needed to determine how doctors and patients make their treatment decisions. Others argue that certain diseases cluster by ethnicity and that clinical decision making does not always reflect these differences.

Paying for Medical Care

As noted in the previous section, disparities in health care are often related to an individual's or a group's ability to pay for health care. This section discusses the costs of healthcare and the different approaches to health care that have been taken by governments around the world.

Health Insurance

Health insurance is a type of insurance whereby the insurer pays the medical costs of the insured if the insured becomes sick due to covered causes or accidents. The insurer may be a private organization or a government agency. According to the 2005 United States Census Bureau, approximately 85% of Americans have health insurance. Approximately 60% obtain health insurance through their place of employment or as individuals and various government agencies provide health insurance to 25% of Americans.

Percentage of persons under age 65 years without health insurance coverage, by age gro and sex: United States, 2004

Figure 7: Percentage of persons under age 65 years without health insurance coverage, by age gro and sex: United States, 2004

While the rising cost of health care is debated, some contributing causes are accepted. Ageing populations require more health care as a result of increased life expectancy. Advances in medical technology have arguably driven up the prices of procedures, especially cutting edge and experimental procedures. Poor health choices also increase health care costs by increasing the incident of disease and disability. Preventable health issues are related to:

  • insufficient exercise

  • unhealthy food choices

  • excessive alcohol consumption

  • smoking

  • obesity (more on this below)

Figure 8: Age-sx-adjusted percent of persons of all ages who failed obtain needed medical care due to cost at some time during the past 12 months, by rac/ethnicity: United States

In theory, people could lower health insurance prices by exercising, eating healthy food, and avoiding addictive substances that are damaging to the body. Healthier lifestyles protect the body from disease, and with fewer diseases, there would be fewer health care related expenses.

Another element of high health care costs is related to the private management of healthcare by large corporations. While this is discussed in greater detail below, it is worth noting that corporate profits have also played a role in increased health care premiums.

Private Insurance and Free-Market Health Care

Two types of health insurance have developed in modern society: private health insurance (or free-market) models and publicly funded health insurance models. The benefits and drawbacks of each of these models is discussed in this and the following section.

Private insurance refers to health insurance provided by a non-governmental organization, usually a privately owned or publically traded corporation. Private insurance as the primary provider of health care in a developed nation is really only found in the United States. It is important to note that while the United States is the most private of any system, there is a substantial public component. Of every dollar spent on health care in the United States, 44 cents comes from some level of government. In addition, government also increases private sector costs by imposing licensing and regulatory barriers to entry into both the practice of medicine and the drug trade within America. Private practitioners also face inflated costs through the government's use of protectionist measures against foreign companies, to uphold the intellectual property rights of the U.S. pharmaceutical industry.

Advocates of the private model argue that this approach to health care has the following benefits:

  • · Some economists argue that the free market is better able to allocate discretionary spending where consumers value it the most. There is variation among individuals about how much they value peace of mind and a lower risk of death. For example, while a public-funded system (see below) might decide to pay for a pap smear only once every five years if the patient was not positive for the human papilloma virus based on cost efficiency, in a private system a consumer can choose to be screened more often and enjoy the luxury of greater peace of mind and marginally reduced risk. When evaluating the pool of current medical spending available to fund cost effective care for the uninsured, this discretionary spending might be moved to nonmedical luxury goods. Also, since current private plans are not very good at limiting spending to cost effective procedures and schedules, those consumers exploiting this will view the transition to a public system as a reduction in their compensation or benefits, and will question whether a society that will allow them to buy a better car or a European vacation, but not better health care, is truly free.

  • Advocates also point to the remarkable advances in medical technology that have accompanied the private insurance/free-market approach to health care. When health care is privately funded, the opportunity for making large amounts of money is an attractive proposition for researchers in medical technology and pharmaceuticals. Thus, the private insurance system, while it may not provide adequate care for everyone (see the criticisms below), does provide cutting edge technology for those who have who can afford it.

  • Advocates also argue that private industry is more efficient than government, which can be quite susceptible to bloat and bureaucracy. However, as is discussed below, this is not always true.

Despite these possible benefits, the private insurance approach is not without its drawbacks. Following are some of the more common criticisms of the private health insurance approach to health care:

  • As noted above, private insurance can be a boon to those who can afford the cutting edge technology. But the flipside to this boon is that the United States, the only mostly-private health delivery system in a developed country, is below average among developed nations by almost every health measure, including: infant mortality, life expectancy, and cancer survival rates. · Another significant criticism of the private system is that it ends up being more costly than publicly funded systems. In 2001 the United States government spent $4,887 per person on health care. That is more than double the rate of any other G8 country, except Japan which spends close to $2,627 per capita annually. Surprisingly, the United States also spends a greater fraction of its national budget on health than such nations as Canada, Germany, France, or Japan. This is particularly surprising considering private insurers are supposed to cover the majority of health care costs.

  • Most experts believe that significant market failure occurs in health markets, thereby leading free market insurance models to operate inefficiently. The consumers of health care are vastly less knowledgeable than the medical professionals they buy it from. An individual is especially less likely to make rational choices about his/her own health care in a case of emergency. The extreme importance of health matters to the consumer adds to the problem of the information gap. This gives the medical profession the ability to set rates that are well above free market value. The need to ensure competence and qualifications among medical professionals also means that they are inevitably closely controlled by professional associations that can exert monopolistic control over prices. Monopolies are made even more likely by the sheer variety of specialists and the importance of geographic proximity. Patients in most markets have no more than one or two heart specialists or brain surgeons to choose from, making competition for patients between such experts very limited.

  • In theory when a government sets billing rates it can negotiate with the professional societies with equal heft and knowledge, reaching a total cost that is closer to the ideal than an unregulated market. In private insurance systems, each insurance company is responsible for negotiating its own salaries. A possible result of this approach is the higher pay in doctors' salaries. Doctors' salaries do tend to be much lower in public systems. For instance, doctors' salaries in the United States are twice those in Canada.

  • The private insurance or free-market approach also fails to provide an efficient delivery for health care because prevention is such an essential component, but one that most people misjudge. Screening for diseases such as cancer saves both lives and money, but there is a tendency within the general population to not correctly assess their risk of disease and thus to not have regular check ups. Many people are only willing to pay a doctor when they are sick, even though this care may be far more expensive than regular preventative care would have been. The one exception is when extensive publicity, such as that for mammograms, is undertaken. Making regular appointments cheaper, or even free (as is done in public systems), has been shown to reduce both rates of illness and costs of health care. Conversely, placing the cost of a visit to a general practitioner too low will lead to excessive visits wasting both a patient's and a doctor's time. Thus while some experts believe free doctor visits produce ideal results, most believe that forcing people to pay some fraction of the cost of an appointment is better.

  • When a claim is made, particularly for a sizeable amount, the use of paperwork and bureaucracy can allow insurance companies to avoid payment of the claim or, at a minimum, greatly delay it. Some people simply give up pursuing their claims with their insurance provider. This is a cost-cutting technique employed by some companies; fighting claims legally is actually less expensive in some instances than paying the claims outright.

  • Insurance companies usually do not announce their health insurance premiums more than one year in advance. This means that, if one becomes ill, he or she may find that the premiums have greatly increased. This largely defeats the purpose of having insurance in the eyes of many. However, this is not a concern in many group health plans because there are often laws that prevent companies from charging a single individual in the plan more than others who are enrolled in the same insurance plan.

  • Health insurance is often only widely available at a reasonable cost through an employersponsored group plan. This means that unemployed individuals and self-employed individuals are at an extreme disadvantage and will have to pay for more for their health care.

  • Experimental treatments are generally not covered. This practice is especially criticized by those who have already tried, and not benefited from, all standard medical treatments. Because insurance companies can avoid paying claims for experimental procedures, this has lead some insurers to claim that procedures are still experimental well after they have become standard medical practice. This phenomenon was especially prevalent among private insurance companies after organ transplants, particularly kidney transplants, first became standard medical practice, due to the tremendous costs associated with this procedure and other organ transplantation. This approach to avoiding paying premiums can also undermine medical advances.

  • Health Maintenance Organizations or (HMO) types of health insurance are often criticized for excessive cost-cutting policies that include accountants or other administrators making medical decisions for customers. Rather than allowing such decisions to be made by health care professionals who know which procedures or treatments are necessary, these health plan administrators are dictating medical practice through their refusal to cover claims.

  • As the health care recipient is not directly involved in payment of health care services and products, they are less likely to scrutinize or negotiate the costs of the health care they receive. To care providers (health care professionals, not the insurers), insured care recipients are viewed as customers with relatively limitless financial resources who do not consider the prices of services. To address this concern, many insurers have implemented a program of bill review in which insured individuals are allowed to challenge items on a bill (particularly an inpatient hospital bill) as being for goods or services not received. If a challenge is proven accurate, insured individuals are awarded with a percentage of the amount that the insurer would have otherwise paid for this disputed item or service.

Concerns about health insurance are prevalent in the United States. A June 2005 survey of a random national sample by the Kaiser Family Foundation found that twice as many United Statesians are more worried about rising health care costs than losing their job or being the victim of a terrorist attack.

Publicly Funded Health Care

An alternative to private health insurance and the free-market approach to health care is publicly funded health care. Publicly funded medicine is health care that is paid wholly or mostly by public funds (i.e., taxes). Publicly funded medicine is often referred to as socialized medicine by its opponents, whereas supporters of this approach tend to use the terms universal healthcare, single payer healthcare, or National Health Services. It is seen as a key part of a welfare state.

This approach to health care is the most common and popular among developed (and developing) nations around the world today. The majority of developed nations have publicly funded health systems that cover the great majority of the population. For some examples, see the British National Health Service, medicare Canada and medicare Australia.

Even among countries that have publicly funded medicine, different countries have different approaches to the funding and provision of medical services. Some areas of difference are whether the system will be funded from general government revenues (e.g. Italy, Canada) or through a government social security system (France, Japan, Germany) on a separate budget and funded with special separate taxes. Another difference is how much of the cost of care will be paid for by government or social security system, in Canada all hospital care is paid for by the government while in Japan patients must pay 10 to 30% of the cost of a hospital stay. What will be covered by the public system is also important; for instance, the Belgian government pays the bulk of the fees for dental and eye care, while the Australian government covers neither.

The United States has been virtually alone among developed nations in not maintaining a publicly-funded health-care system since South Africa adopted a publicly-funded system after toppling its apartheid regime. However, a few states in the U.S. have taken serious steps toward achieving this goal, most notably Minnesota. Other states, while not attempting to insure all of their residents strictly speaking, cover large numbers of people by reimbursing hospitals and other health-care providers using what is generally characterized as a charity care scheme, which often includes levies.

Publicly funded medicine may be administered and provided by the government, but in some systems that is not an obligation: there exist systems where medicine is publicly funded, yet most health providers are private entities. The organization providing public health insurance is not necessarily a public administration, and its budget may be isolated from the main state budget. Likewise, some systems do not necessarily provide universal healthcare, nor restrict coverage to public health facilities.

Proponents of publicly funded medicine cite several advantages over private insurance or freemarket approaches to health care:

  • Publicly funded approaches provide universal access to health care to all citizens, resulting in equality in matters of life and death.

  • Publicly funded health care reduces contractual paperwork.

  • Publicly funded health care facilitates the creation of uniform standards of care.

  • It is also the case that publicly funded systems result in a reduction in the percentage of societal resources devoted to medical care; meaning public systems cost less than private systems.

Publicly funded health care is not without its criticisms. Some purported disadvantages of the public system include:

  • Some critics argue there is a greater likelihood of lower quality health care than privately funded systems. However, because of the universal accessibility of health care, this claim is generally not true.

  • Another criticism of publicly funded health care is that there is less motivation for medical innovation and invention and less motivation for society's most skilled people to become doctors, because of the lower amount of monetary compensation.

  • Price no longer influences the allocation of resources, thus removing a natural self-corrective mechanism for avoiding waste and inefficiency (though the redundancy of the private system - competing insurers - often results in more inefficiency than a single, public system).

  • Health care workers' pay is often not related to quality or speed of care. Thus very long waits can occur before care is received.

  • Because publicly funded medicine is a form of socialism, many of the general concerns about socialism can be applied to this approach.

  • People are afraid that they can't choose their own doctor. The state chooses for them. This also tends to be an over-exaggerated and ill-founded concern as there is some degree of freedom in choosing medical practitioners in public systems.

Parallel Public/Private Systems

Almost every country that has a publicly funded health care system also has a parallel private system, generally catering to the wealthy. While the goal of public systems is to provide equal service, the egalitarianism tends to be closer to partial egalitarianism. Every nation either has parallel private providers or its citizens are free to travel to a nation that does, so there is effectively a two-tier healthcare system that reduces the equality of service. Since private providers are typically better paid, those medical professionals motivated by remunerative concerns migrate to the private sector while the private hospitals also get newer and better equipment and facilities. A number of countries such as Australia attempt to solve the problem of unequal care by insisting that doctors divide their time between public and private systems.

Proponents of these parallel private systems argue that they are necessary to provide flexibility to the system and are a way to increase funding for the health care system as a whole by charging the wealthy more. Opponents believe that they are allowed to exist mainly because politicians and their friends are wealthy and would prefer better care. They also argue that all citizens should have access to high quality healthcare. The only country not to have any form of parallel private system for basic health care is Canada. However, wealthy Canadians can and travel to the United States for care.

Also, in some cases, doctors are so well paid in both systems that prestige is often more important to them than remuneration. This is very much the case in the United Kingdom where private medicine is seen as less prestigious than public medicine by much of the population. As a result, the best doctors tend to spend the majority of their time working for the public system, even though they may also do some work for private healthcare providers. The British in particular tend to use private healthcare to avoid waiting lists rather than because they believe that they will receive better care from it.

Difficulties of analysis

Cost-benefit analysis of healthcare is extremely difficult to do accurately, or to separate from emotional entanglement. For instance, prevention of smoking or obesity is presented as having the potential to save the costs of treating illnesses arising from those choices. Yet, if those illnesses are fatal or life shortening, they may reduce the eventual cost to the system of treating that person through the rest of their life, and it is possible that they will die of an illness every bit as expensive to treat as the ones they avoided by a healthy lifestyle.

This has to be balanced against the loss of taxation or insurance revenue that might come should a person have a longer productive (i.e. working and tax orinsurance-paying) life. The cost-benefit analysis will be very different depending on whether you adopt a whole-life accounting, or consider each month as debits and credits on an insurance system. In a system financed by taxation, the greatest cost benefit comes from preserving the working life of those who are likely to pay the most tax in the future, i.e. the young and rich.

Few politicians would dare to present the big picture of costs in this way, because they would be condemned as callous. Nevertheless, behind the scenes, a responsible government must be performing cost analysis in order to balance its budget; it is not likely, however, to take the most purely cost effective route. It may choose to provide the best health care according to some other model, but the cost of this still must be estimated and funded, and there is no uncontroversial definition of best.

In producing a definition of quality of healthcare there is an implication that quality can be measured. In fact, the effectiveness of healthcare is extremely difficultto measure, not only because of medical uncertainty, but because of intangible quantities like quality of life. This is likely to lead to systems that measure only what is easy to measure (such as length of life, waiting times or infection rates). As a result the importance of treating chronic, but non-fatal, conditions, or of providing the best care for the terminally ill may be reduced. Thus, it is possible for personal satisfaction with the system to go down, while metrics go up.

Behavior and Environmental Influences on Health

The following sections explore some of the ways behaviors and environment can impact human health.

Smoking

The Centers for Disease Control and Prevention describes tobacco use as "the single most important preventable risk to human health in developed countries and an important cause of premature death worldwide" (source). A person's increased risk of contracting disease is directly proportional to the length of time that a person continues to smoke as well as the amount smoked. However, if someone stops smoking the risks of developing diseases steadily decline, although gradually, as the damage to their body is repaired.

The main health risks from tobacco smoking pertain to diseases of the cardiovascular system, in particular smoking is a major risk factor for: myocardial infarction (heart attack); diseases of the respiratory tract, such as Chronic Obstructive Pulmonary Disease (COPD) and emphysema; and cancer, particularly lung cancer and cancers of the larynx and tongue. Prior to World War I, lung cancer was considered to be a rare disease, one most physicians would never see during their career. With the postwar rise in popularity of cigarette smoking came a virtual epidemic of lung cancer.

Alcohol

Alcoholism is a dependency on alcohol characterized by craving (a strong need to drink), loss of control (being unable to stop drinking despite a desire to do so), physical dependence and withdrawal symptoms, and tolerance (increasing difficulty of becoming drunk).

Although acceptance of the American Disease Model is not without controversy, the American Medical Association, the American Psychiatric Association, the American Hospital Association, the American Public Health Association, the National Association of Social Workers, the World Health Organization, and the American College of Physicians have all classified alcoholism as a disease.

In a 1992 JAMA article, the Joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine published this definition for alcoholism: "Alcoholism is a primary chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, mostly denial. Each of these symptoms may be continuous or periodic."

Symptoms of a person's dependence on alcohol may include, but are not limited to, a feeling of necessity in regards to consumption of alcohol, or an inability to resist alcohol if offered. Though these symptoms often arise from a physical dependence on the substance, it is not uncommon for individuals, especially teenagers and adolescents between the ages of fifteen and twenty, to rely on alcohol as a means of social interaction. If a person cannot refuse alcohol in the presence of others, insists on drinking alcohol excessively for fear of alienation and neglect, or feels they cannot socially interact with others unless under the influence then this person is considered socially dependent on the substance. These traits can be noticed in individuals who relocate (such as students attending a new university) whereby an individual with no past history of alcohol consumption begins to consume alcohol in order to associate and relate to others. Social dependence, though not physically threatening in early stages, can lead to physical dependence if the person cannot control their urges and more so their reasons for drinking.

The causes for alcohol abuse and dependence cannot be easily explained, but the long-standing, unscientific prejudice that alcoholism is the result of moral or ethical weakness on the part of the sufferer has been largely altered. Recent polls show that 90% of Americans currently believe that alcoholism is, in fact, a disease (source?). Of the two thirds of the North American population who consume alcohol, 10% are alcoholics and 6% consume more than half of all alcohol. Stereotypes of alcoholics are often found in fiction and popular culture. In modern times, the recovery movement has led to more realistic portraits of alcoholics and their problems.

The social problems arising from alcoholism can include loss of employment, financial problems, marital conflict and divorce, convictions for crimes such as drunk driving or public disorder, loss of accommodation, and loss of respect from others who may see the problem as self-inflicted and easily avoided. Exhaustive studies, including those by author Wayne Kritsberg, show that alcoholism affects not only the addicted but can profoundly impact the family members around them. Children of alcoholics can be affected even after they are grown. This condition is usually referred to as The Adult Children of Alcoholics Syndrome. A1-Anon, a group modelled after Alcoholics Anonymous, offers aid to friends and family members of alcoholics.

Moderate Drinking→ Of course, not everyone who consumes alcohol is an alcoholic or is at danger of becoming an alcoholic. In fact, there is some debate as to whether there are some benefits derived from moderate consumption of alcohol. The controversy over moderate drinking is an ongoing debate about the claimed benefit or harm to human health from moderate consumption of alcoholic beverages. Moderate consumption typically means the consumption of 1 to 3 drinks of an alcoholic beverage a day; the number varies with age and gender. There is wide consensus that over-drinking is harmful: alcohol damages human cells and organs such as the brain, liver and kidney.

Many studies show that consumers of up to 3 drinks a day have a 10% to 40% lower risk of coronary heart disease than those who abstain. Rimm et al. (1999) predict a 24.7% decrease in the risk of coronary heart disease based upon 30g alcohol/day.

Critics of moderate drinking claim that any benefits are far outweighed by the possible consequences of over consumption and that these benefits can be had by less risky means. Scientists also note that studies supporting the benefits of moderate drinking do not control for other factors, such as lifestyle differences between moderate drinkers and nondrinkers. There is evidence that moderate drinkers are more affluent than nondrinkers and as such lead lifestyles that are more conducive to good health in general.

Research on the effects of moderate drinking is in its early stages. No long term studies have been done and control groups would be difficult to establish because of the many variables. Given the current state of the research, an editorial concludes in the December 1997 issue of the Journal of the Royal Society of Medicine that the recommendation to be a moderate drinker is "not only meaningless but also irresponsible" given that the many obvious health hazards of alcohol outweigh "the benefits of alcohol [which] are small and ill-understood" particularly when so many other cardiovascular treatments are available.

Effects of fetal alcohol exposure→ Fetal alcohol exposure is regarded by researchers as the leading known cause of mental and physical birth defects, surpassing both spina bifida and Down syndrome, producing more severe abnormalities than heroin, cocaine, or marijuana, and is the most common preventable cause of birth defects in the United States.

It can cause mental retardation, facial deformities, stunted physical and emotional development, behavioral problems, memory deficiencies, attention deficits, impulsiveness, an inability to reason from cause to effect; a failure to comprehend the concept of time; and an inability to tell reality from fantasy. Secondary disabilities develop over time because of problems fitting into the environment.

Researchers believe that the risk is highest early in the pregnancy, but there are risks throughout because the fetus' brain develops throughout the entire pregnancy. No amount of alcohol, during any trimester, is absolutely safe.

Obesity

Obesity is a condition in which the natural energy reserve of humans, which is stored in fat tissue, is expanded far beyond usual levels to the point where it impairs health. While cultural and scientific definitions of obesity are subject to change, it is accepted that excessive body weight predisposes to various forms of disease, particularly cardiovascular disease.

Venus of Willendorf

Figure 9: Venus of Willendorf

There is continuous debate over obesity, at several levels. The scientific evidence informing these debates is more contradictory than most simple arguments assume. Statistics demonstrating correlations are typically misinterpreted in public discussion as demonstrating causation, a fallacy known as the spurious relationship.

In several human cultures, obesity is (or has been) associated with attractiveness, strength, and fertility. Some of the earliest known cultural artifacts, known as Venuses, are pocket-sized statuettes representing an obese female figure. Although their cultural significance is unrecorded, their widespread use throughout pre-historic Mediterranean and European cultures suggests a central role for the obese female form in magical rituals and implies cultural approval of (and perhaps reverence for) this body form.

Obesity functions as a symbol of wealth and success in cultures prone to food scarcity. Well into the early modern period in European cultures, it still served this role. Contemporary cultures which approve of obesity, to a greater degree than European and Western cultures, include African, Arabic, Indian, and Pacific Island cultures. In Western cultures, obesity has come to be seen more as a medical condition than as a social statement.

Age-adjusted prevalance of obesity among adults aged20 years and over, by sex and race/ethnicity: United States, 2004

Figure 10: Age-adjusted prevalance of obesity among adults aged20 years and over, by sex and race/ethnicity: United States, 2004

Various stereotypes of obese people have found their way into expressions of popular culture. A common stereotype is the obese character who has a warm and dependable personality, presumedly in compensation for social exclusion, but equally common is the obese vicious bully. Gluttony and obesity are commonly depicted together in works of fiction. It can be argued that depiction in popular culture adds to and maintains commonly perceived stereotypes, in turn harming the self esteem of obese people. A charge of prejudice and/or discrimination on the basis of appearance could be leveled against these depictions.

Causes of Obesity→ Conventional wisdom holds that obesity is caused by over-indulgence in fatty or sugary foods, portrayed as either a failure of will power or a species of addiction. Various specialists strongly oppose this view. For example, Professor Thomas Sanders, the director of the Nutrition, Food & Health Research Centre at King's College London, emphasises the need for balance between activity and consumption:

In trials, there is no evidence suggesting that reducing fat intake has an effect on obesity. As long as your expenditure equals what you eat, you won't put on weight, regardless of how high the fat content is in your diet (The Times, London, 10 March 2004).

Obesity is generally a result of a combination of factors:

• Genetic predisposition

• Energy-rich diet

• Limited exercise and sedentary lifestyle

• Weight cycling, caused by repeated attempts to lose weight by dieting

• Underlying illness

• Certain eating disorders

Some eating disorders can lead to obesity, especially binge eating disorder (BED). As the name indicates, patients with this disorder are prone to overeat, often in binges. A proposed mechanism is that the eating serves to reduce anxiety, and some parallels with substance abuse can be drawn. An important additional factor is that BED patients often lack the ability to recognize hunger and satisfaction, something that is normally learned in childhood. Learning theory suggests that early childhood conceptions may lead to an association between food and a calm mental state.

While it is often quite obvious why a certain individual gets fat, it is far more difficult to understand why the average weight of certain societies have recently been growing. While genetic causes are central to who is obese, they cannot explain why one culture grows fatter than another.

Prevalence of overweight among children and adolescents ages 6-19 years

Figure 11: Prevalence of overweight among children and adolescents ages 6-19 years

Although there is no definitive explanation for the recent epidemic of obesity, the evolutionary hypothesis comes closest to providing some understanding of this phenomenon. In times when food was scarce, the ability to take advantage of rare periods of abundance and use such abundance by storing energy efficiently was undoubtedly an evolutionary advantage. This is precisely the opposite of what is required in a sedentary society, where high-energy food is available in abundant quantities in the context of decreased exercise. Although many people may have a genetic propensity towards obesity, it is only with the reduction in physical activity and a move towards high-calorie diets of modern society that it has become so widespread.

The obesity epidemic is most notable in the United States. In the years from just after the Second World War until 1960 the average person's weight increased, but few were obese. In 1960 almost the entire population was well fed, but not overweight. In the two and a half decades since 1980 the growth in the rate of obesity has accelerated markedly and is increasingly becoming a public health concern. There are a number of theories as to the cause of this change since 1980. Most believe it is a combination of various factors:

• Obese people appear to be less active in general than lean people, and not just because of their obesity. A controlled increase in calorie intake of lean people did not make them less active, nor, correspondingly, when obese people lost weight did they become more active. Weight change does not affect activity levels, but the converse seems to be the case (Levine 2005).

• Another important contributor to the current obesity concern is the much lower relative cost of foodstuffs: agricultural subsidies in the United States and Europe have led to lower food prices for consumers than at any other point in history.

• Marketing may also play a role. In the early 1980s the Reagan administration lifted most regulations for advertising to children. As a result, the number of commercials seen by the average child increased greatly, and a large proportion of these were for fast food and candy.

• Changes in the price of gasoline may also have had an effect, as unlike during the 1970s it is now affordable in the United States to drive everywhere, curtailing both foot traffic and the riding of bikes. An indication of the reliance on cars in the U.S. is the increasing number of areas that are built without sidewalks and parks.

• Increases in the service sector of the economy have resulted in a greater percentage of the population spending most of their workday behind a desk or computer.

• A social cause that is believed by many to play a role is the increasing number of two income households where one parent no longer remains home to look after the house. This increases the number of restaurant and take-out meals.

• Urban sprawl may also contribute to the increase in obesity rates, possibly due to less walking and less time for cooking (Lopez 2004).

• Since 1980 both sit-in and fast food restaurants have seen dramatic growth in terms of the number of outlets and customers served. Low food costs and intense competition for market share led to increased portion sizes. For example, McDonalds' french fries portions rose from 200 calories in 1960 to over 600 calories today.

• Increasing affluence itself may be a cause or contributing factor since obesity tends to flourish as a disease of affluence in countries which are developing and becoming westernised (for more information on this factor, see here). This is supported by the observation of a dip in American GDP after 1990, the year of the Gulf War, followed by an exponential increase. U.S. obesity statistics followed the same pattern, offset by two years.

Some obesity co-factors are resistant to the theory that the epidemic is a new phenomenon. In particular, a class co-factor consistently appears across many studies. Comparing net worth with BMI scores, a 2004 study (Zagorsky 2004) found obese American subjects approximately half as wealthy as thin ones. When income differentials were factored out, the inequity persisted: thin subjects were inheriting more wealth than fat ones. Another study finds women who married into a higher status were thinner than women who married into lower status.

Policy Responses to Obesity→ On top of controversies about the causes of obesity, and about its precise health implications, come policy controversies about the correct policy approach to obesity. The main debate is between personal responsibility advocates, who resist regulatory attempts to intervene in citizen's private dietary habits, and public interest advocates, who promote regulations on the same public health grounds as the restrictions applied to tobacco products. In the U.S., a recent bout in this controversy involves the so-called Cheeseburger Bill, an attempt to indemnify food industry businesses from frivolous law suits by obese clients.

On July 16, 2004, the U.S. Department of Health and Human Services officially classified obesity as a disease. Speaking to a Senate committee, Tommy Thompson, the Secretary of Health and Human Services, stated that Medicare would cover obesity-related health problems. However, reimbursement would not be given if a treatment was not proven to be effective.

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RYAN T. CRAGUN
PhD student at the University of Cincinnati

DEBORUH CRAGUN
MS Human Genetics; employed as a genetic counselor at Cincinnati Children's Hospital Medical Center

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