AAcademic Exchange: What in the national debates about health care did you find most intriguing?
Sander Gilman: There are two general questions. Assuming that the present health care bill remains the same over the next few years as it comes into effect between now and 2015-16, one of the real questions has to do with whether the changes will reduce costs and thus enable more people to get better health care. That is, I think the relationship between access and costs was not completely convincingly thought through. The idea was—and this is classic Adam Smith economics—the more people you have in a pool, the fewer percentagewise are going to get ill at any given time, and therefore the general costs will go down. Meaning, if you have lots of healthy eighteen-year-olds in the pool, it’ll pay for older people with more health problems.
The assumption I’m not completely convinced of is that eighteen-year-olds are all that healthy and therefore will not use health care. For example, if the claims about increased obesity in children and teenagers are anywhere near accurate—and I’ve written now four books on the subject, and I think they are more accurate than not—then we’re going to have an enormous number of younger people who will have major illnesses early on, as well as the sequelae from those illnesses. If you become diabetic when you’re forty, you’ll have cardiovascular problems when you’re sixty. If you become diabetic when you’re ten, that means you’re going to be a sick and very expensive thirty-year-old. So that’s the first problem.
The other problem is that while it’s not articulated in the politics, there’s been a set of claims within the realm of medicine that may be counterproductive—claims in predictive health, genetics, public health about being able to intervene with certain illnesses. On the contrary, what has happened is the expenditure of huge amounts of money with very little results. I’ll give you an example. There is an obsession in the United States with “precancer” in women. If you have the “genetic marker” for and a family history of breast or uterine cancer in the United States, advocacy groups and the medical profession advocate double mastectomy or hysterectomies in advance of the appearance of cancer. First of all, this is not effective. What we know is that if you have a breast cancer mutation, there’s a very good chance that if you develop cancer at all, you may develop another kind of cancer. Second of all, the interventions themselves are questionable. We don’t always get all the breast cancer tissue. Also this is a very expensive prophylaxis. It’s much more expensive, for example, than having monthly screenings and if you develop breast cancer, having a lumpectomy, which is much less invasive. But surgery is now part of American health politics. It’s not the case in the U.K. and France, where people have said, you know, maybe a double mastectomy as prophylaxis for risk is not a good idea. It’s a little extreme. They also understand that it puts a real economic burden on the system with relatively few positive outcomes.
AE: What are other ways the reform bill might intersect with your work?
SG: The childhood obesity question has been taken up by Michelle Obama as one of her primary interests. I’m a great advocate of this. I signed a public letter trying to say to her, You’re doing good stuff, but you also don’t want to stereotype all people who are obese as lazy and stupid and unable to deal with these questions. That is, you want to see this as a problem of health, not a problem of morals. The difficulty I’m seeing is that obesity has become a public health issue that has a pot of money available for it. Everybody is jockeying to get a part of that pie: the geneticists are making claims that it’s all a question of genetic inheritance; the endocrinologists are arguing that this is mainly a problem of metabolic change; the people interested in social medicine are saying if people only had access to “whole food” there wouldn’t be any problem with obesity—all of which, in bits and pieces, is true. But right now with health care I’m very anxious about who’s going to be heard. If Mrs. Obama is heard, then it’s not a medical problem but a social problem. Yet for some people it is purely a medical problem. They’re not going to be helped by having access to better food and a better lifestyle.
I’m a great believer that what medicine does best is to think about multiple causes for complex outcomes. And much of what I’ve heard over the last couple of years both in the medical science, sadly, and also in the political realm is exactly the opposite. It’s simple answers and simple proposals. This is the problem.