Posted on: Thursday, March 3, 2005

SECOND OPINION

By Clliff Slater

A major reason for studying history is what we learn from placing past events in context, and since past and present trends are the best indicators of future ones, it often enables us to better understand what might be in store for us.

Like elsewhere in the United States, we in Hawai'i are rightfully concerned about rising medical costs. A useful book for understanding medical cost trends is "The Escape from Hunger and Premature Death, 1700-2100," by Nobel Laureate Robert Fogel.

While the book is not as grim and tedious as it sounds, it does show us that we should be very grateful for being alive in these times — despite all their imperfections.

For example, while most people know that we are healthier today than ever before, few know to what extent. We find that 100 years ago:

• Deaths of children under 5 were 33 percent of all deaths; today they are 2 percent.

• Forty-four percent of men over 65 then had hemorrhoids; today it is 7 percent.

• Thirty-nine percent then had varicose veins; today it is 7 percent.

• Life expectancy at birth in the United Kingdom and the United States was 48 years; today it is closer to 80 years.

We owe the remarkable changes since then not only to improvements in medical technology but also to the vast improvement of our understanding of public health.

In the old days, sewers emptied into rivers and shorelines, affecting the health of those bathing, laundering and drinking.

Cities were dependent for transportation on the horse-drawn streetcars and goods carts. It is difficult to imagine that in New York alone at that time, every single day the city government had to remove 1,250 tons of manure, 60,000 gallons of urine and 40 dead horses. It was a major sanitary problem.

Our food, though arguably less tasteful today, is healthier through cleaner handling, refrigeration and better packaging. And since food is much less a factor in the family budget today than even 50 years ago, we are far more willing to dispose of doubtful food than we once were.

The city air we breathe is better since the banning of coal fires and leaded gasoline. Coal for heating not only generated dust and dirt but was very unhealthy to breathe.

Contrast the knowledge of those times with the most recent additions to health science. While we now understand the risk to the fetus of a mother smoking or drinking alcohol, it is a relatively recent understanding, and it is one mostly about the effects on the child and not on its effects in the grown child in later life. We now know that harms to a child when in the early stages of prenatal development and early childhood are of far more consequence in later life than earlier thought.

What we now understand, and only since the late 1990s, is that biological and social stress in the early stages of cell growth correlate strongly with the onset of chronic diseases at middle and late ages and result in reduced life expectancy.

The outcome of this knowledge will undoubtedly result in far more medical focus on what Fogel calls "insults in utero" — harm to the unborn child through physical harm, environmental harm, iodine and vitamin deficiencies or even the impact of a mother's illness. That will bring more medical spending in this area, and since it is likely to lead to longer lives, it will result in even greater spending at a later date associated with the aged.

In addition, we are more aware today of the impact of trace metals and minerals in food and their health impacts — e.g., the recent discovery of a possible connection between minor amounts of mercury formerly used, but no longer, for the preservation of vaccines and the disturbing growth of autism in children. There may also be a similar connection with the epidemic growth of allergies.

All of this together with continued improvements in public health, improved drugs, increased numbers of the elderly, better online information and better outcomes when we seek medical help these days means exponentially greater increases in spending.

In 1900, we only spent 2 percent of incomes on healthcare; today we spend 14 percent. Tomorrow, it will be greater. The percentage is growing, and as Fogel puts it, "Healthcare is the growth industry of the 21st century."

Cliff Slater is a regular columnist whose footnoted columns are at: www.lava.net/cslater.