History of US Healthcare
Our understanding of health has dramatically evolved over the past two centuries, and we are now entering a new phase.
Phase 1 was religious. People used to think illness came from the gods. You prayed to be healed.
Phase 2 was “domestic medicine” in the US. In the 1800s, medicine was an in-home “family affair”. Women tended to the sick in their homes. They’d use remedies that had little scientific backing and summon a doctor only for life-threatening illnesses. The doctor had hardly any training compared to doctors of today.
Phase 3 was the birth of the US Medical Training. In 1893, Johns Hopkins was founded upon serious scientific inquiry. All medical students earned a four year degree and four years of practice to become a physician. The school also brought the European “research university” to the states, solidifying colleges as not just a place of learning but also of knowledge creation. This mission was met with funding from the National Institute of Health (est. 1873) and the Carnegie foundation (wealth amassed from the new industrialism). This mix led to the pioneering of evidence-based care across the world: treatments for the plague and malaria, blood transfusions, antivirals. The US became good at producing doctors, diagnosing and treating illness. Yet another cause of sickness went unaddressed.
Phase 4 emergence of Public Health. In 1914, attention turned to stopping the spread of infectious disease. Hookworm was rampant in unsanitary water. The Rockefeller Sanitary Commission attempted a failed campaign to eradicate the parasite. The skills required were many: urban planning, politics, medicine, business. They needed a new profession. Enter, Public Health. In 1914, Tulane launched the first school. Johns Hopkins followed with the first endowed public health school after the 1918 influenza pandemic killed 50 million people. Society now had processes to address widespread disease. But they wondered, how can we prevent disease from developing in the first place?
Phase 5 was the failed systemic focus on Individual Preventative Medicine. Research emerged on the health value of lifestyle choices: diet, exercise, sleep, stress relief. Yet the practice of medical doctors barely changed. Why? This obstinance is largely due to the medical system’s complex payment incentives between patients, hospitals, insurance, drug providers (covered in a different article). So instead, lifestyle support became privatized into industries:
- Diet: Healthier eating was more mainstream (and mostly all there was) until the introduction of processed food in 1910s and fast food and TV dinners in the 1960s. Health trends worsened as the government subsidized high-fructose-corn-syrup, and lobbyists lied that sugar was fine and that bread was the base of our food pyramid. Americans refocused on diet in the 1980s with Jenny Craig, Weight Watchers, Smart Balance as other the diet crazes began to trend. Additionally, consumer interest in farmers markets exploded across the US, the number of markets growing from 1,755 in 1994 to 8,144 in 2013. Americans today are refocusing on diet (or at least talking about it!)
- Fitness: Health club chains (today’s modern gyms) emerged the US throughout the 1960s and 70s. Their rise was aided by mainstream popularity of little league and professional sports, and companies like Nike who made running cool. Today, urban areas are speckled with boutique sportswear and a variety of gyms — from yoga studios, to hardcore boxing gyms, Soul Cycle, Barry’s Bootcamp, the list goes on and on. Take your pick.
- Mental health: Freud invented psychoanalysis in 1896. But psychotherapy didn’t reach its peak in the US until the 1960s when celebrities such as Jackie Kennedy and Woody Allen decreased its stigma and made it more mainstream. Meditation became popular in the US in the 60s by a cadre of teachers and hit mainstream in the 2010s with meditation apps such as Calm and Headspace. Today, techniques of social emotional learning have been taught in thousands of schools across the country. Various research centers are investing in understanding the complex intertwining of emotions and their effects on us.
These three areas may sound like recent developments. But individualized preventative medicine isn’t new. Hippocrates emphasized the importance of food exercise and healthy habits way back in the 5th century BC.
The sixth phase focused on Social Determinants of Health. In 1975, a Berkeley PhD student, Michael Marmot, wrote a groundbreaking thesis. He discovered an odd health inequality. Among Japanese men, the occurrence of coronary heart disease was lowest in Japan, intermediate in Hawaii, and highest in California. “This gradient”, he claimed, “appears not to be completely explained by differences in dietary intake, serum cholesterol, blood pressure or smoking.” Something else was at play. What was it? Societal factors. You are more likely to be sick if faced with bad “Social Determinants of Health:” discrimination, poor working conditions, poor access to healthy food, uncleanliness of air/food/water, poor education, or living in a crime-ridden neighborhood. In 2003, Michael Marmot led the World Health Organization’s research on stratification of health outcomes across social positioning. In 2008, the WHO Commission on Social Determinants of Health, led by Marmot, published “Closing The Gap of a Generation” a 232 page report aimed to identify remedies for health inequity. This and other research has informed the efforts of governments, nonprofits, and the health systems globally, including the Affordable Care Act (Obamacare).
In summary, modern western healthcare focuses on these categories:
1. Infection & Disease
2. Body: Diet/Sleep/Exercise
3. Mental Health
4. Social Determinants of Health
It’s naive to think we’ve reached the end of our approach towards health. We’ve been on a two-century long trajectory that will not stop. Today, research is emerging that will take us into a new era. This era, like the ones before, will entail increasing complexity. It will be harder for healthcare professionals to address this emerging category alone. This category will require a society-wide focus, a set of novel and innovative solutions we cannot yet imagine. Phase Seven is just beginning …
Social relationships — the next health category!
