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Pro Re Publica Sanitas

What does it mean to improve public health? There are many measures based on what goes into the process, but fewer based on what results. Since zero input will produce zero output we tend to assume positive results must be proportional to effort expended. When large numbers of intelligent, educated, hard-working people depend on this for income you can be sure such a reporting bias will exist. The result is that much of the resulting activity could be misdirected. There is also the problem that benefits enjoyed by one group not only do not automatically transfer to other groups, but may actually preclude benefits to them.

My own definition is based on incidence of illness. Good public health policy w.r.t. a particular illness reduces incidence of that illness without increasing incidence of others.

Good reasons for decreasing incidence are cures of existing patients with an illness, and prevention of new cases. The eradication of smallpox is the best example of this; incidence has reached zero. Bad reasons for decreasing incidence are sheer neglect of the condition, misdiagnosis and mortality among existing patients.

Improvements in water supplies have made dramatic differences in incidence of cholera and typhoid.

This definition is not, as you might think, restricted to infectious disease. Incidence of rickets, beriberi and scurvy are way down as a result of discoveries concerning vitamin deficiencies. Incidence of trauma in automobile accidents was reduced by the introduction of turn signals, brake lights, rear-view mirrors, speed limits, safety glass and seat belts, though dramatic increases in automobile traffic increased the number of accidents.

By this standard you can evaluate many public health policies. The results are not always reassuring. By focusing on treatment you can show that there has been tremendous progress in mental illness. Looking at incidence presents a very different picture. Concentrating on cures is not going to give meaningful measures when it is possible for the number of cures to exceed the number of patients. It is not even clear that efforts at prevention are reducing incidence at all.

There is a second aspect of the problem of mental illness caused by what I describe as gerrymandering of patients by organ systems. A diagnostic category like major depressive disorder may be the result of a wide variety of pathological physiological conditions: direct brain trauma, subdural hematoma, viral encephalitis, seizure disorders, influenza, cardiovascular disease, MS, SLE, pulmonary conditions, liver impairment caused by hepatitis C, undetected cancer, etc. I don't think I'm exaggerating much to say that it might be caused by any damn thing at all. Most of these conditions also produce unexplained fatigue.

The result of medical specialization is that those dealing with individual organ systems will naturally take the easy and profitable cases, leaving the difficult and confusing cases to others. This has the perverse effect of dumping the most puzzling cases on those who rank low in professional hierarchies.

Economics plays a role here, as limitations on insurance liability, either private or national, are tighter for "mental illness" than for clearly-identified organic diseases. This is even true in diseases like lung cancer or heart disease, where such behaviors as smoking have a major influence on medical costs. This tends to undermine arguments about personal responsibility being the distinction.

It doesn't require any conspiracy for people and organizations to discover that some behaviors are profitable without understanding exactly why. The existence of a convenient diagnostic category for which liability is approximately halved is an invitation to use this as a wastebasket for difficult problems.

Worse, if economic returns are based on treatment rather than incidence, it doesn't take long for treatments offering temporary partial symptomatic relief to dominate a field. These offer a guaranteed cash flow which may last for the lifetime of a patient, if cures are not possible. The Onion had something to say about this.
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" I don't think I'm exaggerating much to say that it might be caused by any damn thing at all. Most of these conditions also produce unexplained fatigue." As we see here, many mental health issues are resolved when biochemical pathways are corrected. Not the same as what They are calling the biochemical solution. Thanks for your writing.

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