The Two Business Problem in Medicine

Some years ago, in a review of the programs and priorities of the New York Academy of Medicine, a consultant suggested framing our analysis in a business context, i.e., defining the academy’s business as well as its product s and its customers.

Where we in the disease business or the health business? What does the distinction imply, and how applicable to medicine is the business construct?

From a dyadic health/disease perspective, most of the biomedical enterprise can arguably be seen as primarily in the disease business. The customers in that formulation are people with diseases, early or late, symptomatic (ill) or not, and the intended product is the restoration of health, i.e., cure, or failing that, alleviation of symptoms and physiologic impacts until the acute episode has resolved spontaneously or in response to treatment, or if disease persists, management of the emergent chronic course.

Physicians dealing with sick patients are in that sense clearly in the disease business, and so is the rest of the clinical enterprise—a wide variety of personnel ranging from laboratory technicians to ambulance drivers, nurses, hospitals, big pharma, neighborhood pharmacies, the people who print prescription blanks, those who develop clinically applied technologies; in fact, the bulk of clinical effort can arguably be viewed as primarily in the disease business, dealing with causes, physiologic impacts, clinical manifestations, treatment, sequelae and, ultimately, costs.

If there is a disease business, it follows that there is a counterpart—the health business. The customers of the health business are people who are presumably free of particular (or multiple) diseases and who seek to minimize disease risk, or who have diseases and wish to prevent or slow progression. The business product is the preservation of health, that is, avoidance to the extent possible of disease-associated risks and slowing of health erosion over the life course, chiefly by minimizing the acquisition or progression of chronic diseases and blunting the health impacts of social and environmental stressors.

The disease business is big—and correspondingly expensive. We are currently spending some $4.1 trillion annually, roughly 19.7% of the nation’s gross domestic product in 2020 [1], on disease and its sequelae and on diagnosis, acute care, long-term management, and related infrastructures. Cost increases are a persisting problem, driven largely by practice patterns, prescription costs, clinically applied technologies and hospital charges, and more fundamentally by the aging of the population and the associated emergence of chronic diseases as the dominant clinical pattern. In addition to the costs of care, the disease business also includes a substantial research and development enterprise, an investment of some $194.2 billion in 2018 [2], of which $129.5 billion came from industry and 43 billion was federal funding, with additional support provided by universities and other private sector sources.

The health business is less diffused, concentrated largely in governmental structures, including state, county, and local health departments and a number of federal agencies, especially the Department of Health, Education and Welfare, the Centers for Disease Control and Prevention, and the Food and Drug Administration. There is in addition a substantial academic health enterprise based in 62 schools of public health, training new professionals and conducting epidemiologic, environmental, and other health-related research and policy analysis, much of it international or global in scale.

Both businesses have changed markedly in recent decades, due largely to better control of acute infections, aging of the population, and the emergence of chronic diseases as leading causes of death and disability. Major clinical and public health impacts have resulted, linked especially to the central characteristics of chronic diseases, notably early onset, clinically silent progression, relative refractoriness to available treatments, and complex causation, notably health-adverse behaviors, social forces, and environmental factors.

A major feature of both businesses is their clinical and epidemiologic lability. Individuals move between the health and disease businesses as acute illness or injury occurs and recovery ensues, or as clinical manifestations of chronic diseases appear. At times, shifts between businesses extend to groups or even entire populations. A striking example reflecting massive expansion of the health business occurred between 1900 and 2000, as average life expectancy in the U.S. increased some 30 years, a change initially due largely to public health measures and increasingly in recent years to clinical advances as well. Paradoxically, this increase has been accompanied by the expansion of the disease business, as clinical evidence of chronic diseases has emerged as a common accompaniment of advancing age.

Epidemiologic lability is also related to instability of the content of both businesses. In the disease business, for example, new infections appear sporadically (e.g., AIDS, MERS, and Covid 19) as others are eradicated (smallpox) or largely controlled, (measles, mumps, and poliomyelitis), and as chronic diseases (heart disease, cancer, stroke, chronic pulmonary disease, and the dementia) increase in prevalence. Content has altered in the health business as well, to such an extent that health can no longer be assumed on the basis of a sense of well-being and the absence of evident disease, because of the pervasiveness of undetected, asymptomatic chronic diseases, for example atheroma, hypertension, colonic polyps, glaucoma, or early stage cancer.

The extent of the shift in disease patterns is reflected in our literature and in medical texts. The first edition of Osler’s textbook, Principles and Practice of Medicine (1892), for example, emerged when infections were dominant, and was introduced by nearly 300 pages devoted to typhoid fever, tuberculosis, syphilis, and various exanthemata [3]. The Cecil-Goldman Textbook of Medicine (25^th Edition, 2016), by contrast, opens with an extended (247 pages) consideration of general principles; tuberculosis, typhoid fever, and syphilis are discussed in 19 pages, and the exanthemata in three [4]. Further discussion of infectious diseases follows descriptions of diseases of the various organ systems, most of them chronic and thought to be non-infectious in origin.

The contrast reflects a major change in disease ecology resulting from the combined impacts of biomedical research, clinical and public health interventions, and policy changes ranging from school health programs to the Medicaid and Medicare supplements of the 1960s. Chronic diseases have emerged as not only ubiquitous but also central.

This ecologic shift has blurred the margins between the health and disease businesses. For example, epidemiologic studies of customers of the health business—ambient, apparently healthy populations—have identified widespread asymptomatic chronic disease and chronic disease risk factors such as smoking, atherogenic diets, or elevated plasma lipid concentrations, risks which are now widely addressed in clinical practice. Conversely, clinical patterns in customers of the disease business (e.g., patients with ischemic heart disease or lung cancer) have generated epidemiologic studies identifying causative or contributing factors. More broadly, the disease business increasingly impacts the personal health-protective behaviors of customers of the health business, from cancer screening to smoking habits, diet choices, immunizations, and even socialization [5], an important trend that requires an informed and motivated population. Sustained health enhancement efforts in this long-term anticipatory sense are generally advised and encouraged by clinicians, but informal and commercial distribution of health-related information of uneven, often questionable, quality, especially through advertising and social media channels, has grown remarkably in recent years; paradoxically, the health professions themselves have not been prominent in marketing authoritative long-term personal health preservation efforts at a population scale.

We need the two businesses to move toward a more effectively coordinated life course approach to health preservation, a more deliberate, more energetic merger of efforts. We need more vigorous joint application of interventions that prevent or slow the course of chronic diseases, introduced early, and maintained during their prolonged, clinically silent phases. Further, apart from specific disease risks, we need a stronger focus at both individual and population levels on the enhancement of health, especially through behavioral and environmental measures.

There is no disease-free state. Disease at some level is ubiquitous, and health is intrinsically unstable because health status virtually always includes some element of disease, and disease risk and underlying disease patterns are themselves unstable. The health/disease mix is a dynamic final common pathway expressing myriad interacting, fluctuating physiologic, subjective, social, and environmental forces presenting needs and opportunities too broad and intermeshed to be encompassed by either business alone, but requiring both. It is time for a more deliberate and effective business merger.