Several years ago I was fascinated by Dr. Atul Gawande’s discussion of ignorance and incompetence. He argued that we in healthcare are no longer ignorant. We know quite a bit about pathology, pharmacology, diagnostics, and various therapeutic techniques. On my visit to Cape Town this week I was reminded of this as I passed the hospital where Christian Barnard performed the first heart transplant almost fifty years ago. The last half century has been remarkable. What we suffer from now is not ignorance about disease and therapeutics; it is our incompetence in managing the equitable distribution and sustainable financing of all we know.
As an industry, we behave as though we prefer treating disease rather than preventing it. That preference makes us continually incompetent when it comes to saving resources and reducing the cost of care. The origin of our incompetence runs deeper than our emotional and professional inclinations, complicated as it is by the social determinants of health which are foundational to health preservation.
My visit to South Africa has been interesting for many reasons, not the least of which is the discovery that over the last decade the life expectancy of South Africans has increased almost ten years, from the low fifties to the low sixties.
http://www.mrc.ac.za/Media/2015/1press2015.htm
Those gains have been made even as so many black South Africans live in abject poverty. The economy is stalling now, largely because China has reduced their use of South Africa’s raw materials. The unemployment rates of non-whites in South Africa are five times higher than the white minority, 40% versus 8%.
http://businesstech.co.za/news/general/68842/uncovering-sa-employment-by-race/
What has changed for the better in the post-apartheid era is that more people have the hope that life might improve as segregation by law is replaced by increased access to education and healthcare. A black middle class is growing, despite the fact that so many remain in abject poverty. Despite its economic woes, healthcare is now a universal (though less than optimal) entitlement in South Africa.
South Africa is slowly making progress, matching the rhetoric of equality and opportunity to the realities of a complex economy still transitioning from centuries of social injustice. It is a slow process. Despite their continuing problems there is much to praise and celebrate.
What can we say for ourselves? Are we ready to ask ourselves how to move away from our fascination with hospital and specialty-based practice and give more than lip service to pursuing health preservation and managing chronic disease? It is time for us to move away from what I call “repair care,” fixing things that are broken, or managing pathology rather than preventing it. Can we ever achieve our Triple Aim Plus One objectives without a shift of resources from “repair care” to a system of care primarily built on a philosophy of disease prevention and the improvement in the social determinants of health? The more we learn, the less ignorance we suffer from, the less excuse we have for maintaining our incompetence.
