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Now, if there is anything on which the biological sciences have prided themselves in these latter years it is the substitution of quantitative for qualitative formulae. If I summed up the lessons of Louis in two expressions, they would be these:
Formez toujours des idees nettes. (Frame your thoughts neatly) Fuyez toujours les a peu pres. (Always avoid approximation)
—Dr. Oliver Wendell Holmes, 1860 (1)
America’s health care system is neither healthy, caring, nor a system.
—Walter Cronkite, 1993 (2)
There are four times as many health care lobbyists as there are members of Congress. According to the Center for Responsive Politics (www.opensecrets.org), in 2005 there were 2,084 health care lobbyists registered with the federal government. With 535 members of Congress, that’s 3.895 lobbyists per member.
—SiCKO, Michael Moore, 2008 (3)
THE NUMERICAL METHOD
In the current debate over the future of medical care in the United States, we could do worse than to consult two authorities in the field, Prof. Pierre C. A. Louis, the father of medical statistics (4)
, and Michael Moore, "the angry filmmaker (5)
." Moore’s SiCKO suggests that we have a lot to learn from France; Prof. Louis reminds us that it wouldn’t be the first time.
Over a century and a half ago, Louis introduced his "numerical method" into the life sciences. He studied 77 patients with febrile pneumonia at La Pitié hospital in Paris and found that the number of those who improved after traditional bloodletting was no greater than of those left alone (6)
. He was the first to show that numbers, not intentions, determine whether medical treatment works. Moore’s SiCKO showed that structure, not money, determines whether a nation’s medical system works. Michael Moore tells us that although the United States spent a world-record $5,711 per capita on health care in 2003, only 40% of Americans were "satisfied" with its delivery. In contrast, France spent $3,048 per capita and satisfied 65% of its population. They also live longer in France: life expectancy in the United States is 77.5, while the French average is 79.6 (3)
.
Other sources confirm SiCKO’s numerical conclusion: the French have us beat by a country mile, i.e 1.6 km. (7
8
9)
. An extensive study by the World Health Organization in 2000 ranked France’s health care system as best in the world "because of its universal coverage, responsive health care providers, patient and provider freedoms, and the health and longevity of the country’s population." The United States clocked in at #37. The U.S. took a hit due to the high cost of health care, inequality of access, and the growing number of those without insurance—close to 46 million individuals in 2005 (7)
.
It gets worse. A recent study by Ellen Nolte and C. Martin McKee tabulated deaths in 19 countries due to conditions in which medical science can make a difference (e.g., myocardial infarction). Again, France ranked first in preventing "amenable deaths" while the United States placed dead last. Nolte and McKee calculated that if the U.S. performed as well as the top three countries (France, Italy, and Australia) there would be over 100,000 fewer "amenable deaths" in the United States each year (8)
.
The U.S does lead France in one statistic, however. We have more people doing biomedical research. There are 9.6 researchers in the U.S. for every thousand employees, while France has 8 (by comparison, Germany has 7 and Mexico 1) Does this mean that France is skimping on basic biomedical research in order to boost medical care delivery? Not really. The annual cost of health care in France is 10.5 percent of the country’s per capita GDP and French biomedical research gets 0.8%. Total American health care costs are 15% of GDP per capita and biomedical research is supported at 1.2%. Bottom line: both countries spend about the same percentage of their total medical bill on biomedical research, about 8 percent. (9
, 10)
But while research expenditures in the two countries are proportional, the total medical experience is quite different in each.
A TALE OF TWO COUNTRIES
Sources more rigorous than SiCKO confirm that we can learn a lot from France (11)
. The present system in France (the Sécurité Sociale) developed after World War II and resulted in complete universal coverage by 2000. This goal was achieved without the nasty public–private wrangle that blocks health care reform in the U.S. Nowadays, patients in France are reimbursed an average of two-thirds of all medical costs (hospital, office visits, drugs) directly from Sécurité Sociale. The rest of the cost (set by doctors or hospitals) is reimbursed by one of three large private insurance funds that cover almost all wage earners. These funds collect fees either from employers or individuals, who are charged affordable rates. The private funds, which had their origins in trade and professional insurance co-ops of the last century, are structured like the old Blue Cross/Blue Shield in the U.S. or the Krankenkassen in Bismarck’s Germany. Those who are unemployed or "underemployed" (i.e., income under 6600 euros/year) are covered by La couverture maladie universelle, a government insurance fund that pays medical costs for the importune (12)
.
Almost all primary care doctors—70% are in private practice—and most specialists have signed up with the Sécurité Sociale. The law guarantees a patient’s choice of practitioner and preserves physician autonomy. Unlike the practice in America’s insurance systems, no bureaucrat needs to preapprove a procedure, direct a treatment, or limit a hospital stay. (I’m reminded of my experiences in the single-payer system of the U.S. Army where the needs of each patient came first without regard to cost, rank, or local convenience). When a French patient sees a doctor of choice, a single microchip-enhanced Sécurité Sociale card permits that doctor immediate online access to the patient’s medical chart. That very same card directs reimbursement to the patient’s bank account of any out-of-pocket expenses for the visit/consultation/procedure. And unlike Canada or the U.K., there are no long waits for elective surgery (9)
. The French are also not required to listen to ads for proprietary drugs during the news hour. No wonder the majority of patients are satisfied.
Moreover, as Moore shows in SiCKO, French doctors remain snug in high-middle class comfort (3)
. While an average American physician makes five times the gross income of his French colleague, the American doctor works under a heavy burden of debt for his or her premedical and medical education, expenses for their children’s home care and day-care, and for nursery and secondary school fees. In France, each of these is provided by the state. Then, of course, the American doctor is responsible for his own health insurance costs, for prohibitive malpractice insurance, and a platoon of clerks required to cope with our Mandarin reimbursement schemes. Finally, whereas academic physicians in the U.S. must raise much of their own income from grants and/or hospital practice, French university professors are employees of the state.
LEARNING FROM LOUIS
Not only SiCKO and the WHO have suggested that we’re playing second—or 19th, or 37th—fiddle to France in medical care. Recently The Boston Globe headlined a column praising "France’s Model Healthcare System" and proposed that "Perhaps it’s time to look at French ideas about health care reform (9)
." Bostonians rarely cede preeminence to others in the world of ideas, not to speak of medical practice. Most of them agree with Dr. Oliver Wendell Holmes who once called Boston’s statehouse "the Hub of the Solar System (13)
. But let’s recall that Holmes himself had gone to Paris to learn French ideas and the numerical method from Professor Louis.
In 1833, Oliver Wendell Holmes arrived in Paris to study the new science and for a young American the experience was bracing. He wrote to his parents in Boston:
I am getting more and more a Frenchman ... I love to talk French, to eat French, to drink French every now and then (these wines are superb, and nobody gets drunk, except as an experiment in physiology); and I do believe, if Napoleon was alive, and I stayed here much longer, I should want to fight a little (14)
I have become attached to the study of truth by habits formed in severe and sometimes painful circumstance and self-denial. For, trust me, the difficulties in the investigations of our profession ... the cold and damp and loathsomeness of the dissecting-room, are exceedingly repulsive to the beginner (15)
But Holmes persevered and, after two years in Paris, returned to Boston with his new microscope, where he eventually introduced Louis’s numerical method and dissection-based anatomy to the back waters of Back Bay. His temperament squared the Anglophile bent of a Yankee Brahmin (his term) with the new scientific spirit of Paris. He was not the only Bostonian to catch a whiff of France:
The more I see of French character, the more I am delighted with it. I have hardly heard an—As I was writing this, [Ralph] Waldo Emerson came up to see me. He had been sitting some time when I heard another knock, and in walked—James Russell [Lowell]! I never was so astonished in my life; but as he is here, and I must attend to him, without ceremony I shall take the liberty to conclude my letter ... Give my love to everybody (16)
The literary Flowering of New England followed upon the commercial success of Boston after the American Revolution, and similarly, the scientific rise of the École de Paris followed the intellectual ferment of Paris after the French Revolution and Napoleonic era. If the large central hospitals of Paris which brought Holmes to Paris were a legacy of the Revolution and of Napoleon, the new scientific spirit was a legacy of a young genius named Xavier Bichat (1771–1802). Bichat’s theory that disease resides not in organs, but in tissues, conquered Europe and was brought to American shores by doctors from Boston, Philadelphia and New York (17)
. Years later, Holmes asked:
And is it to be looked at as a mere accidental coincidence, that while Napoleon was modernizing the political world, Bichat was revolutionizing the science of life and the art that is based upon it; that while the young general was scaling the Alps, the young surgeon was climbing the steeper summits of unexplored nature; that the same year read the announcement of those admirable "Researches on Life and Death," and the bulletins of the battle of Marengo (18)
Holmes looked back at that time of change in Paris and concluded that there was the "closer relation between the Medical Sciences and the conditions of Society and the general thought of the time, than would at first be suspected (19)
." In Paris, after the Napoleonic decades and the 1830 revolution, reform was in the air—medical no less than social. Following the example of Bichat, the École de Paris launched a medical revolution that would elevate study of the human body and its ailments to an exact science, to explore "the steeper summits of unexplored nature." Their goal was a system of human biology as grand and coherent as Lamarck’s evolutionary biology or Cuvier’s animal kingdom at large.
Before the nineteenth century it had been uncommon for doctors to record their findings quantitatively. But, again following Bichat, clinicians began to assign numbers to a patient’s vital signs, the pulse, temperature, and respirations—and then in 1819 came Laennec’s stethoscope. After pulse and temperature were routinely noted, after heart sounds were recorded and analyzed, doctors could begin to settle their puzzling cases not by conjecture but by comparing them to similar cases with similar numbers. By this means Louis finally ended therapeutic blood-letting in modern hospitals. Holmes was right on when he wrote of his mentor’s work "I consider his modest and brief Essay on Bleeding in some Inflammatory Diseases, based on cases carefully observed and numerically analyzed, one of the most important written contributions to practical medicine, to the treatment of internal disease of this century ... it was a revolution (20)
."
The spirit of the Ècole de Médecine revolution is captured by Holmes in a letter which explains to his friend John Sargent why he cannot write poems for The New England Magazine:
... it is always with my note book in my hand; that I often devote nearly two hours to investigating a difficult case, in order that no element can escape me, and that I have always a hundred patients under my eye. Add to this the details and laborious examination of all the organs of the body in such cases as are fatal—the demands of a Society [Louis’s Society of Clinical Observation] of which I am a member—which in the course of two months has called on me for memoirs to the extent of thirty thick-set pages—all French, and almost all facts hewn out one by one from the quarry—and No, John, a heavier burden from my own science, if you will, but not another hair from the locks of Poesy, or it will be indeed an ass’s back that is broken (21)
UNIVERSAL COVERAGE AND THE MORGUE
In Paris, Holmes studied the diseased organs of "such cases as are fatal" in dissecting rooms where victims of murder, suicide, or accident joined those felled by disease. The bodies were gathered from the dead-house on the rue Morgue to become the stuff of medical knowledge at the École de Médecine further down the Seine. Charles Meryon’s chilling etching shows the quay-side mortuary ready to receive the night’s cargo from scows on the river; the unwanted bodies were sold for cash to students of medicine eager to practice surgery, learn anatomy, or venture into forensics. Our name, "the morgue" comes from that dead-house by the Seine.
On the other side of the Atlantic, students had few opportunities to dissect the human body. Holmes explained that after tutelage in Paris, "the attentive student may return a sounder physician at twenty-five than many who slumber till sixty in our own languid scientific atmosphere (22)
." But parochial piety held sway in America to mid-century: in the 1820s the Vermont Academy of Medicine proclaimed that "bodies disinterred hereabouts would not be used in the department of practical anatomy," and as late as 1845, only half of American medical schools required time in the anatomy lab (23)
. The difference between the American experience and the French is spelled out by twenty-four year old Oliver Wendell Holmes:
The whole walls around the Ècole de Médecine are covered with notices of lectures, the greater part of them gratuitous; the dissecting rooms, which accommodate six hundred students, are open; the lessons are ringing aloud through all the great hospitals. ... It is an odd thing for anybody but a medical student to think of, that human flesh should be sold like beef or mutton. But at twelve o’clock every day, the hour of distribution of subjects, you might have seen Bizot and myself—like the old gentlemen one sometimes sees at a market—choosing our days’ provision with the same epicurean nicety. We paid fifty sous apiece for our subject, and before evening we had cut him into inch pieces. Now all this can hardly be done anywhere in the world but at Paris ... I have told you all this to let you know that I am not staying at Paris for nothing (24)
Michael Moore’s film and his subsequent web postings have made many Americans aware that our health care delivery system in 2009 is as far behind the rest of the world—and especially the French—as American medical science was behind its Parisian counterpart in 1830. The reasons are not dissimilar: parochial piety and our provincial belief that nowhere else are things better done than here.
By the time Holmes had settled into French ways, he asked his parents in Paris,
How could I ever have dined at two o’clock? How could I have put anything to my mouth but a silver fork? How could I have survived dinner without a napkin? ... It is very narrow and ridiculous, and yet it is very common, to hear people taking the standard of their own fancy for that of necessity. [An American] will tell you that he prefers a separate plate from his neighbor, but has no idea of any napkin but the tablecloth—another would shudder at an iron tumbler, but is astonished that his neighbor has an aversion to an iron fork. Now as for napkins and silver forks, the most ordinary, meanest eating houses in Paris consider them as indispensable,—and so with regard to many things which we consider as luxuries, they make a part of ordinary existence with the Parisian (25)
More and more American are convinced that our broken health care system is as outmoded as the use of iron forks or a tablecloth used as an alternative for a napkin or two. More and more Americans also agree with Michael Moore and SiCKO that universal health care coverage should be as much a part of ordinary existence for Americans as it has been for Parisians for over a decade.
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FOOTNOTES
The opinions expressed in editorials, essays, letters to the editor, and other articles comprising the Up Front section are those of the authors and do not necessarily reflect the opinions of FASEB or its constituent societies. The FASEB Journal welcomes all points of view and many voices. We look forward to hearing these in the form of op-ed pieces and/or letters from its readers addressed to journals{at}faseb.org.
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