Health policy and debate misfire: how private corporations, non-profits, medical professionals and government health bureaucracies colonise our ill-health

We have an epidemic of evolutionary novelty, and it is killing us.
Bret Weinstein

Health policy is a matter of lively debate in the US, largely because the US political system has never fully settled on a coherent health system.

Health as a policy issue has all the factors that make for difficult public policy. It really matters to people. There are deep information asymmetries (lots of folk do not know what they need to know and have to rely on others). It can be ferociously expensive. Both public and private provision have obvious problems that the partisans of the other can point to. Lots of people’s incomes are at stake.

Something of a perfect storm of difficulties.

Health issues can be divided into acute (infections, accidents, violence) and chronic (everything else).

Western medicine is generally very good at dealing with acute conditions. Acute conditions have clear indicators of success; they are an immediate, identifiable problem; they fit in with the anatomical foundations of Western medicine; and there is a very broad incentive to get it right. There is certainly grounds for debate about how best to provide and fund acute care. Nevertheless, acute medicine is mostly a relatively straightforward provision-and-insurance problem.

If acute care was split off and dealt with specifically, I strongly suspect reasonable mechanisms with good incentives could be agreed on fairly easily. Mainly because the inherent incentives in acute care are success-oriented.

Chronic conditions are a very different matter. Western medicine has been far less successful at dealing with chronic conditions. Cancer is still often a death sentence and the metabolic health of Western populations (obesity, high blood pressure, diabetes, etc) has been steadily getting worse for decades.

Moreover, as noted here, most of those chronic conditions are related to the mismatch between how we evolved to live and how we do live.

Health expenditure has been consuming ever higher shares of GDP. There is a view that it is perfectly natural that health expenditure should go up. As people get richer, they want to fund better health, they live longer, so of course health expenditure goes up.

I want to suggest that is (mostly) bollocks. As we get richer and more knowledgeable, it should be easier to achieve and maintain good health. We should not be getting chronically sicker, which we are. Health expenditure is going up far more because we are getting chronically sicker than because of some preference for better health or the experience of increased longevity.

Incentives matter

Looked at dispassionately, the reason for the increasing chronic ill-health of Western populations is simple. That is precisely what the current incentives are structured to produce.

Start with Big Food Products. Their incentive is not to provide nutrition, their incentive is to get you to eat more. Since what you eat affects how much you eat, and because palatability and nutritional value are so weakly connected, getting us to eat more is both relatively easy and immensely profitable. If we eat more and more, if we eat more and more of what is palatable but not metabolically healthy, thereby increasing our metabolic stress, we will get more and more metabolically unhealthy. Which we are. But we will eat a lot more of Big Food Products’s multi-billion dollar income-earning offerings on our way.

People will do more of what makes their income go up. People are paid to do more of what makes their income to go up.

Consider Big Pharma. Their incentive is far more to provide suppression of symptoms than it is to provide cures. A genuine cure — you take this, the problem goes away, so you can stop taking this — is much less profitable than suppression of symptoms. For instance, tablets for high blood pressure do not cure what causes the high blood pressure, they suppress the symptoms. An amazing amount of prescriptions are not curative, they merely suppress symptoms.

People will do more of what makes their income go up. People are paid to do more of what makes their income to go up.

Consider health advocacy. The dominant donors for health advocacy non-profits such as heart associations, diabetes associations, and so on are Big Pharma and Big Food Products. Moreover, if those conditions actually went away, if they became insignificant, then so would the point of having those non-profit associations and the jobs they fund.

People will do more of what makes their income go up. People are paid to do more of what makes their income to go up.

Consider Official Psychiatry. What distinguishes psychiatrists from clinical psychologists is that psychiatrists can prescribe drugs. (And clinical psychology is more likely to have a stronger base in actual scientific evidence.) So, psychiatrists have a strong incentive to focus on the prescription of drugs.

Psychiatric drugs are almost invariably not curative. You generally do not take them, get cured by the drug, and stop taking them. We do not know enough about the interaction between neurophysiology, neurochemistry and cognitive patterns to reliably produce curative psychiatric drugs.

Psychiatric drugs typically suppress symptoms. Which means that they are often used much longer than an actual cure would be. Indeed, it is often not clear that they are any better than, and may be worse than, the passage of time. (They may be worse than the passage of time because of the possibility that they could be suppressing curative responses that might occur if things were allowed to run.) But suppression of symptoms can easily provide a more secure stream of income than an actual cure. With failing to ask awkward questions, or consider awkward data, being very successful income-and-authority self-defence devices.

People will do more of what makes their income go up. People are paid to do more of what makes their income to go up.

As an aside, and on a somewhat related issue, in the US, gender-affirming therapy plus the Dutch medical application model is the basis for treating gender dysphoria. This maximises the chance that anyone presenting with gender dysphoria will be medicalised and so become a permanent consumer of artificial hormones, with the more income to be made the earlier in life people transition. The gender-affirming medicalisation approach has been endorsed by various peak medical bodies, bypassing normal interrogation of the scientific evidence. (Once a viewpoint gets enough “this is what good people believe” oomph behind it, it can memetically capture institutions remarkably quickly, particularly if dissent is sanctioned.)

Getting back to chronic conditions in general, general practitioners, your ordinary medicos, are in much the same situation as psychiatrists. Suppression of symptoms can easily provide a more secure stream of income than an actual cure. With failing to ask awkward questions, or consider awkward data, being very successful income-and-authority self-defence devices.

Stop and consider what doctors in the past were paid to deliver as “cures”. It is clearly entirely possible to sustain a medical profession on a very poor knowledge base. Let alone a system that does successfully suppress symptoms, at least to a degree, and for significant amounts of time.

People will do more of what makes their income go up. People are paid to do more of what makes their income to go up.

Consider government health bureaucracies. Notionally, they spend money to improve the health of the populace. In reality, their revenue goes up the chronically sicker the populace gets. The behaviour that is selectively rewarded, by increasing their budgets, is behaviour that generates (or at least does not seriously stop) the populace getting chronically sicker.

Hence we see nutrition guidelines that have not been, and are not, grounded in the science, that make no evolutionary sense (our foraging ancestors did not eat breakfast, did not eat frequently during the day, did not eat much in the way of whole grains, did not eat seed oils and definitely ate a fair bit of fat) but do lead to a chronically sicker population, so increased government health budgets and larger health bureaucracies.

People will do more of what makes their income go up. People are paid to do more of what makes their income to go up.

It is striking how pervasive the effect of the official nutritional guidelines are. They affect all food provided by government agencies — including thereby undermining the metabolic health and capacity of armed service personnel — determine nutritional content of medical training and advice provided from large medical practises.

It is not that there is some malicious conspiracy to preside over ill-health. Instead, social selection processes operate, where access to income flows are what is being selected for. The incentives are to go with the income flows. They are certainly not to have less income.

Especially when huge sums are at stake, as they are, selection will be for ideas that are good at generating income, rather than selecting for truth or scientific accuracy.

To understand how dire the issue of nutrition is, consider this: calories in, calories out. This is at once an obviously true mantra — we have to be in calorie deficit to lose weight — and yet is so profoundly misleading as to effectively be a lie.

For here’s the thing: what we eat affects how much we eat, how much we move and how active our metabolism is. Calories are not remotely equal. There are essential proteins. There are essential fats. There are no essential carbohydrates. With enough fat and protein, your body will make all the glucose it needs. Any nutritional guidelines that encourage you to eat frequently, and to eat lots of carbohydrates, are encouraging you to eat more and to, for most people, metabolically stress your body.

Why would government health bureaucracies produce such nutrition guidelines? Consider what increases health expenditures and who has the most incentive to lobby hardest. Do not delude yourself that they are well-grounded in the scientific evidence, which is a difficult matter in nutrition, making it easier to select for convenient agendas and to maintain policy inertia.

Colonising ill-health

The calories in, calories out, mantra goes with “people are getting obese because we are getting greedier and lazier”. Apparently, something magical happen a few decades ago to destroy people’s culinary moral fibre. This is not an explanation, it is a justification for colonising people’s ill-health.

Consider that what you eat affects how much you eat, how much you move and how active our metabolism is. Consider that rising obesity, and other signs of metabolic disorder, coincide with the adoption of modern processed foods (with lots of seed oils). And then look again at the “greedy and lazy” pseudo-explanation. (At this point, anger is a reasonable reaction.)

Colonisers always claim that they are there, and that they are justified, because of the “problems” and “deficiencies” of the colonised.

We have an entire interlocking set of industries and professions that colonise people’s ill-health far more than they provide genuine cures. And the “greedy and lazy” explanation of obesity blames the victims for their profitable exploitation by those — corporations, non-profits and government bureaucracies — that are colonising our collective ill-health.

Who makes money from people eating less, eating less frequently, and perhaps fasting beneficially? Who makes money from the opposite? And how much?

People will do more of what makes their income go up. People are paid to do more of what makes their income to go up.

Another factor is that the anatomical-structure focus of Western medicine may be not well structured to deal with conditions that are far more about energy flows, about the energetics of the body, rather than its structures per se. Though to have so many incentives working for suppression (or even generation of) symptoms, rather than actual cures, hardly encourages adopting a more effective analytical paradigm. Hence the continuing scandal of the lack of serious nutritional training for doctors.

As has been observed, you take an animal to the vet and the vet will ask you what you have been feeding your pet. You go to your doctor, they are not likely to ask what you have been eating. If they do, there is a high probability they will not be asking from a knowledge base grounded in solid science. (A depressing amount of what passes for nutrition ‘science’ is of remarkably low scientific quality: associational studies in particular have a startling failure rate.)

What all this comes down to is Western populations getting chronically sicker and the budgetary burden of heath expenditures getting progressively worse. Because that is what the incentive structure of Big Food Products, Big Pharma, health advocacy, Official Psychiatry, standard medical practice and Big Health Bureaucracy are all structured to produce. They are structured to colonise our (increasing) mental and physical ill-health far more than providing good nutritional practices or actual cures. (Good nutritional practices and cure may often amount to the same thing.) With the flow of funds from corporations to research, advocacy groups and doctors aggravating the problems

So, where acute care is a relatively straightforward provision-and-insurance problem with generally pro-social incentives, chronic conditions are a profoundly dysfunctional mess that no system of provision will do more than generate ever higher expenditures, so long as that continues to be what the incentives structures are overwhelmingly set up to create.

The endless, deeply ideological, arguments (better characterised as memetic warfare) over public versus private provision in health are just arguments over how much private or public bodies will colonise the chronic ill-health of Western populations. Whether they will do so is not currently in dispute.

(And I agree, private providers will colonise our ill-health more efficiently and with more charm. They have to work harder than government bodies, colonisation generally being easier if folk are coerced into providing the income flow.)

Can anyone, in all the sound and fury over health policy, direct me to anything that suggest policy makers have even asked the right questions? Because if they have not even asked the right questions, how can we expect good answers?

But, then again, who has the incentives to ask the right questions?

• Policy
• Health
• Nutrition
• Politics
• Obesity