This article appears in the Encyclopedia of the Future, Macmillan and Company, 1996
Healthcare - the management of the resources of healing - is one of the most complex and difficult enterprises on the planet, and in the mid-1990s it is changing with great speed and turbulence. This turbulence is likely to continue for some time into the future, for a combination of reasons both within healthcare and outside it.
Where we are now
In the mid-1990s, relatively few nations around the world are satisfied with their healthcare systems. In the United States, continuing rapid increases in costs have ballooned healthcare into a $1 trillion industry accounting for nearly 15 percent of the world's largest economy - yet U.S. statistics for such benchmarks as infant mortality and longevity consistently fall behind those of many other industrialized nations, and some 40 million U.S. residents lack health insurance. Despite these facts, the chance for significant healthcare reform seems to have come and gone after the defeat of President Bill Clinton's plan and all of its rivals in late 1994.
Other developed nations, though their per-capita costs are far lower, also face tough political struggles over rising costs and constricted resources. At the other end of the scale, the World Health Organization (WHO) estimates that more than half of the world's 5.6 billion people lack access to the most essential drugs - vaccines, antibiotics and painkillers - and more than a third of the world's children are malnourished. Many Third World governments spend less than 1 percent of gross domestic product on healthcare.
Factors in the future of healthcare
A number of outside factors will effect healthcare in the future. A less predictable climate worldwide means an increase in natural disasters such as floods, droughts, famines, typhoons. The absence of the constraints of the cold war, the continued devolution of the former Soviet countries, the increase in effectiveness and the lower cost of many weapons (especially conventional small arms), growing atomization along ethnic and nationalist lines, and the growing scarcity and depletion of natural resources, point to the likelihood of increased chaos and war. For healthcare this means an increase in trauma, in malnutrition (as the chaos disrupts food supplies), of infectious disease and stress-induced illness, as well as a diversion of resources away from healthcare toward arms and reconstruction.
Other trends point toward continued and locally increased industrial pollution, which affects people's health over wide areas. Continued population growth will stretch all resources thinner. Increasing industrialization and urbanization around the world tend to break up the family, clan, and village support systems that have traditionally supported health. The increasing power and size of global corporations, less stable global finances, the increasing influence of donor nations, of central finance agencies such as the World Bank and the International Monetary Fund, and of the central government banks and finance ministries of wealthy countries, may mean even more constraint on resources for healthcare in many Third World countries.
Finally, certain purely medical changes endanger healthcare around the world. In the ongoing war between pathogens and antibiotics, overused antibiotics seem to be losing their effectiveness against the rapidly evolving pathogens. And the rapid increase in cheap international travel allows new epidemics rapidly to become global. The spread of HIV has gone essentially unchecked in much of the world. As of 1994, HIV was infecting 13 million adults a year. The WHO expects 5 million children worldwide to become infected with HIV between 1995 and 2000. Southern Asia and Sub-Saharan Africa are expected to bear the brunt of this epidemic.
All these changes will tend to push national health systems increasingly into crisis and chaos. The effect will be most marked at the ends of the economic spectrum, in the bloated U.S. healthcare industry and in the highly strained economies of the Third World. It will be least marked in the other industrialized nations and in the robust "Tiger" economies of East and Southeast Asia.
China, with the world's largest population (1.17 billion) presents an enigmatic future. Since the 1949 revolution, China has built a healthcare infrastructure that has been widely admired for its comprehensiveness, wide social base, preventive focus, and efficient use of the country's scant economic resources. China's economy is growing rapidly, and it is expected within a decade or so to become an economic powerhouse, a middle-income country, which always bodes well for healthcare. But early signs are showing up of an increasing gap between classes, between urban and rural areas, and between coastal and inland areas, as well as signs of increasing social strain, such as the open re-emergence of infanticide, baby-selling, and prostitution, and a rise in the death rates of children under five. Some observers, as well, express concern over China's long-term political stability. The most hopeful signs for the future of health in China are 1) the government's strong, widespread, family planning programs, 2) its focus on strengthening the corps of low-cost, primary health professionals in the neighborhoods and villages, and 3) its focus on educating girls, and the relatively high literacy rate of its women (68 percent). Studies by the World Bank and the WHO have shown the education of females to be the most effective method of improving the health of populations.
We cannot expect technical developments with anything like the life-changing power that the inventions of antibiotics, antisepsis, painkillers, and X-rays brought to the early decades of this century. And some technical advances, such as distance surgery, may be spectacular but are unlikely to have a large effect on the health of most people. The areas that show the most promise for actually improving people's health include:
But in fact the most important effect of technical advances will not come in the invention of new medical techniques, but in the more effective use of the techniques we already have.
Shifts in direction
We can expect to see four major types of change in healthcare around the world in the coming decades, and two others that will be most pronounced in the United States.
Within the United States, two trends stand out: