Summary Chapter 1, Introduction (Mattias Fritz)




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Chapter 5 – The Production of Health (Peter Olsson)


This chapter deals with the role of health care in society and the contribution of health care to the health status of the population. Also, the question about what is the best way to produce and distribute health is raised.

The Production Function of Health


The production function can be expressed as HS = f (Health Care, Lifestyle, Environment, Human Biology) and summarizes the relationship between inputs and outputs and it is important to inquire about this relationship.


Historically, the contribution of practitioner-provided health care to the historical downward trend in mortality has been negligible. However, it is imperative to distinguish between total and marginal contribution of health care (see page 99 to view these graphs). The health status is expected to be an increasing function of health care with decreasing marginal contribution. In conclusion, total contribution can be high but marginal contribution low since we are currently on the flat of the curve where the marginal contribution of health care is diminishing.


The authors also raise the question whether the production function is always upward sloping. Is it possible that the production function eventually will bend downward, i.e. is it possible to get too much healthcare so that the health of the population is harmed? There are two scenarios where this is possible:


  1. Iatrogenic (provider-caused) diseases, which are inevitable by-products of many medical interventions, e.g. surgery.




  1. Medical “nemesis”, taking away our abilities to face the natural hardships of life by “medicalizing” problems that occur. It has been argued that medicalizing would lead to less personal effort to preserve health and less personal determination to persevere; the result is a decline in the health of the population, and thus a negative marginal product for medical care.



The distinction between total product, marginal product and the possibility of a downward sloping production function makes it important to question the wisdom of each of our public health care programs.

The Historical Role of Medicine and Health Care


Medical historians generally agree that practitioner-provided interventions played only a small role in the historical decline in population mortality rates. Effective medicine to the extent that it has an impact on mortality rates is a recent phenomenon that appeared only well into the twentieth century, and although the magnitudes of other causes of mortality declines are disputed, it is clear that a larger role might be attributed to public health measures and the spread of knowledge of the sources of disease. Also, a great deal of the credit can be attributed to environmental improvements such as the agricultural and industrial revolutions.

The Rising Population and the Role of Medicine


Population increases generally come from three sources:


  1. Increased birthrates

  2. Reduced mortality

  3. Increased net immigration


In England and Wales in the period following 1750, immigration was most likely not an important source of population increase during the time and likewise, fertility did not account for the change since birthrates declined during the period. Declining birthrates are common in countries undergoing industrialization and modernization, but in contrast, mortality rates declined substantially.


Research shows that reductions of airborne and waterborne infectious diseases account for the largest portions of mortality reduction. While many argue that these reductions are due to improvements in medical science, effective medical intervention was not available until later, well after the greater part of the mortality decline had occurred.

The Role of Public Health and Nutrition


If medicine cannot be credited with the large declines in population mortality rates there are two other alternative candidates that explain the decline:


  1. Reduction in exposure to infection (had the greatest impact).

  2. Improvement in the human host’s ability to resist infection.


Public health measures that helped decrease mortality rates include immunization of populations, quarantines, standards for sanitary water supplies, and standards for the sanitary handling and treatment of foodstuffs.


Also the improvement in nutrition was an important factor. The introduction of foods such as corn and potatoes combined with large agricultural advances made a significant contribution to the improvements.

What Lessons are Learned From the Medical Historian?


Even though much of the previous content in this chapter has questioned the importance of medical intervention for improvements in public health, one cannot conclude that medical research is unimportant in history or in the present day medical research contributes not only through improvements to medical practice, but also through its influence on health-enhancing practices.


When analyzing historical data it is important to use matching numerators and denominators when assessing the effectiveness of different treatments. Also, history is history and we must weigh the investment in health care against other investment alternatives.


Conclusion from history: have a healthy scepticism towards the effectiveness of any given medical practice and its benefits to the population. Today, outcome studies have become more common to assess health care effectiveness.

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