First Principles

Apologies. I missed yesterday because my life was just too hectic. Right now I'm living in two different places and working (mostly) in a third, gradually disentangling myself from one home and trying to get established in another, finding my way in a new work environment and taking on new projects, and commuting more than 1 hour every day, which I have never done before and don't care to continue. Meanwhile, just getting the normal stuff done -- from auto maintenance to doctor appointments (yeah, I get doctored) to shopping -- is complicated and requires advance planning about where I am going to be and how I am going to get there. Add to that several recent Mondays in Baltimore and it's very draining.

I'm not complaining, not at all. All this is in service of an opportunity I chose to accept, and it will all get sorted out and settle down in due course. But it leads me to reflect a bit on what health really means and how it is produced. We have some conventional measures of population health which are awfully crude -- infant mortality rate, life expectancy.

We can look at age adjusted rates of specific illnesses, if they happen to be available for a given society, although these are generally very much distorted by what we call ascertainment bias. You don't have diabetes unless you've been diagnosed. So one population might have a higher rate of diabetes than another because the people are more likely to have insulin resistance and hyperglyecmia; or because they are more likely to have doctors who do tests and end up telling them that they have diabetes.

The simplest thing to do is ask people how healthy they think they are. The simple question, "Compared to other people your own age, would you say your health is excellent, very good, good, fair or poor" is actually strongly predictive of life expectancy among older people. But why do people answer as they do?

Many people do not take pills their physicians prescribe, even inexpensive ones with few or no discernible side effects, even though the doctor has told them, and they may well believe, that they're likely to live longer if they take them. Maybe it's just not worth the hassle, or they'd rather spend the $15 a month copay on something else, or life is better if you just don't worry about too much stuff.

One of the strongest determinants of population health, as conventionally measured, is social inequality. Egalitarian societies are healthier, even if the average level of wealth is lower, within a pretty wide range of total affluence. And, up to a point, richer people also say they are happier, on average -- although plenty of not so rich people also claim to be happy and lots of rich people aren't.

My affluence is slightly above average, and I don't have any diagnoses of major diseases. I have a bit of osteoarthritis as most of us do as we grow older, but it really doesn't stop me from doing anything except maybe running marathons. My life is satisfying in some respects but not others. What's missing is actually important, but it can't be fixed by doctors.

I am really unhappy, though, because of what I see happening around me. I'm in a reasonably good position to weather the storms ahead but most people are not and we may well be headed for very unpleasant times. This disturbs me greatly. So am I healthy? I could go to a psychiatrist or psychotherapist and discuss my angst. I don't think I would get a disease label but you never know. In any case, what would be the best investment in my health and that of the people around me? Should it focus on the services of physicians and the goods they purvey? If not, what should be a higher priority use? If we spend less on medicine, what should we spend more on?

Those are probably more important questions than the ones I usually discuss here.