Prescription for an Ailing Care System: Combat Health Illiteracy
Dr. Walter Bortz of Stanford University argues that we need to shift our medical system's focus from disease to health.
Dr. Walter Bortz, a clinical professor of medicine at Stanford University, vividly recalls a meeting in which officials of the medical school outlined plans for a new hospital.
“The director regaled us of all its glories, telling us, ‘We’re going to have this and this and this,’” he said. “I put my hand up and asked, ‘But what are you doing to keep people out of the hospital?’”
He got no answer, of course. But the question sums up Bortz’s mission in a nutshell: He wants to change the basic relationship between the public and the medical establishment. He argues that people need to take charge of their own bodies, and health institutions need to educate and guide them toward optimal health.
Bortz calls this approach “Next Medicine,” which is also the title of his latest book (published by Oxford University Press). The author of six other books and 131 research papers (at last count), the extremely active 82-year-old is a recognized authority on aging. During a recent conversation over lunch, he talked about his ongoing effort to shift the focus of the medical establishment and combat what he calls “health illiteracy.”
What’s the fundamental problem with today’s medical system, as you see it?
The two tools in medicine’s black box are pills and (surgical) tools. They work for certain things, but not for either diabetes or aging, which are the two big global health challenges today. What are we going to do with 600 million disabled old people? We need a new paradigm—not illness, not disease, but health. I’m trying to help shape that process.
What’s stopping us from shifting to a prevention and health-maintenance orientation?
It’s about the locus of control. Medicine wants to control, because that’s where the money is. People don’t want to take care of themselves; they want somebody to do it for them. That’s the historic moment we are at.
Many will read this and ask, “Isn’t our health largely determined by our genes?”
Only 15 percent. That figure is taken from twin studies, since they share precisely the same genetic pattern. And it may be less than that, since the seeming influence of heredity may be a product of shared family values. Genetics play a role, but it’s blamed for too much.
If they’re not blaming their genes for illness, people often say, “Well, I’m just getting old.” Is that a cop-out?
It wasn’t until I pulled my Achilles tendon that I was able to define aging. My leg became frail. But what is frailty? It’s not a disease. Is aging a disease? No. So it needs a different explanatory platform. It became my scientific responsibility to find it. I wrote a major paper in JAMA in 1980 called "Disuse and Aging." It differentiates disuse, which is reparable, from aging, which isn’t. It’s an important differentiation. We were accepting (so many physical limitations) and saying, “That’s just aging.”
I hearken to the serenity prayer: Change what you can, accept what you must. We now know that “Are you fit or are you frail?” and “Are you a resource or a liability?” are choices. Fitness is a 30-year aging offset. Biologically, a fit person of 80 is like an unfit person of 50. To me, that’s profound.
So the rate at which we physically decline …
… Is up to us. My doctor son and I calculated that, if you’re not fit, you get older at a rate of 2 percent per year. If you are fit, you get older at a rate of one-half percent per year. You can’t see the difference over a short period, but you can over 30 years.
How do we get people to take responsibility for their own health?
My rubric is, if you’re going to change behavior, you need three things: information, opportunity and incentive. An overweight woman suffering from diabetes who comes to me as a doctor will expect me to give her a pill. She doesn’t have the information that her weight is contributing to her disease. We must give her health literacy. It’s medicine’s responsibility to allow her to take care of herself.
The second is opportunity. It’s no good having the knowledge if you don’t have the time or resources to implement it, or you only have McDonald’s in your neighborhood.
Then there’s incentive. When you pay your income tax, why not be rewarded for having a certain BMI? It’s not that different from (making people wear) seat belts or helmets. Why not embed a pedometer in your body? Every April 14th, you would see what your pedometer setting is and plug that into your tax return.
What changes need to be made in the health-care system?
We’re saddled with wrong personnel. We have all these specialists. We need to downscale that. You don’t need more neurosurgeons; we need more nurse practitioners. You can’t say, "Don’t operate" to a surgeon—that’s who they are—but you can have a Kaiser-type system that rewards people for staying healthy. Get rid of fee-for-service medicine.
What did the Affordable Health Act get right, and what did it get wrong?
The important thing that is did was ensure near-universal coverage. It was unconscionable that we were the only (industrialized) country in the world that did not have total coverage. But the question becomes: coverage of what? Do we simply have a license to have a daily MRI?
We need to create a whole culture of health. If we don’t have sidewalks, we need city planners (to make sure they’re built). If we have too much sugar in our diets, we need farmers (to grow healthier foods). We need to ask ourselves, "What is health?"
These ideas usually come from people outside the medical establishment. Do you have unusual authority to make such a critique?
I’m inside the tent. My dad was president of the AMA. I have all these credentials. I wanted Oxford to publish my book Next Medicine because I thought it was the place to try to impact my profession. They welcomed me immediately.
You still train doctors at Stanford. Is the new generation of physicians thinking more holistically?
Yes. Three or four years ago, I heard about a guy at Harvard named Eddie Phillips, who started the Institute for Lifestyle Medicine. I thought it was amazing that an academic institution would put their imprint on such an institute. Stanford would never do it! So I have sent Stanford med students there, and we now have a course on lifestyle medicine, which was originated by the students. It’s a wonderful way to shame the faculty.