This article in the Journal of the American Medical Association (JAMA) is the best article I have ever seen written in the published literature documenting the tragedy of the traditional medical paradigm.

This information is a follow-up of the Institute of Medicine report which hit the papers in December of last year, but the data was hard to reference as it was not in peer-reviewed journal. Now it is published in JAMA which is the most widely circulated medical periodical in the world.

The author is Dr. Barbara Starfield of the Johns Hopkins School of Hygiene and Public Health and she desribes how the US health care system may contribute to poor health.

ALL THESE ARE DEATHS PER YEAR:

• 12,000 -- unnecessary surgery 8

• 7,000 -- medication errors in hospitals 9

• 20,000 -- other errors in hospitals 10

• 80,000 -- infections in hospitals 10

• 106,000 -- non-error, negative effects of drugs 2

These total to 250,000 deaths per year from iatrogenic causes!!

What does the word iatrogenic mean? This term is defined as induced in a patient by a physician's activity, manner, or therapy. Used especially of a complication of treatment.

Dr. Starfield offers several warnings in interpreting these numbers:

• First, most of the data are derived from studies in hospitalized patients.

• Second, these estimates are for deaths only and do not include negative effects that are associated with disability or discomfort.

• Third, the estimates of death due to error are lower than those in the IOM report.1

If the higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000. In any case, 225,000 deaths per year constitutes the third leading cause of death in the United States, after deaths from heart disease and cancer. Even if these figures are overestimated, there is a wide margin between these numbers of deaths and the next leading cause of death (cerebrovascular disease).

Another analysis concluded that between 4% and 18% of consecutive patients experience negative effects in outpatient settings,with:

• 116 million extra physician visits

• 77 million extra prescriptions

• 17 million emergency department visits

• 8 million hospitalizations

• 3 million long-term admissions

• 199,000 additional deaths

• $77 billion in extra costs

The high cost of the health care system is considered to be a deficit, but seems to be tolerated under the assumption that better health results from more expensive care.

However, evidence from a few studies indicates that as many as 20% to 30% of patients receive inappropriate care.

An estimated 44,000 to 98,000 among them die each year as a result of medical errors.2

This might be tolerated if it resulted in better health, but does it? Of 13 countries in a recent comparison,3,4 the United States ranks an average of 12th (second from the bottom) for 16 available health indicators. More specifically, the ranking of the US on several indicators was:

• 13th (last) for low-birth-weight percentages

• 13th for neonatal mortality and infant mortality overall 14

• 11th for postneonatal mortality

• 13th for years of potential life lost (excluding external causes)

• 11th for life expectancy at 1 year for females, 12th for males

• 10th for life expectancy at 15 years for females, 12th for males

• 10th for life expectancy at 40 years for females, 9th for males

• 7th for life expectancy at 65 years for females, 7th for males

• 3rd for life expectancy at 80 years for females, 3rd for males

• 10th for age-adjusted mortality

The poor performance of the US was recently confirmed by a World Health Organization study, which used different data and ranked the United States as 15th among 25 industrialized countries.

There is a perception that the American public "behaves badly" by smoking, drinking, and perpetrating violence." However the data does not support this assertion.

• The proportion of females who smoke ranges from 14% in Japan to 41% in Denmark; in the United States, it is 24% (fifth best). For males, the range is from 26% in Sweden to 61% in Japan; it is 28% in the United States (third best).

• The US ranks fifth best for alcoholic beverage consumption.

• The US has relatively low consumption of animal fats (fifth lowest in men aged 55-64 years in 20 industrialized countries) and the third lowest mean cholesterol concentrations among men aged 50 to 70 years among 13 industrialized countries.

These estimates of death due to error are lower than those in a recent Institutes of Medicine report, and if the higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000.

Even at the lower estimate of 225,000 deaths per year, this constitutes the third leading cause of death in the US, following heart disease and cancer.

Lack of technology is certainly not a contributing factor to the US's low ranking.

• Among 29 countries, the United States is second only to Japan in the availability of magnetic resonance imaging units and computed tomography scanners per million population. 17

• Japan, however, ranks highest on health, whereas the US ranks among the lowest.

• It is possible that the high use of technology in Japan is limited to diagnostic technology not matched by high rates of treatment, whereas in the US, high use of diagnostic technology may be linked to more treatment.

• Supporting this possibility are data showing that the number of employees per bed (full-time equivalents) in the United States is highest among the countries ranked, whereas they are very low in Japan, far lower than can be accounted for by the common practice of having family members rather than hospital staff provide the amenities of hospital care.

Journal American Medical Association 2000 Jul 26;284(4):483-5