It's not that the American health system is completely deficient in small, clever, inexpensive fixes. It's just that sometimes they're awfully hard to find.
The whole system tilts heavily in the other direction. We specialize in giant, cumbersome, ruinously expensive fixes. Thus, while we duly celebrate some clever little tools, we compulsively improve on others until they are almost unrecognizable, and still others we blithely ignore.
Take what must be the greatest cheap medical fix in all of history: the bar of soap. Soap never stops proving itself. As recently as 2005, a study from the slums of Karachi, Pakistan, showed that free bars of soap (and lessons in how to use them) cut rates of childhood killers like diarrhea and pneumonia by half.
But you don't find soap in American hospitals anymore, at least not in its classic solid rectangular form. A variety of expensive improvements have replaced it, all created in response to the various ways in which modern doctors and patients reflexively undermine good, inexpensive tools.
First, we automatically capture these things for our own personal use: Bars of soap left in any public place are likely to disappear in short order. (That is why toilet paper rolls are generally locked into their little metal houses.)
Second, we find fault with them. People will actually use the observation that bar soap is "dirty" as an excuse not to wash their hands. (Studies have shown that you will not pick up somebody else's germs from a piece of soap, however dingy it may look.)
Finally, we ignore them. Who notices a bar of soap? It does nothing for you unless you notice it — but it is so humble and boring; and sudsing, rinsing and wiping are so pedestrian. Also, if you are in a hurry, they seem prohibitively time-consuming. Studies continually show low hand-washing rates among rushed hospital personnel. Hence the large-scale adoption of more convenient liquid products, and the slow segue into alcohol-based hand sanitizers, which obviate the rinsing and wiping.
And lo, a simple good thing has been tweaked until it is no longer simple. Instead of soap now we have a gigantic selection of luridly colored products augmented with every variety of additional germ killer imaginable.
Some of these concoctions are indeed far more potent than ordinary soap in dispatching germs, when tested under careful laboratory conditions. No one has managed to prove that any of them controls infection rates in a hospital (or, for that matter, in a home) better than universal, assiduous scrubbing with regular, inexpensive, plain old soap.
Other little miracle tools are just as widely disrespected. No one taking medication should be without one of those little plastic pillboxes with one or more compartments for each day of the week; these are heroic tools, overlooked, underpriced and invaluable.
Granted, many people take too many medications and would be well advised to skip a few. The lives of some, though, depend on accurately sorting through the contents of a plastic bag full of hoary amber bottles with indecipherable labels. Setting the pills out a day or a week at a time in nice, clean little plastic rooms can dissipate the chaos instantly.
The most recent good little thing to hit the modern hospital is the checklist. Dr. Atul Gawande, the writer and surgeon, has called it a tool "almost ridiculous in its simplicity." And indeed, it is no more than an ordered list of things to get done.
Schoolchildren have made these lists for centuries, but doctors, incredibly, have not. In arenas like the operating room — where success depends on the integration of many different agendas, a dozen kicking chorus lines moving seamlessly across the stage — medical professionals working together never thought to make a master list.
Then Dr. Peter J. Provonost, a critical care specialist at Johns Hopkins, showed several years ago that a variety of endemic hospital problems could be virtually eliminated with checklists. Lists efficiently overcame staff forgetfulness, haste and overconfidence, and rates of intravenous catheter infections, pneumonias and a variety of medical errors plummeted. Checklists are now becoming routine; whether they will go the way of the bar of soap, improved beyond all recognition, remains to be seen.
We often overlook easy little fixes because they lie just tantalizingly out of reach, near yet very far. Weight loss is a prime example. It can solve and prevent many horrific medical problems, yet somehow it seldom happens. And so we are forced to deploy our usual giant, cumbersome and expensive tools for heart problems, joint pains and the rest.
Five years ago my patient Harry was teetering at the 300-pound mark — a 35-year-old with the medical problems of a much older man. Diets just didn't work. He managed to stop smoking, but then he got even larger.
Then he started medication for hepatitis C, an expensive combination of drugs with many of the side effects of chemotherapy. People grow weak and achy with this treatment, as if they had the flu for months. Often, as in Harry's case, they lose their appetite.
Six months later we had to call the whole thing off; his hepatitis was a relatively resistant strain, and the treatment was doing nothing for the disease. But remarkably, it had improved his health anyway. Harry was almost 100 pounds lighter, and his blood pressure, blood sugar and cholesterol levels were now perfect.
You could call it the $20,000 diet — the approximate cost of all the drugs — and in some sense, given that he has managed to keep most of the weight off, you even make a case that it was worth it. Certainly weight-loss surgery would have cost a similar fortune, and the long-term complications of obesity probably even more.
But even so, what a peculiar, postmodern fable his story is, as are many of the circuitous routes we wind up traveling when the great little shortcuts elude us.
