Debating the Fundamentals of Healthcare at the Oxford Union
I recently had the privilege of participating in a 130-year-old British tradition: the Oxford Union debates. I’ve always enjoyed the traditions and excellence of British universities, even if places like Oxford (and my own institution, Duke University) can be a bit pompous! The full debate will be available on YouTube, but because I was the last of six debaters (three on each side), I diverted considerably from my prepared remarks to be responsive to ongoing themes. Accordingly, I thought it might be interesting for some people to see my full prepared remarks.
The format of the debate is to take a side on a “House proposition.” You don’t get to choose which side you take, as the historical mission of the Oxford Union is to prepare students for open discussion and exchange of ideas. People who know me know I always love a good argument, so I would have been happy to argue either side. However, the proposition was almost impossible for my opponents (Professor Dame Ijeoma Uchegbu and investigative journalist Gerald Posner) who were obliged to argue that profit motives have NO place in public health. Dr. Freda Lewis-Hall and I were assigned the “con” position (a double negative, so we were arguing in favor of the profit motive).
The format is to alternate debaters beginning with a student on each side and then two senior debaters. I believe that my colleagues on the con side and our debating opponents did a great job, including deftly handling a fire drill in the middle of the debate.
The next day I spent some hours at Rhodes House, where I got to enjoy some very lively interchanges with Rhodes Scholars, followed by some great discussions about how to operationalize clinical trials and translational medicine with senior Oxford and Ellison Institute leaders.
This House Believes that Profit Motives Have No Place in Public Health
Madame President, Madame Officers, Ladies and Gentlemen,
As a country doctor from South Carolina, I’m honored to appear in the seat of the intelligentsia of the former British Empire to argue the point that there IS a place for the profit motive in public health. I have had the privilege of working in most sectors involved in the delivery of healthcare and public health in the United States: clinical practice; academic medicine; the industries that develop and market pharmaceuticals, biologics, devices and digital technologies; and the U.S. federal government, both as a civil servant and as a political appointee. I contend that the salient issue is not whether the profit motive has a place—I believe it does. But there is a significant challenge in getting it right. How do we harness the profit motive for the good of more people rather than the current bias toward serving the well-to-do and privileged?
If only people were not human, I could buy the argument that the pure joy of pursuing goals such as extending longevity and improving the well-being of the global population is all that we need in order to optimize public health. Alas, people are in fact human, and as I’ve already stated, I am at a great disadvantage as a country doctor from South Carolina, entering this majestic environment—Oxford University has done as much as almost any other institution to introduce modern government civil service to the world. I submit that in this imperfect world, it is essential that we have a balance in which regulation is used to provide guard rails and swim lanes for the industries driven by the profit motive to align profit with public health.
As we examine the profit motive and its alternatives, it may be useful to consider basic definitions. The profit motive is defined by Google’s Gemini AI, quoting the Oxford English Dictionary, as “the desire for financial gain as an incentive in economic activity.” By the way, while I was able to check the dictionary through the Duke University library, Dr. Lewis-Hall had to pay for access to this venerable Oxford book. As we discuss this issue, let’s not confuse the basic foundation of economic activity that motivates individuals and allows us to interact with a common currency intended to reflect the value of an activity.
What is health? I like the definition that appears in the World Health Organization’s Constitution: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” The pursuit of work and financial well-being is included as an essential element of overall well-being by most scholars who have evaluated this issue.
And what is public health? Once again consulting the Oxford English Dictionary, it’s defined as “the health of the population as a whole, especially as monitored, regulated, and promoted by the state.” When viewed from the perspective of the operational functions of the enterprise, it’s defined as “a multifaceted discipline focused on improving and protecting the health of populations through organized efforts, both public and private. It involves preventing disease, promoting health, and prolonging life, primarily through a combination of scientific knowledge, evidence-based interventions, and community engagement.”
I submit that there is nothing in these definitions that would specifically preclude the profit motive from being part of these activities. In fact, I believe that most of these activities benefit from the discipline imposed by competition in profit-driven world. But at the same time, there is a lot to discuss regarding “the population as a whole.”
First, having participated in the development and deployment of many interventions that are critical to the public health, I find it obvious that without the motivation offered by the potential for profit, the invention, development, and deployment of new technologies tends to get mired in bureaucracy. I’ve seen what it takes to develop effective treatments for heart attack, stroke, heart failure, blood pressure, high cholesterol, and most recently, highly effective vaccines in record time. The opportunity to profit motivates people to go the extra mile, work the extra hours, and take the risks of failure that are necessary to successfully bring safe and effective new therapies to the public.
Second, let’s not forget the powerful impact of financial incentives in motivating individual behavior. Simply reminding people of the right thing to do is an important element of the overall story, but financial motivations tend to prevail. One particular public health intervention that has made an enormous difference comprises measures designed to reduce, and hopefully ultimately to eliminate, the use of combustible tobacco products. The key insight that unleashed coordinated public and private effort was achieved thanks to the British Doctors Study and the tireless efforts of Sir Austin Bradford Hill, Sir Richard Peto, and Sir Richard Doll, the latter of whom I had the privilege of meeting here in Oxford. But make no mistake about it: while banning indoor smoking had a major effect on reducing tobacco use in the UK, the huge tax placed on the product also played a significant role. These taxes led to easily measured changes in behavior at both individual and population levels and delivered enormous reductions in death and disability. The desire of people to have more personal profit by not spending on highly taxed tobacco products is a great example of the use of economic incentives for the benefit of public health!
One of the most important health issues in the United States right now is the unhealthy diet of Americans. Having spent the past two days at Canary Wharf, I’ve noticed that y’all tend to eat like we do: lots of ultra-processed food, high in salt, sugar, and unhealthy fats. Turning this around will take more than preaching—the basic infrastructure of agriculture, food distribution systems, restaurants, and grocery stores needs to change. However, passing laws without considering the fundamental need of people to make a good living is destined to generate resistance. In fact, people who take the “we’re from the government and we’re here to tell you what to do” attitude are destined to not be elected—and therefore not be in a position to pass laws. Financial or profit incentives are essential for success here.
Another critically important, and in my view unfortunate, reason to have profit-driven companies involved in public health is the frequent inability of our governments to collaborate with other governments across national boundaries. Multinational companies have the depth of expertise and the distribution systems needed to provide most countries with necessary public health interventions, from toilets to vaccines to HIV medications. This was a critical element of the COVID pandemic response, which, imperfect as it was, depended on reliable manufacturing and distribution of products including personal protective equipment, vaccines, and antiviral medications. I saw this first-hand in my job at Alphabet, including its well-known subsidiary Google, where we participated in everything from providing governments with basic information about the pandemic to manufacturing ventilators. Now we have a situation where the top levels of the U.S. government are not supporting life-saving public health measures, so I am thankful that we have global corporations that can continue to produce necessary vaccines, medications, and devices.
The British Empire and the bureaucracy it spawned provide many examples of what happens when government dominates in spheres of public activity. I’m probably the only person in these hallowed halls to have once given an invited lecture here at Oxford on bureaucracy and the risks of assigning power to government bureaucracies rather than promoting competition for efficiency to achieve societal goals. Sometimes great things such as the National Health Service are the result, but it’s also possible to get mired in complexity and lose sight of the ultimate goal. Just ask people trying to practice primary care right now in your system.
I am not here to argue that the current mix of for profit and not-for profit motives in my home country is the right mix. Let’s examine some of the key areas of misapplication of the profit motive in the United States:
First, the system is currently configured to provide benefits in terms of the social determinants of health to those who are already wealthy. Over half of Americans could not raise five thousand dollars in the case of a medical emergency. If the lower half of wealth earners in the United States were to attempt to eat wholesome, healthy food, a major part of their daily budget would go to food. The U.S. already has alarming rates of food insecurity, which means a large proportion of people don’t know where their next meal might come from. Amid this health tragedy driven by financial toxicity, the six trillion dollar “wellness industry” caters to the wealthy and well-to-do. As the science writer Ed Yong noted, writing for The Atlantic: “Technological solutions…tend to rise into society’s penthouses, while diseases seep into its cracks.”
Another key flaw of the US system is the extreme financialization of the delivery system. I literally couldn’t differentiate the board meetings of for-profit companies and not-for-profit healthcare delivery systems—both are deeply focused on quarterly financial statements. The investment portfolio becomes as important as the operating finances in this environment. And too often, the profit and loss for each activity takes priority over human need.
The current financialization model itself gives rise to further distinctive problems: fragmentation and suboptimization. Fragmentation, frequently discussed as an impediment to effective healthcare delivery, arises when the system has too many discontinuities that require time and effort to overcome. Suboptimization within the context of a fragmented system is particularly detrimental. Suboptimization refers to a system in which constituent parts of the system have incentives to optimize their own segment regardless of the impact on the system as a whole. For example, the pharmacy of a hospital or a health system is rewarded for spending less on preventive medicines for the system pharmacy, even if the impact on downstream costs and health outcomes is compromised.
Another result of fragmentation and suboptimization is that profit is taken by “middle people.” This is because each discontinuity in the system creates transactions from which profit can be taken. In the U.S., the overwhelming power of pharmaceutical benefits managers, insurance companies, and hospital administrators compared with nurses, doctors, pharmacists, and those who actually practice public health provides all the evidence I need.
But before we attribute all of this to the profit motive, let’s remind ourselves that systems run purely by governments are notorious for administrative bloat. I still love the satire about the ideal British hospital having no patients because they cost money and complicate the life of the administrators.
I believe that what we need to do is to agree on purpose and then optimize the balance of profit-driven activity with proper regulation, so that those who fulfill the mission also profit. We know the list of our major causes of death and disability. We also have effective interventions for most of them, with major advances on the horizon. Is the goal of healthcare to optimize the frontiers of healthcare for the benefit of the wealthy? Or is it to effectively deliver the best possible care to everyone? I believe that the U.S. has lost its way on this question, which at least in part accounts for the fact that we are in last place in terms of longevity and healthy longevity among high-income countries. But the UK has also lost its way in a system encumbered by too much antiquated bureaucracy.
When the profit motive operates in the absence of a consensus on purpose, we have a major problem. And when government bureaucracy loses sight of its reason for existing in the first place, we also have a major problem. Imagine a world in which the profitability of components of the system was aligned with the goal of optimal health of the population and the number of people delivering useful services and technologies exceeded the number of “middle people” administering the system, whether or not for profit. Let’s align basic human economic instincts with the health needs of all people.
All you need to believe to vote NO on this proposition is that there is SOME role for the profit motive and that we can redefine our purpose to align profit with human good as much as possible.