Restrictive practices in medicine are holding high-income countries back

A paper in this week’s New England Journal of Medicine (NEJM) is part of a pattern: middle-income countries do a lot of primary care better than advanced economies. They get better results at much lower costs, usually because they are not hobbled by powerful, well-paid health professionals seeking to protect their revenue streams.

The NEJM paper shows that hypertension care delivered at home by community health workers (CHWs) delivers better results than care delivered through a clinic. It is reporting on interventions in rural South Africa. The team that did the research comes from the University of KwaZulu Natal and Harvard. Do not, though, expect to see people in Massachusetts benefit from the findings any time soon.

In the most sophisticated community model in South Africa, 83 percent of trial participants had their blood pressure under control after six months, an outcome that was sustained after a year. In that model, patients were seen by a nurse with decision-making authority; they were given an automated blood pressure monitor that sent regular messages to an app used by the nurses; CHWs — lay health workers who live in the communities where they work — helped patients use the machines and delivered medicines that the nurses had prescribed. The nurses got reminders about regular review of readings, prompts from a national management protocol and suggestions about prescribing updates. Medicines were sent automatically to the CHWs, who delivered them to patients.

In the world’s most expensive healthcare system, about 60 percent of Americans with hypertension knew they had it in 2024. About half of them were taking treatments and about 20 percent had their hypertension under control. Unsurprisingly, heart disease and stroke are the leading causes of death in the United States and hypertension is a major risk factor for both.

In a 2010 report, over 40 percent of Americans with hypertension were managed by internists, who now earn over $250,000 a year on average, although about one in eight were managed by cardiologists, with an average salary of about $420,000. A Journal of the American Medical Association paper in late 2024, reported that, “70% of adults with uncontrolled hypertension who were aware of their condition reported taking antihypertensive medication.”

Crudely — and I appreciate that we shouldn’t compare data from very different sources and different populations — Americans are about a quarter as likely to have successful treatment of their hypertension as are rural South Africans in this pilot. The Americans pay a fortune; the SA government pays very little, but uses technology wisely. This should not come as a surprise. It follows closely the track record of the two countries in treating HIV.

In 2022, 90% of South Africans living with HIV knew they had it; 91% of those aware of their status were on effective treatment (highly-active antiretroviral therapy or ART); and 94% of those on ART were virally suppressed. Suppression means that the virus cannot be detected in the person being treated; that the disease is unlikely to progress; and that it is virtually impossible to transmit it to another person. South Africa’s success is mostly the result of good community care, efficient delivery of medicines to convenient pickup points and strong leadership. It is doing well, especially given the vast number of its citizens living with HIV, but most of its neighbours are doing better.

The US Centers for Disease Control do not report data in the same format, but in 2023, only 67% of Americans living with HIV were virally suppressed. About a quarter received no medical care at all that year. A US government webpage lists at least 10 kinds of professionals who may make up an HIV care team. Almost all will include an infectious disease doctor, who earns about $250,000 a year, a bargain in American terms.

I could keep giving examples — open heart surgery in a production line model for under $2,000; one-stop breast care clinics to diagnose early-stage breast cancer and manage it; AI-powered skin lesion analysis by CHWs. All deliver better results at a fraction of the cost. We should also not just pick on the USA as a comparator: France and Germany don’t do much better. Worst of all, some of these examples are over a decade old but entrenched medical interests have stopped advanced economies from adopting models of frugal innovation that would improve quality of life and avoid premature deaths.

There are examples in the other direction. For example, about 90 percent of children with cancer survive at the very best treatment centres in the USA; fewer than 20 percent do in some low-income countries. (A coalition involving St Jude Children’s Research Hospital, the WHO and partners are working on exactly this) The patterns are not so stark in adult cancers and neurological diseases, but also clearly favour the advanced economies. However, risk stratification based on big data, standardised treatment protocols and the rapid introduction of some new diagnostics all seem likely to happen faster in middle-income countries than outside centres of excellence in high-income ones.

There is little appetite to take on the vested interests in most countries and concern over making so much current investment redundant. For example, many GPs in Ireland, where I live, won’t rely on validated smartwatch readings to monitor blood pressure because all have bought devices that patients take home for 30 hours and that inflate a cuff every hour.

Change will accelerate rapidly from here on. The innovators will come from middle-income countries without our sunk investment or our abundant human resources. If we, in the advanced economies, want to be early adopters or even part of the early majority, we’ll need to be more willing to disrupt entrenched and dysfunctional systems.