I was a chemistry major back in the day, and although I don’t pull out my chemistry background much anymore, one term still has relevance: the rate limiting step. See, in any chemical reaction, there’s always one part that is the slowest. If you want to speed things up, you’re going to be able to make the most difference by focusing on that step.
When I think about health care, I feel like American medicine rarely heeds that advice. To combat the obesity epidemic, we see people panicking about whether their vegetables are fully organic instead of recognizing that way too many people get too few vegetables at all. We see people fighting against vaccines and decrying them as “not good enough” when they’re still better than almost anything else we have in medicine. We see people obsessed with extending life at the extreme end of the human lifespan while ignoring simple things that might make children far, far better off (think having enough to eat, maybe).
This is why medical myths tick me off. Why are we obsessed with Halloween candy, but ignore how costumes can get kids hit by cars? Why can’t we focus on the stuff that is really dangerous?
But as Dan Diamond points out, not everyone is looking at the wrong things. Bill and Melinda Gates are doing it right. From 1990 to recently, the childhood mortality rate has been cut in half. Why? Cause they pay attention to the things that matter. What kills kids worldwide? Malaria – and they’re hard at work on a vaccine. No worries about phantom illnesses or the craze of the week. Instead, they’ve got a solid focus on the things that actually matter.
So what do they propose to keep things going? Again – rate limiting steps:
1. Encouraging breastfeeding. When mothers breastfeed, it boosts newborns’ immune systems and gives them essential nutrition. Newborns that have been breastfed for the first six months since birth are 14 times more likely to survive, Bill and Melinda Gates write.
2. Administering antibiotics. Training and empowering health care workers to immediately deliver injectable antibiotics to ill newborns would save 300,000 lives every year.
3. Using resuscitation. Distributing hand-pumped oxygen masks and offering basic training could be “critical” for saving newborns that are struggling to breathe, according to Bill and Melinda Gates. Breathing problems contribute to about one-third of newborn deaths around the time of delivery.
4. Drying the newborn. Simple steps, like cleaning and warming the newborn through skin-to-skin contact can prevent 20% of newborn deaths caused by preterm birth complications.
5. Cleaning the umbilical cord. This is “essential” to preventing infections, Bill and Melinda Gates write. A common antiseptic agent called chlorhexidine works well.
No fancy new medicines. No genetic tests. It’s easy to roll your eyes and say this is common sense stuff, and it is in much of the developed world. But I think the Gates want to do the most good they can for children worldwide, period. And they can do so by improving things for those who have it the worst. That’s the rate limiting step. Further, they can do the most good in the places that need it the most by focusing on the things that are actually killing kids. In this case, it’s nutrition, hygeine, and infection control. They won’t make any breakthroughs or money with this stuff, but it has a large chance of succeeding.
The lessons for the US are clear though. What’s the number one killer of kids in the US? Accidents – by far. But the number of foundations and NIH dollars going into that is miniscule. Know what consistently makes the top five? Suicide and homicide. How much time and money do we spend on researching ways to reduce that?
There aren’t any drugs to help these things. No devices or procedures. There’s no money to be made. For whatever reason, we spend our money on research and interventions for other things. And then we wonder why real change is slow.
I argue all the time that this is what health services research is about. We don’t cure diseases. We don’t make the papers for new drugs or new therapies. We don’t win Nobel prizes in medicine. We don’t hit grand slams. What we do is hit singles every day.
We take the stuff that we know works and figure out how to get it to more people. We figure out how do it most cost-effectively. We try to improve quality on a large scale, raising all boats by bringing the tide up just a bit. It’s not flashy. But it works. The lessons from chemistry classes sank in, and I love what I do so much, that some days I can’t believe they pay me to do it.
And I couldn’t have more respect for the Gates Foundation for putting some serious resources behind it in the places that need it the most.