Improvements in automotive design and plumbing practice occur, when they do occur, outside your immediate circle, and they are overwhelmingly the work of engineers. Scientists — particularly social scientists — are taught to hate and fear engineers, but it is with engineers that practically all the improvements to details of modern life, where it does improve, originate. It is the same in medicine. In fact, it is often experienced engineers pursuing a second career in medicine who pioneer new procedures and practices. (E.g., read Gawande about changes to anesthesiology; or look up the leading hip replacement surgeon, working in Sacramento.)

Medical scientists work to understand biological processes, but there’s remarkably little prestige in applying such understanding to better patient care. That medicine does not recognize the role of the engineer is a crippling impediment to progress.

I think you’re generally right: if civilization were to hold a “contest” to eliminate the chronic diseases of civilization, with one contestant the medical/pharmaceutical establishment and the other the Seth Roberts’ and Richard Bernsteins of the world, I would bet on the latter to produce better solutions at lower cost with fewer side effects. I think the internet will greatly help the latter also relative to the former.

But does that imply that the medical establishment should not be allowed to be a contestant at all? I don’t think so, for three reasons:

First, the medical establishment is a collective, made up of individuals. The word “maverick” describes an individual member of the establishment who comes to hold a view outside the establishment (which often results in excommunication), and many medical advances have been the results of mavericks: William Harvey was a maverick, as was Ignaz Semmelweiss.

Second, the medical establishment should be allowed to compete because sometimes it comes up with the best solution. I had my thyroid gland removed, and need synthetic thyroid, an invention of the medical establishment, in order to live. You and I, and perhaps the majority of college-educated Americans, suffer from an incurable disorder of unknown cause, that tends to get worse over time, and that untreated is crippling to one’s quality of life. It’s called nearsightedness, and the medical establishment has figured out a way to treat it in such a way that no one really thinks about it as a disease at all. I’m happy about that. Maybe one day a pharmaceutical company will discover a treatment for obesity that renders it as inconsequential as nearsightedness is today.

Third, the competition itself between the two contestants is healthy for society. Each side pushes (or should) the other, or at least embarrass the other, to improve solutions to problems.

So why should the doctor care about your ideas. He just wants to do his job and get paid. Your ideas do not make that any easier for him. Give him $100 million and he will quit his job and do something that he wants to do like play golf.

Then approach him with a tip on how to play golf better and he will listen to you. “Money makes the world go round.” Many people do not believe in God, but they believe in money. Money did not exist for 3 million years and then they locked up the food and created the need for money.

1) Doctors will not be the ones responsible for big improvements in American health, outsiders (non-doctors) will.

2) Big improvements in American health will involve advances in prevention.

3) Big improvements in American health will involve patients taking charge of their care.

By “test historically,” I mean: Can we look at the great health innovations of the past to see if they fit Seth’s three assertions? Here is one list of the greatest medical innovations in history:

http://www.infoplease.com/ipa/A0932661.html

I don’t know if it’s the best list but it’s probably pretty good. Just looking through it as a non-expert, I can see several examples of Seth’s premises in action, but also several counterexamples: of advances coming from within the medical establishment, of advances via treatment rather than prevention, and of advances that happened without patients taking charge of their care.

Seth, is there anything “special” about the specific diseases of American modernity (obesity and diabetes, asthma, allergies, depression, etc.) that leads you to believe that advances in them will come via your three assertions?

I do think that perhaps you overestimate the degree to which patients will take charge of their health. Many people simply don’t care, and others aren’t smart enough, the two categories overlapping of course.