Intended for healthcare professionals

Education And Debate Current controversies

Who needs health care—the well or the sick?

BMJ 2005; 330 doi: (Published 21 April 2005) Cite this as: BMJ 2005;330:954
  1. Iona Heath, general practitioner (
  1. 1Caversham Group Practice, London NW5 2UP
  • Accepted 2 February 2005

Shifting drug spending from the worried well in developed countries to those with treatable disease in poorer nations will benefit the health of everyone


Investment in health care, especially when it is driven by the interests of pharmaceutical companies, seems to produce a J curve. For most of the curve, the more money spent, the better the health outcomes, but after a certain point, the more spending and the more emphasis on health at the expense of other areas of human activity and achievement, the worse overall health becomes. Many poorer countries are trapped high on the long arm of the curve while richer countries seem intent on exploring the upper end of the short arm through the excessive self confidence of preventive medicine.1 The emphasis on preventive care damages patients in rich countries by tipping them towards misery. This process is built on a foundation of fear and is fanned by economic and political pressures.

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A fraction of the spending on preventive medicine in rich countries could make a huge difference to the health of poorer nations

Health and wealth

Amartya Sen has compared people living in Bihar, Kerala, and the United States.2 Bihar is the poorest state in India, and Kerala is the state that has invested most heavily in education and achieved the highest rates of literacy. Predictably, life expectancy is lowest in Bihar and highest in the United States, with Kerala's falling between the two but much closer to the United States. However, the rates of self reported illness are paradoxical: low in Bihar, where the low expectations of health are disturbing, and enormously high in the United States, which is equally disturbing but for different reasons. Kerala combines the greatest longevity and the highest rate of self reported illness of all the Indian states. It seems …

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