Dean's Message

Donald E. Wilson, MD, MACP, The John Z. and Akiko K. Bowers Distinguished Professor and Dean

It is generally accepted that the United States has the most advanced medical care in the world. People from around the globe come to the U.S. to take advantage of the latest high tech treatment available, primarily at medical schools and teaching hospitals. Academic medical centers—our temples of modern medicine—represent our nation’s principal investment in health care knowledge and expertise.

Unfortunately, while we have the most advanced medical care in the world, we do not enjoy the best health. But why? Cost, quality and access are three potential barriers. Our problem does not, however, appear to be related to health care spending: Americans spent $1.7 trillion on healthcare in 2003, a 7.7 percent increase over 2002, and fully 15 percent of our gross domestic product.

What about quality? In 2004, 62 percent of Americans polled said they were dissatisfied with the availability and affordability of health care in this country, and nearly half reported being dissatisfied with the quality of care. Perhaps we do not define health properly; health is usually easier to perceive than to define. The definition I like is that of “optimal well-being.” It suggests that health for one person may not be the same as that for another. As we achieve greater advances in genomics and understanding the molecular basis of disease, we no doubt will be better able to determine the optimal well-being for each and every individual.

The lack of health insurance is a formidable barrier to good health. In 2003, over 45 million people in America were uninsured, 8.4 million of whom were children. It is no surprise to any of you that the uninsured are less likely to have preventive checkups or regular screenings for curable diseases, or that the uninsured are diagnosed at later stages of illness, or that they have worse health care outcomes than those with insurance. What is surprising is that we have allowed so many to remain uninsured for so long.

And then there are disparities. One of the reasons disparities are so difficult to identify and correct is that most people do not understand what a disparity is—indeed many of us in the medical community don’t recognize a disparity even when it is looking us in the eye. A health disparity is roughly defined as an inequality in health care. Disparity in the context of public health and social science has begun to take on the implication of injustice. A health disparity should be viewed as a chain of events signified by a difference in environment, access to, utilization of and quality of care, health status, or a particular health outcome that deserves scrutiny. Such a difference should be evaluated in terms of both inequality and inequity, since what is unequal is not necessarily inequitable.

Let me give you an example. Everyone knows that hypertension, a common and pernicious killer, is more common in black men and women than in whites. However, even though black patients are even more aware of hypertension as a problem than are whites, and are more often treated, they are less likely to be controlled on treatment (45 percent for blacks versus 56 percent for whites). One question is whether the treatment provided is as rigorous in both groups. Even in instances where insurance and preventive care should not be factors, such as in Medicare managed care plans, disparities between white and black patients in screening, in the practice of evidence-based medicine and in follow-up care are clearly evident.

Many of you know of my abiding passion for ensuring that all people receive the best health care available. We created the University of Maryland School of Medicine Center for Health Disparities to help identify and eliminate ethnic, racial, geographic and socioeconomic differences in the diagnosis and treatment of illness, and to promote equal access to health care. Once disparities are identified, we work in collaboration with local communities to develop culturally competent strategies to eliminate them. This is but a start.
If we are to move beyond the debate and start taking real action that will begin to provide quality care for all, we need to make some very hard choices. We must decide how much care is adequate to ensure a healthy population.

As Americans live longer, our demands for more drugs and more—and more expensive—care drive up health care costs exponentially. In addition, we, as Americans, expect to have access to the most sophisticated medical and therapeutic technology. There needs to be some kind of government-sponsored coverage that would provide all individuals with the ability to prevent disease and sustain health. And by “health” I do mean “optimal well-being.” Surely the working poor and uninsured should not have to debate whether or not they can seek basic medical care for an ill or injured family member.

We have the potential to have the best health care system in the world. That is not an illusion. What is an illusion is that Americans have equal access to and receive culturally sensitive quality health care. We need to insure that each person will achieve an optimal state of well-being. Sooner or later we must reform our health care system and provide care for all of our citizens.

On September 7, 2005, Dr. Donald E. Wilson announced that he will retire on September 1, 2006, ending what will be a 15-year deanship at Maryland.