Maimonides’ middle path in the use of health care

Underuse and, more recently, overuse of health care services are major concerns for health systems worldwide. Underuse occurs when a treatment or other service that is necessary does not reach the patient either through neglect or failure to follow proven care practices. For example, influenza vaccination is a simple, low-cost intervention which has been shown to reduce children’s risk of flu-related admission to intensive care by as much as 75% and hospitalization in older adults by 57%. Yet vaccination coverage remains below target levels at an average of 47% in older adults in 26 OECD countries. Additionally, there is evidence to show that vulnerable populations receive little more than or even less than half of recommended care and, dependant on the quality of a person’s health insurance, beneficial care may be underutilized. For example, screening rates for individuals with highdeductible – as opposed to traditional – plans are lower for breast, cervical and colorectal cancer. Meanwhile, overuse occurs when a service is given without medical necessity or justification. Over half of US physicians admit to requesting unnecessary procedures upon patient insistence, and most agree that, on average, a physician does this at least once a week. Health care costs are rising in most countries, up to a third of which is due to overuse, draining resources from underfunded areas in the system. The overuse of medications may lead to harm. For example, overuse of antibiotics leads to antimicrobial resistance, a threat which currently claims the lives of 700,000 people a year and is projected to increase to 10 million lives and 100 trillion USD globally by 2050. Additionally, over-utilization of services leads to poor patient outcomes. For instance, imaging tests such as X-rays, CT-scans or magnetic resonance imaging (MRI) are commonly used without appropriate indication and expose patients to potentially cancer-causing levels of radiation. Individuals who undergo an MRI scan for low back pain do not recover faster than those who are not scanned and are eight times more likely to have surgery. Similarly, those who undergo a CT or MRI scan for headache are more likely to undergo unneeded follow-up tests and referral to specialists for expensive consultations. It is baffling and disconcerting that such exploitation and squandering of resources arises from both the underand over-utilization of the system. The challenge is to attain just the right amount of high-quality health care, while avoiding low-quality services which do not improve patient outcomes and are not efficient or effective. Insights as to how to achieve such a perfect balance in health care may come from an unconventional, yet strangely logical place: the writings of a 12th-century polymath who was a prominent philosopher, physician and Jewish religious figure, Moses Maimonides. Maimonides was born in Spain in 1135 and died in 1205 in Egypt. He was widely respected both in the Islamic and Jewish worlds. He was first appointed as court physician to the Grand Vizier Al Qadi al Fadil, then to Sultan Saladin, and remained the royal family’s physician after the Sultan’s death. A prolific writer, his works include some of the most vital to philosophy, such as the Guide of the Perplexed, Treatise on Resurrection and Letter on Astrology. Maimonides also wrote 10 medical works focusing on a range of conditions such as asthma, digestion and health promotion. He focused not only on conditions but also on disease prevention and the external determinants of health.