Notes from the EBM Crusades

by Phil MD

Health is a political issue, not just a medical one.

Germs and genetics are well-appreciated determinants of health, and our medical care is focused on addressing them. But this is, at best, half the equation. Social circumstances, environmental exposures, and behavioral patterns contribute as much as germs and genetics. Despite this, our healthcare system (and our healthcare policy) does not address economic and social policies that directly impact these crucial health determinants. In other words, by convention our system is designed around the acceptance of a clear divide between the strictly biological determinants of health and the social ones. Never the twain shall meet. Or better yet, if they do meet, the result is usually inconsequential or politically self-serving.

In the Sep 20, 2007 issue of the New England Journal of Medicine, Dr. Steven A. Schroeder writes a wonderfully succinct article in which he makes a point that needs to be made over and over: that the ingredient to better health is not simply more medical care. The following is a chart from the article showing the contribution made by the determinants of health on premature (i.e., unnecessary) death:

As you can see, social determinants of health are important, and there is an unknown, yet crucial, link between social determinants and behavioral patterns.

Indeed, the category of “behavior patterns” is a big black box with internal and external determinants. But, again, there is often an artificial divide between internal determinants of behavior, and the external forces that influence behavior. The notion that we are not 100% in control and 100% responsible for our actions strikes at the heart of the prejudices that we have built around notions of free will and individual responsibility. But the evidence is pretty overwhelming that, indeed, no man (or woman) is an island, acting independently, free from the influence of social and economic determinants.

Let’s take a look at some of the behavioral causes of premature death provided by Dr. Schroeder:

As an example, let’s consider smoking. The individual responsibility argument held sway for decades. Simply stated, the argument was that smoking is a personal choice, plain and simple. Looking outside the personal sphere—at regulations, or tobacco companies—was considered off base. Tobacco companies were seen as simply providing a product, just like any other company in a free market system. People are free to choose to buy the product, or not. The responsibility starts and stops with the individual.

This myopic view of personal behavior ignores what we know about the determinants of behavior, and about the unscrupulous marketing techniques employed by the tobacco industry. Yet, this view is a strongly held prejudice, especially by those quick to point out the virtues of a free market system, but less willing to acknowledge its hazards. But the stakes are high:

…there are still 44.5 million smokers in the United States, and each year tobacco use kills 435,000 Americans, who die up to 15 years earlier than nonsmokers and who often spend their final years ravaged by dyspnea and pain. In addition, smoking among pregnant women is a major contributor to premature births and infant mortality. Smoking is increasingly concentrated in the lower socioeconomic classes and among those with mental illness or problems with substance abuse. People with chronic mental illness die an average of 25 years earlier than others, and a large percentage of those years are lost because of smoking.
…as many as 200,000 of the 435,000 Americans who die prematurely each year from tobacco-related deaths are people with chronic mental illness, substance-abuse problems, or both. Understanding why they smoke and how to help them quit should be a key national research priority. Given the effects of smoking on health, the relative inattention to tobacco by those federal and state agencies charged with protecting the public health is baffling and disappointing. [Emphasis added]

The documentation of the health hazards of second hand smoke helped move the tobacco issue beyond the realm of individual responsibility and into the realm of social policy:

Laws, regulations, and litigation, particularly at the state and community levels, led to smoke-free public places and increases in the tax on cigarettes — two of the strongest evidence-based tobacco-control measures. In this regard, local governments have been far ahead of the federal government, and they have inspired European countries such as Ireland and the United Kingdom to make public places smoke-free. [Emphasis added]

It should be noted that stronger penalties were possible, including the decision to make tobacco illegal, but every corrective action is limited by what is politically feasible at any given time.

But the question remains: Would there have been the political will to impose penalties on the tobacco industry, if it hadn’t become impossible to ignore the public health threat of second hand smoke? What I mean is that the documented threat from second hand smoke clearly showed (in a way that was no longer easy to deny) that the consequences of the smoker’s choice affected not just the smoker, but those standing nearby. This subtle difference, in my opinion, was essential in gaining political allies in favor of addressing some of the social determinants influencing this personal behavior. We seem to be willing to tolerate quite a lot from industry, even when it directly encourages self-destructive behaviors, as long as the consequences of that behavior can be made to seem confined to the individual.

The paradox, of course, is that self-destructive behavior is never completely confined to the individual. All self-destructive behaviors have a “second hand smoke” effect on society. (Perhaps self-destructive is the wrong word. We could substitute poor health choices or some other term, but I think that we all know what I’m talking about.)

Let’s move on to the issue of obesity. This issue is where the tobacco issue was one or two decades ago. The focus remains on the effects of poor personal dietary choices. Social determinants such as stricter regulation of fast food and subsidies for healthier food choices are seen as out of bounds in the current discussion. Such political moves are seen as a distraction away from forcing individuals to take 100% responsibility for their own actions. Despite an appreciation for the easy availability of junk food from crib to grave, a lifestyle that promotes fast food consumption, and an economy that makes poor health choices more economical than good ones, obesity is made into a purely moral or medical problem. The “second hand smoke” effects of obesity include increased rates of diabetes, heart disease and other chronic problems; inability to work and increased absenteeism; increased health care costs; and many others. These are probably ultimately more harmful than the effects of tobacco, but they are less directly harmful than second hand smoke. No one is going to get cancer from sitting next to an obese person eating a cheeseburger.

The relevance of these issues to the current political process is obvious. First of all, each presidential candidate is currently rolling out there own version of health care reform. Most try to expand health insurance coverage in different ways. Some advocate the elimination of private health insurance companies, but most don’t. Nevertheless, they all fall short in light of the paradigm that I’ve described above. As is evident from the evidence on premature deaths, more medical care is only a small—albeit necessary—part of the solution. The correct solution requires an integrated approach that takes into account the social determinants of health. The most effective political response to the health needs of our country would break down the divide between the biological and social determinants of health, and it would promote a policy approach that moves beyond a self-serving exclusive focus on individual responsibility, and accept the political responsibility to hold industry accountable through strong regulations when necessary.

Of course, political will is weak these days. Economic interests are strong and dominant. But that should not stop us from formulating the problem correctly. An incorrect formulation of the problem is a narrow focus on simply expanding access to medical care. In short, universal health care is a necessary step. But it is not sufficient toward achieving the health gains that we should all expect.

Health is a political issue, not just a medical one.

What Does People Centered Health Really Mean?

There's been a lot of talk about "people centered health," but my impression is that there's not a really clear definition of the term. In this post, I'm going to attempt to have a go at a defnitiion. Neverthleless, my attempt is really to solicit some opinions and help in defining this. I'm concluding this post with my take on what are the "revolutionary" components of people centered health in the hopes of soliciting comments that can clear this up for me and others.

Perhaps not a definition, but a recent article by Joe Flower for the Center for Health Design, sheds some light on the subject:

Most physicians and health professionals agree that Mr. Elswit’s perception is typical: Sick people are treated
in effect like prisoners in many health-care settings. The people-centered health-care movement responds to this chronic neglect of the patient experience by proclaiming a call to arms. Hospitals, say leaders of this movement, should never add to the pain and trauma of being sick or injured.

There is no shortage of low-cost opportunities to build a better patient relationship. Some peoplecentered
practices are clinical, including the enforcement of such fundamental (but too often forgotten) measures as having doctors and nurses wash their hands between treatments, installing better ventilation in hospitals,
and responding reliably to the call button. (In a 2004 study of hospital accidents, the Center for Health

Design found that a major cause was patients struggling out of bed, alone, to go to the bathroom because no one showed up to help them.) Other innovations provide simple dignity: giving patients hospital gowns with
Velcro closure tabs or straps, for modesty; or training staff to answer telephones by the third ring, to knock
before entering a patient’s room, and to introduce themselves and explain what they’re there to do.

My impression is that there's real ambiguity with respect to this term. The problem with this is that the term can be used to push programs or agendas, leading to cynicism. I've seen doctors roll their eyes when they here this term. Not because they don't want change (they do), but because they've seen initiatives (under this guise) which have very little to do with improving care and more to do with hidden agendas. Even though there've been committed efforts to define what this is, it's not easy to really get handle on the meaning of this term (or phrase). Fortunately, the World Health Organization recently had a go of defining the core values of "people centered health:"

Empowerment
Participation
The central role of the family and community in any process of development, and
An end to gender and all other forms of discrimination.

WHO goes on to admit that, "Despite its long history and increasing popularity, people-centred health care has not been satisfactorily and collectively enunciated at the health system level." WHO goes on to describe the characteristics of such a system from the viewpoint of each stakeholder:

For individuals, patients and their families:

Access to clear, concise and intelligible health information and education that increase health literacy;
Equitable access to health systems, effective treatments, and psycho-social support;
Personal skills which allow control over health and engagement with health care systems: communication, mutual collaboration and respect, goal setting, decision making, and problem solving, self-care; and
Supported involvement in health care decision-making, including health policy.

For health practitioners:

Holistic approach to the delivery of health care;
Respect for patients and their decisions;
Recognition of the needs of people seeking health care;
Professional skills to meet these needs: competence, communication, mutual collaboration and respect, empathy, health promotion, disease prevention, responsiveness, and sensitivity;
Provision of individualized care;
Access to professional development and debriefing opportunities;
Adherence to evidence-based guidelines and protocols;
Commitment to quality, safety and ethical care;
Team work and collaboration across disciples, providing co-ordinated care and ensuring continuity of care.

In health care organizations:

Accessible to all people needing health care;
Commitment to quality, safety, and ethical care;
Safe and welcoming physical environment supportive of lifestyle, family, privacy and dignity;
Access to psychological and spiritual support during the care experience;
Acknowledgement of the importance of all staff - managerial, medical, allied health, ancillary – in the delivery of health care;
Employment and remuneration conditions that support team work people-centred health care;
Organisation of services that provide convenience and continuity of care to patients;
Service models that recognise psycho-social dimensions and support partnership between individuals, their families and health practitioners.

In health systems:

Primary care serves as the foundation;
Financing arrangements for health organisations that support partnership between health practitioners and people accessing health care;
Investment in health professional education that promote multidisciplinary team work, good communication skills, an orientation towards prevention, and integrates evidence about psychosocial dimensions of health care;
Avenues for patient grievances and complaints to be addressed;
Collaboration with local communities;
Involvement of consumers in health policy;
Transparency.

Conclusion

I highlighted in red the items which, for me, are the clearest components that can provide a notable change in health care. First off is giving people (patients) access to quality health information. This is easier said than done for we need to define what quality means (e.g., not skewed towards the Pharma view, etc.). Secondly, there's a holistic approach to delivery of health care. This could be quite revolutionary if we include alternative medicine (e.g., herbal medicine, acupunture, etc.) as a valid component of health care delivery.

Teamwork and collaboration (as equal partners) among various stakeholders such as doctors, ancillary staff, etc. combined with a focus on continuity of care seems to me as something that easier to state and much, much harder to execute. Last but not least are transparency and recognizing the importance of Primary care in the whole process.

These concepts are easy to put in a blog post. Nevertheless, I've been around enough doctors (e.g., Dad and brother) to know that these changes are extremely hard to imagine. Why am I writing about all of this? The reason is that I really believe (am I naive?) that the web presents a tool that can really drive these changes. How exactly can this tool (web) drive something as complex as change in health care? I'll leave that for my next post. :)

Presidential Debate and Health Care

As I wrote in the last post, it's pretty telling that my (unscientific) poll showed that most people are pretty pessimistic about any improvements to the health care system in the US (at least in the near future). This is pretty notable considering the hieghtened attention given to this topic during the recent presidential debates.
Although the economy seems to be trucking along at a decent pace, there do seem to be some pretty ominous clouds on the horizon if one takes into account how broken the health care system is, the mounting national debt (more than 50% GDP) and miscellaneous obligations (e.g., Social Security, Medicare, Medicaid, etc.). I'm no economist, but if this were a household, I don't think it'd be considered too stable.
If the country were a household and the primary bread winner lost her/his job, it'd be in a heap of trouble. A comparable situation would be if China and Japan decided to stop financing our debt by not purchasing anymore T-bills.
This all reminds me of the Jack Nicholson movie with the memorable line, "What if this is as good as it gets?" I mean, we all assume that, eventually, the health care system is going to get better. It's a key issue in the presidential election. Things have to get better, right?
But, what if this is really "as good as it gets?" How pessimistic should we be? Or is there really reason to be optimistic and believe that access to, quality and cost of health care are really going to move in the direction that we desire?

Unscientific Web Poll on Uninsured

First of all apologies for the lack of posts these past few months, but I've been considering expanding this concept of looking for new ideas on health and health care to a more advanced platform.

I started this blog to share what I've been reading or learning about health, but my main objective is to learn more from others. In order to accomplish this, I'm going to start posting more often and, hopefully, I'll get some more interesting feedback.

Nevertheless, I'm thinking of expanding beyond a blog and creating a site for people with the same needs as myself. Specifically, though I know there are a lot of websites devoted to Health care, I'm actually looking for something with more of a point of view (e.g., not so pro-Pharma and a bit more open minded). Any ideas would certainly be welcome on this.

On another front, I conducted a small, unscientific web poll soliciting a prediction on the number of uninsured Americans in the future and came up with the chart at the top of this post. For the most part, people would seem to be pessimistic (I'd count myself among them) about the future of the uninsured in America.

Even more interesting, the female respondents (70 out of the 200) were more realistic/pessimistic since 77% of these (compared to 71% of males) feel that the number of uninsured will increase. Even more interesting is the fact that 100% respondents in the 35-49 age group concur with the mayority of respondents (that the number of insured will increase).

Looking forward to your comments. :)