Sunday, September 23, 2007

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.

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