Healthy People or unhealthy promotions?

Leading Health Indicators
Healthy People 2010? A story is making the rounds (e.g., here) about how well or how poorly the US has met goals set in 2000 for improving the health of its population by 2010. Not so well, by most measures, though there have been some improvements (some, in spite of ourselves -- heart disease mortality tends to go up or down without our understanding why).

There are more obese Americans than a decade ago, not fewer. They eat more salt and fat, not less. More of them have high blood pressure. More U.S. children have untreated tooth decay.

But the country has made at least some progress on many other goals. Vaccination rates improved. Most workplace injuries are down. And deaths rates from stroke, cancer and heart disease are all dropping.

As a new decade approaches, the government is analyzing how well the U.S. met its 2010 goals and drawing up a new set of goals for 2020 expected to be more numerous and - perhaps - less ambitious.

Why is meeting these goals so difficult?

The government uses 'leading health indicators' to measure the health of the population. These indicators are:

• Physical Activity
• Overweight and Obesity
• Tobacco Use
• Substance Abuse
• Responsible Sexual Behavior
• Mental Health
• Injury and Violence
• Environmental Quality
• Immunization
• Access to Health Care
  

Healthy people and the NIH
Note that, except for the goals that require political action, this is primarily a list that can only be accomplished by getting people to change their behavior. Which is interesting, since Francis Collins set five goals for the NIH when he took over the directorship last year, and which he reiterates in this week's Science, none of which have anything to do with changing behavior, and everything to do with high-tech research (he does include the goal of increasing access to health care, but it's clear from the mixed, at best, results of Healthy People 2010 that there isn't a straight line between health care and health). He begins his Science essay with this:

The mission of the National Institutes of Health (NIH) is science in pursuit of fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to extend healthy life and to reduce the burdens of illness and disability.

Collins sounds as though the mission of the NIH is in accord with the Healthy People 2010 (and now 2020) goals set by the Office of Disease Prevention and Health Promotion, and the US Dept of Health and Human Services, but if they were really on the same page, he'd have put health education first and foremost in his list of priorities for the NIH. Or, Healthy People 2020 would include goals like Sequence everyone's individual genome, or biome, or nutriome, which big science, with Collins at the political forefront, has been promising for years will work miracles for our health.
To put it politely, Collins' goals remain wishful thinking with respect to health benefits, but a big boon for big science. We could generate more healthy years for more people, by far, by changing lifestyle exposures than we ever could by all the 'basic research' and genetics one can dream of. And this is not just keeping an old car running rather than inventing better cars: healthful lifestyles will work every generation.

Technocracy welfare
Dr Collins is instead a sales agent for our technocracy welfare system (of which we personally, it must be acknowledged, are beneficiaries), in the form of largesse from Congress. In fairness, one of his priorities includes focusing more on global health, which is laudable, especially for someone who has been a medical missionary in Africa, and it's very easy to argue that improving the health of people living in poor and underserved countries is good for the US as well, because extremely drug resistant TB doesn't stop at borders. But, most global health issues are understood, and we could go a long way toward solving them with money, infrastructure development and public health measures, which will help a lot more people a lot faster than high tech research.

But, issues with the NIH aside, if the "Healthy People 20whenever" goals are so clear, and could be met if only people would change their behavior, why isn't that happening? Because figuring out how to get health education to actually work is a long-standing challenge for public health. It is not rocket science and health policy should not be turned into rocket science.  But it is difficult, which you might think is perhaps a little odd, since advertisers seem to have no problem getting people to buy sexy cars, or supersize their fries. Why can't advertising be just as effective when it comes to health-related behaviors? Well, health-related behaviors that improve health, since supersized fries is health-related.

The facile answer is that advertisers sell fun stuff, while public health tries to sell restraint, moderation, eliminating the fun stuff. It's hard to do.

Reality checks
It's good to have goals. An organization needs goals. But, when the goals are so often much loftier than what can be accomplished, the organization needs to stop and think about why they've overshot, and what can be done about it.

There are three reality checks here. First, the taxpayers footing today's technocracy bill are not generally going to benefit from the work of no-matter-how-many DNA sequencers crunching. Those who do have serious genetic problems that can be understood in other ways, will hopefully benefit, even if that's years of hard work away. But cheaper ways to actually increase health--the behaviors mentioned above--exist and the same funds (and policy changes) could be put to those ends. They will, if adopted, pay off for as many generations as current technology promoters promise.

Second, these NIH programs are largely costly self-promotion. Without doubt there is a lot of good research done within, and paid for by, the NIH. And a lot of it is technological in ways that are fully justifiable. But it's embedded in huge amounts of self-protecting bureaucracy and baloney.

Nobody seriously could think that we would have 'Healthy People 2010' (unless we really hurry up!). This is advertising, but not of the health improvement kind.  It's spending money where it shouldn't be spent, primarily fostering scientists rather than taxpayers. It is cynically cruel to make grandiose promises that cannot be kept. It's reminiscent of the old communist countries' Five Year Plans that we so routinely ridiculed. We can do better. We can try more sincerely. And we can be accountable for what we boast about.  Note that the goals for Healthy People 2020 are going to be 'less ambitious.' 

Third, a minor point....or is it? Francis Collins says he believes in a personal God, roughly the fundamentalist Christian God. If that's the case, and if those who live virtuous temporary lives here on Earth will have eternal rewards in the Hereafter, then why on earth is it important to pour money into future technological solutions rather than to save the quality of life of those who are here right now, so they can live in faith and do good, rather than suffer in privation?

Well, leaving the last bit aside, the point here is to take with a grain of salt the advertising and hyperbole. If pure science and the fun of its practice are the purpose of research money, then let's just say so--this is about us and our careers--and stop pretending this is all about health per se. There have been major improvements in some areas of health, and technology (including genetics) has clearly played a role. But overall it's hard to argue that we're happier, or healthier, than we were before pouring billions into a lot of things we've been pouring billions into, things we know very well (as we've opined in numerous posts) are not bearing much fruit from the Tree of Life.