Monday, January 4, 2010

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.


Holly Dunsworth said...

I was so deluded with "HOPE" that until recently I was still waiting for Obama, from his desk in the oval office, to ask us all to stop eating so much "fun stuff" that kills us. To tell us that it's the American thing to do or something like that. Psshhh. So much for cheap health education from people with a heart and tons of media access.

John R. Vokey said...

EXCEPT FOR SMOKING, there is NO (let me repeat that: NO) substantial evidence that a) allegedly medically-related broad changes in lifestyle (ignoring the obvious: smoking, street drugs, guns) make any difference in mortality, and b) even if a) were true that any advertising campaign regarding same makes one iota of difference. We really have no good evidence that any of the current ``risk factors'' often cited that allegedly we could change by changing our lifestyles have any positive effect at all. Indeed, the few (and I mean very few, one only needs one and a bit hands to count them) real experiments on these issues shows at best NO positive effect, and most often a negative long-term outcome (cholesterol treatments being the prime example). The epidemiology on these questions has the current reputation of being not just more often wrong than right, but being wrong virtually all the time. I am amazed that we still pay lip service, as here, to any of it at all.

Oh, and as for smoking (the one case trotted out as an example of an epidemiological success), two points: Nobody needed epidemiology to make the point, and it is the ONLY such case (beyond the obvious: e.g., juggling live hand grenades as a crowd sport) that can be made with any substance.

Anne Buchanan said...

John, thanks for keeping us honest yet again. Basically I think we're on the same page and basically I agree with you, except that 'moderation in all things' is probably decent medical advice. Though, it depends on what you're aiming for.

It's easier to be categorical if you're talking mortality as the outcome rather than 'health', because then it depends on how you define 'health'. If the definition of health includes thin (which the US government's definition seems to), then thinner equals healthier, even if it doesn't necessarily lead to longer life. If you define health as longer life, well, then you can't know if you've been healthy until you're old, which doesn't do a whole lot of good.

What's led to lower mortality in rich countries? Public health. Clean water's big, antibiotics (temporary though that might be), vaccination, probably better OB/GYN practices, probably the year round availability of fruits and vegetables -- probably mostly stuff money can buy.

Lowering mortality is easier than improving 'health', because 1) health is slippery to define, and 2) even if you can define it (as the US govt has done), no one has a clue how to get there.

But, however it's defined, it's clear that the NIH is a hugely expensive way to NOT get us there in a hurry.

John R. Vokey said...

But isn't mortality the only real objective measure? I must admit that I would rather not die than be a healthy corpse. I think any 80 year old will admit that, yes, pains and aches aside, they are much happier that they didn't die a healthy death at 30. The convenient thing about mortality is that it is incontrovertible, and can't be twisted into something more convenient politically. ``Health'' is just a smokescreen for really doing nothing about the important outcomes, especially as it is sold as a failure of the ``unhealthy''. One of my favourite (I have more than one) cartoons in this regard is this:

(I hope the link comes through)

Anne Buchanan said...

Yes, nice cartoon. One I have hanging on my office door shows two cavemen sitting in a cave. One of them says, "Something's just not right -- our air is clean, our water is pure, we all get plenty of exercise, everything we eat is organic and free range, and yet nobody lives past thirty." Probably you've seen it.

I'm not quite sure what you're getting at here, though, John. Is mortality the only real objective measure? Again, it depends on why you're measuring. Body composition, BMI, weight and so on are 'objective measures'. And, according to the US government, Healthy People are thin, so apparently someone thinks that lowering the average BMI of the population would improve health. Presumably the idea is that thin/healthy people cost the medical system less money (though of course some argue that the least costly people of all are dead people), though I think the conceivers of the Healthy People initiatives probably do have quality of life in mind as well.

There's a difference, albeit a subjective one, between reaching 80 in good health, and reaching 80 after years of chronic illness. Both 80 year olds are alive, but they are living very different lives. 'Quality of life' is a subjective measure, yes, and however you define it, it's not always improved by the medical system, but when one 80 year old can run marathons, and one can only sit on the couch and watch television, there's a significant difference.

But I assume you're not arguing that the medical system can't ever improve quality of life -- just leave a broken leg to mend on its own, or a complicated birth to take care of itself, or TB lesions to heal, and the advantages of medical care are starkly revealed. I'd say the healed leg, the successful birth and cured TB are 'important outcomes'. All things being equal, I'd rather have medical care than not.

But perhaps I've lost track of your point.

Ken Weiss said...

I would argue with your statement, if I understand it, that epidemiology has made no differences in health or mortality. I think that studies of radiation and cancer, asbestos and mesothelioma, folic acid and spina bifuda,fluoridation and dental health, iodine and goiter, and a number of others are instances in which association between risk factors and outcomes successfully worked and exposures could be reduced or avoided, and health improved.

This doesn't reduce the importance of the hype factor in biomedical research communities, but I think it's unfair to label it all as 'rot' as in a sense you seem to be doing.

John R. Vokey said...

I guess if that was thought to be my point then, as opined, I failed to communicate what I meant to be saying, and I apologize for that.

So, what was I saying? All ``rot''. No. Mostly ``rot'', yes, as concerns ``lifestyle'' variables, none of which were in the list from Ken about the alleged positive benefits of epidemiology.

We aren't in disagreement here, as I exempted the obvious. As with religion, epidemiology seems to get a pass that it does not deserve, and gets untoward funding that would be better spent (even fractionally) on some basic science.

John R. Vokey said...

I never claimed that ``epidemiology has made no differences in health or mortality''. That would be ridiculous. All I claimed is that the current claims to ``lifestyle changes'' for those not otherwise at risk (hence, my attempts at humour regarding the obvious: live grenade juggling) were unsupported empirically.

There is no good *experimental* evidence about cholesterol, obesity, or just about any other ``life-style'' measure other than smoking that merits concern in the sense that personal attempts to change them make any difference at all *with respect to mortality*.

Whether reducing weight makes people feel better about themselves (health?) is a different issue entirely. I could ask the same about wearing feathers. These are different issues, and should not be confused with real health.

And, Anne, I do agree about setting broken bones, and great surgeons: they have talents worthy of seeking out. I have no idea what that has to do with what I was claiming.

Anne Buchanan said...

John, as I said, I wasn't sure I was on to your point, as my rambling showed. Ken and I have both written a lot about the short comings of epidemiology, so I think we're basically in agreement.

Anonymous said...

Perhaps I'm way off here, but I think an important distinction is whether you are looking at a population or a person. If you are looking at a population than I think lifestyle and eduction has proven to have enormous effects on health, quality of life and longevity. If you think of it in terms of an individual, then no. A person can eat well, exercise, have the fortune of having the kind of job/money that allows them to escape nasty environmental toxins but can still have the bad luck of still getting terminal cancer.
People still die, they always will. But the rise in diabetes is undeniably linked to overeating and is completely avoidable. More money goes into issues of obesity which affects are relatively small proportion of the world's population than goes towards issues of food distribution which affects a much larger proportion of people on this planet. Individuals can make major improvements to their health (quality of life) through their own behaviours, but yes they will still die. A little education will go a long way to rid our society of completely preventable diseases like Type II diabetes. Compare this solution to tackling a problem like curing cancer. Not to say that we shouldn't keep trying, just why not fix the easy stuff first, keeping more of us healthy to pursue cancer research.
If looked at from a population perspective, the effects will be huge.

Anne Buchanan said...

For a lot of reasons, epidemiology is a lot better at explaining point source causation than chronic diseases like heart disease or asthma. Throw epidemiology at an infectious disease epidemic, and you'll probably get a pretty quick answer as to what's causing it. But, again for a lot of reasons, epidemiology isn't nearly so good with chronic diseases.

How _would_ you figure out if multivitamins are 'good' for people? First, define 'good', i.e., your outcome measure (death? no cancer? can run further than before? subject says s/he feels better?) then find an appropriate, healthy, large population who will take multivitamins for, well, for how long? And starting at what age? And throw in a control group -- what factors are you controlling for? Then, take your final data and factor out competing causes of illness, mortality, or running further, deal with the possible effects of dietary differences, etc., etc. Current methods just aren't up to the task of parsing this kind of complexity.

What _is_ responsible for the current asthma epidemic, that started in the 80's? Look in the literature and you'll find it's the hygiene hypothesis, the cockroach and dust hypothesis, that it's due to bottle feeding, no, it's breast feeding, and on and on. Many state-of-the-art studies totally contradicting each other. And environmental causation is supposed to be something that epidemiology is good at. It's understandable that the field has turned to genetics to explain this stuff. Genes follow rules, after all. And indeed, as epidemiology with infectious disease, human genetics has a history of heady successes with single gene disorders. But complex diseases are a whole different story.