Treatments that don't cure the disease; we are spending money on the wrong things

In �Heralded treatments often fail to live up to their promise� (Kansas City Star, May 17, 2014), Alan Bavley, writing with Scott Canon, continues to demonstrate that he is one of the excellent health journalists � excellent journalists � in the US, along with Elisabeth Rosenthal of the New York Times. The common practice in the news media (and, thanks to a typo, �medica�) is to hype the new, exciting, dramatic, expensive, and hard to believe even though you want to. In politics, we often see the media acting as flaks for the government, the rich, and the powerful (sometimes, of course, these can be in conflict). Bavley and Rosenthal  and their ilk actually do investigative journalism, trying to the best of their ability to find out the truth rather than to reprint press releases.

The article begins with a review of a surgical procedure that was designed to control high blood pressure (hypertension) without drugs, by cutting some of the nerves to the kidneys. It made sense, it was seen as a big breakthrough (�The potential benefit was huge,� said a cardiologist). Unfortunately, when actually subjected to appropriate scientific study, it didn�t work. Or, rather, it worked just as well as placebo, a sham surgical procedure. The same cardiologist remarks ��This could be considered the biggest disappointment in cardiology of this century, but �the medical community went about it right.� 

Science worked. Unfortunately, the authors add,

�If only that were always the case. A combination of industry marketing, overly eager doctors, demanding patients and news media ready to cheer on anything that sounds like a breakthrough is popularizing many drugs, surgeries and other treatments long before they�re adequately tested. Far too often, they�re ultimately proved ineffective, no better than older, cheaper therapies, or even hazardous. Billions of dollars are wasted and tens of millions of patients are put at risk�

Yup. They go on to cite the Vioxx scandal, in which Merck concealed evidence of its biggest-selling drug causing an increase in heart disease. But that was taken off the market; many other unproven (or worse, proven to be ineffective) treatments are not. They talk about arthroscopic knee surgery, still often being done for conditions for which it has been shown to be no more effective than a sham procedure. They discuss surgical robots, costing upwards of $1.5 million, and proton-beam radiation treatments (those babies, the machines, really cost a lot!) for which the evidence of effectiveness compared to more standard and much cheaper treatment is mixed, at best. But hey, if you�re a hospital, and the competition has robots and proton-beam accelerators, who�s going to come to you if you don�t have one? Poor people? Heaven forfend!

And it is all about getting the advantage on the competition to make more money. A good argument can, and should, be made that competition in hospitals helps no one. That if there were an expensive item that there were an actual medical need for one of in the community, there should be one, not one at every hospital. But that would presume that the goal of the health system was to increase the health of the American people at the lowest effective cost. It isn�t. It�s to make money. If I can get your patients to come to me instead, it is seen as a victory (from a competitive business sense). It is really a loss for the health of our people and the pocketbooks of us all.

It is particularly depressing because that money is not buying us health. If you still harbored the belief that �we have the best health care system in the world�, it�s time to acknowledge that you are wrong (although we forgive you given the hype!). We should all know how expensive our health care system is, that we spend way more than any of the other developed countries (members of the Organization for Economic Cooperation and Development, OECD). The attached graph, from Steven Woolf, MD, PhD, who was a plenary speaker at the recent Society of Teachers of Family Medicine Annual Conference, shows a comparison of spending and life expectancy for the OECD countries. That�s the US way off to the right, spending more than anyone by far, but having a life expectancy close to the Czech Republic. Better than Mexico, Poland, Slovakia, Hungary and Turkey, but at enormously greater cost!

Woolf was the lead author of the Institute of Medicine�s (IOM) recent report �Shorter Lives, Poorer Health� , which presents depressing, but unfortunately accurate, data on our health status. We are among the �leaders� in death rates from communicable and non-communicable diseases and from injuries. Only for a few causes are our death rates better than the average. Our life expectancy at birth is worse than any of the 17 comparison countries for men, and second worst for women. Our probability of survival to age 50 is lower than any of 21 comparison countries. At any age until 75, we are never better than 15 out of 17 in terms of life expectancy. We do have better survival rates once we reach age 75, but there is no information on how much of that is keeping people alive despite poor quality of life.

Want more? In case you think it is only the minority populations (although that would be part of our population), non-Hispanic whites rank no higher than 16 of 17 at any age below 55. And the only portion of our population for whom mortality rates have risen is non-Hispanic whites with less than 12 years of education. From 2005-2009, the US had the highest infant mortality rate of the 17 countries and the 31st highest in the OECD. Non-Hispanic whites and mothers with 16+ years of education also have higher infant mortality rates than those in other countries. Among the 17 peer countries, mortality from transport accidents decreased by 42% in the OECD between 1995 and 2009, but by only 11% in the US. The same trends hold for child and adolescent health � and ill-health and mortality.

And then there are the areas where we really shine, particularly health issues related to guns.

• In 2007, 69% of US homicides (73% of homicides before age 50) involved firearms, compared with 26% in peer countries.
• A 2003 study found that the US homicide rate was 7 times higher (the rate of firearm homicides was 20 times higher) than in 22 OECD countries.
• Although US suicide rates were lower than in those countries, firearm suicide rates were 6 times higher.

We have the highest child poverty rates in the OECD, our preschool enrollment is below most countries, and the ratio of social services spending to medical spending is below almost all other OECD countries.

This is insanity. We are spending enormous amounts of money, but we are spending it so that our hospitals can compete with each other, so that we can deliver the most expensive and high-tech care whether it benefits people�s health or not, and we then do not have any money left to do the things that would really enhance health: expanding education, creating jobs, decreasing poverty, ensuring that people had homes and enough to eat.

Not to mention the guns.

More guns and less education is a prescription for poor health

Within the span of one week, my state of Kansas was headlined in two pieces in the New York Times, unusual for a small state. Unfortunately, neither was meant to be complimentary. �What�s the matter with Kansas Schools?� by David Sciarra and Wade Henderson appeared as an op-ed on January 8, 2014, and �Keeping Public Buildings Free of Guns Proves Too Costly for Kansas Towns�, by Steve Yaccino, was a news article (middle of the main section but top of the web page!) on January 12. Both are political and social issues; for example, the thrust of the �guns� article is that Kansas municipalities (like Wichita) that want to keep guns out of public buildings (like the library) are financially stymied by the cost of the security requirements the legislature has put in place in areas where carrying guns is not permitted. Like abortion (and neither of these pieces addresses Kansas� virulent anti-abortion laws), guns are a very hot-button issue that inflames deep-seated passion in places like Kansas, and so is (sometimes) education. I will, however, focus my comments on the health impacts of these laws.

First, guns. Guns are, very simply, bad for people�s health. (Obviously, even when used as �intended�, for hunting, they are bad for some animals� health, but this is not my focus.) Having guns around increases the risk of death or injury from them. Having guns intended for hunting stored locked and unloaded is the safest, but this doesn�t work for guns intended for self-defense since that renders them less available for that purpose. Carrying guns on your person, in your car, in public, on the street, and into businesses, public buildings, schools, and health care settings increases the risk. This is not what gun advocates, and concealed-carry advocates believe. Their idea is that there are bad guys out there carrying guns, either criminals who might want to rob you or crazy people who might want to shoot up your school or post office, and that carrying a gun allows one to protect oneself, and possibly others, by shooting down the perpetrator before more damage can be done. Thus, it protects your health, and that of others.

Nice idea, but completely unsupported by the facts.  Guns kill lots of people, injure many more, and virtually never save lives. This is the case even when used by police, and even more true when use of guns by police officers is excluded. It is true despite the widely-publicized, often repeated on the internet, and frequently invented stories about a virtuous homeowner shooting an armed robber. I have no doubt that such cases occur, but with such rarity as to be smaller than rounding error on the number of deaths and serious injuries inflicted by guns.  Suicides and homicides are among the leading causes of death in the US, most are caused by guns, and almost none of the homicides are �justifiable manslaughter� from a person protecting him/herself from an armed invader. The mere presence of easy-to-access guns in the environment increases dramatically the risk of successful suicide (see my blog, Suicide: What can we say?, December 12, 2013, with data from David Hemenway�s �Private Guns, Public Health�[1]). In addition, the number of �accidental� deaths (where someone other than the intended victim was shot, or someone was shot when the intent was �just� to threaten or show off, or by complete accident, sometimes when an unintended user � say a child � gets hold of a loaded gun) from guns is way ahead of any other method of harm (knives, bats, etc.)

When we go beyond having guns to carrying guns in public places, the data is less well collected. However, the trope of the heroic law-abiding, gun-carrying citizen drawing down on the evildoer in a public place, like say a movie theater or the waiting room of your clinic, is a terrifying thought. First of all, almost none of them are Bat Masterson or Wyatt Earp or Annie Oakley (except maybe in their own minds) and the idea that they will hit who they are aiming at is wishful thinking; the rest of the folks are caught in a gunfight. It is scary enough when this involves police officers, but if half the waiting room pulls out pieces, the results will be, um, chaotic. Harmful. Not to mention what happens when the police show and don�t know who to shoot at (maybe if you are a gun-toting good guy you can wear a white hat�).

So, having guns around, and the more easily they are available, is absolutely harmful to the health of the population, and generally you as an individual. If people, including legislators, and Kansas legislators in particular, want to encourage gun carrying for other reasons, they should at least be aware of and acknowledge the health risks. But what about education? The cuts in state education will, quite likely, harm the education of children (or if, as the article notes, the state Supreme Court forces the legislature to fund K-12, the education of young adults since the money will likely come from higher education), but what about health?

There is a remarkable relationship. More education leads to better health. Better educated people are healthier. The relationship is undoubtedly complex, because better educated people also have better jobs and higher incomes, which is also associated with health. This is addressed with great force in a recent policy brief �Education: It Matters More to Health than Ever Before�, by the Virginia Commonwealth University Center for Society and Health sponsored by the Robert Wood Johnson Foundation; for example, while lifespan overall in the US continues to increase, for white women with less than 12 years of education, it is currently decreasing! The RWJ site also includes an important interview with Steven Woolf, MD MPH, Director of the Center. �I don�t think most Americans know that children with less education are destined to live sicker and die sooner,� Dr. Woolf says. He discusses both the �downstream� benefits of education: �getting good jobs, jobs that have better benefits including health insurance coverage, and higher earnings that allow people to afford a healthier lifestyle and to live in healthier neighborhood,�and the �upstream� issues, �factors before children ever reach school age, which may be important root causes for the relationship between education and health. Imagine a child growing up in a stressful environment,� that increase the risk of unhealthy habits, poor coping skills and violent injuries.

In several previous blogs I have cited earlier work by Dr. Woolf, one of the nation�s most important researchers on society and health, notably in "Health in All" policies to eliminate health disparities are a real answer, August 18, 2011. I included this graph, in which the small blue bars indicate the deaths averted by medical advances (liberally interpreted) and the purple bars represent the potential deaths that could be averted if all Americans had the death rates of the most educated. I also included a link to the incredible County Health Calculator (http://chc.humanneeds.vcu.edu) which allows you to look at any state or county, find out how the education or income level compares to others, and use an interactive slider to find out how mortality and other health indicators would change if the income or education level were higher or lower.

In the US, the quality of one�s education is very much tied to the neighborhood you live in, since much of school funding is from local tax districts and wealthier communities have, simply, better schools. (This last is completely obvious to Americans, but not necessarily to foreigners. A friend from Taiwan was looking at houses and was told by the realtor that a particular house was a good value because it was in a good school district. She called us an asked what that meant; �In Taiwan, all schools are the same; they are funded by the government. No one would choose where to live based on the school.�) This difference could be partially compensated for by state funding for education, which is why cuts in this area are particularly harmful, including to our people�s health. In fact the most effective investment that a society can make in the health of its people is in the education of its young.

An educated population is healthier. Wide availability and carrying of guns decreases a population�s health. Unfortunately, the public�s health seems to carry little weight in these political decisions.

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[1]Hemenway, David. Private Guns, Public Health. University of Michigan Press. Ann Arbor. 2007.