"Health in All" policies to eliminate health disparities are a real answer

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At the recent American Academy of Family Physicians (AAFP) sponsored National Conference of Family Medicine Residents and Students (NCFMRS) held in Kansas City (hey, it can be an advantage to live in the Capital of Family Medicine!), I had the pleasure of hearing Dr. Steven Woolf’s presentation “Health Disparities and the Role of the Family Physician”. I have previously cited (eg, Economics and Disease Prevention, February 13, 2009) the work of Dr. Woolf, a professor in the Department of Family Medicine at the Virginia Commonwealth University (VCU) College of Medicine. He is one of the most distinguished health services researchers in the country, and a clear and articulate speaker.

His presentation, appropriately for residents and students, began with a description of the role of the family physician in the care of both individual patients and the communities in which they practice. He noted the major health toll exacted by “personal health behaviors”, headed by tobacco (accounting for 400,000 deaths per year) and including diet/activity (300,000), alcohol (100,000), microbial agents (90,000), toxic agents (60,000), firearms (35,000), sexual behaviors (30,000), motor vehicles (25,000), and illicit use of drugs (20,000, presumably not counting licit use of prescribed drugs). Note that, of these, only microbes are in the usual “traditional” area of medicine. His point was that to truly improve health the practitioner needs to go outside the hospital or office to the community, where these causes of ill health are located. “Health in All” policies include transportation, land use, built environment, taxes, housing, agriculture, environmental justice, etc. As an example he notes that 2.3 million (2.2%) of continental US households are more than a mile from a supermarket and do not have access to a vehicle. While Russell Shorto’s “Opinionator” piece in the NY Times July 31, 2011, “The Dutch way: bicycles and fresh bread” points out that one advantage of using bicycles as much as the Dutch do is that you can’t carry more than a day’s worth of groceries so that the bread can be fresh and preservative-free, this is not the way of things in the US; poor access to healthful food is a big contributor to poor health.

 

Woolf then went on to demonstrate the familiar (but maybe not to residents and students) data on the remarkable health disparities that exist in the US, particularly by race, socioeconomic status, and educational level (although also by geography, language, and other characteristics). For example, the attached table shows a 24-29% disparity between the age-adjusted mortality rates of white and black males over the period from 1991-2000. The other table shows that the health status of college graduates is much better than that of people with some college, which in turn is much better than HS graduates who have been health than those who have not graduated from HS. These disparities are truly remarkable and should be intolerable. Woolf notes that while most of our current research is focused on finding treatments that are effective, we would save far more lives if we were to focus, instead, on equity by eliminating the health disparities gap.

In a “thought experiment” that he published with colleagues in the American Journal of Public Health in 2007, “Giving everyone the health of the educated: an examination of whether social change would save more lives than medical advances”[1], Woolf demonstrates that even if we attribute all reduction in mortality over to medical advances (nowhere near true; most are due to the types of societal change generally characterized as “public health”, such as clean water, sanitation, and cleaner air), eliminating the disparities that exist on the basis of educational level would dwarf that change, as shown in this table. 

But our society spends virtually all of its research dollars on developing new treatments that then are available to only a portion of our population, and have relatively little effect even on those who receive it. Big PhARMA spends $32 Billion/yr. While the National Institutes of Health (NIH), which is part of the Department of Health and Human Services (HHS), spends $28 Billion/yr, primarily on developing new treatments, HHS’ Agency for Health Quality and Research (AHRQ), which looks at systems and utilization, receives only $300 million/yr.

Woolf and colleagues have also developed a great new tool for visually looking at the impact of disparities on health on a state and county level. Called the “County Health Calculator” (http://chc.humanneeds.vcu.edu), it allows you to pick a state or a county and compare its income level and educational level to that of the entire country (for states) or the entire state (for counties), or one state or county to another. It also presents the “best” and “worst” levels (for state or county), and allows (this is really neat!) you to use a “slider” to move the indicator to find out how changing the educational or income levels up or down would affect mortality. That is, you can see how many more lives would be saved – or lost – if your state (or county) had the income or educational levels of the average, best, or worst state (or county).

The results are truly amazing.  In Kansas, for example, the two suburban Kansas City area counties are almost polar opposites. Johnson County has the highest level of education, measured as % of adults with at least some college, at 78%, and income, measured as % of adults in households that have a “basic income” (defined as at least 2x the poverty level), 86%. Wyandotte County is near the bottom, with a “some college” education level of 39% and a “basic income” level of 56%. (Statewide levels in Kansas are 58% for education and 70% for income.) Using the slider, we discover that if Wyandotte County’s basic income level of 56% were raised to Johnson County’s 86%, 201 or 28% of deaths would be averted per year. If the “some college” education level were to go from the actual 39% to Johnson County’s 78%, it would result in a reduction of 272, or 38%, in the annual death rate!

No drug comes close to this. No treatment of any kind comes close to this. If a new drug were shown to reduce mortality from a disease by 5%, or even 1%, it would get incredible advertising – hundreds of millions of dollars – and huge publicity, in both the scientific and lay press. But the simple fact that so many more deaths could be prevented, so many lives could be improved, by addressing the social determinants of health, is scarcely covered, and hardly funded at all.

We are in thrall to, primarily, the pursuit of corporate profit, but also to a “scientific” perspective that sees new discoveries as the true goal of research rather than “moving the bar” and changing the actual outcomes for actual people. Eliminating health disparities, which improve health and decrease the death rate, will also “bend the cost curve” in ways that only improving access will not. In one of his slides, Woolf presents data from Milstein, et al, in a 2011 Health Affairs article [2] demonstrating that over the next 25 years neither providing coverage nor coverage + access to care, but only both plus “protection” – addressing behavioral and environmental risks – will do so.

There is no contest to the value of a dollar spent on changing social conditions as opposed to finding “more effective” treatments.  There is also no contest in where we actually spend our money. There is something rotten in the state, and it isn’t the state of Denmark.

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[1] Woolf S., et al., “Giving everyone the health of the educated: an examination of whether social change would save more lives than medical advances”, Am J Public Health. 2007;97:679–683

[2] Milstein B et al., “Why behavioral and environmental interventions are needed to improve health at lower cost”, Health Affairs 2011;30:823-832

Breast cancer screening: conflicting evidence? what are the important questions for health?

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Several new, and sometimes contradictory, studies about breast cancer and screening mammography have recently appeared in the medical literature. In a recent study from Norway, published in the New England Journal of Medicine, Kalager et. al[1] looked at the impact of mammography screening of women 50-69 years old in that country by comparing groups of women who were screened and those who were not screened between 1996 and 2005 and comparing them both with comparable groups for the 1986-1995 period. They discovered a significant decrease in the rate of breast cancer detected in women who were screened – but also in women who were not screened. The decrease was greater in the women who were screened, but this only accounted for 1/3 of the reduction in breast cancer mortality in that group; while the reductions in each group were statistically significant, the difference between them was not (quite). Overall the reduction in the death rate in screened women was 7.2 per 100,000 woman-years, and in the non-screened group 4.8 per 100,000 woman-years.

Meanwhile, Cancer published an article from Sweden looking at mammography screening for women who were 40-49 years of age. Because not all Swedish counties screened women that age, they were able to do a retrospective comparison between those counties who began screening at 40 compared to those counties who began at 50. Hellquist, et. al.,[2] found a significant risk reduction (a relative risk of 0.74 for women invited to screening and of 0.71 for those actually screened). Over 16 years of the study “…there were 803 breast cancer deaths in the study group (7.3 million person-years) and 1238 breast cancer deaths in the control group (8.8 million person-years)”, or converting to the same units as the other study, a reduction of 3 deaths per 100,000 woman years, from 14 to 11. The authors note that 1252 women this age would need to be screened to prevent one death.

The Swedish study provides data to support screening women at 40 (although the reduction was greatest in the 45-49 group, which is not surprising as the incidence of breast cancer increases with age). The Norwegian study shows that the rate of breast cancer has decreased anyway. The Swedish study is not a randomized controlled trial, but rather solely a historical comparison, and thus did not control for differences between the women who got screening and those who did not that might have affected breast cancer risk.

So which are we to believe? Both, to the extent that we can understand the methods used. The question is what are we to do? “We”, here, being both women who might choose to undergo mammography screening, and doctors who have to decide whether to recommend it, especially to those under the age of 50. For me, it will involve discussions with each woman, dependent on her individual risks and preferences. The population health benefit is small but significant; while for any woman the risk reduction might be of value regardless of the cost, that woman (and everyone else) has to also bear the cost of screening all those women – 1252 to save the life of one woman 40-49 in the Swedish study. Clearly, women who have a higher risk (family history) will benefit more, since they are more likely to have breast cancer than those without such a family history.

The cost is not only all those mammograms, but the cost of further tests (additional views or ultrasound) in women with questionable results (more common in younger women who on average have denser breasts), in biopsies – not without risk, though low – and pathology reports, discomfort etc. Not to mention what that money might otherwise be spent on. Feeding the homeless? Providing prenatal care? Fighting HIV/AIDS? Building more bombs? Bailing out big financiers? I would certainly agree that there are social programs that could more effectively use the money currently being spent to screen low-risk younger women for breast cancer with far more social benefit; I would also acknowledge the very low likelihood of any saving in mammography screening being used for such purposes rather than other high-tech medical care or further health system profit.

A more important question, perhaps, is why, at any age level, are certain parts of the population – poorer and minority women – less likely to be screened? To the extent that screening does detect cancer in earlier stages, when intervention can be done, and thus make a difference in mortality, why is it not being done as effectively with minority women? For example, African American women are less likely to get breast cancer, but more likely to die from it.

But people do want “answers”, definitives. Newspapers like to publish “breakthrough” research that seems to provide them. When the “answers” seem contradictory, it leads to frustration for many, and a decision to do what they had planned to do anyway, to do what seems to make “sense” (and what they can afford). After all, if sometimes we hear that Vitamin C or E or beta-carotene is a wonder drug to prevent cancer, or Alzheimer’s, and later studies show that it isn’t, and sometimes may even create greater risk, what are we to do?

One thing we could choose to do is to listen to those who are sure that they have the answers, even when these are based upon no data or carefully-selected data. If someone advises people based upon a single study, regardless of the scientific quality of that study and how often its results might have been refuted by later studies, they can be more confident and sure of themselves. This can inspire confidence on those they advise. (I am reminded of the story told by a colleague, fresh out of residency, who was practicing with farmworkers in the Imperial Valley of California. These folks, he said, are used to going to a doctor who listens to their problem, nods, tells them what they have, and gives them a shot to fix it. “I,” he noted, “listen, then tell them to take off all their clothes, examine them for a long time, and then finally tell them I’m not sure what it is, but it probably doesn’t need a shot – and that the shot might even be bad for them – and likely it will go away with time. Who are they going to trust?”). Showing confidence in your opinion is very persuasive. Thus the term “confidence men” (now shorted to “con”).

By the way, I don’t think this is such a good choice. That studies may seem contradictory is part of the nature of science, of how the studies were conducted, on whom, with what controls, using what methods. A future blog will discuss the work of Dr. John Ioannidis, whose work has raised questions about how much of the work published as research is true, made recently au courant by David H. Freedman’s article in the November Atlantic “Lies, damned lies, and medical science,” and some of the important lessons to be learned – and not learned – from his work. Nonetheless, this confusion does not justify complete nihilism – do whatever you want and it’s all the same – or much less undertaking treatments that have never really been studied. (See Drugs, Tobacco, Doctors and the Health of the Public, September 10, 2010.)

In the meantime, remember that there are probably not too many magic shortcuts to better health. A healthful diet and more exercise will make you fitter and stronger and able to do more things; reading and thinking and doing puzzles are interesting, stimulating and fun, whether they prevent Alzheimer’s disease or not.

[1] Mette Kalager, M.D., Marvin Zelen, Ph.D., Frøydis Langmark, M.D., and Hans-Olov Adami, M.D., Ph.D, Effect of Screening Mammography on Breast-Cancer Mortality in Norway, N Engl J Med 2010; 363:1203-1210.

[2] Hellquist BN, et. al., Effectiveness of population-based service screening with mammography for women ages 40 to 49 years, Cancer published online Sept 29 ,2010
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