Saturday, May 15, 2010

Public Health and Changing People's Minds

In his Perspective “Why we don’t spend enough on public health” in the New England Journal of Medicine (May 6, 2010;362(10):1657-8), David Hemenway of the Harvard School of Public Health goes beyond the familiar complaint of the field that it is underfunded, particularly in contrast to medical care, despite the fact that it responsible for a much greater proportion of, well, the public’s health. He describes, as the title states, why.

Medicine is primarily a private good — the patient receives the main benefit of any care provided. Payments usually come from the individual patient and, in the developed world, from private and governmental insurance. Public health, on the other hand, provides public goods — such as a good sewer system — and relies almost exclusively on government funding.”

The fact that public health provides a more general good would seem to be, well, good, but because it doesn’t as easily benefit a particular individual (me, or someone I know, or at least someone I can see a picture of) it is less engaging. People, Hemenway points out, are “wired” to value present need more than future benefit; cost today for potential benefit tomorrow is not easy to “buy” and is certainly rarely politically popular. In addition, the absence of disease (because it was prevented) is less obvious – and thus unfortunately less valued – than the cure of a disease that didn’t have to occur. We don’t wake up every morning and say “thank goodness I don’t have cholera because we have a clean water supply!”, but would be very grateful for a cure if we did contract cholera.

In addition, of course, and very importantly, Hemenway notes that while there are well-heeled advocates for spending money on medical care (e.g., pharmaceutical companies, hospitals, doctors), the money is generally working against public health measures which often threaten extra cost to business – regulation of air and water pollution, environmental restrictions, occupational health laws, smoking bans, alcohol restrictions. And especially gun-control, where opposition to minimal studies supported by the CDC on this major health problem were so opposed by congressmen influenced by the gun lobby that they effectively stopped research into this area. Or, more recently, where members of Congress such as Sen. Lindsey Graham (R-SC), tie themselves into verbal knots trying to show how hard they will be on suspected terrorists, and how many Constitutional rights they are willing to abridge – unless it is the Second Amendment, and mainly the NRA. When addressing the issue of restricting the ability of people on the “no-fly” list to buy guns Sen. Graham is uncompromising: “I think you’re going to far here.” (“Congress Up in Arms”, Gail Collins, May 6, 2010) .

Hemenway cites the example of “Baby Jessica” who fell down a well in Texas in 1987 whose story gripped the country: “As a nation, we will spend tens of millions of dollars to save one Baby Jessica but are often unwilling to spend an equivalent amount to prevent the deaths of many statistical babies…The scandal that people remember about Hurricane Katrina is not so much the lack of preventive measures (e.g., stronger levees) that would have averted the calamity but the inadequate rescue efforts.”

This is why TV commercials for “Save the Children” and like charities that show the faces of actual children, or even better the agencies that allow us to “adopt” specific developing-world children by sending money to them, the individual kids, are so much more effective than general appeals for contributions to help the oppressed around the world. It is also why, when the New York Times published “Faces of the Dead” on the 7th anniversary of the Iraq war, it was so much more powerful than simply saying “more than 4,000 have died”, or even listing their names. It is now an interactive site; click on any of the little boxes and the photo changes to that dead serviceman or woman, with their name, age, hometown and service branch. Please check this site out, but have a box of tissues beside you.

The more common tack taken by public health experts has been to try to provide more and more data, to policymakers and the public, about the importance of public health measures past, current, and (potentially) future, in the expectation, or at least hope, that this will convince them and result in a greater commitment (spelled, like all commitment, “M-O-N-E-Y”) to public health undertakings. Hemenway’s piece, demonstrating that anecdote, personal stories, and treatment of existing conditions that are actually hurting people, are more powerfully convincing than data, evidence, and effective prevention, must be very frustrating. Indeed, the issue (and I would say the problem) goes beyond public health to health and medical care in general; indeed it applies to most issues in the policy arena. Data, whether presented in “dry” tables, journal articles, Congressional testimony, or the media, does not seem to change peoples’ minds.

Hemenway says that “societal change is hard”, but so is individual change. The case for this conclusion is clearly presented by Christie Aschwanden in “Convincing the Public to Accept New Medical Guidelines”, in e-zine Miller-McCune, April 20, 2010. In this important piece, Aschwanden begins by looking at the unwillingness of long-distance runners to change their use of ibuprofen (“Vitamin I”) for preventing pain and inflammation even when studies demonstrated that its use made these problems worse and those results were presented to the athletes. The conflict between the phenomenon called “naïve realism”, which is “the idea that whatever I believe, I believe it simply because it’s true,” versus the actually more naïve belief that “truth wins”. She discusses the recent breast cancer screening recommendations, and the belief (in part the result of a successful program of “education” from cancer awareness organizations) that the more screening of the more people, the better.

For years, women were taught the necessity of early detection for breast cancer based on the notion that breast cancer is a relentlessly progressive disease that will inevitably kill you if you don’t remove it in time. That story about breast cancer — call it the “relentless progression” mind model — is easy to grasp, makes intuitive sense and offers a measure of comfort: Every cancer is curable as long as you catch it in time.”

This is not a correct model, but it is hard to convince someone who had a mammogram, found cancer, had it treated, and is now alive, that mammography screening for everyone is not a good idea, much less that her cancer had a certain percent chance (much lower than prostate cancer, to be sure) of regressing on its own. I have addressed the breast cancer recommendations previously (Breast Cancer Screening and Evidence-based Medicine, November 25, 2009), so will rather focus on the studies that show, as she quotes social psychologist Robert J. MacCoun, “If a researcher produces a finding that confirms what I already believe, then of course it’s correct. Conversely, when we encounter a finding we don’t like, we have a need to explain it away.” I have previously noted that “data is only useful if it confirms my preconceived notions”; Aschwanden’s article cites study after study showing the same, on medical issues from breast cancer to low back pain. The President has called for more comparative effectiveness research (as have I, Comparative effectiveness research, March 27, 2010) but “How do you convince doctors and patients to dump established, well-loved interventions when evidence shows they don’t actually improve health?”

More generally, this is not just an issue with health beliefs. Aschwanden cites studies that demonstrated that people who believed Sadaam Hussein has weapons of mass destruction continued to believe it after being show evidence that it was not true. The opposite may occur, in fact; the presentation of facts that contradict your beliefs may serve to remind you of why you believe it and reinforce them. “It comes down,” Aschwanden writes, “to something the satirist Stephen Colbert calls ‘truthiness,’ a term he coined in a 2005 episode of his Comedy Central show, "The Colbert Report". ‘Truthiness is what you want the facts to be, as opposed to what the facts are,’ Colbert said. ‘It is the truth that is felt deep down, in the gut.’”

I admit to some my own truthiness. I want to believe, despite all this evidence, that people can be convinced by the evidence. That we will reconfigure the great imbalance of funding for individual medical care and public health because of the opportunity to improve people’s health and prevent disease; that we will choose prevention, screening, and treatment strategies based on evidence of effectiveness rather than myth or the financial benefit that accrues to the vendor of the service, and that we can unlearn that which is wrong as well as learn anew what is right. And that, even in the political arena, policy decisions may be guided by facts and reality rather than convictions. I know this is naïve, but I really want it to be true. Doesn’t that count for something?


Michael Ejercito said...


The CDC has no credibility on the issue of guns.

Citing them is like citing the United Auto Workers on the issue of electronics.

Josh Freeman said...

I don't believe I cite the CDC on guns; I thought I was citing Dr. Hemenway's critique of the CDC's work on guns.

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