More important than our circadian rhythm: Creating a society that is safe and has health care for all

The New York Times, in addition to covering world and local news, has a lot of “feature” type news, generally appealing to educated, urban, and often higher income people, especially in New York, who are a large percent of its readers. Obviously its Arts coverage reflects the enormous NY arts scene, but also frequently seems to be more in-depth, designed to appeal to an even smaller group. Similarly, while its health coverage often includes news and opinion pieces on the social inequities in health care, on community risks (such as gun violence), and on policy issues, it also includes pieces aimed at what might be called “individual health self improvement”, sometimes involving new(ish) research.

An example is the recent front-page piece on “Circadian Medicine”, that reports on research about following our “body clocks” to get the greatest health benefits from how we do things like eat, exercise, etc. It starts with a look at the effort to move toward permanent daylight savings time and how this affects our personal and work lives.  Of course, this is ultimately a sociocultural issue; the amount of light and dark each day is unchanged, but the question is when our particular area decides to do things. Farmers and ranchers, for example, do not work based upon the time it says on the clock. If we wanted to, we could work from 9 to 6 instead of 8 to 5 rather than changing the clocks.

What is actually more important about this piece, to me, is that it goes on to emphasize how individuals can (possibly) improve their health by choosing the correct time of day to do their health-inducing activities. It is thus yet another effort to look at what each of us can (provided we have the education, autonomy, money, and time) do to make our individual selves healthier. Maybe. Such emphasis is not wrong per se (except, of course, when it is wrong, as has been, for example, our obsession with taking vitamin supplements when we are not vitamin deficient, as see F. Perry Wilson on Medscape, “It’s official: vitamins don’t do much for health”). The real issue is that it is a distractor, in that it focuses upon something that is perhaps slightly beneficial for some people (or not) but will not have a major impact upon the health of the public or the populace, taking our attention away from focusing on the very many major serious things that do have a significant effect upon the health of the public, and that we, as a people, could do something about.

 Like what? Let’s start with some data that should be scary: Among wealthy countries, the US is the only one that has seen a leveling-off and decrease in life expectancy, as reported by “Our world in data”. I have reported on this trend several times previously (Lower life expectancy in the US: A reflection of racism, classism, and social inequity April 29, 2022, Decreasing life expectancy in the US: A result of policies fostering increasing inequity, November 29, 2019) and examined some of the various proposed explanations. Case and Deaton, among others, suggest that the increase in the death rate (particularly among less affluent whites) are “deaths of despair”, mediated through the use of substances (alcohol, tobacco, opioids and other drugs). No doubt these are major contributors, but there are also others. One that has many people very concerned, as it should, is the ubiquity of gun violence in the US. This is a major contributor to death rates in populations such as young males, where suicide and homicide are very important causes of mortality. Most of us can reel off the names associated with major episodes of mass shootings, especially school shootings like Columbine, Sandy Hook, and Uvalde, but these are the tip of the iceberg. An interactive story in the Times documents the 63 “mass shootings” (four or more people shot) in May 2022 alone, and there were 65 in June, and 25 in July -- and as of only July 8 when this was published! And this does not count the many more deaths where “only” one to three people were killed! In the wake of Buffalo and Uvalde, Congress finally passed a very weak gun law. It did break an impasse, but in the minimal amount of restriction it places on gun ownership and carrying, it reinforces the idea that “America is a gun”, as in Brian Bilston’s poem. Any other country with only one major mass shooting has reacted much more dramatically and effectively. While articles continue to appear, such as the Op-Ed of Patti Davis describing the reaction (in her) and lack of reaction (in the nation) to the shooting of her father, Ronald Reagan, 41 years ago, we still are in thrall to the gun lobby and to folks who truly believe that they are at risk if they don’t have and carry guns that they make it easy for those who are going to create major violence and death.

And what about when we get sick? We – Americans – are as a group less able to access care than people in those other countries because we don’t have universal health insurance or access. Dr. Aaron Carroll, in an Op-Ed on July 7, emphasizes the impact of health insurance deductibles, noting that it is not just the uninsured but the underinsured, for whom deductibles are a major obstacle (along with other inappropriately-designed out-of-pocket payments) who suffer from not being able to access medical care, especially in time. The numbers that he cites for deductibles, and for co-payments and co-insurance, are amazingly high, as is the impact that it has on the health of those affected. For example, “The good news is that the A.C.A. limits these [out-of-pocket expenses] in plans sold in the exchanges. The bad news is that they’re astronomical: $8,700 for an individual and $17,400 for a family,” and for people in Medicare drug plans “a simple $10 increase in cost-sharing, which many would consider a small amount of money, led to about a 23% decrease in drug consumption.”

The fact that it is the Medicare drug plan (Part D) that is cited here is not coincidental; it, along with both Medicare Advantage (Part C) and the newer REACH (formerly DCE) program implemented by CMS (the Center for Medicare and Medicaid Services) are the portions of the Medicare program focused on providing profit to investor-owned companies rather than health care to American seniors. A recent report by the Urban Institute on Geographic Predictors of Medical Debt, in Health Justice Monitor, shows, unsurprisingly, that those areas with the highest concentration of poor, uninsured and underinsured people, and people with chronic diseases have the highest level of debt. And the lowest level? Those areas with the highest concentrations of people over 65. This, of course, is the only part of the general US civilian population that has essentially universal health insurance, despite the efforts of the programs above to decrease or dilute it. Although this seems worth mentioning, the Urban Institute did not; maybe they thought it was obvious.

But in this country nothing is obvious to most people and needs to be pointed out.  This includes our legislators, federal and state, to whom often the only thing that seems obvious is who is contributing to them. With all respect, we need to be focusing less upon our body clocks and circadian rhythm and more on the things that made a real difference in our nation’s health.

We need to decrease the availability of semi-automatic guns with high-capacity magazines. We need government policy focused upon creating well-paid, good-benefit jobs that will decrease “deaths of despair” rather than maximizing corporate profit. And we need high-quality universal coverage and access to health care for all our people. What we do not need are more programs like Medicare Advantage, Medicare Part D, and REACH that channel public tax dollars to private enterprises as profit.

What we do need, we needed long ago, and we need it now.

Belief vs. "truth": how people often make medical decisions

In a fascinating article in the “Medicine and Society” section of the New England Journal of Medicine, “Beyond belief—how people feel about taking medication for heart disease”[1], Lisa Rosenbaum discusses some of the reasons that people do not take medicines prescribed for them by doctors, really for any condition, not just heart disease. These reasons go beyond the obvious ones of personally experiencing side effects and not being able to afford them; indeed, she starts out discussing the fact that folks don’t use aspirin, a very cheap drug, even after having been diagnosed with coronary heart disease, for which the evidence of benefit is very strong.

Rosenbaum addresses a number of reasons, beginning with simple belief. A friend tells her that “My parents [whom Rosenbaum describes as “brilliant and worldly”] are totally against taking any medication”. Another person she meets, prescribed a “statin” (an anti-cholesterol drug), has no intention of taking it and indeed expresses disdain that is “raw and bitter” (the disdain, not the pill). For him, it is tied to the suffering he saw his sister endure when taking toxic anti-cancer drugs. Her hairdresser suggests another reason: taking medication means acknowledging that you are sick, and people don’t want to acknowledge that. He says that he gives his grandmother her nightly medication by telling her they are vitamins—after all, vitamins are to make you healthier, not treat your sickness.

Rosenbaum tells more stories, relating more reasons, but most come down to a belief, almost to an unchangeable worldview. Some of the issues seem to be semantic. People do not want to take “chemicals”, but will take vitamins. Connotation, and the “frame” that people put around words and concepts (sickness, drugs, natural, chemical, etc.) are very important. Of course, they’re all chemicals, and of course anything (“natural” or produced in a laboratory) that can have a biologic effect (good or bad) can have other effects (good or bad).  People sometimes cite the side effects of drugs even when they haven’t experienced them but have read or heard about them, and credit them with more importance than the beneficial effects. While some people have always made decisions based on creating a parallel to what happened to someone they know, the Internet has probably magnified the universe of people they “know” and stories that they “hear”.

Perhaps the scariest reason Rosenbaum points out is that the success of medical treatment has led people to minimize, in some cases,  the seriousness of the disease. As a cardiologist, she points to acute myocardial infarction (heart attack), which used to require 4-6 weeks of hospitalization, and now often has people out of the hospital in 24 hours. She talks to a person who contrasts it to the flu, which “can knock you down for days or a week or two, [while]the heart attack, once they do the thing, you’re in good shape.” And yet, “once they do the thing”, whatever it is, stents or clot lysing (presumably not yet bypass, which does require a longer hospitalization) and you feel better, you still have the disease; only the use of certain drugs along with diet and lifestyle changes can modify the trajectory of the disease. But the latter are hard, and maybe we don’t want to take drugs. Because, you know, we are feeling better.

I admit to initially feeling anger, hostility, as I read the “reasons” that these people would not take medicine, feeling that they were stupid. I don’t mean that I was angry that they don’t take medicine; this is their decision. In addition, there are lots of important reasons to be wary of taking medicines that go beyond personal experience with side effects. Not the least of these is the fact that they are heavily marketed by drug manufacturers, who are in business solely to make a profit, and regularly invent new “diseases” that “need” treatment in order to market their drugs and make money. In addition, “indication creep” (which I have discussed before, The cost of health care: Prevention and Indication “creep”, drugs, and the Sanders plan, June 25, 2011, particularly citing a piece by  Djulbegovic and Paul, “From efficacy to effectiveness in the face of uncertainty: indication creep and prevention creep”).[2] This means that a drug, which is found to be effective and relatively safe for a certain condition, at a certain severity level, in certain people, starts to be used by physicians (often encouraged by the manufacturers) for other people with less severe levels of conditions, and sometimes for other indications for which efficacy has not been proven. For example, starting drugs for cholesterol at levels below which treatment has been shown to reduce mortality, or putting younger (or older) people on treatments only shown to benefit older (or younger) people, or men or women.

Indeed, this appeals to another system of beliefs common in people (including doctors), that if a little is good, more is better; if reducing cholesterol in people whose level is above “X” is good, why not in people whose cholesterol is a little below “X”; if getting your average blood sugar below “Y” is good, why not a little lower still; if aspirin is good prevention and reduces death in men who have coronary heart disease, why not use it in men who don’t but otherwise look a lot like men who do? This sort of belief may lead to behavior opposite of that described by Rosenbaum (that is, taking medication when it is not of value rather than not taking medication that is likely to be of value) but it stems from same root—making decisions based on beliefs rather than evidence. And it is not uncommon to see both behaviors manifested in the same people: someone who would “never” take “artificial chemicals” (regulated drugs) into their body who ingests large amounts of unregulated chemicals (labeled as “natural”). The apparent contradiction is non-rational to me but makes sense to them.

I often—maybe usually—agree with those who say “less is better”, such as Ezekiel Emanuel in his New York Times op-ed “Skip your annual physical”.[3] But I hope that I do this when, as in the case of the annual physical, the evidence does not demonstrate benefit, and the cost is high, as it is for many heavily-marketed drugs. And, of course, my anger subsides as I realize that I often feel the same things, and maybe even sometimes act on them. I don’t want to be a sick person, certainly not one with a chronic disease (it’s bad enough to have the flu!) and taking a medicine for a condition labels me as such. I don’t want to take medicines just because they “might” help (prescription or over-the-counter, made by traditional pharmaceutical manufacturers or “natural” companies) if there is not good evidence, and I don’t want to experience unpleasant side effects. But I do take the medicines that have been shown to benefit people like me, with the same or similar risk factors, and even put up with some side effects (e.g., mild myopathy from the statin).

I am not going to change anyone’s worldview, no more than Dr. Rosenbaum is likely to change that of the “brilliant and worldly” friends of her parents. And I am certainly not going to become an advocate for treating for the sake of treatment, or being a flak for drug companies. But if there is strong evidence that taking a drug (in the lowest effective dose) for a condition that I in fact have (denial or not) is likely to have a “patient-important” (meaning lower risk of premature death or better quality of life) outcome, and I personally do not experience serious side effects, I will take the drug.

The key issue here is not making decisions to do, or not do something (have a physical or take a drug) because of a general belief that such things are good or bad for you, but rather to evaluate the evidence of how it might benefit or harm you, and to make a decision that balances these filtered through your own value system, how much you value the potential benefit or harm that might come.

To me, this is a rational approach.

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[1] Rosenbaum L, “Beyond belief—how people feel about taking medications for heart disease”, NEJM 8 Jan 2015;372(2):183-87

[2] Djulbegovic B, Paul A., From efficacy to effectiveness in the face of uncertainty: indication creep and prevention creep”, JAMA. 2011 May 18;305(19):2005-6..

[3] Emanuel E, “Skip your annual physical”, New York Times, January 9, 2015.