Monthly Archives: May 2011

The misuse of health statistics by politicians

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Rudolph Giuliani prostate cancer[This post contains links to the New York Times. If you position your mouse over a link, you can view the destination URL at the bottom of your browser.]

When former New York City mayor Rudy Giuliani was seeking the Republican presidential nomination in 2007, he used to give a campaign speech that referred to prostate cancer and health care. His sound bites were turned into a radio commercial and included the following:

I had prostate cancer five, six years ago. My chance of surviving prostate cancer — and, thank God, I was cured of it — in the United States? Eighty-two percent. My chance of surviving prostate cancer in England? Only 44 percent under socialized medicine.

What’s wrong with this picture? Several things.

The numbers themselves – the 82 and 44 percent — were incorrect. Chances of survival are typically stated as the prospect of living another five years. According to the National Cancer Institute, the five-year survival rate for prostate cancer in the US is 98.4%. For England (according to the United Kingdom’s Office of National Statistics), the number is 74.4%.

Where did the lowly 44% for England come from? Giuliani’s health care adviser started with the number of people who have prostate cancer and the number who die (called incidence and mortality rates): how many people have the disease in a given year and how many die from the disease in that year. From those numbers he came up with a five-year survival rate. This is not possible. “Five-year survival rates cannot be calculated from incidence and mortality rates, as any good epidemiologist knows,” according to the Commonwealth Fund.

Comparing apples to oranges

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Why is it so hard to reduce US health care costs?

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Why is it so hard to reduce US health care costsProfessor Victor Fuchs and Dr. Arnold Milstein, both of Stanford University, have an article in a recent issue of The New England Journal of Medicine that asks: Why is it so difficult to reduce health care costs in the US? The article is available in its entirety online, but for those short of time, here’s a concise (and depressing) summary.

The graphic accompanying the article is dramatic in its simplicity. Health care spending in the US is 17% of GDP. In other developed countries (Western Europe, Canada, Australia), the number fluctuates around 10%. And yet life expectancy in the US is the lowest of these countries – almost four years below that of the number one country.

We know that some physicians and health care providers manage to operate at less than 20% of the average cost of care, without sacrificing quality. If everyone followed their example, the US could save $640 billion a year (US health care costs for 2008 were $2.3 trillion). Why doesn’t that happen, or as Fuchs and Milstein put it: “Why don’t cost-effective models diffuse rapidly in health care, as they do in other industries?” The answer comes down to perceptions and behaviors. Read more

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Bruckner on the good life, money, and the unequal world of work

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Consumer Society by Barry SmartOnce more, from Perpetual Euphoria: On the Duty to Be Happy. This time on our relation to wealth.

Why is it American conservatives deplore European social democracy? Could it be that it doesn’t stimulate consumerism enough to satisfy a free market economy? (emphasis added in the following quotations)

[T]he power of the great upheavals of the preceding century in France, including those of 1936 and 1945, consisted not only in redistributing the social pie, but also in creating new kinds of opulence for the majority of the people: free time, poetry, love, the liberation of desire, the sense of everyday transfiguration. Not being content to manage penury, but discovering everywhere new goods that are unquantifiable and escape the rule of profit, prolonging the old revolutionary dream of luxury for everyone, of beauty made available to the most humble. Today, luxury resides in everything that is becoming rare: communion with nature, silence, meditation, slowness rediscovered, the pleasure of living out of step with others, studious idleness, the enjoyment of the major works of the mind – these are all privileges that cannot be bought because they are literally priceless. Then we can oppose to an involuntary poverty a voluntary poverty (or rather a voluntary self-restriction) that is in no way a choice to be indigent but rather a redefinition of our personal priorities. This may involve giving up things, preferring freedom to comfort, to an arbitrary social status, but for a larger life, for a return to the essential instead of accumulating money and objects like a ludicrous barrier set up against fear and death. In the end, true luxury is the invention of one’s own life, master over one’s destiny; “but everything that is precious is as difficult as it is rare” (Spinoza).

This is not to say that Bruckner fails to appreciate the situation of the poor. Written in 2000, way before the financial crisis, this comment is even more relevant today:

[P]overty in developed countries may never be overcome, simply because the rich no longer … need the poor to get rich. … The misfortune of being exploited has been succeeded by the still worse misfortune of no longer being exploitable.

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Why are we so willing to undergo cosmetic surgery?

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Miss Plastic Surgery finals China
Miss Plastic Surgery pageant, Beijing
A recent article on cosmetic surgery in China observes that, despite the highly publicized death of aspiring pop star Wang Bei (see The death of Wang Bei: Cosmetic surgery as a moral choice), “the ugly side of Chinese obsession with beauty … is a gamble that millions of people are willing to take.” Why is that?

The high rate of cosmetic surgery in Asia has been widely discussed, including an article in The New York Times. What caught my attention in this more recent piece was the postmodern/feminist spin.

Susan Feiner, a feminist economist, offers these comments: (emphasis added)

Parents are caught between a traditional world view and a postmodernist world view. On the traditional side especially, your daughter is your property and potential to social advancement. … On the postmodern side you have this idea that western beauty, this imported beauty ideal, is really a sign of your family’s openness to the future. So those two impulses – a very traditional impulse and the more modern neo-liberalism impulse come together at the moment of submitting your own daughter to the knife. …

On one hand we have all of this acceptance and even approval for women to become doctors and lawyers and political leaders and at the same time what’s been held up to women is this Walt Disney notion of our lives. That really even if you are a doctor or a lawyer or a political leader the best you can really do is to be beautiful and get some wealthy rich man to take care of you, so the best possible outcome for any women is to be both hugely successful professionally and be knock-down beautiful.

Why so much willingness to reshape the body?

What drives the popularity of cosmetic surgery? As bioethicist Carl Elliott notes in one of my favorite books, Better Than Well, medical enhancements, along with body size, are part of the logic of consumer culture: “You cannot simply opt out of the system and expect nobody to notice how much you weigh.” Read more

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Bruckner on the family, being gay, and AIDS activism

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The perfect familyI recently read and very much enjoyed Pascal Bruckner’s newly translated book, Perpetual Euphoria: On the Duty to Be Happy (originally published in 2000). Here’s a passage from the chapter “The Fat, Prosperous Elevation of the Average, the Mediocre.” (emphasis added in the following quotations)

[W]hat a contradiction to see in civil unions or in gay marriage with adopted children the forerunners of the disintegration of the family! It is exactly the reverse: it is the familial order that is triumphing over all of us, no matter what group or belief we subscribe to, and it is hard to see any argument, anthropological or other, that we could make against it.

Good point. Lost on conservatives, unfortunately. The new normal in family formation is resisted by those who cling to traditional values, while the traditional value of family prevails.

The paragraph continues with a discussion of conformity and anticonformity, and includes the following footnote:

According to Lucien Sfez, in 1995, 45 percent of literature majors at Stanford said they were gay, a figure that has little to do with reality. The author sees three reasons for this phenomenon: it is cool to say you’re gay and not to have the brutal image of the heterosexual; gays being a minority are protected by labor unions; and finally, gays cannot be accused of sexual harassment. La Santé parfait, p. 65.

The first reason makes sense, the second is irrelevant today, and the third certainly isn’t true in the US.

The footnote appears in connection with a critique of identity politics. “People state their identities only to make others yield, and display them noisily, perhaps out of fear that without them they would not exist.” Later on, however, in a chapter on suffering, Bruckner does not fault those who go public with an identity that features an incurable disease or disability.

The impact of AIDS activism on attitudes towards illness

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Pascal Bruckner on doctors and patients

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Doctor patient relationshipA concise summary of the history of the doctor-patient relationship: It began with reverence and respect for the physician, changed dramatically in the 20th century, is in an unhappy state today, but may aspire to something more satisfying in the future. (emphasis added)

There is no figure more ambivalent than the doctor, who is simultaneously a preacher, a magician, and a healer, the master of both life and death. For a long time the image of him oscillated between two extremes: that of an arrogant practitioner intoxicated by his power and endowed with all the attributes of knowledge; and that of the family doctor, the tutelary divinity of French society who knew how to combine sound, precise diagnosis with friendly advice about what to do. …

Everything changed when medicine became specialized and liberalized. In the hands of a specialist, not only is the human body fragmented, but each part of it is subject to competing authorities. The result of this new status is that in dealing with a physician we oscillate between faith and absolute suspicion. Since he is supposed to know everything, a doctor has no right to be mistaken. … The contemporary patient is a skeptic who does not believe in any treatment but tries them all, combining homeopathy, acupuncture, sophrology, and allopathy, a little like new converts who embrace several religions to increase their chances. Read more

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Can pharmaceutical drugs benefit society?

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Goethe quotation: Whatever you can do ...Here in the US, we’re apt to hear about the British health authority NICE (National Institute for Health and Clinical Excellence) when a stage-four cancer patient makes a desperate appeal for access to an expensive drug not in the approved formulary. The British system has been characterized as rationing, and conservative US politicians like to use such incidents to argue against “socialized” medicine, which will surely do away with Granny before her time is up.

There are big changes currently underway in the British health care system, and NICE will actually be replaced by a different decision-making process in 2014. Although health care reform in the US (the Affordable Care Act) rejects the British model, a recent article in the New England Journal of Medicine suggests there’s much we can learn from the British experience.

Why not design drugs to have wider societal benefits?

Of particular interest is the concept of the social value of drugs. The idea is that if a drug demonstrates “wider societal benefits,” the British government would be willing to pay more for the drug. Presumably this financial incentive would lead the pharmaceutical industry to invest more heavily in products with a high value to society.

What might these values be? In discussions of how the new system would work, the only example provided is drugs that benefit the care-takers of patients. The article’s authors, however, suggest a few more: “narrowing health inequalities, advancing children’s life prospects, reducing burdens on social services, increasing tax revenues, and decreasing workforce absenteeism.” Read more

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What gets lost in the bureaucratization of medicine

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Medical practice as an artIn a recent issue of JAMA, Dr. Michael H. Monroe recalls how medicine has changed in the mere 14 years he’s been practicing. His desk has a drawer on the lower right where – at the start of his practice — he began collecting articles and stories on the medical humanities and the art of medicine. Over time, that drawer has fallen into neglect.

Addressing a mentor who retired shortly after he began his own practice, Dr. Monroe writes: (emphasis added)

A 14-year career of rounding, teaching, and publishing has not the longevity you had at your “retirement,” but it feels like it’s become an increasingly wearying few years. Concerns of coding, billing, documenting, administration, computers, surveys, rules, regulations, and politics have increasingly occupied my mind and space like an intracranial tumor, slowly compressing my right hand drawer. …

Medicine today is science, and business, and law (perhaps not in that order) but not so much art as it seemed to be even when I started. It is a world of statistics, evidence-based medicine, and quality improvement; of increasing things to count, to codify, and to structuralize. I know why we are counting, why it is important, essential even, and we are doing better, say the numbers, and I mark the progress but still can’t shake the feeling that in medicine, things easily counted need to be distrusted. Despite years of study and numbering, after all, we still haven’t settled the role of vitamins, hydrochlorothiazide, mammograms, aspirin, diabetes control, or almost any other topic in medicine including statistical analysis itself. What I have slowly realized and come to reluctantly is how hard it is to prove that anything is true. … Read more

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