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Friday, October 5, 2018

Population Health and an aging world

I first used the above photo in my recent post on "The Silver Tsunami." Then, in a subsequent post on "The Biden Cancer Initiative" I cited an article I ran across at STATnews.
More research on ‘dying healthy’ will also help us live healthier

Helping people live longer has been a central goal of medicine for decades. The quest to extend life raises an interesting question: Should we keep investing in research aimed at adding even more years to the already impressive gains in the average life expectancy that occurred during the 20th century?

We can only go so far. There’s likely an unalterable biological limit to the human life span, somewhere around 115 years (though there are, of course, occasional outliers). Virtually all humans die before reaching that age, most of them before they turn 90.

This limit should give us pause…

Advances in medical treatment, including cancer treatments, are increasingly unlikely to provide further significant gains in human longevity. An analysis of 71 cancer drugs consecutively approved between 2001 and 2012, for example, suggests that their overall contribution to survival was just 2.1 months; the gains attributable to personalized cancer medicine have, so far, also been minimal.

Lacking evidence that the human life span can be radically increased by new medical technologies, we believe it’s time to shift our country’s investment priorities away from medical research that aims to extend life and instead focus on the same social, cultural, and political factors that successfully prolonged life in the last century.

That means more public investment in education, transportation, and housing. That kind of investment would directly contribute to the prevention of chronic diseases such as diabetes, heart disease, and many cancers, and would do more to improve the quality of life of the population than additional medical research aimed at treating individuals with specific diseases…

One way to preserve quality of life throughout the life span is to compress aging-related illness and disease into as short a time as possible.

Others before us have suggested that the U.S. is now at the point of diminishing returns in high-tech medicine. Unfortunately, calls to redirect resources away from research into extending life and toward quality of life have been ignored in the past, and the same will likely happen now. We believe that is a mistake…
I immediately tangentially thought of "A Good Death."

I looked into the authors of the foregoing STATnews piece, both faculty members of the Boston University School of Public Health.

Sandro Galea, MD is the author of this intriguing book:
HEALTH MATTERS. A CONCERN with our health and well-being crosses national, partisan, and ideological divides. Our concern with health has led us to remarkable achievements that have made for a healthier world during the past century. Life expectancy worldwide is higher than it has ever been. In the past century alone, we have increased life expectancy by a mind-boggling 30 years after centuries during which life expectancy was more or less stagnant. We have dramatically reduced death from infectious disease, and large numbers of people worldwide have access to quality medical care when they need it. Yet, our health achievements leave much to be desired. Although life expectancy has increased overall, billions of people continue to die prematurely, and substantial healthy life years are lost worldwide due to disease or disability. Our collective health achievement is marred by tremendous gaps, with global life expectancy ranging from a high of 83 years in Japan to a low of 47 years in Malawi. The United States has worse health metrics than nearly all other high-income countries, even as the country spends far more on health than any other country worldwide. Population health in the United States is characterized by racial/ethnic and socioeconomic gaps, despite decades of study and effort to narrow these disparities. These successes, and failures, are all the remit of public health.

At heart, public health is concerned with the social, economic, cultural, and political conditions that shape the health of populations. The vast majority of health achievement during the past century is attributable to an improvement in these conditions: to better living conditions in cities, improved educational status for women and men, safer water and sanitation, availability of nutrient-rich food, stable housing and shelter, and reduction in violence and injury. Conversely, our shortcomings represent our failure to tackle the social divides—across countries and within countries—that become health divides. This is compounded by our mis-investment of resources in curative care and away from education, physical and social conditions of cities, social justice, and efforts at disease prevention that create the conditions for healthy populations…
1. The Aspirations and Strategies of Public Health 
DURING THE PAST century, public health has been responsible for an extraordinary number of achievements. Going forward, the field stands to make similar contributions to health in this century. Our rapidly changing world continually presents us with new challenges, including chronic diseases, increasing income disparities, the threat of bioterrorism, and climate change. In the face of these concerns, public health is well positioned to lead the way.

Yet, despite its record of achievement, organized public health appears to be on the defensive. High-profile initiatives such as the burgeoning precision medicine agenda and the continuing war on cancer have captured attention at the highest levels of politics, diverting resources into individualized efforts at disease prediction through genomic approaches, at the expense of population-based public health action geared toward the foundational drivers of health [2, 3]. Given that much public health scholarship arises from academic public health institutions that are heavily dependent on federal funding agencies, our national preference for cutting-edge technology and expensive treatment over less eye-catching prevention measures threatens to monopolize the direction of public health scholarship for decades to come. Public health is not alone in this financial uncertainty. We share funding and infrastructure deficiencies with transportation, education, and almost all other endeavors that are reliant on public funding and leadership. Investments in much of this infrastructure have been declining, or barely keeping pace with needs, for decades [4]‌. In this context, every extra dollar spent on medical care comes at a high opportunity cost, at the expense of public health [5].

The difficulties we face do not center on disagreements about the core goals of our field, which have always been, and remain, broad and aspirational. According to the American Public Health Association, “public health promotes and protects the health of people and the communities where they live, learn, work, and play” [6]‌. This statement captures public health’s goal of shaping the conditions that enable healthier populations, with a key emphasis on the prevention of disease…

Galea, Sandro (2017-06-20T23:58:59). Healthier: Fifty Thoughts on the Foundations of Population Health (Kindle Locations 184-258). Oxford University Press. Kindle Edition.
OK. More stuff to have to study up on. I have to confess I don't know much about the nuts and bolts of "public health" as an academic and/or professional domain. I spent my three tenures with the HealthInsight Medicare QIO first as a Nevada acute care hospitalization outcomes analyst (pdf), and then as an EHR implementation and workflow analyst (DOQ-IT, Meaningful Use REC) working the ambulatory primary care space (Family Med, Internal Med, Peds, OB/GYN). In that arena, mention "population health" to the harried docs on the enervating productivity treadmill would just get you eye-rolling, grumpy, dismissive responses -- "If we each provide the best care for our patients, 'population health' will take care of itself."

Not that simple, by a long shot. But, then, none of us in the trenches had time for debating abstract macro policy issues.
"Yet, despite its record of achievement, organized public health appears to be on the defensive."
In particular given the priorities of the Trump administration. And then there are the competing economic priorities and chronic misalignments revealed in Rosenthal's excellent book "An American Sickness." 
An Aside: where might "Data Science" fit in to this? And, broadly, the "Upstream"? In that regard, "Your ZIP code matters more than your genetic code."
And, let us not forget the "exposome."
Take a Deep Breath and Say Hi to Your Exposome
Researchers begin to explore the unique cloud of airborne microbes and chemicals that surrounds each of us

In the past few decades, researchers have opened up the extraordinary world of microbes living on and within the human body, linking their influence to everything from rheumatoid arthritis to healthy brain function. Yet we know comparatively little about the rich broth of microbes and chemicals in the air around us, even though we inhale them with every breath.

This struck Stanford University genomics researcher Michael Snyder as a major knowledge gap, as he pursued long-term research that involved using biological markers to understand and predict the development of disease in human test subjects. “The one thing that was missing was their exposure” to microbes and chemicals in the air, Snyder says. “Human health is clearly dependent not just on the genome or the microbiome, but on the environment. And sampling the environment was the big hole.”…
 Add one more discipline to the "Omics." 


Roaming around their website led me to this:
Health Law, Ethics & Human Rights Research

The Affordable Care Act
Constitutionality, implementation strategies, Medicaid expansion, role of private health insurance companies, coverage of public health screening, and patient-oriented research.

Clinical Bioethics
Analysis of clinical case consultations performed at Boston Medical Center dealing with end-of-life care, reproductive health, patient capacity to participate in decision-making, and resource allocation.

Genetics & Genomics   
Genetic screening and counseling strategies, including fetuses, newborns, children, and adults. Introduction of whole genome screening into the clinical setting. Role of government mandates and informed consent. Genetic privacy, genetic transfer experiments, and regulation of synthetic biology.

Health Promotion
Legal and ethical issues in health promotion programs among employers, health care payers, government, and communities as well as the constitutionality of state and federal laws designed to change health behaviors (e.g., cigarette labeling laws, container size limits for sugary drinks, etc.)

Health & Human Rights
Development of a theory linking health to respect for human rights, including the meaning of the international “right to health.”

Patient Rights & Patient Safety

Defining the legal rights of patients, including the “right to safety” and the role of evidence-based medicine in setting the standard of care.

Medicine & the Holocaust
Study of the role of medicine during the Holocaust, focusing on racial hygiene, eugenics, euthanasia, and genocide. Care of Holocaust survivors, research on perpetrators and bystanders.

Military Medical Ethics
Study of existing military doctrine, application of civilian medical ethics to the military; special emphasis on ethics standards at Guantanamo, including hunger strike protocols, and the concepts of “dual loyalty” and “dual use.”

Reproductive Rights
Constitutionality of new state laws that restrict abortion services.

Research on Human Subjects
Study of the changes needed in federal research regulations and methods to improve subject understanding of research and improve the consent process and its documentation.

Religion & Public Health
The role of religion in public health policy and the First Amendment limits on governmental interference with religion and religious practices.

Emergency Preparedness
An examination of how public health should work with national security agencies, including the relationship between epidemics and bioterrorist attacks.

Medical Privacy
Privacy of medical and genomic records, quality assurance studies, and electronic health records, as well as the access the government has to private health information.

Legal & Ethical Implications of Wellness Programs
An analysis of the reciprocal interactions between corporate wellness programs and the laws governing health insurance and employment.

Forensic Medicine
Forensic evaluations of refugees and asylum seekers, as well as victims of abuse and torture. Setting standards for same.
Wow. Makes me want to move to Boston and apply.

My interest in these areas has been abiding ever since grad school [pdf] in the 1990's ("Ethics and Policy Studies"). apropos, see my prior post on "Information Ethics."

Oh, and I've alluded to this a couple of times:

I reached out to these folks, and gently pointed out that their "Ethical Framework" pdf download document had no definition of "ethics." The email reply I got blew me off -- "we all know what we mean, we're not gonna get bogged down in abstract academic jargon."

Right. In Silicon Valley-speak, just "Don't Be Evil" while you "Fail Fast and Break Stuff" in your Agile Scrums.

Dudes, I'm not talkin' obtuse ivory tower "Dialectical Hermeneutics,"or hypothetical "gotcha" moral dilemma "Trolley Problems," etc, just a common-sense primer of sufficient detail. e.g., from a book I got onto via Science Based Medicine:

Ethical Frameworks and Principles
Ethical considerations of any problem or issue can be divided into two major categories: (a) nonconsequentialist and (b) consequentialist approaches. 1 Nonconsequentialism considers that the action (or even just the motivation behind an action) is the crucial ethical factor. In other words, the action itself is more important than the actual outcome (consequence) of the action. By contrast, consequentialism holds that outcomes (as opposed to actions) should be the crucial determinants of ethical decisions…

The inherent subjectivity of ethics presents a problem: even when reflexive and uncritical responses (such as the ‘gut reactions’ of tabloid readers) are excluded, along with religious outlooks, medical ethicists still do not all agree on which ethical principles are best.

It was in response to this reality that an approach to ethical analysis known as principlism was developed. Principlism attempts to factor in both nonconsequentialist and consequentialist approaches. The standard version is based on four core principles:

(1) Respect for autonomy (a nonconsequentialist principle—but one that utilitarianism also supports).
(2) Nonmaleficence (‘first, do no harm’—a nonconsequentialist principle).
(3) Beneficence (increase overall utility—a consequentialist principle; it is essentially utilitarianism).
(4) Justice (fairly distribute benefits, risks and costs—a nonconsequentialist principle). 
Principlists apply this approach to an ethical case by examining how each of the four principles (in turn) applies to the issues raised by the case. It is quite common for medical ethics committees to use this method to reach decisions. Principlism can be very useful as a structured ‘checklist’ method to address ethical problems and therefore finds favour amongst laypeople or non-ethically trained professionals, who predominate on ethics committees…

Ernst, Edzard. More Harm than Good?: The Moral Maze of Complementary and Alternative Medicine (Kindle Locations 83-208). Springer International Publishing. Kindle Edition.
That entire chapter is excellent. One need not, however, even go to that much trouble. Any quick Google search will get you tons of relevant, succinct definitional information on the topic of Ethics.

Below, a good, accessible, inexpensive resource:

I still have all of my many grad school texts, but I keep this in my Kindle as a handy refresher.

It was emphasized to us in grad school early on that "Ethics" was not about some lookup cookbook of "right/wrong," but rather a frequently arduous process of rational moral deliberation comprising evidence (including accrued wisdoms), logic, and -- yes -- "values" fused in honest attempts to derive just decisions and policies.


My latest issue of Science Magazine arrived today. This therein is relevant to the discussion in this post:
Cancer prevention: Molecular and epidemiologic consensus

Prevention of any disease can occur at two levels: (i) avoiding or reducing risk factors coupled with increases in protective factors (primary prevention, which is preferable when it can be practiced) and (ii) detection and intervention early in the course of disease evolution (secondary prevention). But despite substantial epidemiologic data showing that a large proportion of cancers and cancer deaths are preventable, decreases in cancer mortality rates in developed countries have lagged far behind decreases in mortality rates from heart disease (1), another major disease amenable to prevention (for example, 18 versus 68% decrease, respectively, between 1969 and 2013 in the United States) (2). We believe that one main factor explaining the relatively modest reduction in mortality is the limited support for cancer prevention research, which receives only 2 to 9% of global cancer research funding (3). As a United Nations (UN) High-Level Meeting begins this week to review efforts to combat noncommunicable diseases, a key question is how to prioritize resources to realize the potential of cancer prevention…


Off-topic erratum: I drove today for the first time since my August 23rd SAVR aortic valve surgery. I start cardiac rehab PT next Tuesday. Doin' OK. Can definitely hear/feel that new valve thumpin'.

More to come...

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