Evidence Based Public Health

A recent edition of the Chronicle of Higher Education had an article talking about the overemphasis of medical education on jamming large quantities of basic science information, in lectures delivered by non-physician scientists, and underemphasis on laboratory work and clinical contact. Another of the frequent observations of recent medical school graduates was that the physicians under whom they trained rarely practiced "evidence based medicine" which is what the curriculum had taught them to see as the ideal of medical practice.

The truth is that physicians, especially specialist physicians, are among the least well suited to practice that kind of medicine. Evidence based medicine is premised on the idea that doctors should act more or less exclusively based upon journal published, empirically established medical studies. The problem with that is that physicians don't have the luxury of dealing only with what we know. They take patients as they find them with the ailments they present with in the office or emergency room. Sometimes, the medical literature provides guidance, sometimes it doesn't. Sometimes the literature provides guidance, but the cost of looking for the guidance is high, and the benefits of doing so are modest. Patients usually come back if a doctor's recommended course of action didn't work. Physicians routinely make informed guesses, or rely upon what has worked for their mentors, even if it has not been rigorously tested, and until we reach a point a century from now, where almost everything has been exhaustively subject to empirical testing, the practice of medicine will remain as much an art as it is a science.

But, the case for an evidence based approach to health, more generally, for the general public, is much stronger. Sitting here as a blog a Scooter Joe's coffee shop, in the shadow of Anthem's office building (Anthem is Colorado's Blue Cross/Blue Shield health insurance provider), makes one acutely aware of just how tangible the benefits could be. The platonically best way (if not always the most practical way in the short term) to reduce health insurance costs is for people to live more healthy lives so that they don't need as much health care.

While we don't know everything about health care, we do know a lot of useful things, some of which are contrary to popular wisdom, and others of which merely refine it. This blog, as my regular readers know, regularly covers health issues, generally in brief scrapbook notes about new proven or disproven cures, or newly established health benefits (or the lack thereof) of lifestyle choices like diet, exercise and environmental exposure to various risks. Almost always, they are backed by scientific journal articles or similar quality evidence, sometimes with direct links, and other times with links to secondary sources that in turn rely on scientific journals for their conclusions.

The larger project is to gather up and organize this scrapbook in a collection that can provide a canon of evidence based health findings that can serve as a basis for informing the public about how to live a healthy life, and can guide policymakers in making good use of public health funds and policies. Because these recommendations for individuals and policy makers come backed by empirical evidence, they have a very high likelihood of working in practice.

Our society's public policies towards individual health decision making is remarkably nihilist. We embrace the dogma of patient autonomy to the point of absurdity, even allowing patient autonomy, in many cases, where well established evidence shows that the choice being made is a poor one by measures that almost every patient in that situation would share. I'm not sure that this is necessarily bad public policy. Recent politically motivated decisions at the Food and Drug Administration regarding emergency contraception, and the administration's desire to pander to its religious right base by impeding vital stem cell research and human-animal hybrid research (which is not as ghoulish as it might seem) point to the risks of putting health decisions ultimately in government hands. But, this doesn't mean that there isn't a large place for a more broadly based campaign of public information, subsidy and encouragement of public health measures that have been proven to work.

Evidence based public information campaigns work. The "put babies to sleep on their backs" campaign greatly reduced deaths from sudden infant death syndrome. A public information campaigns directed at the harms of smoking have reduced smoking rates in the United Staets to levels lower than almost anywhere else in the developed world (go to Europe or Japan or South Korea, and you will be shocked at how many people smoke). Very mild traffic fines for not wearing seat belts or not wearing motorcycle helmets have very significant effects on behavior that have substantial impacts on motor vehicle fatality rates. Publicity has been as big of a factor as harsher criminal penalties in reducing drunk driving deaths. Public health guidance has dramatically cut consumption of whole milk and butter (both of which are high in saturated fats) and has also significantly reduced pork consumption. As a society, isn't it reasonable to devote more time on the airwaves to providing people with evidence based health guidance, which people may voluntarily follow to improve their own lives, as we do to helping people decide which brand of beer to buy?

The ultimate goal, beyond mere public information campaigns, is to reshape the culture. No, not the high culture we observe in theaters and view in museums, or even the low culture we absorb on television and listen to on the radio. What I mean is that we need to change the prevailing folk wisdom about how to respond to illness, about what to eat on a day to day business, about how to raise infants and children, and about what kind of exercise regimes are desirable, among other things.

The United States is uniquely suited to realizing this goal. We are more of a melting pot than we are a salad bowl, culturally. New contributions are fused into a larger American culture and made a part of it. As everyone knows, what passes as Mexican or Italian or Chinese or Mongolian food in the United States is sometimes nearly unrecognizable to recent arrivals from those respective countries. It has been Americanized. Usually, this is offered as a criticism. But, this doesn't have to be so. California, which has lead the way in the positive side of Americanizing foreign cultural influences, has shown that sometimes Americans can go one better than the originators. We can cook Mexican foods using healthier fats and oils than those used in the home country. We can make pasta with more whole grains. We can can pay more attention to keeping our food chain disease free than many in China do. We can benefit from a greater variety of vegetables than the traditional Mongolian diet permits. Our material culture is still a work in process and, as such, is malleable. With the proper persausively presented guidance, it can be the healtiest culture in the world and serve as an example for others to follow.