Something Not Unlike Research

Inequality? Oh we'd love to help, but...

post by Bill Gardner

Arnold Kling and Nick Schulz argue that the growth in US inequality derives from two factors:

• Technology that allows a few very able persons to achieve extraordinary things (think Sergey Brin), and
• Defective families and assortative mating based on ability that result in large groups of people at the bottom who lack the talent to produce much of value.

These are important causes of inequality. Kling and Schulz would do something about these things if they could, they really would, but 

there may be less that government can do than one might hope. Research from Heckman suggests that education is a relatively feeble remedy for the effects of family background (although Heckman believes that early intervention, in preschool or even before, shows promise). In order to make a dramatic impact on inequality, government would have to do something about the fundamental causes: technology and marriage patterns. However, putting a brake on technological progress seems hardly feasible or desirable. And forcing people to select mates at random rather than on the basis of similar backgrounds and tastes seems similarly unlikely. As much as inequality may be a problem, no real solution is in sight.

OMG, if the only alternatives are freezing technological progress or making people marry random partners (on second thought, this is the best explanation for my first marriage, and the kids turned out great anyway), then I guess there really is nothing to be done.

Or maybe we could try the following:

• We could give every mother good prenatal care, and institute programs to reduce premature delivery. 
• We could provide every child with universal, high-quality preschool education. Please, read Heckman for yourself. He isn't saying that early interventions "show promise." He's saying that "Early interventions promote schooling, reduce crime, foster workplace productivity, and reduce teenage pregnancy." 
• We could reform our criminal justice system. The US has 751 persons in prison per 100,000 population. Canada has 117. England's rate is 151; Germany's is 88; and Japan's is 63. Mexico has 204. The global median is 125. Are Americans really six times as violent and criminal as the rest of the world? The burden of US incarceration falls on the poor and above all on people of color. It destroys families. But it could be fixed.

America could do these things and it would still have considerable inequality. But these are solutions that would help and, contrary to Kling and Schulz, they are in plain sight.

Social microstructure and health behavior change

post by Bill Gardner

Fighting chronic illnesses and curbing rising health care costs will require that we change health behavior on a population scale. How do we do this? There is lots of smart work on how to use incentives and persuasive health communications to induce people to change. But we also need to understand how change diffuses through a population. 

The importance of the microstructure of your social network for health behavior change was demonstrated in a brilliant set of experiments by the sociologist Damon Centola, reported in Science. By all means, read the whole thing.

What Centola did was create artificial social networks. In each network, each participant is connected to 6 other participants. The network on the left consists of neighborhoods of 6 persons with many connections to each other, and fewer connections to others. On the right, people also have 6 connections, but they are distributed across the population so as not to create clusters. People in the left are close to a small group, but far away from everyone else. People are the right are closer to a randomly chosen population member, but they do not belong to a close group. 

Strangers were recruited to serve at nodes in the network. What they were asked to do was to decide whether to perform a health behavior, specifically to sign up for an online health forum. If a person decided to join, messages were sent to his 6 neighbors informing them of the decision. The question is, given that one person decides to join the health forum, in which network did the behavior spread faster? What he found was

Individual adoption was much more likely when participants received social reinforcement from multiple neighbors in the social network. The behavior spread farther and faster across clustered-lattice networks than across corresponding random networks... My findings show that, not only is individual adoption improved by reinforcing signals that come from clustered social ties but this individual-level effect also translates into a system-level phenomenon whereby large-scale diffusion can reach more people and spread more quickly in clustered networks than in random networks. 

So, changing health behavior is not just a matter of incentives and persuasion. These tools work better if their power is focused, when all your friends change together.

Centola suggests that public health programs target "clustered residential networks," but is this going to work if we are increasingly bowling alone? To my mind the obvious target is the workplace. Workplace wellness programs may work not just because the boss holds the levers, but because workplaces are often the locus of our most important social networks. But where will we be if workplace-based insurance ends, and these programs go away?

The Prevention and Public Health Fund: Where is the money going?

post by Bill Gardner

Evidence-based strategies for preventing chronic diseases are essential for improving the health of current and future generations. So it is distressing to read Sarah Kliff's reporting on the political jeopardy of the Prevention and Health Fund:

Republicans have regularly attacked the $16 billion investment [over 10 years] in programs meant to reduce chronic diseases and improve Americans’ health. Wyoming Sen. Mike Enzi has quipped that the program was a “slush fund” for jungle gyms... “There’s certainly concern among the public health advocates,” says Jeff Levi, who chairs the new National Advisory Group on Prevention, Health Promotion and Integrative and Public Health “The concern is will it fall into a catch all category of things that can be cut, and that’s a challenge.” ...The White House proposed slashing its budget for the first time in its last deficit reduction proposal. House Republicans, meanwhile, would like to zero out the program’s funding in their budget...“The question is: are we funding the status quo, are we funding the stagnant quo, or are we getting an effort...that’s transformative?,” Maryland Sen. Barbara Mikulski vented at a Senate hearing on the fund last week.

Sadly, I think there is something to Sen. Mikulski's concerns. I looked at what the Fund is doing in the state of Ohio. The graph shows how much money will be spent on three types of activities in Ohio over 10 years (the vertical axis is in $1000s). The categories are:

1. Community and Clinical Prevention: Prevention activities that have been shown to be effective in reducing health care costs and promoting health and wellness. Specific activities include: a) Assisting communities with the integration of primary care services into community-based mental & behavioral health settings, b) HIV Prevention, and c) Tobacco Cessation. 
2. Public Health Infrastructure: To strengthen state and local capacity to prepare health departments to meet 21st century public health challenges and support the training of existing and next generation public health professionals. The money supports information technology, laboratories, public health training, and something called 'capacity building'.
3. Primary Care Training: Spending to expand the primary care workforce. These are training programs for (in order of increasing spending): State health care workers, physician assistants, advanced nurse practitioners, and primary care physicians.

There is an argument to be made for each of these categories of spending. But I'm concerned about the priority of infrastructure and training programs relative to actual community interventions. The latter appear to be getting less than $100,000 / year. The details will matter here. Are the Infrastructure and Primary Care Training funds being spent in ways that will generate a sustained increase in evidence-based preventive care by primary care practitioners? If so, the money could be well spent. If not, we will just have more doctors doing more of the same. I hope that the Senators push the Prevention Fund managers hard on this point.

 

 

 

Loyalty Cards and Public Health

post by Paul Kelleher

Matthew Yglesias recently wrote:

The way modern business works, a wide range of retailers charge you less if you swipe a loyalty card so they can engage in some nefarious data tracking schemes.

And here's Kevin Drum a few years ago:

I really loathe retail loyalty card programs. Really really really. 

And here are members of the Wisconsin Division of Public Health and the Wisconsin State Laboratory of Hygiene who in 2006 investigated an outbreak of E. coli O157:H7 infection:

We conducted a shopper card investigation to refine the data we were getting with regard to the products of concern. Case patients were asked for their shopper card number and whether they would permit the Wisconsin Division of Public Health to review their purchase history. A major grocery chain in Wisconsin (which includes multiple brands in their stores) provided a list of all purchases made with participants’ shopper card numbers during the 4 weeks before the respective illness onset. Purchase histories were compared with self-reported consumption. [...]

Of the 27 case patients with available shopper card information, 17 (63%) purchased brand A spinach; of these 17 case patients, 2 (12%) had shopper card information that indicated a purchase of brand A spinach, but they had not identified a brand during their interviews. The concordance of recalled information with shopper card information was not associated with age. Of the 15 case patients who had shopper card information that indicated purchases of a specific brand of spinach and who also recalled during their interviews a specific brand of spinach they consumed, 14 (93%) purchased the same brand of spinach that they recalled consuming. The 1 case patient whose recollection differed stated in her interview that she only consumed brand D spinach, but her shopper card information only indicated a purchase of brand A spinach. [...]

An environmental investigation conducted by the FDA and the California Department of Health Services identified E. coli O157:H7 isolates with a PFGE pattern indistinguishable from the outbreak pattern in samples obtained from river water, cattle manure, and wild pig feces in and around a field used to grow brand A spinach with the P227A product code. Beginning with Wisconsin’s recognition of this outbreak, the rapid response of the public health system in Wisconsin and nationally...and the cooperation among many partners permitted FDA officials to quickly announce a broad national alert regarding fresh spinach and, within 15 days, to narrow the focus of environmental investigation to spinach that was processed by a single company and grown in 3 California counties.

Of course, currently this public benefit of shopper cards is purely ancillary to the shopper's own interest in saving a few cents here and there. But notice one interesting thing. If a private lab finds E. coli in the stool of ill patients whose clinicians have ordered tests to determine the illness, the lab is required (in some/many/most/all? states) to send the E. coli isolates to a state lab for DNA testing. This testing allows state investigators to draw links between seemingly unconnected illnesses. And if I understand this correctly, the state has the power to do this DNA analysis on the stool of a private citizen* without his or her consent (and maybe even without telling him/her about it)---all in the name of public health. And yet when shopper card information would be equally helpful, state investigators are required to ask patients for their shopper card number "and whether they would permit the Wisconsin Division of Public Health to review their purchase history." How quaint.

*It is true that the DNA analysis is done on the DNA of the E. coli bacterium, not on the DNA of the person's whose stool the E. coli was found in. Good luck explaining that distinction to the American public. 

It's good to be the King. Isn't it?

post by Bill Gardner

From Angus Deaton, in a manuscript about the health gradient, the finding that social advantage is associated with better health. The health gradient is found in societies through out the world; which makes us believe that it is somehow baked into social life. But health and social advantage have not always been associated.

It is sometimes supposed that the gradient has always been with us, that rich people have always lived healthier and longer lives than poor people. That this supposition is generally false is vividly shown by Harris (2004, Figure 2) who compares the life expectancies at birth of the general population in England with that of ducal families. From the middle of the 16th to the middle of the 19th century, there was little obvious trend in general life expectancy. For the ducal families up to 1750, life expectancy was no higher than, and sometimes lower than, the life expectancy of the general population. However, during the century after 1750, the life prospects of the aristocrats pulled away from those of the general population, and by 1850–74, they had an advantage of about 20 years. After 1850, the modern increase in life expectancy became established in the general population. Johansson (2009) tells a similar story for the British royals compared to the general population, though the royals began with an even lower life expectancy at birth.

I suppose we could have learned this from Shakespeare. 

The health gradient is, in my view, the central injustice. It has not always been here, so perhaps we can make it go away again.

 

Prevention -can- reduce the growth in health care cost

post by Bill Gardner

Austin Frakt read a recent article by Charles Roehrig and David Rousseau and wrote

Bottom line: prevention can’t play a major role in curbing the rate of growth in health care spending. The rationale for prevention is for health and other economic and social benefits (greater ability to work, enjoy leisure, etc.). [italics added]

The basic idea is that

Spending on Health Care = (Number of Cases) x Spending/Case.

If so, growth in Spending must result from either the increase in Cases, or the increase in Spending/Case. Roehhrig and Rousseau's found that between 1996 and 2006, only about 25% of recent growth in health care costs can be explained by the increased prevalence of diseases. The rest of it resulted from increases in the Spending/Case. Moreover, even if the Number of Cases had stayed constant during this period, the increase in Spending/Case was so aggressive that Spending would nevertheless have grown faster than GDP.

However, I disagree that this shows that "prevention can’t play a major role in curbing the rate of growth in health care spending." I completely agree that our increase in Spending/Case has been the main cause of growth, and I completely agree that we must find more efficient ways to deliver care. But even if increasing Spending/Case is the way Spending grew, it doesn't follow that that reducing it is the only way it could grow or shrink. If we found the means to prevent some of the major chronic illnesses, and thereby reduced the Number of Cases, that would help reduce the growth in Spending.

Roehhrig and Rousseau show that this has happened for a group of diseases for which we have effective prevention strategies:

Our findings do document, however, that changes in clinical prevalence have had an impact on spending growth for certain conditions. One of the greatest public health achievements in the past fifty years is the reduction in cigarette smoking, and this is almost certainly reflected in our finding that spending growth was less than the rate of GDP growth for respiratory conditions, in spite of the rapid growth in treated prevalence and spending for asthma. [italics added]

Spending also fell for cerebrovascular diseases (which include strokes). Again, reduction in smoking contributed to this fall. So the results also suggest that you can reduce health carespending if you can implement effective prevention strategies. Reducing smoking was a home run for prevention; we are behind in the game now, and we need another big hit.

Do contemporary Republicans believe in public health?

post by Bill Gardner

Please do not misread the question. I am not asking whether modern Republicans want members of the public to be healthy. Of course they do.

What I am asking about is Public Health as a discipline and a social project. Do they believe that health has some of the characteristics of a public good? That is, do they believe that there are cases in which individuals making decisions in the market will not successfully coordinate their behavior to support the institutions that underlie public health? That we may need government for vaccination, sewers, monitoring of epidemics, monitoring of the safety of air and water, ..., on through public insurance? 

 

Public Health and individual liberty are in mild but real tension, and liberal societies find ways to balance utilitarian and libertarian concerns. I wonder, however, do the current group of candidates accept any government role in the promotion of public health?

I am particularly struck by Rep. Paul's comments about charity and health care in the video above. When you eat in a diner, it is not unusual to find a jar or a box below a homemade sign, asking for contributions to help pay for the cancer care of a child of a local family. It is heartwarming when you see that people do contribute. But it is also terrifying, as one knows full well that the contributions gathered this way won't even be a rounding error in the cost of the child's care. But mostly, like my Canadian and European friends, I am shocked that we put our neighbors through this. 

h/t to my friend Brian Wilcox, who posed this question and to Kaiser Healthcare News for the video.