The Politics of Measurement: Miscalculating Public Health

Here’s an update in the value of doubt from veteran health journalist and muckraker (the word is a medal of honor) Shannon Brownlee, writing in the Washington Post:

Striking fear… serves pharmaceutical companies, which want you to worry about diseases, because people who worry are more likely to go to their doctors and ask for drugs than people who don’t. It turns out that much of what we — and our doctors — think we know about many health problems has been shaped by drugmakers and their marketers.

High anxiety happens to be good for the bottom line of some big corporations. But perhaps that money could be better spent to keep us healthier.

We’ve all been taught that we are at risk for everything, and that the solution is to go to the doctor and get meds. The medicines have all been tested, in big randomized studies, so they seem safe. Refraining seems dangerous.

But their are a series of interlocking flaws in that assumption. In the worst case, companies with a stake in selling chemicals can hide the side effects, or the fact that the drug doesn’t do anything for you. Sometimes, testing shows the positive impact of a drug, but it takes years for side effects to surface. (By pure coincidence, Shannon’s article appeared the same week that the FDA announced that it’s investigating a possible link between the popular asthma drug Singulair and suicide.) And, as she writes, drug companies have made a concerted effort to sell their wares as preventatives for real (and invented) conditions.

Take statins, which are prescribed very widely to prevent heart disease. As Shannon wrote this week on a list in which we both participate (quoted with permission):

…the problem with the statins is that while they have been shown to reduce risk in patients with heart disease, they have not shown efficacy as a primary preventive measure.

In other words, if you’ve got serious symptoms of heart disease like having had a heart attack or stroke, then taking a statin has been shown to lower your risk of second event. But there is zippidy-doo-dah evidence that taking a statin for primary prevention — to prevent a first heart attack or stroke — is effective.

All right, but why not take the stuff just in case? One reason is that the odds of negative effects could be higher than the odds of positive effects.

But beyond that, the drug model of health is way too limited. In the U.S., she says, “unnecessary care… accounts for as much as a third of the nation’s health care bill.” The proportion may be lower in fortunate lands, like mine, with socialized medicine – but money is still being spent on unneeded drugs.

What if the same funds were invested instead in, say, public transportation? Here are some potential public health benefits:

  • Less air pollution.
  • Public transportation increases the value of densely packed housing in cities. When more people live in cities, less green space gets turned into suburbs.
  • In turn, those city dwellers will walk more – to the bus stop, to the nearest grocery, to get a cup of coffee – and will therefore weigh less and have healthier hearts.

Besides, perhaps there will be some spare change left over for bike paths.

No randomized experiment will show whether drugs or public transport prevents more heart attacks. There are no exact control groups for a city or a country. But there is research available to show the impact of walking on health, or public transport on the development of urban areas. Deciding how to use that information is political as well as scientific. It requires a more inclusive model of medicine than one focused on pills.

Previous posts in this discussion:

The Politics of Measurement: Drugs and Fences

Getting the Treatment Right: Conventional and Alternative Medicine

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