Myths We Love

Megan Scudellari’s, “Myths that will not die,” (Nature, Dec. 17, 2015 Vol. 528 pages 322-325) http://www.nature.com/news/the-science-myths-that-will-not-die-1.19022 focused on five myths: (1) screening saves lives for all types of cancer; (2) antioxidants are good and free radicals are bad; (3) humans have exceptionally large brains; (4) individuals learn best when taught in their preferred learning style; and, (5) the human population is growing exponentially.

Each statement had some initial evidence to support it but over time more research challenged the initial outcomes. What was compelling as I read the article was realizing that there were factors that seem to perpetuate if not strengthen a myth. These factors include a vocal community of supporters; the development of products, industries, and research lines to address or remedy the situation; and, attempts to discredit new research. As a result, myths like lies that are repeated, become accepted as truth. In the end the damage is done to all of us because rather than moving forward with science we are in a chokehold because of what others want us to believe.

As I look forward to 2016 and beyond, my hope is that as our knowledge grows we will use information wisely and change what we know and espouse. "Trust, but verify," should apply to much of what we do in health so that we can achieve the healthier and longer lives we all want.

Me and Burgers

I love hamburgers but lately I only eat them at home. I do not want to seem like a wuss but it seemed to me that when I ate burgers outside my home my microbiome let me know that they were displeased with my selection. Some of the people I know thought that I was just being picky when I said that I preferred meat that did not have added antibiotics or hormones.  Today's Washington Post made clear that my microbiome led me to a healthier choice.

Coca-Cola Funds Global Energy Balance Network

WHO is recommending limits in sugar intake because of the worldwide increase in people who have excess weight. Drinking one typical can of sugar sweetened beverage exceeds the limit. Nevertheless, it seems that Coca-Cola is interested in research that documents that excess weight is not due to bad diets but to not enough exercise http://nyti.ms/1KZUZ4e They just funded the Global Energy Balance Network to lead this work. 

How to Reach the Hispanic Community...

Here is the link to my article that appeared on May 6, 2015 in El Mundo, Section on Business and Innovation, Madrid, Spain. http://www.elmundo.es/economia/2015/05/06/5549dfc8e2704ee34b8b4574.html .  The translation is below. 

Reaching Everybody

I was having a conversation with the CEO of a major company about how to reach 57 million peple in the United States. When I mentioned that I was talking about reaching the Hispanic consumer there was a pause and a palpable change in the conversation. The enthusiastic CEO went into automatic mode accentuated by polite comments that indicated interest and understanding. Then the entire project was handed off to the person responsible for Diversity — a death knell for meaningful work.

The Chief Diversity Officer is a C suite position without budget responsibilities that lacks the clout that is necessary to execute. These positions are meant to deflect challenges to the status quo rather than define the possibilities and the opportunities in a growing market. With neither a place in the chain of command nor the portfolio that could make the necessary investments it is a place where ideas go to die. The Diversity person is there to make the company appear like they are doing something to serve their diverse consumer base.

Just like EEO Offices of decades past or the more recent renaming of similar offices as Minority, Disparities, Equity, or some other politically palatable name of the moment these offices do little more than develop plans and do training. Most companies take a 20^th century approach and establish an employee group that is made up of the targeted community to advise them; hire outside expertise on the targeted group; create an advisory group of stakeholders; create a diversity, health equity, multicultural, or alliance development office; translate existing documents, webpages, etc. to the target language; add pictures of the target group; add food selections at corporate cafeterias that cover a variety of countries; and, sponsor “Month of…” events.

While these may be well-intentioned the totality of activities make it obvious that what has been accomplished is mostly veneer. Even worse they can be seen as a defensive response devoid of the tools to create the type of meaningful inclusion that produces financial results. This is bad for business and for our economy.

Reaching Hispanics or any target group means reaching individuals with an image, work, and product that resonates with who they are and what they want. It takes more than a diversity office to do that…it takes leadership and the commitment by every person in a company.  That leadership is hard to come by when Hispanics are one in six persons in the U.S. but at Fortune 500 companies are less than 2% of the CEOs and less than 4% of the Boards of Directors.

Trust and brand loyalty go hand-on-hand and today each individual wants to know that a company knows who they are and what they want. Too often I hear that Hispanics are too diverse and because of that it is hard/incorrect/disrespectful to get a single message that resonates with everyone. That type of strategy reveals a lack of understanding of the American marketplace.

With the rare exception of being in a building that is on fire and yelling ”Fire,” it is unlikely that a single word can reach everyone. The era of the single message went the way of having only a handful of major networks. Each person wants and expects to be reached with a message that is tailored to them; that is why Google has been so successful. Google knows each of their users and craft messages for them.

So when I am asked how do you reach Hispanics? It’s the same strategy that you use for everybody—use language and images that are meaningful to the individual, make clear that you understand what they want and desire, and as a result earn trust and respect. You do different things at different times. Reaching everybody is no longer a one shot deal.

Big Data and You

El Mundo, one of the most prestigious newspapers in Spain, created a daily supplement on innovation and entrepreneurship (title Innovadores) and as an advisor to Bankinter's Future Forum I wrote this article on "Big Data and You."

http://www.elmundo.es/economia/2015/03/05/54f8359e268e3ed9248b457f.html

Here is the translation:

Big Data and You

We all accept that there is an abundance of data that are used to define everything about us. The data that are collected are then harvested by all types of entities and put together in ways that communicate more to others than we may want to share. But with the promise that the data cannot be traced back to the individual we release much of what is private about our lives. Nowhere is this more evident than in the health care setting where data are being merged from different sources to produce predictive models for deciding upon the type of treatment an individual should receive.

The use of big health data has been heralded as a giant leap forward in that information from different people can be used to give a fuller picture of what are the risk factors that we need to pay attention to. With these aggregated data and the risk profiles they provide health care providers at every level are equipped with an array of protocols about how to treat a patient. These data can also provide new and compelling alternatives to what would be considered the usual standard of care.

But we must proceed with great caution.  Recent research[1] funded by the National Heart Blood Lung Institute in the U.S. documented that commonly used risk assessments of atherosclerotic cardiovascular disease (ASCVD) overestimated the risk by 37 to 154% in men and from 8 to 67% in women. That translates into a huge amount of people getting treatment they did not need.

Big data are the results of combining lots of smaller bits of information. How big data are gathered and how they are merged can become a problem. This is made worse if at the point of care risk scores replace talking to the patient or the ever elusive listening to what the patient says. The promise of health care providers to “Do no harm” can be compromised by the overreliance on tools that are meant to add to the clinical conversation and not dominate them.

Jane L Delgado, PhD, MS,

President and CEO

National Alliance for Hispanic Health

Washington, DC

janeonhealth@gmail.com

---

[1] Andrew P. DeFilippis, MD, MSc*; Rebekah Young, PhD*; Christopher J. Carrubba, MD; John W. McEvoy, MB, BCh, BAO; Matthew J. Budoff, MD; Roger S. Blumenthal, MD; Richard A. Kronmal, PhD; Robyn L. McClelland, PhD; Khurram Nasir, MD, MPH; and Michael J. Blaha, MD, MPH. An Analysis of Calibration and Discrimination Among Multiple Cardiovascular Risk Scores in a Modern Multiethnic Cohort. Ann Intern Med. 2015;162(4):266-275. doi:10.7326/M14-1281

Fruits and Vegetables Should be Desirable and Affordable

Today the Alliance released the 2014 Healthy Americas Survey, a bilingual phone survey with a nationally representative sample of 846 respondents fielded from February 16th to March 2nd of this year. The Downloadable version of the 2014 Healthy Americas Survey is available at the Alliance’sHealthy Americas Institute website at www.healthyamericasinstitute.org. 

The findings show that access to care is part of the solution for achieving the best health outcomes for all. While there are obvious steps people can take which are critical, e.g., drinking less soda and sugary drinks and eating more fruits and vegetables, these options are not as simple as they may appear.

There is a huge amount of creative talent and dollars that are spent on getting people to buy sugary drinks. It would be wonderful if we could spend as much on advertising for fruits and vegetable and other healthy options as is spent on options that are not as healthy.  While PSAs are helpful they are few and far between and often play in the off-hours to fill in the time when no one wants to buy advertising time. Moreover, fresh fruits and vegetables are often financially out of reach for families with modest means.

We need to make it desirable and easier for everyone to eat in a healthier way.  

It’s Not About the Base— It’s About Quality

Quality health outcomes are not just about the denominator, big data, or public health data; it is about the individual. The allure of numbers is strong because numbers can be analyzed and the implication is that the data are objective. Nevertheless, our quest for precise data and measurements is often futile as too many times visually intoxicating three-dimensional charts tell us nothing about what is happening at the point of care.

Our measurement system must be radically different from what it is today. We should stop using the medical, economic, or business derived terms of “patient” or “consumer”  and focus on the person or individual. For the first time, technology and individual use of powerful computing devices (smartphones) give us the capacity to move beyond groups to individual focus.  

At the very least quality health measures should be publicly reported and include more mortality and morbidity outcomes. Additionally measures must be sufficiently nimble to:

1. Rapidly reflect new science.  
2. Rapidly include new technologies.
3. At a minimum be analyzed by race, ethnicity, and gender.
4. Encourage care that is tailored to the individual.
5. Avoid the tyranny of big data when caring for the individual.
6. Address that quality is defined in different ways by each person. 

Our future care depends on having measures that matter to each one of us.

The Naming of Biosimilars

At the cutting edge of all our progress in personalized medicine is the development of  biologics. These are medicines that are manufactured or extracted from biological rather than chemical sources. Biologic is used to describe the structure in the original or innovator medicine that was developed and biosimilar is used to describe the medicines that are developed that are similar to the original biologic.

Biologics and biosimilars hold great promise for the next generation of personalized medicine but only if we are able to track their effect on individuals. These are powerful new medicines. Consumers should know what they are getting and healthcare providers should be able to track the effects of what their patients get. While it is good to have these new medicines it is essential to be able to track them once they are given to patients.

To make this point we sent a letter to the FDA Commissioner today that was signed by over twenty-one partner organizations reaffirming the importance of giving each product a unique name www.hispanichealth.org/biosimilarsFDA . The value of what we know about the impact of these products would be substantially diminished if we are unable to track the products once they are approved. 

It is good science, good practice, and common sense that each product should have s prefix or suffix added to its name so it can be tracked. All that is needed is a distinguishable name. That should be an easy call for the FDA to make and one that responsible companies should applaud.

Sugar Sweetened Beverages--- Less is More than Enough

And so it continues...The Alliance is the lead signator supporting the NYC Health Department. Tomorrow (June 4) the Court of Appeals for the State of New York will hear oral arguments N.Y. Statewide Coalition of Hisp. Chambers of Comm. v. N.Y.C. Dep’t of Health and Mental Hygiene.  You can watch the debate live—oral arguments will be streamed from the Court of Appeals’ website starting at 2 p.m. E.T. https://www.nycourts.gov/ctapps/The Court’s summary of the case is available here:https://www.nycourts.gov/ctapps/summaries/Daily/2014/June%204.pdf

Pesticides cause illnesses is not new news.

For decades we have known about the hazards of pesticides and yet the headline from 34 minutes ago is "Pesticides Suspected in Spike of Illnesses in Washington State".  Try breathing the air in Fresno and you will understand why so many children there have asthma.  Workers throughout the nation have known about these hazards, complained about them, and pleaded for action.  At best they have received an acknowledgement of their situation.  We now have evidence about the hazards of some pesticides as endocrine disrupting chemicals.  The science is there but what is still missing is the will to act.

Science will Drive Innovation

El Mundo, one of the most prestigious newspapers in Spain, has a business supplement on innovation and entrepreneurship.  They invited me to write an article on innovation and it was published yesterday.  The original article in English is what follows below.

Innovation in health is being driven by two major changes—the science behind the understanding of health and disease and the expectation that consumers need to be better informed about their own health.

Science has moved us from looking at single causal factors to recognizing that there are many factors that impact on our health and that these factors are connected in ways that we previously were unable to measure. This means that innovation in health will be less about the separate parts of the body (heart, lung, brain) and more about the systems that are key to wellness. Our historic view of microbes as something that must be destroyed has been upended and provides a great example of why a change in focus from single causes and functions to co-dependencies is so important in understanding the mechanics of our health ecosystem.

We know that microbes are found in and outside of every person and for the most part help to keep your body working well. Some aid in digestion while others on the skin actually protect you from having harmful microbes pass through your skin. We need to be able to understand what they do and how to help them do what they need to do. Taking a systems approach to microbes requires us to collect and analyze data on our microbiome by looking at it as one interrelated system. And the solutions and business opportunities are in the products and technologies that work with this system.

At the same time, the vision of health that was defined by longevity is being recalibrated to focus on wellness, activity, and productivity and the quality of those longer years of life. With this new definition comes the demand for more information to be made available to consumers in a meaningful way. The Internet has trained consumers worldwide that information should be available within a few clicks. And this is especially true for the information about our own health and the health of others.

The blossoming area of biometrics and ways that this information can be gathered creates opportunities to market an array of new products. Professional athletes are the earliest beneficiaries of some of the new products that marry biometrics with giving immediate feedback.

For the average weekend fitness warrior there is now wearable technology embedded in clothes, e.g., smart fabrics, that monitor heart rate and pulse and transmit this information through wireless technology. A person can have the information sent to a cell phone or a computer where their every movement and its effect on their body can be studied and monitored. And the opportunities for innovation exist in the devices that are being developed, their use, the analysis of the data, and even in the development of protocols of what happens when there is a breach in a person’s privacy.

Innovation means addressing desires and wants even before a person recognizes there is a need. It is science that will be the key gateway to our future and the successful entrepreneur who will monetize it by new products or services.

Affordable Care Act and the Alliance

Between September 30, 2013 and February 23, 2014 the Health Promotion Advisers at the Alliance spoke to 15,862 consumers about what the Affordable Care Act means to them.  There were many important lessons but the top ten were:

1. All consumers know that insurance is important to have.
2. The state you live in makes a huge difference.
3. Consumers like to know what are all of their options.
4. Technology is a great tool but it is not enough.
5. Mobile platforms are essential.  
6. If you have never had health insurance, or even if you did, the language of insurance is confusing.
7. Comparisons based solely on monthly cost is the wrong way to make a selection.
8. Co-pays should be more accurately described as "you pay"
9. Coverage for mental health needs to be upfront.  
10. Conversations with an informed and trusted source are key.

Devious Maids is an Insult to Everyone

Raul Reyes' commentary in USA Today is on the mark http://www.usatoday.com/story/opinion/2013/07/09/devious-maids-latinos-tv-show-column/2461193/.  The new show "Devious Maids" should go into television oblivion.  While it is an adaptation of a novela (Spanish soap opera) the producers overlooked that in the Spanish original all the characters were Hispanic. That makes for a very different story line. The producers even missed in the translation of the title which in English would be, "They are the Joys of the Home."  

Just as damaging are the defensive statements that the story of the maids should also be told. Huh? It is not their story that is being told and most important of all the story where Hispanics are maids has been told so many times.  This type of show only reinforces stereotypes. 

We need other stories about Hispanics and there are plenty of good ones still waiting to be told.

Coca-Cola Joins BIO

I was reading today's POLITICO Influence that I receive by email when I was surprised to read: "COCA-COLA JOINS BIO: Coca-Cola Company has joined the Biotechnology Industry Organization. The trade group is expanding its multinational members. The group also added Scott Vitters, general manager of the PlantBottle Packaging Platform for Coca-Cola Company, to its Industrial and Environmental Section Governing Board."

Expanding its members?  When I looked at the webpage for BIO it indicated that it was the world's largest biotechnology organization http://www.bio.org/articles/about-bio.  Now that is what I call expansion.

Freedom is Not About the Size of a Sugar Sweetened Drink

Today, the Alliance was the lead signatory on an amicus (friend of the court) brief filed in the NY Appellate Division of the Supreme Court supporting the NYC Board of Health’s (BOH) public health rationale and authority to limit serving sizes of sugar sweetened beverages to 16 ounces in New York City food service establishments. The brief filing comes two weeks after a lower court ruled that the NYC BOH policy could not be implemented following a court challenge organized in part by the beverage industry.

While we were able to have many signatories to our Amicus Brief what was most interesting and challenging were all of those organizations that should have immediately signed on and who were silent.  If you are concerned about wellness and health promotion then you should be focused on those actions that support people be healthy.  

Instead what we found was that trigger words were thrown around to invoke a knee-jerk response but were often devoid of content.  The refrain that people's "freedoms" were being attacked seem not only misguided but made light of the very concept of freedom.  More than anything it is very sad to see the effect of financial pressure placed on organizations to make decisions that are contrary to their espoused mission.

It is a reminder that decisions based on integrity are priceless.

Forget about pay for performance (P4P)

The principles of behavior modification demonstrate the importance of incentives. What is also well documented is that extrinsic rewards, i.e., financial incentives, have limited impact on complex behaviors.  Moreover, extrinsic rewards are most effective with young children. 

Consequently, based on the science of human behavior P4P would result in the desired performance in very limited settings and situations. We should not be surprised by the outcomes that we have experienced by applying P4P to health care...more money is not the answer.  

http://content.healthaffairs.org/content/31/9/1932.abstract?sid=6eb2c26a-18b9-4a35-a1cc-5b44b41c8ca2

When Setting Targets Misses the Mark

The solution to the problems we face in health care are frequently reduced to one sentence pronouncements.  National health care is put forth as the best answer and in the same breath the National Health Service, a la British model is lauded as the way to go. And while that model may have elements we may want to adopt (home visits for parents of newly born infants) we also need to be well aware of its failures.

Today's New York Times on Page 9 describes the recent report which looked at conditions at Stafford Hospital in England from 2005 to 2009 where care became so negligent that, "...patients left unbathed and lying in their own excrement and urine..patients left so thirsty that they drank water from vases..."  It seems that they were trying to meet health service targets and balance the books. While many of the senior managers were let go, the top regional person is now at the helm of the National Health Service in England and it seems that no one lost their license because of the way patients were treated.

There are many lessons to be learned from Stafford hospital.
http://www.nytimes.com/2013/02/07/world/europe/hospital-report-cites-appalling-suffering-in-staffordshire.html

Epilogue: Case Study Ellen—Good Policy is Not Enough

These last few months have been so intense.  I have seen health care providers who struggle as they try to care for patients while others acted as if caring for a patient was a burden.  It was at the point of patient care that I saw the greatest variability in how someone was treated.  

I remember the nurse in the step-down unit who had said that the IV should be changed every 72 to 96 hours and became annoyed that after 96 hours I asked how come the IV had not been changed.  Her response was that she was dealing with more pressing patients and she would get around to it.  It was clear that the needs of the individual had become either dominated or subservient to some benchmark or target. This is not the health care any of us want or deserve.

As all this occurred I contacted the leadership at Georgetown University Hospital and they were responsive to my many concerns.  They  made it clear that the policies they had developed had not been followed.  All were apologetic and all apologies were accepted but the bottom line is that the patient suffered and died.

Part IV: Case Study Ellen— Another Trip to the ER

I returned to DC on Monday and my intention was to visit Ellen at the Rehab Center and see how she was doing.  The plan was that she would be there for a while to regain her mobility and then go home.  As I was driving I decided to call Ellen's daughter to see how things were going.  

She let me know that the Rehab Center wanted to call 911 and have an ambulance take  Ellen to Suburban Hospital.  Ellen's white blood cell count was high and they felt she needed to be taken there even though her primary doctor was affiliated with Georgetown University Hospital (GUH).  We were told that the Montgomery County ambulance would not take her to GUH which is located in Washington, D.C.  The only way Ellen could get to GUH was by hiring a private ambulance. And so we did.

So once again Ellen, her daughter, and I were on our way back to the ER.  This time I  let the Georgetown staff know we were coming ahead of time.  We were glad that Ellen was put in the same area designated as Fast Track B. We chuckled about what "Fast Track" means.  

This time Ellen had a wonderful nurse (Jason) who did all he could to make her comfortable.  The 4th year resident (Bobby) had a good disposition and was very patient with her. Ellen had blood drawn, ultrasound of a swollen leg, chest x-ray, and answered many questions. The physician on duty told us that her white blood cell count should not have been alarming as that may have occurred because of some of the medicines she was taking.

In the end they released her to go back to the Rehab Center.  There was nothing wrong with her or perhaps more accurately there was nothing found that could be fixed. Consequently, at 2:20am on Tuesday Ellen was transported back to the Rehab Center by the regular ambulance service.  On Thursday at 1:45pm Ellen died.