RX for Health Policy and Practice, Part I

GUEST: Dr. Jessie Gruman
VTR: 10/22/04

I’m Richard Heffner, your host on The Open Mind.

And our program today is largely about the unhappily quite prevalent dis-connect between much of America’s extraordinary researches in medicine and the health sciences AND our nation’s actual health policies and practices.

Appropriately enough, then, our guest is Jessie C. Gruman, the President and Executive Director of the Center for the Advancement of Health, a Washington-based policy institute funded by the John D. and Catherine T. MacArthur Foundation and other foundations to translate health research into effective public policy and private practice.

Now the Center notes that its task is specifically to ensure that evidence on social, behavioral and economic factors is applied to the prevention, the management and the treatment of disease.

And I would ask Dr. Gruman whether that makes her in fact a lobbyist – at long last a lobbyist for perhaps the best cause Americans could possibly embrace: their own and their families’ health and well-being. Is that a fair or unfair designation?

GRUMAN: If you mean “lobbyist” by trying to influence elected officials to put in place policies that are going to influence how things operate in this country, I would say “Yes”.

If you were to kind of designate that more as a, as a partisan issue, I would say “Not at all”. I think this country invests heavily in health research. We spend billions of dollars trying to find out more about what causes disease; how to treat disease, how to manage it; how to prevent it. And we make very little use of that information and so, in some ways, it’s lobbying for the use of information that the taxpayers have paid for in the policies and practices that are actually going to affect their health in the short term and in the long term.

HEFFNER: How do you account for what has been called this dis-connect between the two?

GRUMAN: Well, you know, that’s a very … it’s a very long and complicated answer; let me see if I can parse it a little. First of all, you know, the intrusion of science into medicine is a relatively recent phenomenon. Until the beginning of the 20th century, medicine was really much more of an art and science and the whole idea of doing randomized controlled trials really wasn’t a part of the, the basis of medicine and it wasn’t used to, to shape the practice of medicine.

People were doctors because they had apprenticed to other doctors. The training of physicians was really the apprenticeship and learning from what other people had observed. And, and I don’t want to discount the importance of learning from observation. But we know …we’ve learned over time that science, and kind of the systematic observation of phenomenon, can help us develop more effective interventions for health.

And so at the beginning of the 20th century, the Flexner Report was a report that really said “It’s time for us to, to start using science as the basis of medical practice.” And it revolutionized both medical education and it revolutionized the practice of medicine. But in some ways the … you know the idea of physicians as a small business who learned from observation has stayed with us in a very profound way. And we really don’t have the information systems and the wherewithal to, to sift through the science, to figure out what’s the best thing to make use of then to, to teach every physician to use it and given the resources to make use of that information, and then to deliver those services to their patients.

HEFFNER: So how do we accomplish that?

GRUMAN: There are a lot of really interesting efforts currently underway. I mean none of them … large enough and systematic enough, I think, to, to mean a complete overhaul of the American medical care delivery system, but there, there are a number of things that have been, have been taken on in the past, I would say 20 years that probably will, over time, make a difference. They’re, they’re, they’re necessary, they’re not sufficient.

But, for example, the Bush Administration has been very adamant about the idea that, that you need electronic patient medical records. Now why, why would you need that? Well, first of all because patients go to many different doctors, and there’s no way of keeping the information about them in one place. I mean one of the things that we find, increasingly these days, is that patients are their own medical historians.

They have to schlep their, their huge medical files with them. They’re in charge of coordinating their care amongst all their specialists and their primary care physicians. And this is particularly true with older people. And, and, it’s a big burden. So one of the things an electronic medical record would do, would, would be to keep a sequential record, not only of your entire history and, and to coordinate and bring in all of the information from various specialists, but it also would allow physicians to track their … not only their own patients, but amongst all of their patients over time, you know what really is working and what’s not working.

It’s also a great tool for research and will help us to understand what’s really effective in, in treating patients in the real world.

HEFFNER: Now, to what degree, is this innovative approach, using technology in effect?

GRUMAN: Oh, relatively modestly. [Laughter] The Bush Administration has put a high priority on this and has put some money behind it. And I think that there are a lot of, of information start-ups who are really looking hard at how can they kind of contribute to this and how can they make money off of this. You know the real difficult thing with electronic medical records is the idea that you have to have “inter-operability”, that is, that you know, there may be all of these small companies that are developing electronic medical records for patients, but if they don’t relate to one another, it’s not going to make any difference.

HEFFNER: Now, now, wait a minute … you, you say “may”. Are you describing the present situation? Are you saying that there is too little coordination among them?

GRUMAN: Oh, there’s very little coordination among them. There are efforts, there are efforts, but, you know, this is a … in our country we believe that, we believe that the market will take care of these things. And one … and to go back to your original question about what’s the big dis-connect between, between what we know and what we do in medicine. And I would say … I would characterize that the major disconnect is, as there are a number of places where commercial interests don’t coincide with the interests of patient health. And it’s in those places where we see this muddle and we see this breakdown between what science says and what we actually do to keep people healthy.

HEFFNER: You’re being so gentle.

GRUMAN: [Laughter]

HEFFNER: You know, I’ve been reading you and it seems to me that there have been a number of places where you have been rather plaintive about your description of the marketplace approach …

GRUMAN: Plaintive? No … I would say “direct”.

HEFFNER: Okay.

GRUMAN: I think that there are real limitations in, in the commercial interests with regard to health. I mean there’s some very obvious places where the market fails. And I’m not an economist so I don’t want to talk in those kind of terms, per se, but I, but I think there are a number of places where anyone can see how commercial interests simply are not going to make the difference.

The, the very notion of the flu vaccine and the problem that we’re currently going through with the flu vaccine is a perfect example of where, where commercial interests fail. It’s for, for a variety of reasons, it’s simply not feasible or profitable for, for vaccine manufacturers to manufacture vaccine. It’s just … it’s very difficult. And you think about the flu vaccine.

In some ways … I think that what’s currently going on with the flu vaccine is probably the biggest public health intervention to improve compliance with flu vaccines … and people haven’t, until this year, really wanted to get a flu vaccine. And, and this is a very difficult thing for manufacturers … they develop the vaccine and they produce it and they, they ship all of these doses and then … or, it’s not even ordered because … and they have to throw it away because there just is no demand for it. Well, so there’s very little interest in developing a flu vaccine, so there are only two manufacturers of the flu vaccine this year. And one of them has failed and now we don’t have flu vaccine. And we’re in a situation where we’re rationing medicine; we’re rationing the flue vaccine. It seems to me that, that … the more sensitive we are to understanding where commercial interests fail, the better we’ll be at targeting public resources to those areas. But the flu vaccine is not the only place where this happens. Another place where, where people are very well aware of commercial interests failing is in orphan diseases, that is low prevalent conditions where, you know, maybe only 50,000 people, 80,000 people have the disease and it’s a terrible disease and its very debilitating. But no money goes to research on that and, even if there is research, and there is a possible cure, there really isn’t much incentive for, for a drug manufacturer to develop the medicines for that disease because it’s going to be used by so few people.

HEFFNER: What’s the solution to that problem?

GRUMAN: Well, the government has, has a program that gives tax incentives and other incentives to pharmaceutical companies to, to invest in both research and development and production of drugs for those kinds of diseases.

But if … in some ways that’s … it’s not a perfect system; it doesn’t always … it doesn’t work … it doesn’t work to solve the problem. But it’s kind of the model for how … if, if we look at the entire realm of health problems, and we really try to identify where are the places that, that commercial interests fail … those are the places where we really should be putting public resources.

HEFFNER: Other people, other nations? How do they handle these problems or aren’t they faced with them on this scale?

GRUMAN: I think that … I, I don’t know … I mean … the first thing that flashed through my mind was … “Well, how do African countries deal with this problem?”. And I think that African countries deal with the, this problem in a very … the whole notion of the, the research enterprise as an, as an engine for the economy is simply … in developing countries … is simply not part of the constellation.

HEFFNER: But in developed countries?

GRUMAN: In developed countries …

HEFFNER: Western countries.

GRUMAN: The research engine … the United States spends the most money proportionately of our GDP on research, on health research. And it, it really is … an important economic driver in this country. Not only does public research result in very important information that’s directly used to develop health policies and to direct practices. But it also then is spun off into biotechnology and pharmaceutical development and really, in some ways, it’s a subsidy of the pharmaceutical industry and biotech industry … our public investment in science.

HEFFNER: Behavior. That’s a word that appears quite frequently in the materials that I read that you have contributed. You … I guess it’s … it’s in this “Healthy Living Influenced By More Than Genetics”

GRUMAN: HmmmHmm.

HEFFNER: … willpower is the … and you wrote that, “When the human genome was unveiled in 2000, every malady seemed at first to be genetics based in the way that to a hammer everything looks like a nail. But it turns out only about 3% of disease is caused by a single faulty gene.” And then you quote one of the pioneers in the field as saying, “I believe all of our behaviors, all of our sizes and functions clearly have a genetic component, but genes only explain a part of any process. Thus illness and longevity”, you continue, “depend on the interplay between what we were born with and what we have done since then. Because we can’t choose our parents, we can’t control our genes, but we can control our behavior.”

Now, your concern with behavior. Is that to any extent undermined by the marketplace approach to, to American life?

GRUMAN: Well, that’s a very … that’s a very interesting question. I don’t, I don’t … I don’t think that you can see those two things as, as behavior that’s undermined by the American approach. I think we live in the context … we all, whether we live here or whether we live in Guatemala, or Zimbabwe, we’re all very powerfully influenced by the context in which we live. And I, I think that in the United States there are different challenges than in those other countries, and the, the importance of the advertising industry, for example, in influencing our behavior is, is very different here than it is in other countries but it still is, is an important piece of what … what are the things that shape, ultimately, our behavior and our ability to take care of ourselves.

HEFFNER: Here. For good or for bad?

GRUMAN: Well, gosh, you know, I think that there are a lot of good … the context we live in is … influences us profoundly and I think that there are good things and there are bad things and you live in New York City. We take public transportation a lot, and, and we walk a lot; and those, those two things contribute to our … the preservation of our environment and also contribute to our own health.

So there are things that … people say, “Aw, you live in the city, it’s unhealthy.” But, but, you know, there are things that you can see either way. I think the fundamental issue is that, that I think is important to talk about when you talk about behavior is that everything that we know about what makes us healthy is linked to improvements in health through out behavior.

We’re the ones who make hundreds of decisions a day about our health. Now we may not think that they’re about our health, but deciding what to have for breakfast, how much sleep we get, walking to work, not walking to work, looking both ways when you cross a street … all of these things can influence our ability to actually function well and keep us safe or not keep us safe. So, so there are all these kind of large secular decisions that we don’t think of as health decisions, and then there are the decisions that are very directly related to our health … do we take that pill, do we not take that pill … when was the last time you took a full course of antibiotics? I mean that’s something that, that it seems to me …

HEFFNER: You mean instead of taking for a few days …

GRUMAN: To stop at four …

HEFFNER: … and then stop.

GRUMAN: Exactly. You know, I’m … just the whole idea of … there are these things that we know that will increase the probability of us being healthy, and many of us struggle, mightily, to do those things. We struggle to, you know, get a colonoscopy when we’re 50 or to get an annual mammogram, or to get our kids vaccinated or to get our parents their pneumococcial vaccine or to, you know, make sure you have the right … if you have a chronic condition to make sure that you have the right drugs and you take it as you’re supposed to and that, that when you … and knowing which symptoms are going to be the things that are really dangerous and which pains don’t make any difference.

It’s not a simple thing and most of us kind of go through our days not thinking of this as a catastrophic problem and not thinking of this as “Well, I must, I must think about my health now.” We just … we make these decisions routinely. The problem is … and it’s not really a problem … the difference between 20 years ago, 30 years ago, is that we know so much more about what are the things that can keep us safe and what are the, what are the practices and what are the drugs we can take that, that can make a difference in living a life that’s productive and, and allows you to function for as long and as well as you can. And the question is, how can we make the best use of that information?

HEFFNER: Well, there is somewhere, again … in one of these papers … the one … the recent one on what we know and when we know it …

GRUMAN: MmmHmm.

HEFFNER: … and you write, “As long as people are getting their health information from the media and systematic reviews are not the key reference when reporting on new findings, individuals do not yet have access to the best and most accurate information for the health decisions they are increasingly required to make on their own.” Is that a criticism, indirect, perhaps, of all of the media coverage of scientific advances? Is it a slap at advertising for drugs? What is it that you’re saying here? What is your concern?

GRUMAN: My concern is this … that in this country we are increasingly being asked to make decisions about our own health and health care. And there are a number of things that are, are contributing to that. One is just … through the changes in health care have meant that many of us don’t have the same physician that we’ve always had. Many of us change physicians frequently as our insurance plans change and we don’t have access to the same physician.

The Bush Administration’s emphasis on health savings accounts, which basically are very high deductible catastrophic insurance that are accompanied by these tax free savings plan that you use to pay for your health care up to $2,000 for a family … have put us in a position of having to make, on our own, a variety of decisions that, that many people are not prepared to make. Or need a lot of help making and, and one of the wonderful things about the Internet and, indeed, about the growing use … growing coverage of health and science in the media, is that there’s a wealth of information for people to draw on in order to make these decisions.

HEFFNER: Yes, but then I have to ask you about something I’ve been told again and again, and you’re an expert in this. You mentioned the Internet …

GRUMAN: Exactly.

HEFFNER: … and the wealth of informational sources … how do I distinguish between the information that is valid and that which is nonsense. I know there’s a lot of nonsense in the areas that I know more about; let’s say the political science area.

GRUMAN: Right. Well there’s a tremendous amount of nonsense on the Internet and there’s a tremendous amount of nonsense actually, in, in the print and broadcast news. And if you think about why this is, it’s because the news media wants news. They are less interested in … if I were to ask you, Richard, you know, what’s the purpose of news? What are, what are news people trying to do?

HEFFNER: Trying to make a buck. Is …

GRUMAN: Well …

HEFFNER: … what my answer would be, unfortunately.

GRUMAN: [Laughter] Okay.

HEFFNER: … because the same thing you said about commercialization and the marketplace …

GRUMAN: Well …

HEFFNER: … is true of news directly.

GRUMAN: Right, and, and in order to be news, it has to be new. And so there are all these new single studies coming out … some of them are wonderful single studies with thousands and thousands and thousands of subjects and the nurses … in the new nurses’ study that just came out … thousands of subjects. And when something happens in the nurses’ study you know that it’s something that you’ve got to look at.

But the nurses’ study doesn’t produce new findings every day and there are lots of tiny, little, you know … how many days have you opened up the newspaper and found that we have, indeed, cured cancer. You know … there’s this kind of persistent hyping in, in a somewhat irresponsible way about new scientific findings and that really contributes, I think, to people’s confusion. I mean are you supposed to drink coffee, or are not supposed to drink coffee? Are you supposed to exercise every day and if you exercise, are you supposed to do it 60 minutes or 30 and fast, or slow. I mean people are really confused. And so, I think that this is a real problem.

The point that I was making with regard to the systematic reviews is this … in science, when you … we, we know … we can be confident of our findings when we have a variety of studies that have replicated the same finding. That’s the most robust, the most unbiased way of determining what we know. A single study can be very flawed, but you add the single study to six other studies and look at them together, then you really have a sense of “do we know that aspirin is good for you to prevent heart attacks?”. Do we know that, that diabetics need foot exams at this … at these interval? I mean those … and those are called med-analyses or systematic reviews.

And one of the things that we’ve been finding in kind of looking at how the media reports on science is that these systematic reviews are almost never reported on and really are very difficult for people to find and, and get access to. It costs money to look at these systematic reviews and to my mind these are, these are the kind the, the solid gold of what science has produced so far; it’s a synthesis of everything we know on a variety of different medical questions. And this information should be the basis of our own personal behaviors with regard to health and they also should be the basis of physicians’ practice. And should strongly influence what’s paid for and what’s not paid for. But there are all sorts of interesting problems in getting access to that information. One of the interesting problems … and you’ll …

HEFFNER: In the minute we have remaining.

GRUMAN: Oh. One of the interesting problems is, is that the Medicare modernization act prohibits the … looking at pharmaceuticals head to head in order to compare them and figure out which is more effective. And it’s this kind of comparison that we really need in order to find out best what’s going to work to keep us healthy and to prevent and treat the diseases that confront us.

HEFFNER: Dr. Gruman you’re going to have to elaborate upon that because I’m not gong to let you go. Please stay where you are and we’ll do another program because this is too important. Okay?

GRUMAN: Thank you. Sure.

HEFFNER: Thank you for joining me today, though on The Open Mind. And thanks, too, to you in the audience. I hope you join us again next time, and if you would like a transcript of today’s program, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.

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