Category Archives: public health

Mortality amenable to health care

public health

“Mortality amenable to health care” is a statistical measure of the, well, mortality amenable to health care.  Briefly, it’s a measure of how many of a population’s deaths from certain causes could have been prevented by proper health care, or as the authors of a recent paper put it: “potentially preventable with timely and effective health care”.  It’s a statistic which in itself means nothing (it won’t tell you whether your grandmother’s death could have been prevented by timely and effective health care), but which can be used to compare different populations (like, people in different countries or (in the US) different states, and to track changes over time in the health care being provided to a population (if the MAHC is rising, then either the timeliness, quality, or amount of health care available to the populations is falling).

In a recent study reported by the Commonwealth fund (in the Journal of Public Health Policy, citation at the link), a group of three authors found significant differences between the various states in this measure, ranging from a low of 64 per 100,000 in Minnesota to a high of 142 in Mississippi (what a surprise) and a whopping 158 in the District of Columbia (bet it’s not among politicians, and also not a surprise).  Furthermore, they found that the US placed dead last in this measure among the 19 developed nations for which data was available from the OECD.  (The lowest?  France, at 65 per 100,000.  France, people.  Seriously, that sucks so much I can feel the interstellar vacuum getting harder).

Even better, the authors showed that there were some hard indicators of which regions or populations were going to have high MAHC, based on already measured public health indices.  Number of diabetics getting recommended preventive care, visits to emergency departments(1) by asthmatics, readmission to hospitals of recently discharged people, and admission to hospitals of long-term nursing home residents were all indicators of high MAHC.  These are the kinds of measures which doctors are railing against (well, to be fair, many doctors.  Other doctors, like me, are cheering the measures, and demanding they be used to provide the public some openly available information about the health care providers in their region).  Because many doctors feel both helpless to change those numbers, and trapped by a reimbursement system which, in effect, punishes them for making the numbers better.  This doesn’t work so much on an individual level: ask a specific physician whether they’d like to fix those numbers, and they’ll all tell you “Of course!”, but it works in subtle ways.  Fixing the numbers means working together with people who have traditionally been, not enemies, but rivals: hospital administrators, nursing home administrators, politicians in some cases.  And as you fix them, you watch your income figure drop, and suddenly there are just…other priorities.  Going to the meetings that keep the “fix the problem” process on track becomes less important.  Maybe you are frustrated with one of the other participants, and decide to say so to your colleagues, or the other members, or, heavens forfend, the media.  And suddenly the process is derailed; these things happen, couldn’t be helped, back to business as usual.  It’s never so open as “I decided to kill the process because it killed my income stream”, but that’s nevertheless what happened.

When it comes time to make the kinds of changes we need to make, I believe it’s crucial to 1) acknowledge the fact that income is a factor, and take steps to minimize and equalize the impact, and 2) see that the process keeps going, despite the lost income.  Maybe, after a while with the new system, new income streams will be found which encourage doing the right thing-that’s always been my thinking.  And one of my fondest hopes.

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1) Never “Emergency Room”.  It’s the “Emergency Department”. That’s probably the only absolute in the Physician’s Pen style guide.

Host, agent, environment

public health

In infectious disease, we tend to talk about the triad of factors which lead to disease.  These factors are host, agent, and environment.  In human disease, the host is a human, of course, but each human comes with a set of genes, co-existing diseases, nutritional status, and so on.  An agent is something which causes disease-a bacteria, a virus, or a toxin.  And environment is, well, environment.  The milieu in which one lives.  The world around you-clean or dirty, safe or dangerous, pleasant or ugly.

Medical students are taught this paradigm early on, usually during microbiology in their first year.  And after that, most of us go on to forget environment entirely, concentrating on host and agent.  In some ways, this is predictable-we see the hosts as patients, and the agents as the enemy.  And it has resulted in a lot of success for us as physicians; while I continue to decline the “best health care system in the world” appellation, we physicians are, individually, often excellent at what we do, and occasionally, we rise as a team to something near excellence, in individual cases or groups of cases.

We’re at the point, though, where working at the host/agent interface, while effective, is more and more costly.  If we want maximum bang for our buck, or even to make the bucks we’re spending elsewhere more effective, we must act on the environment.  In part, we should do this because, like any three legged construct, if we make two legs strong, the third leg will inevitably break and we fall.  In part, of course, we should do it because it’s right.  But mostly, in my opinion, we ought to do it because if we do we can get better health for free.

(Well, relatively free.  Cheap, anyway).

What’s the environment, in this situation?  It’s everything that isn’t host, essentially.  How easy is it for you to get food?  How stressful is it to walk around in your neighborhood?  What toxic substances are in your soil, your water, your air?  All of this matters, because it all informs what sort of host you present to the agents.  If you are constantly exposed to a low level of a toxin, your reaction will be different when exposed to a high level of that same toxin, or a related one.  (Might be better, might be worse; it depends.  Point is, it’ll be different, and the differences are part of why you either stay well or get sicker than someone from a different environment).  If you are chronically stressed, your reaction to a minor additional stress will be different than someone who generally has it pretty good (this is one of the theories of why African-Americans have higher rates of things like high blood pressure and cardiovascular (heart disease and stroke) issues.  Racism, goes the theory, makes your general stress level higher, and this translates into higher disease rates.  It has the advantage of being plausible; it has the disadvantage of being hard to craft a policy solution around.

And here we come to the point of this little diatribe.  Environment matters in health.  It makes you who and what you are, and in turn it dictates, in some ways, how you will respond as a biological organism to a health threat.  In the US, though, we seem entirely content to ignore the role environment plays in disease, especially if it means improving the environment of someone other than ourselves.  We (a significant fraction of “we”, in any event) dislike government regulation of the environment.  We don’t like the idea of transferring our wealth to improve the health of others.  But we balk much less (so far) at the idea of transferring our wealth to cure these folks once their environment has made them sick (which is essentially what laws like EMTALA, the Emergency Medical Treatment and Active Labor Act, require; if you get sick, you must be treated-as long as you can drag yourself to an emergency department, or in some jurisdictions, can get an ambulance to pick you up).

Are we, anytime soon, going to realize that we are being penny-wise and pound foolish?  Money spent to improve the health of a whole population really does “lift all boats”; healthier people are consumers for longer, can provide you services better, or be better employees, or better employers, or any number of things which will make your world better because there are healthier people in it.  And “environment” often has very porous walls; a problem in someone else’s environment, be it a toxin or a level of social unrest, has a way of leaking into your environment, whereon it is the very devil to get back out without getting it out of every other place where it can be found.  This was a lot of the point behind the advances in public health made in the 19th century – laws to improve everyone’s health by improving the environment (“No Spitting” laws made an enormous dent in decreasing TB transmission well before we could treat TB), really did improve everyone’s health, rich and poor alike (if your servants don’t have TB, you are less likely to get it, for instance).

In high school, I chanced to read a poem by John Donne, about how no man is an island.  The last line has always struck me, especially if read the right way, as by an advisor to a king: “Send not to know for whom the bell tolls.  It tolls for thee”  (John Donne, Devotions Upon Emergent Occasions (1624), Meditation XVII).