Redefining compassion: "A spiritual technology"

This is a TEDxUN talk by Krista Tippett. It is fantastic!
If you are in a rush, just go to around minute 10:00 or so. But really the whole talk is well worh considering.

Comparative effectiveness 101

I have to say I do not understand the opposition to including costs into the comparative effectiveness research (CER) equation. Perhaps I simplify too much, but here is how I think about it.

Comparing two therapies is like using a microscope to focus at different levels of depth. Starting from the lowest magnification, we can ask "do they both work?" Of course in order to make this question answerable with data, we need to define what we mean by "work". Once we have defined that, the question becomes whether or not both comparators produce an effect in the same (desired) direction. If they do not, then the comparison can stop here, as the one with the positive direction of effect wins out. If they do both produce a desired effect, then we focus on the magnitude of that effect. There are several ways to do this, including comparison of 1). the effect size and variability of each to one another, 2). the proportion of patients who achieve a certain threshold of response (aka response rates), and 3). the adverse events frequency and severity. If these parameters are identical between the two, then the decision clearly hinges on the cost. Why is this so hard to accept? We would not want to pay more money for an identical car, so why would we pay more for a drug?

Of course, life is never quite this simple. Most of the time we will find small differences that are amplified by marketing messages as the reason to prefer a particular therapy. And this is all fine and good, and it is OK if a patient prefers one to the other because of some of these subtle differences. The question here becomes "how much are we willing to pay for a unit of this difference?" And unless the patient herself is willing to write the check, this is the pivotal issue facing our society today in the realm of the healthcare debate. So far our politicians have refused to do the real math, and are pandering to the opinion that we can pay for whatever we want in healthcare. This stance resonates with the public, terrified of the fictional death panels, and, more importantly, with the business of medicine, as this approach provides ample fuel for this engine of economic growth. But does it really improve our health, the primary goal of healthcare? I think not, just look at the state of our health and compare it to the rest of the world. And secondly, what is it doing to our national budget?

I will concede that I have simplified a complex issue. But not that much, believe it or not. With a modicum of math literacy people can easily wrap their brains around these concepts and make their own decisions, rather than being manipulated by disingenuous obfuscations of politicians concerned more with stuffing their coffers with corporate money than looking out for the well-being of the nation.      

Dear Dr. Val

Dear Dr. Val,

I enjoy reading your blog and the contributions from many of the leading medical bloggers that appear on it. Occasionally, the spirit moves me to post a comment, but for the second time in just a few months my comment has not made it to your blog. Why? I also tweeted you to ask if there are technical difficulties peculiar to my comments, but I did not get a reply. Why?

I know that some bloggers have a policy about what comments get rejected. I know that I will not accept abusive, profane or overtly marketing comments on my blog. I am sure you have the same standards. So, why not accept mine? I read Dr. Novella's post with great interest yesterday, and got passionate enough to write a pretty lengthy response. I am grateful to you and to Dr. Novella for allowing me to think through some of the issues that I commented on. But I was hoping for a dialogue... How will we ever arrive at mutual understanding or even better individual understanding without a cogent dialogue?

I do understand that the blog belongs to you, and you must have many reasons not to accept all comments, and that is your right. Perhaps you never even saw it, perhaps you no longer follow my tweets and thus did not get my queries. That is all fine. If I cannot get my comment on your blog next to the corresponding post, I will put it here and hope that you will come for a visit. If you do, I will welcome your comments. So, here it is:

What a great post! Dr. Novella makes the point that there is no evidence for the superiority of consuming organically produced foods over the conventionally produced ones in terms of health benefits. To arrive at this conclusion he relies heavily on a recent systematic review supported by the UK Food Standards Agency, which examined 12 studies, 8 of them in humans, 6 of which were RCTs and the remaining 2 observational studies. Because the article is available by subscription only, I could not access the whole paper. However, knowing what conducting clinical trials entails, I doubt that the 6 experimental studies followed the subjects for all that long. Perhaps not long enough to detect the benefit? Would love Dr. Novella to comment on this.

Additionally, divorcing the potential direct health effects due to consumption of organic products from the effects of the production on the environment is a false dichotomy. The pesticides do not just stay on the skin of the produce, but get into our water supply; the antibiotics given to the animals in CAFOs do not just get into their meat, but also get into the water and produce resistant pathogens -- there is plenty of work from the Netherlands to support the connection between agribusiness practices and human pathogen resistance emergence. Also, look at the staggering findings by the USGS about the contaminants found widely in our water supply and in what amounts.

The monoculture model of conventional agribusiness also requires enormous amounts of petroleum for fertilizers and pesticides as well, a resource that is dwindling. And, perhaps most importantly, the impact of monoculture farming on the land itself is devastating, decimating arable lands and creating essentially sterile deserts which need centuries to recover.

Having said all this, the mass-produced organic food business is not much more environmentally friendly than the conventional agribusiness, relying on monocultures and artificial fertilizing and pesticide management, as Dr. Novella aptly points out. Additionally, because it is concentrated in places remote from where it is consumed, its carbon footprint is still enormous. The really sustainable way to farm and eat, environmentally and human health-wise, is returning to small local farming, with a short distance from farm to table and a self-perpetuating cycle of earth's nutrient consumption and repletion by a diverse biome, just like nature intended.

My final sentiment is that, as people involved in healthcare of our nation, we must care about social and environmental justice. While these issues may fall more comfortably under the rubric of Public Health, doctors and nurses and other personnel at the bedside need to develop a greater appreciation for the context in which disease develops. This context includes healthy and sustainable food production and other social and environmental concerns.