The price of marginal thinking in healthcare policy

I find it fascinating how our brains have this propensity to latch on to what is at the margins at the expense of seeing the bulk of what sits in the center. This peripheral only vision is in part responsible for our obscene healthcare expenditures and underwhelming results.

I have blogged ad nauseam about the drivers of early mortality in the US. In one post I reproduced a pie chart from the Rand Corporation, wherein they show explicitly that a mere 10% of all premature deaths in the US can be attributed to being unable to access medical care. The other 90% is split nearly evenly between behavioral, social-environmental and genetic factors, of which 60%, the non-genetic drivers, can be modified. Yet instead of investing the bulk of our resources in this big bucket of behavioral-environmental-social modification, we put 97% of all healthcare dollars towards medical interventions. This investment can at best produce marginal improvements in premature deaths, since the biggest causes of the effect in question are being all but ignored.

A couple of other striking examples of this marginal magical thinking have surfaced in a few recent stories covered with gusto in the press. One of the bigger ones is the obesity epidemic (oh, yes, you bet it was intended), and its causes. This New York Times piece with its magnetic headline "Central Heating May Be Making Us Fat" entertains the possibility that because of the more liberal use of heat in our homes we are no longer engaging our brown fat, which is a furnace for burning calories. And this is all well and good and fascinating, in a rounding out sort of a way. And it is just as interesting to hear that lack of sleep may be contributing to our expanding waistlines. But it is also baffling that we are still expending these enormous amounts of energy (OK, this one was not intended) on finding the silver bullet, when the target is not a supernatural being, but a super-sized expectation. Is it really that mysterious that we are fatter now than we were 20 years ago, when our current portion sizes are 70% bigger and we spend our days worshipping at the temple of the screen, in all its manifestations? While I am all for learning as much as we can, what we need right now is immediate action to abrogate this escalating epidemic, and I think we can all agree that the way to do it is not through lowering house temperatures. Plenty of behavioral research is available to inform our strategies to get people to eat less and move more. Let's start translating it into practice rather than latch on to one marginal magical idea after another.

And finally, I have to touch upon lung cancer, of course. The current fodder for this was provided by the Washington Post with this story about the growing advocacy among lung cancer patients for early detection. You may recall that recently I did several posts on the heels of the large NCI-sponsored study National Lung Screening Trial (NLST) whose purpose was to understand whether early detection of lung cancer in heavy smokers may improve lung cancer survival. I do not wish to go into all of the specifics of this study and my interpretation of the results -- you can find my thoughts on this study in particular and on screening in general here. What I do want to reiterate is that 85% of all lung cancer is caused by a single exposure: smoking. And guess what? The same behavioral strategies that can help people stop overeating can be deployed towards smoking cessation. Yet, instead of spending 85% of all expenditures on smoking cessation efforts, we prefer to allocate it to early detection. My point is that we need both, but the balance has to be informed by pragmatism, not the marginal magical thinking.

And so it goes that the Pareto principle is bleeding into our healthcare policy decisions -- this is the steep price of the marginal magical thinking. What will it take to get the blinders off and face up to the idea that some intervention points are just more impactful than others? Marginal panaceas will improve our lives, but only at the margins. And without being addressed, the big elephants in the room are likely to stampede us.

Evidence-based... fashion?

The line between consumerism and obesity is not that difficult to draw, and mechanisms for this relationship are plentiful. Passively sitting in front of screens, consuming sugary drinks and snacks peddled by sponsors, forgoing outdoor activities have all been implicated in our lard problem. On the other hand, when we think of the clothing and fashion industry, we think of the opposite extreme of the eating disorder spectrum: anorexia. At the same time, some have suggested that, in fact, the unattainable thinning of the paragon of womanhood is itself responsible for the paradoxical growth in waistlines.

I think there is another mechanism at play in the fashion paradox. Have you noticed how our clothing sizes have become, shall we way, more forgiving? It seems to me that what is a size 12 waist today probably would have qualified for a size 16-18 two decades ago. Assuming that an inch has not changed that much over the last 20 years, something is wrong. Is there a big conspiracy by the clothing manufacturers to make us feel thinner than we are? This is not altogether inconceivable, since experience dictates that when one feels larger than normal, one may confine her wardrobe expansion to shoes alone and forgo a confrontation with the truth. So, encouragement from numbers may be just what is needed to drive continual clothing sales.

Another uniquely consumerist factor plays into this game: the microscopic half-life of a piece of clothing in the American closet. From where I stand, the American consumer is poised for a nearly 100% turnover of her wardrobe every season. And even if I am somewhat off in my estimate, there seems to be a sense of entitlement to a constant stream of new items. So, if this assumption is correct, it is easy to engage in a frequent deception about size by a constant creep of what is considered size 12, for example. The evidence of stable size we seek from new clothing is, thus, flawed.

So, once again I maintain that, in order to conquer our obesity problem, we need to turn away from consumerist ethic. After all, if I still have my size 12 pants from 4 seasons ago, and I can no longer fit into them, this is grade A evidence that I need to pay the piper.