Talking About Health; Why Health Communication Matters

Why did it take until 1991 to start emphasizing women in medical research?

109_0925 October 24, 2010

Another topic I introduce in the chapter, ‘What’s politics got to do with it?’ is funding for medical research. In many countries, U.S. included, government has a budget for medical research. For far too long, women were excluded from medical research funded by the National Institutes of Health in the U.S.

Several reasons supported this exclusion and biological sex inequity in United States health care research. Celeste Condit and I discuss these more fully in our book, ‘Evaluating women’s health messages.’ First, scientific research traditionally had been conducted by men. The questions they formed for research related to other men.

A second reason has to do with the predominant scientific method. It involves the testing of hypotheses, typically involving the relationships between two to four variables and attempting to control for differences. Women’s lives include obvious and continuous biologic transitions, leading scientists to prefer to use men as research subjects. This was the case even when the medications and techniques being tested were designed for women.

The most often cited reason to exclude women from medical research study populations was the potential for pregnancy. The possibility of causing harm to a fetus deters research for both moral and financial reasons.

A fourth reason–funds for health care research are scarce, creating intense competition among all researchers, which brings the discussion full circle. Men were primarily responsible for selecting the individuals who conducted the research and granted preference to other men conducting research about men.

Let’s hope that in this era of most stringent competition for research dollars, biological sex inequities do not again emerge.

What’s politics got to do with how we talk about health care in the U.S.?

October 16, 2010

122_22282 As I describe in the chapter, ‘What’s politics got to do with to do with it?’–more than we care to admit. Access to care is what we usually talk about.., but access to knowledge based on what research gets funded and access to treatment based on what drugs and products are approved relate to politics as well. And even access to information, as policy forms around labeling and package inserts and other ways to help us make informed decisions. All relate to politics… I was thinking about some of these issues while touring a Marcellus shale mining site and wondering about the health and welfare of workers and communities alike.

A couple of days ago, I posted my thoughts about events leading to how we talk about the focus on politics and access to health care In the U.S. Here are a few other events worthy of note… The Great Depression led the government to identify access to health care as a political priority. Now it was unemployed workers who were unable to pay for their own health care that got the government involved. Because so many workers were unemployed, this led doctors’ incomes to fall. Middle class citizens began to rely on public hospitals and state and local health departments to receive health care. In turn, doctors began providing more services through these venues. Doctors charged the welfare departments, and State welfare departments in turn charged the federal government. This cost-shifting system was supported by political priorities established in debates at the federal level and then by passage of such policy as the Social Security Act in 1935. 149_0821

President Truman expanded Social Security and recommended national health insurance in 1949. He continued to work toward it–unsuccessfully–until 1953. A role for government support of health care shifted from keeping workers working based on commerce to a role for government based on those in need or underserved–with the initial stimulus being the unemployed.

A role for government and politics in access to health care shows great expansion in the realm of the underserved and needy during the era of the Great Society, when Presidents Kennedy and Johnson expanded the social welfare and services system. The government’s role now extended well beyond keeping a work force healthy. The effort to provide health care included powerless groups, such as children and the elderly.

The government’s role in protecting workers’ health also grew during this era. But the focus shifted with new initiatives such as the Occupational Safety and Health Administration (OSHA), which was inaugurated in 1971, aligning with efforts to assure health and reduce the need for health care. In OSHA’s first three decades, fatalities in the workplace were cut in half, while injuries were cut 40%.

122_2235 A role for government in health care as a strategy to promote the economy began to threaten the economy as health care costs mounted in efforts to bridge the gaps associated with underserved groups. President Nixon reflected this reality in his attempt to decentralize decision-making about health care, reducing the federal government’s obligations in this realm. This was part of his policy of New Federalism, a doctrine designed to draw lines between issues for national versus state or local governments. Largely, this era focused on wresting control from the federal government and revenue-sharing with states, returning a portion of taxes collected back to state and local decision-making, policy from 1972 to 1986. President Reagan also used the term New Federalism in his block grant approach, shifting monies to state and local initiatives related to providing health care.

President Clinton came into office with health care reform established as a priority. The six principles stated in a health care reform speech in 1993 reveal that the nation was not yet ready to accept limits associated with access: [1] Security: Guaranteed, comprehensive benefits; [2] Savings: Controlling health care costs; [3] Quality: Making the world’s best care better; [4] Choice: Preserving and increasing what you have today; [5] Simplicity: Reducing paperwork and cutting red tape; and [6] Responsibility: Making everyone responsible for health care. The first, third, and fourth principles reveal an emphasis on access, while the second, fifth, and sixth were the guides to be used in controlling cost. The conflict in pursuit of these two divergent paths contributed to the plan never passing, which leaves the government’s obligation in access to health care in a costly dilemma…and that is how we talk about health care in the U.S.–as a costly dilemma relating to assuring the health of workers who will contribute to the economic well-being of the country and assuring the health of groups unable to access care on their own…

How do we talk about a right to health care in the U.S.?

October 14, 2010

It was little more than a decade after the Constitution was adopted when the U.S. Congress debated a role for the government in providing health care for some U.S. citizens. It was argued that when merchant seamen, who acted on behalf of the welfare of all U.S. citizens, became ill and/or disabled, it was only “just” to pay for their health care. In accord with this premise, Congress passed an act to provide for merchant seamen’s medical care in 1798. Congress used the authority of Article I, Section 8 of the U.S. Constitution to support this policy. It empowers the federal government to regulate commerce with foreign nations and to tax for the general welfare as a means to that end.

So–the health and well-being of individual seamen was not the argument used to support a role for government. The need for a government role in health and health care resided in a focus on commerce. If the seamen could not do their jobs, it could harm the nation’s commerce. Other early federal debates led to the provision of health care to the armed forces. It was argued that a healthy army and navy were necessary for national defense. Then, in the first two decades of the 20th century, middle class progressives realized that the American industrial society’s working-class citizens suffered ill health and injury, affecting their ability to work–harming the nation’s productivity levels.

Workplaces were often unsafe, causing injury to workers and their ability to work. In recognition of these facts, a number of economists formed the American Association for Labor Legislation (AALL) in 1905 for the purpose of studying labor conditions and labor legislation. The group advocated for health reforms in industry and sought compulsory health insurance. Initial efforts to argue the merits of such legislation focused on workmen’s compensation. This strategy aimed to provide access to care for workers injured on the job. Woodrow Wilson joined the AALL. He included their social insurance plank in the 1912 Progressive party’s platform. In 1915, they published a model health insurance bill in legislative language to be considered by State legislatures, with California, Massachusetts, and New Jersey supporting the proposal out of the 12 States that discussed it.

As debate continued within the States, so did opposition to a proposal for government health insurance. World War I produced the War Risk Insurance Act that established a comprehensive system of benefits for servicemen and their dependents. A broader policy was defeated, however, with AALL leaders naively assuming that such reform would be viewed as beneficial to all.

Once access to health care is argued around the role of commerce, the challenge becomes how to separate whose ill health and injury would not fit within that realm. If each citizen who works–and this includes those who work inside the home to enable others to work outside the home–contributes to the economy, then the argument appears to support the need to guarantee health care for all. Children will be the next generation of ‘workers’, so their care should be supported as well.

The Congressional Committee on Costs of Medical Care in 1927 proposed Health Maintenance Organizations [HMOs] as a strategy aimed to provide affordable health care to all citizens. A minority report written by doctors and adopted by the American Medical Association took the position that HMOs would hurt the quality of health care. As a result, the Committee’s recommendation was not seriously considered. Congress, however, initiated a program to cover its own members’ health care. And so, talk about a right to health care in the U.S. a century ago…not very much different from talk about a right to health care in the U.S. today.

Does drinking diet soda cause osteoporosis?

October 11, 2010

As I observe in the chapter, ‘What are my risk factors?’, we have a lot of competing goals in life that put being healthy in competition with other things going on. I was attending a conference and met a graduate student who was on crutches. I asked her what happened. She said that she had a fractured pelvis and it was blamed on osteoporosis. She told me that her osteoporosis was caused by drinking too many diet sodas. I decided that I would find a research review article about osteoporosis to share with my undergraduate health message design class. I did. And it reported that the evidence is inconclusive about a link between diet soda and osteoporosis. There was a collective sigh of relief from my students about that statement. Until I asked them, “How would we draw a conclusive link between drinking diet soda and osteoporosis? Why isn’t the research finding considered to be conclusive?”

And so, we launched into another discussion about self-report data and relationships based on having a condition versus not having the condition. “How much diet soda do you drink each day?” I asked. Some were able to answer, while others said, “It depends…” “On what?” I asked. “How hot it is outdoors.” “How much money I have.” “…you know.”

“I do.” imgp1303 I know that we often build an understanding about health conditions based on asking people questions. As a form of communication, asking people health questions is both an art and a science. How do we ask a question in a way that someone can give us an accurate and complete answer? If asked about how much diet soda you drink on an average each day, how do you decide to respond if you only drink diet soda when it is hot? Do you say, “none,” because it is winter? Do you respond “less than one a day” because you divide it out and even though you may drink a six-pack a day in the summer, summer is only really two months long…so it seems to average out to…less than one a day?

Trying to answer a question about how much diet soda has been consumed for a survey that may later be used to relate to participant responses about whether they had been diagnosed with osteoporosis or not may give some evidence to support a relationship. But the evidence is not…strong. If there are enough survey participants to consider all those who consume large quantities of diet soda and divide them into two groups–those with osteoporosis and those without osteoporosis, one might find that there are significantly more with the condition than without… This provides another kind of evidence.

If we think about what bones are made from…and we take diet soda and soak a bone in it…either or both may also provide some evidence that drinking large quantities of diet soda weakens one’s bones and contributes to osteoporosis. But we are not going to have a medical research study in which we give a randomly selected group large quantities of diet soda in order to see if their bones become weak… So, yes, this story of a student whose doctor was willing to tell her, “Stop drinking a six-pack or more of diet soda a day. In fact, stop drinking diet soda–period–and maybe we can prevent more bone deterioration,” imgp13045 suggests that her doctor used the evidence of a patient before him to guide a recommendation that the published medical research says was based on inconclusive data… And I say, “Let’s be truthful about what we mean when we talk about the data and the evidence. Let’s be willing to consider the ethical boundaries of research studies. Let’s realize that ‘inconclusive data’ sometimes means that a clinical trial, the gold standard of medical research, is not appropriate and so, there will never be “conclusive data”…

Could we please use a different word–one besides ‘stress’–when we talk about what causes health problems?

119_1914 September 21, 2010

Today is my daughter-in-law’s birthday. I thought about her this morning as Dr. Oz talked about the health of skin for women in their 30s, their 40s, and their 50s… For women in their 30s, like my daughter-in-law, the guest dermatologist noted that ‘stress’ is a big contributor to skin problems. Sigh. From the vantage of late 50s, I wish that we might use other words to communicate about health conditions and changes. What if instead of saying with stern expression and furrowed brow, “When we don’t get enough sleep because our toddler doesn’t sleep eight hours or our elementary age child wakes up sick and keeps up in the night, it causes us stress,” we said with a chuckle, “I have a much greater appreciation for my parents now that I’m learning to catch a few hours of sleep here and 20 minutes there. I understand now why ‘sleep’ could make the top five list for ‘things I want to do on my vacation.'” Sometimes, it is all in the framing.

We talk about loss versus gain frames in communicating about health. Loss frames emphasize the costs associated with developing new health habits, while gain frames emphasize the benefits associated with developing new health habits. Stress is all about losses and costs. Life is all about gains and benefits. So, yes, even though the dermatologist also cautioned that alcohol causes premature aging of the skin, I hope my daughter-in-law is celebrating her life today, and perhaps even toasting the year ahead….

Does your family have copies of or know where to find your advance directive?

161_10623 August 28,2010

Even though I did not live near my grandmother and didn’t get to see her very often, she greatly influenced me. Even in death, she became a role model. She had copies of her advance directive in places where her family and others could not miss them. She had one on her refrigerator door, held there by those little plastic fruit magnets. And she had talked to her daughters about her wishes. She did not want extreme means to be applied to try to save her life. She wanted to have the quality life that she had lived. She remained independent until her death, which was well into her 80s. She lived in her own home. She lived on property that she walked everyday of her life except when she was recovering from hip surgery or the snow was too high to navigate with snow shoes. She read even though it meant using magnifying lenses and a magnifying light. She did handwork…even though it meant using magnifying lenses and a magnifying light. She drove her own car…to have a meal in town with her family each week, to church on Sundays, to a general store to buy yarn or fabric to continue or start another project…. She made the best chocolate bundt cake ever…from scratch. She could turn the toughest piece of meat into the most tender, pounding it with a kitchen hammer designed for that task, and cooking it in the oven on a low temperature for a long time… She would say, ‘have an advance directive… ‘

So for the next couple of weeks, I will pursue conversations with family about having an advance directive. I will let you know how it goes. Perhaps you might do the same…

How does Bret Michaels manage life-on-the-road and Type I diabetes?

August 9, 2010

I attended Bret Michaels concert at the Clearfield, PA county fair on Friday night. resized_bret_michaels_1_3059 It was a celebration of life. He thanked fans for their prayers and support for him during the past year. He literally seemed to breathe in the positive energy and well wishes of the fans at the concert. Which communicated something about health…. http://gantdaily.com/2010/08/07/bret-michaels-rocks-at-the-clearfield-county-fair/

As covered in the news and entertainment media, Bret had some life-threatening health events this year. He appeared on the show, ‘Celebrity Apprentice’ and, in fact, won… but during the season, he revealed his nearly lifelong efforts to manage diabetes. And he talked about the emotions he felt while waiting for news about whether his daughter had the disease.

I don’t know Bret or his daughter. But I do know that one of the reasons we don’t talk about health in our families is that we feel a sense of blame for the ‘bad’ things that got passed on to us through our genetic pool and a sense of responsibility about passing them along to our own biological children.

Try this: for every so called bad thing, make a list of the good things that were passed on to us and that we may pass on to others. When having those family health history conversations, balance the good with the not so good news.

It might be, for example, that Bret’s positive and affirming way of looking at life has a genetic component and that he will or has already passed on such resilience to his children. I suspect that at the very least, that attitude goes a long way toward helping him to manage life with a chronic condition like diabetes…

Do you know what condition is linked to a bull’s eye rash?

July 14, 2010

Someone recently told me, “I read your blog when I get a chance and it is interesting… but what am I supposed to do with the information there?” I paused for a moment. And after a bit of conversation, I decided to take the blog in a different direction for awhile. While I hope information will still be interesting, I thought we could try a bit of an experiment to see if we can make the information more directly useful. So, here goes.

What is one health risk you face because of something you like to do for fun? For example, if you like to go hiking in the woods, you face risks relating to poison ivy and/or ticks. I like to hike and often face these risks. I am very sensitive to poison ivy. So I know what poison ivy looks like… well, sort of. Leaves of three. That is a description that fits a lot of plants in the woods, so it is a bit challenging to avoid all plants with leaves of three. And in fact, I am not always successful in doing so.

As for the result of not successfully identifying and avoiding poison ivy, I am all too familiar with the blistering rash that comes with exposure to the plant. Recently, after a weekend in the woods, I developed chills and aches–severe ones that seemed like a summer flu. As I buried myself under quilts for a second evening, I noticed a rash with a familiar red appearance forming on me. I was pretty unhappy about what I expected to be coming. The morning after noticing the rash, I looked for the blisters I was expecting as part of what I assumed was going to be poision ivy rash. Instead, I found that the rash was now about 12 inches in diameter and rather circular with an area of red surrounded by a white circle and then more red in a rather prominent circle.

This is when online health information searching comes into play for me. I went online and searched for ’causes of red rash.’ It wasn’t long before I came upon a picture of my rash–and the label, a bull’s eye rash, and the link to Lyme’s disease. Alas, in a short time, I was in the doctor’s office getting antibiotics and grateful for the online health information that advised me to ‘call my doctor.’ The effects of Lyme’s disease added to my haste to follow the advice.

I realized through this experience that one of the most important things for us to do when communicating about health is to find out what signs or symptoms go along with a condition. So, my challenge to you is to identify a condition that you feel at risk for and then identify through an internet information search the symptom or sign that goes along with diagnosing the condition. Be specific. For example, chills and muscle aches go along with Lyme’s disease but they fit a lot of things. The bull’s eye rash…that is a very specific clue to the condition.

Share what you learn here…

Why “knowing” is not enough to support doing?

June 20, 2010

How many of us don’t know that overexposure to the sun causes skin cancer? Or that eating too much and exercising too little causes weight gain? Or working too much and having too little fun contributes to depression? Or getting too little sleep and worrying about things we have little to no control over leads to exhaustion and stress?

Too often, health messages are about the “knowing,” when–quite often–we already know facts about health. What we don’t know is “how” to do the things the facts suggest we should do. As I discussed in the last post, when we talk about health, we often talk about our family, our work, and the things we do to have fun. So what we want to talk about and what we hope others will share with us is the “how to” meet our employer’s expectations and not work too much, sleep too little, and worry about meeting our obligations. How to have fun in the sun and not get skin cancer. How to adapt our family life to the recommendations that our doctor makes at an annual check-up.

I have adopted the practice of asking my doctor the “how to” question. For example, my OB-GYN noted a two pound weight gain at my annual check-up and cautioned that if I gained two pounds every year, that would be quite bad for my health. I said that I had changed my diet and exercise to decrease my cholesterol levels and that I had noticed a bit of weight gain. I inncreased how many nuts I eat, including almonds and walnuts, while decreasing animal proteins that I eat. It seemed to help with levels of bad cholesterol…which had decreased…but also added calories to my diet.

“It is just all about being active enough to use the calories you consume,” she said. “How you do that is up to you.”

Fair enough. But to support doing that, I need to know “how to” do it…one reason an entire industry of diet foods delievered to our homes exists and one reason that so many online sites offer the experiences and stories of so many of us talking about…”how to” do what we already “know” we should do…

Why don’t we talk about ‘health’ when communicating about our health?

June 11, 2010

A lot of attention is given to patient stories. Most online health sites have a link to patient stories. Why? Often because the stories make content more ‘real’ than numbers and statistics alone do.

When we tell our stories, we can describe how we feel, what matters in our life, things about family, what kinds of things we do for fun, and how we earn a living. Implicitly, we talk about these things because we value our good health, and being healthy comprises one important goal. But being healthy often needs to be adapted to our family, recreational, and occupational lives. And so, we talk about these topics, implicitly hoping for conversation about how to adapt to possible health risks while sustaining these other areas of our lives…