Talking About Health; Why Health Communication Matters

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.

What does the “food pyramid” tell us about health communication and ‘old science’, ‘new science’, ‘conflicting science’, and no science’?

143_07811 May 3, 2010

I cannot recall the first time I heard about the ‘food pyramid’ but it was decades ago. The United States Department of Agriculture [USDA] online site at http://www.mypyramid.gov/ provides an overview of the research in this area. Right under the image of the pyramid on the homepage, the follow sentence is bolded: “One size doesn’t fit all.” Over to the left of the pyramid, the heading, ‘Specific Audiences,’ includes ‘Preschoolers’, ‘Kids’, ‘Pregnant & Breastfeeding’, and ‘General Population’–giving us a sense of groups whose needs vary. Skimming through some of the information, it doesn’t take long to affirm one of the points that I make in my book, Talking about health…

When communicating about health, sometimes there is no science to guide prevention guidelines, diagnosis, or treatment. A quick review of the history of the food pyramid shows that even before vitamins and minerals had been discovered, the USDA provided dietary guidelines–the first time appearing in 1894. The first food pyramid was published in the 1960s. The goal is to help us know how to talk about food and nutrition without having to be an expert. So food is divided into groups and we gain a sense of how much of each group adds up to a more versus less healthy diet.

Often, what we know in any area relating to health is based on ‘old science’ that we learned in school several years or even decades ago–forgetting the simple fact that times change. New knowledge is generated everyday. If asked, we know this truth. The trick is to apply it when we are communicating about health. ‘New science’ may support the ‘old science’ or build on its core idea. ‘New science’ may also conflict with ‘old science’ creating doubt and indecision. It is helpful when talking about health to consider the ‘age’ of the science we are using and also the characteristics of the people the science is based on. As suggested by the latest food pyramid, when science takes into account the ‘age’ of and audience, the food pyramid looks slightly different for different groups…

What is math anxiety and what’s it got to do with my health?

117_1754 March 16, 2010

Math anxiety is the tendency to feel anxious at the thought of doing math. This feeling may happen when faced with making change, calculating a tip for the waiter or waitress, balancing a checking account, figuring out how much of an over the counter medicine to take, or adding up how many calories or other nutrients food contains. Not surprisingly, if we feel anxious about these everyday tasks, the prospect of trying to understand health statistics seems even more daunting and causes even greater anxiety.

Math anxiety causes people to avoid situations that might lead to the feeling. In other words, if math makes us feel anxious, we avoid numbers and statistics and any situation where we might have to face dealing with math. Of course, such avoidance means that we miss opportunities to practice math and succeed, which would reduce our anxiety and increase our confidence in our ability to do math.

This reality is particularly alarming when it comes to our health. To make informed decisions, we will probably have to consider some information that is presented as health statistics. It may be information about our risk for a disease, or it may be information about our benefit from a treatment. In either case, it is information that would help us make a more informed decision.

What is the solution? Don’t avoid math. Make the extra effort in whatever situation it might be to understand the statistics and practice the math. In the end, it will pay off. Make the extra effort to be sure your doctor knows you want to know the numbers and what they mean. Make the extra effort to be sure that your local school system is providing opportunities for students to practice math, reduce, their anxiety, increase their confidence in doing math, and improve their skills…

What about public health care reform?

117_1784 January 10, 2010

I never hear anyone talk about public health when they talk about ‘health care reform.’ This bothers me because we have a univeral system of public health in the U.S. and we spend quite a lot of resources on it. The services linked to our public health care system range from checking the quality of restaurants and ‘grading’ them to providing newborn screenings. We spend quite a lot of time deciding what services to provide in each state. Besides registering births and deaths, and newborn screenings, many states have prenatal care programs, other women’s health programs, and a wide range of programs from smoking cessation to drug prevention to cancer screenings.

We don’t talk much about public health. But what might a connected system of health care built on the system of clinics and services for public health look like? How would doctors and health care staff feel about building on their infrastructure? Some states have regional health care directors? How would they regard an effort to connect the services they oversee to a broader range of services for the public to consider as a choice for care?

Anyone?

How much “chemo” is too much or too little?

122_0568 January 3, 2010

It doesn’t surprise us to think about needing different dosages of medications…pain relievers, aspirin, and so on. But how often have you heard anyone talk about the dosage for chemotherapy?

My good friend will begin chemotherapy for her colon cancer in a couple of weeks. She was reading a bit online about some of the research related to the treatment. She read that obesity may make it difficult to determine the right dosage for someone’s chemotherapy to be enough to work. Not that she is fat. Quite the opposite. She is a petite woman of average weight. So she wonders if perhaps she needs a lower dose of chemo to work but to avoid some of the toxicity that a so called average dose would have for her. She will ask her oncologist about it.

Another example of important work being done in cancer research studies to help patients get the most out of their treatment. It would be awful to go through chemo and have it not work because you were overweight and didn’t get a high enough dosage…

Another example, too, of how the ‘normal’ dosage is not a one size fits all prescription. A good lesson to keep in mind when we talk about health…our size and the dosage we need.

What’s new for HPV in 2010?

imgp0009 January 2, 2010

Near the end of 2009, the U.S. FDA approved the use of an HPV prevention vaccine for boys. It will be interesting to see how this will be sold in the marketplace. After taking such care to sell a vaccine as a strategy to reduce the incidence of cervical cancer with the slogan, “I want to be one less,” and assuming that even among a public with moderate to low levels of health and science literacy — most know that males do not have a cervix, what will the pitch be to convince parents to vaccinate their sons? It seems unlikely that any ad will focus on selling a vaccine to parents that implies that their sons could be the vectors of disease for girls, as that would turn attention toward sex which the advertisers so carefully avoided in focusing on cervical cancer.

Whatever the pitch, part of our conversation should focus on the vaccine’s efficacy. Clinical studies vary in estimating how many years of protection a vaccine affords, but it seems to be around three years. Some say it may be five years. In either case, there is no revaccination policy at present. As consumers, parents, patients…we need to advocate for a policy.

We need to ask ourselves if and when it is the right time to be vaccinated. We need to understand what HPV is and how it is transmitted. Since the virus is spread in skin to skin contact, a condom may not be enough protection from getting the virus if we come in contact with it during sex. We should talk about that fact with our daughters who may be trying to decide if the use of a condom is the best way to protect themselves from sexually transmitted infections and diseases. And we need to talk with our sons about the fact as well, and remind them that the HPV prevention vaccine does not protect from HIV.

We need to realize that for women, being vaccinated does not mean we do not need to have cervical cancer screenings. Will the advertisers include that in their future messages?