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Health paradigm for the 21st C, part 2

Okay, Part 1 of this post was precipitated by the Society of Participatory Medicine’s request for ideas about what members would like to see them do. I talked about my take on the whys and wherefores of participatory medicine. This post is a list of eight activities I’d like to see supported by the Society for Participatory Medicine:

1. Develop an actionable plan for the goal of enabling each individual to become his or her own primary care authority for 90%-95% of health incidents.

Primary care docs want to go specialist because it pays more, so why not elevate the individual to the primary care provider and boost the physician to the role of spcecialist involved as needed? A few months ago during the health care debate on The Health Care Blog I saw a remark (by a physician, as I recall) that about 80% of health events are handled by the individual: cuts and minor trauma, headaches, colds and flu, aches and pains, nutrition, supplements, upset GI, menstral issuses, and on and on. The “drugstore” often the supply center for first-line of public treatment. What if that percentage could be elevated to with the right tools and support to 90% or 95%?

2. Develop a plan for building well-developed, well-funded information support systems specifically to support lifelong personalized health learning and decision making.

The internet is little more than a platform for informaiton storage and cheap distribution with content kluged together from unrelated sources.  However, people have already adopted the internet as a primary source for health information (Pew Internet Surveys). But so far there is no well-funded health resource base specifically designed to achieve anything like the goal above. The internet is a hodgepodge of sites and information of variable quality. WebMD and other commercial sites provide general content as part of their marketing platfrorm. Wikipedia is one crowd-sourced way to compile informaiton, but its quality has been challenged and the whole enterprise criticized. Medepedia, with content from academics from reputable institutions, arose pretty much to be an authoritative alternative to the noise of internet health information, but it’s primarily a reference work and does not seem to have figured out the public involvement part. There are thousands of nonprofit and government sites with bits and pieces of information, but there is no sign of a national commitment to an architecture designed to empower the public with knowledge in a person-specific or engaging way. The only site I am aware of that seems withing striking distance of the comprehensiveness of necessary is the National Library of Medicine.  Their Mediline and PubMed resources might be a precursor to a more innovative way of supporting personal medicine.

The information from a well-designed and well-networked system should contain a mechanism that helps everyone understand what medical information is “evidence-based” and what the certainty level  of current evidence is. The substantiation of information should be on a dynamic, constantly-updated basis. The system should also help people learn that scientific process works toward greater certainty over time and grey areas with less than 100% proof are a necessary part of understanding medicine.

3. The integrated health knowledge network suggested in iten 2 should take a systems approach to human biology and medicine.

In the 20th century the human organism was disassembled for study by segmentation and reductionism. Specialized areas of medicine, nonprofit organizations, and governmental expert agencies took off in their own directions too. The result is a very fragmented picture of health that still dominates today. Knowledge supporting personal health engagement should put the puzzle of health together. The knowledge base of health and life education should follow guidelines that support clarification of how various sub-systems of the human organism play a part in the function or malfunction of the whole.

4. The approach to participatory medicine should be founded on the principle that learning about health is a lifelong matter.

Information should be communicated and made available on an as-needed or just-in-time basis throughout life but within a cohesive systems framework. As I pointed out in an earlier post, parents are beginning to accumulate and electronically record information about children at birth. With the cost of full genome sequencing plummeting it is likely that the process will eventually become routine at birth. It does not seem out of the question that health knowledge can start at birth with a full family genome and health history as a basis for baseline health assessment and risk estimation.

From the outset, children are curious about their bodies and many teachable moments are possible if appropriate information is provided in a personalized, situation-specific way. A whole range of age-appropriate information should utilize current and future technology to find innovative ways of interfacing health information with many learning opportunities throughout life. Games, avatars, social networks, and virtual environments could be employed to engage various groups. People cannnot and need not become experts in all aspects of medicine, but over time they can become experts about themselves and the health matters that are issues for them as indicated by genomic data, family history, race and cultural variables. Needless to say, a health support information system will need to have as its mission staying abreast of and innovating with emerging technology.

5. Facilitate the evolution of an open sytem of quantifying sensors and devices that measure many aspects of bodily function, health status, fintess, and consumption that can be seamlessly integrated with the knowledge network, EHRs and informed by personalized health models.

The problem with life is that we are born without a “dashboard” for our bodies and with no operating manual. When health problems arise the symptoms such as pain, swelling, and other sensations are often too late to prevent acute illness. And our bodies provide few perceptible clues about the percursors of chronic conditions.

Health 2.0 activity has shown that there are many entrepreneurs eager to supply devices and services related to a personal approach to health. But technology standards committees need to be established or coordinated so that devices and data supporting participation can avoid what has happened in the electronic medical record industry. Interoperability and integration are essential, and the particpatory movement will be inhibited if these characteristics are not incorporated from the outset. Open data standards, open applications, and open media standards are necessary to put together the systems of communication, data recording and transmision, security, and social networking that are sub-systems of the greater vision.

The price of admission for entrepreneurs for participatory medicine should be open standards all around. Consumers should be advised not to support products that cannot be integrated with other components of the greater system (motto: “Homie don’t play ‘dat”). An encouraging development in this regard is the Open Mobile Health Exchange . Nevertheless, ongoing advocacy in needed to keep standards open.

6. Drive a counter-culture movement that encourages the US population to reset its expectations of the market economy from tollerance of the current state of health irresponsibility to one of health-benefit.

The market system in the US is health-indifferent; it is not accountable for focusing on consumer products that are designed to exploit basic cravings regardless on long-term personal or societal health burdens. In fact health corruption and health correction are complementary streams of income. Billions of dollars are spent on the design and marketing of products that contiribute to illness only to be answered by products and services marketed to compensate and bring us back toward health. It’s an amazing wealth engine where the right and left hands wash each other.

The weird thing about health “responsibility” in US society is that, with regard to food and drink, only consumers, not producers of goods, are considered responsible. If we over-consume a product designed and marketed to maximize our consumption, the producer is not held accountable. That’s the way it used to be with tabacco, but we changed the preception of responsibility about tobacco between the 1970s and the end of the last century.

A similar cultural change is needed about food and drink. We have a start;  producers of suggary cereals and high fructose corn syrup drinks have been criticized for marketing them to children. Similar accountability — or at least  social scorn — is necessary for other consumables. Producers have gotten away with saying, “Hey, we don’t force you to drik all that corn syrup. It’s your fault, not ours.” Perhaps as the extreme cost in dollars to US society from obesity and its consequences generates even more pain we’ll be less willing to swallow the denial of culpabiity that the marketplace hides behind.

7. Advocate for the funding developemntof human biological system models that can be personalized so that a constant stream of information may be analyzed and used as a source of near-real-time feedback about our health status and behavior.

We need sophsticated human systems biology and computer health models based to the best scientific information. They should be designed so that health data from our genomes, family history, lifetime health history, and from daily activity can be combined to form a personalized profile or algorithm. Our own model — embodied perhaps as an avatar — could be constantly available to interpret data and give us feedback or status reports. Such personalized models could also set the appropriately personal context for health information and learning.

8. Work to support augmented reality development for an environment that will enable us to get information on-the-fly about what our options are for the things we eat and drink.

Institutional support is needed to creating an augmented reality environment of information for restaurants and markets via databases that support easy access to informaiton about what we’re consuming. Bar codes, wi-fi, Bluetooth,  RFID tags  and new future technology should allow smartphones to immediately obtain information about the nutritional content of meals in restaurants and packaged products in markets. I already use an app called “FoodScanner” that uses the iPhone camera to scan package barcodes, look them up on a remote database, and provide me with the nutrition information food products are required to have on the package. The information can be saved for future use, but the whole process is pretty klutzy. A system that automatically grabs infomation and checks it against a personal profile of stuff to avoid is not hard to imagine.

When I was  in school at ~13-years-old we had “hygiene” class in which we had to learn the parts of the body (“pipes and plumbing,” as it was known) and their functions. Then in high school we boys got movies and slide shows with “the coach” to graphically show how disgusting VD and pregnancy are. That was supposed to deter us from sex until marriage. It was also  all I got from public education about health. I suppose it was somehow supposed to enable me to maintain my health for life.

The steps I outlined above is, I hope, a more robust approach and consistent with technology and lifestyles of the near future. The iGeneration evidently no longer sees a reason to fill their heads with generalized infomation with less that obvious personal applicability. They already know they have the option of getting appropriate information at the time it’s needed. Perhaps they’re already aware that the infomation they’ll be exposed to during their lives will be changing constantly. Making this situation lend itself to a healthier population is going to require many elements working together.

The things I’ve suggested also are simply ideas for a long-term process. If there’s one thing I’ve learned from a career in public health it is that change tends to be a lengthy, nonlinear process requiring tolerance for uncertainty and unexpected developments. Change is a career, not a project.

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Health paradigm shift needed for the 21st C, part 1

The Society for Participatory Medicine recently asked its members (I’m one; it’s open to the public) what they wanted from the society. The request prodded me to think about what might be undertaken to advance “participatory medicine” or “health 2.0” which are similar if not identical concepts. Others might be better at identifying distinctions.

The purpose of the Society for Participatory Medicine is: “To accelerate change in the culture of healthcare to a more participatory model, through leadership, advocacy, information and tools.” I think it’s fair to say “participation” means a more even role between doctors and patients in making decisions in medical situations. If you go back to my parent’s generation (mid-twentieth century) typically doctors held the information, authority, and decision making power in virtually all medical situations. People didn’t expect to need to know much because, if you got sick, you went to the doctor and he — typically, he — told you what was wrong, what he’d do about it, wrote the prescriptions, and sent you to the hospital if necessary. If you lived in that era you know that generation gratefully accepted the doctor’s direction and didn’t ask many questions. The TV show Marcus Welby, MD, dramatized the medicine of the time.

But, as I described in an earlier post, a portion of the population was not satisfied with the situation and began to question established practices. This was especially true of women not too happy with male-dominated gynecology. In the 1970s, as I recall, emphasis on “informed consent” began to grow. When I went to work in cancer public health in the early ’70s it was shocking to learn that some doctors did not tell some of their patients they had cancer because the physicians judged the patient couldn’t take the shock. The patient participation movement has really accelerated since the internet broke the dam on medical information. The public has gotten much freer access to information from sources other than their personal physicians, which, in may cases, wasn’t much.

That’s the past, the 20th century model. Where can we go from here? Organizations are pushing the envelope, but I’d like to entertain a few ideas for the 21st century that would shift health and medicine in a more radical way.

In earlier times much of health care was the domain of women: an extension of their maternal, nurturing role in the family. The late 19th and the 20th centuries saw the rise of “scientific” medicine. (For an excellent history get hold of sociologist Paul Starr’s, The Social Transformation of American Medicine: The rise of a sovereign profession and the making of a vast industry. The title alone says a lot.)  The complexity and volume of medical knowledge as well as the financial advantage of professional exclusivity eventually resulted in the consolidation of medicine into the system of medical education, licensing, legal authority for therapeutic practices, and self-policing that dominates today. And the swelling of a huge medical industry focused almost exclusively of physicians as the kingpins and market managers reinforced the doctor-centered system. The responsibility for learning and applying medical knowledge placed doctors in a paternalistic position while patients remained in a passive, unschooled position.

I would not challenge the notion that medicine has made great progress under the current system, nor that the trend to super-specialization of medical knowledge will continue. But I have to ask: Should relative passivity and health ignorance of the public and inability to make health judgments remain our aspiration going forward? Are we not capable of knowing much more, of participating more fully in  effective health behavior? That includes accepting the power and responsibility for our own wellbeing. In the past when information was more difficult to distribute relatively low health literacy might have been more understandable and acceptable, but surely we can do better in the future.

My position is that we have already more powerful knowledge tools than even a couple of decades ago and those tools are growing in capability as we speak. There are seeds of a potential to put individuals in a much improved position if we are willing to build systemic support and institutions that augment our abilities as much as the institutional infrastructure that supports the medical profession. It is possible if we have the will to put much greater innovation into it. I believe we can up our game as “patients” — the noun we have accepted — and relate to physicians and scientific/medical institutions in a more capable way.

This is not just some power grab. It seems to me taking charge of our health is not only possible, it is essential. The pathetic political struggle currently going on around “health reform” in the US shows how powerless we’ve allowed ourselves to become. While various interests use politicians as sock-puppets to stage a drama about the future of medicine, we citizens have become primarily ineffective, frustrated spectators. But I hope many folks have learned that we cannot continue to let our most precious possessions — our health and that of our family — remain in the hands of others. And we’ve learned our financial wellbeing is intimately tied to our health status. Serious disease has too often become a financial catastrophe aw well.

Well, I’ve spent a lot of words on the history and context behind what I think we ought to consider for a health promoting environment for the future. In the next post I’ll get down to grinding out the main points.

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feel good, look good, and live forever!

I spent almost all day yesterday listening to the health care reform summit. It triggered some recdollections.

Years ago — was it 15 or 20? — I attended a couple of conferences at Berkeley about managed care, the solution du jour for relentlessly rising health care expenditures. On one panel was Leonard Schaeffer, former president and CEO of WellPoint. (I emphasize “former” to insulate him from the heat the company has taken recently for double-digit premium increases to some customers.) He mentioned that he was often asked at meetings, “What to people want?” with respect to healthcare. His standard reply was: “They want to feel good, to look good, and to live forever.”

He said this only partly in jest. As the CEO of a major payer company he had seen that there was heavy demand by customers to pay not only for treatments alleviating physical ailments but also for treatment to relieve their distress, to make them look more like they thought they should, and to forestall the ravages of age and the ultimate insult, death. The boundaries of the three categories were so ill-defined that it was possible to expand what people wanted reimbursement for indefinitely. This resulted in the administrators dilemma: satisfying the customer’s expectations without utterly exhausting the bank.

Apparently not much has changed. Our expectations for medical relief remain largely unbounded. Perhaps it’s because after WWII we came to expect medical miracles: antibiotics that knocked down infections, vaccines that eliminated polio and communicable diseases, surgery that seemingly made anything possible. I recall watching open heart surgery on fuzzy black and white nationwide TV broadcasts because it was such an astonishing development. After that we sent men to the moon.

When I went to work in the cancer field we had an organizational slogan: “We want to wipe out cancer in your lifetime.” “Wipe out” as in totally eradicate. Seriously! It wasn’t a disingenuous promise; it only reflected the limits of what we knew about the complexity of the disease at the time. People in the cancer field had to let that notion go by the wayside as we began to see that terms like “cure” and “eliminate” were perhaps over-statements when dealing with a disease that stemmed from malfunctions of the most basic biological processes of living things.

The aim of much of the cancer community today is to shift more cancer cases into chronic conditions (as opposed to acute, lethal episodes). Well, that’s progress and perhaps an inevitable step in greater mastery of the disease; but one of the most serious problems we have in health care today is the rising cost of chronic diseases. A study published in Health Affairs a week ago indicated that half of the increase in Medicare spending 1997-2006 was due to increases in prevalence of cases of 10 diseases or to increased cost of treating cases. Cancer isn’t even in the top 5 of the chronic disease list…yet.  One of the biggest surprises of my career was that the financial barriers to state-of-the-art treatment would become a challenge nearly as serious as the intricacy of the disease itself.

We have a difficult time in America discussing pragmatic matters like to cost of protracted care in the same conversation with the good of “saving lives.” Extending life is taken as an unalloyed good. You can become a pariah for mixing the two (i.e., examining comparative effectiveness becomes “death panels” or “pulling the plug on grandma”). I don’t know how many times over the years I’ve listened to well-meaning people advocate efforts requiring a lot of resources with the argument that, “If we can save just one life it will be worth it.” Have I just become too callous when I react: “Uhm…maybe some good can be  done putting the resources elsewhere”? In my entire 40 years in public health I never heard a serious discussion about the unintended or down-side effects of doing whatever it takes to retard illness.

But it’s not a discussion that can be avoided much longer. During the health care debate yesterday everybody seemed to agree on a couple of things: 1) we needed reform for humanitarian reasons, and 2) the continued relentless rise in costs will bankrupt us. One of the Republican senators said something like (I’m paraphrasing), “In a perfect world we’d want everybody to have everything, but we can’t afford this.” I’m a lifelong, unrepentant liberal, but I thought that was a pretty straight statement, one that resonated with me. The truth of  that specific assertion can be argued either way, but it is a matter we have to address. It’s bigger than just the price of the the current health fix. We need to have some frank talk about allocating our less than infinite resources for many benefits that might be achieved. I’m hoping that the baby boomers — of which I’m one — currently heading into the nexus of this issue can bring forth some of the brashness with which we’ve talked about many things in our time (drugs, sex and rock ‘n roll, etc.) and break down the taboo about discussing the realities of life, death, and the price of peanuts.

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Hmm, is the China juggernaut that obvious?

I’ve done several posts — as recently as yesterday — mentioning the spectacular rise of China as a change driver with widespread effects. My assessment is that this will have big impact on people everywhere and be a disquieting influence that will disturb a lot of people. But my question now is: Am I just reitterating what’s become obvious to Americans?

In today’s Washington Post there’s a report of a Washington Post-ABC poll headlined: “Poll shows concern about American influence waning as China’s grows.”

Facing high unemployment and a difficult economy, most Americans think the United States will have a smaller role in the world economy in the coming years, and many believe that while the 20th century may have been the “American Century,” the 21st century will belong to China. […]

Asked whether this century would be more of an “American Century” or more of a “Chinese Century,” Americans divide evenly in terms of the economy (41 percent say Chinese, 40 percent American) and tilt toward the Chinese in terms of world affairs (43 percent say Chinese, 38 percent American). A slim majority say the United States will play a diminished role in the world’s economy this century, and nearly half see the country’s position shrinking in world affairs more generally.

This has a lot of Americans worried. Losing economic hegemony is not only perceived as a loss of power, but it also suggests that perhaps the country has lost its mojo, it’s in decline. I’d look at it another way. I’m a big fan of Fareed Zakaria’s 2008 book, The Post-American World. His first chapter is titled: “The Rise of the Rest.” His view is that America will remain a powerful and influential country, but other countries like China, India, and Brazil will gain much economically and gain world influence. In other words, wealth and power will have to be shared. His perspective suggests not that this is the end of American glory but that an adjustment to historical evolution is necessary.

The US is about 5% of the world’s population. Since WWII we’ve enjoyed enormous economic prosperity, military power, and prestigue. But history moves on, and the other 95% of the world’s people are developing too. How 5% would expect world dominance to last I don’t understand. Back in 1997 William Greider published a book I also admire: One World, Ready or Not: The Manic Logic of Global Capitalism. In essence, Greider said the capitalism widely advocated in America had won; communism was discredited. The consequence of that is that labor income would move to the masses of people around the world willing to work for less than Americans because they have a much lower standard of living. Capitalism is the force leveling incomes worldwide, and, hence, influence.

A participant in the WashPo survey put it pretty well:

Annetta Jordan, another poll participant, said in a follow-up interview that she has witnessed the shifting economic strength firsthand. Jordan, a mother of two from Sandoval, N.M., was working at a cellular telephone plant in the early 1990s as production and hiring were ramped up. By 1992, the plant had 3,200 workers. “Then this whole China thing started and we were very quickly training Chinese to take our jobs,” she said. Now the plant has 100 people left. “We’re transferring our wealth to China,” she said. “I see that as a very negative thing. When I was younger, a lot of corporations had a lot of pride and patriotism toward America. But corporations have changed. If we in the U.S. go down, that’s okay; they’ll just move their offices to Beijing.”

Ahh, the fruits of success!

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Global economics as a force of change

I played out my career in the nonprofit part of the economy: public health cancer control. I knew people involved in many causes who were constantly striving to achieve specific kinds of “change.”  Toward the end of my years in the field it struck me that what is actually happening is the converse: there are an unprecedented number of broad forces instigating change and they interact in weird and wonderful ways. Indeed, in today’s world there’s really no way to stop change; but many outcomes are not controllable or consistent with what folks want to see. In the USA today there are those who “want our country back,” and they blame the Obama administration for upsetting a past order they recall as more satisfying and proper. From what I can  tell a lot of people have a hard time putting their finger on just what it is that’s wrong, but somebody is to blame for their unease.

A couple of weeks ago I posted about the huge growth in the economy of China forecast by economists: $123 trillion GDP by 2040. I was reminded of that again in a recent article in Wired News by Zach Rosenberg about how the American auto industry is swinging to fulfill the thirst of the Chinese middle-class for automobiles. They’ve read the projections too. It’s not exactly a nuclear secret that the next 900 lb. creature in the room will be a giant panda. Rosenberg quotes a GM executive:

“This is clearly the market of the future,” says Freidhelm Engler, General Motors director of design in China. “It’s not going to slow down.”

To sell cars in China a lot of cultural tweeks are need. For example, a design concept of the Buick Regal specifically for China has new features.

Inside, the back seat envelops the passenger “like a clam” … in the same manner as an emperor’s throne. Interior coloring is nearly monotone from the rear passenger’s perspective in accordance with Chinese expectations of a car. Notice the deep purple color. GM says was “chosen to elicit the right level of attention and respect” and named it euphemistically after a rare and slow-growing Chinese tree, It was designed, Engler says, to look like a smooth fabric blowing in the wind.

And beyond that, the Chinese will begin to exert influence back on the US.

With the demands of the enormous Chinese market, the expansion of Chinese companies into the West and the introduction of Chinese vehicles to U.S., American consumers should expect to see some Chinese characteristics make their way across the ocean. “Decoration to enhance proportion,” says Engler, “may show up in North America in coming months.”

Do you suppose these changes are going to result in more jobs in the US on the assembly line? Are Americans going to be happy with “Made in China” stickers in the most sacred of American symbols: the automobile? This is certainly not going to be a resurrection of the era of the ’57 Chevy.

For people who are unsettled by change the future is going to be a very distressing place. Even for the people who keep calling for change, what we get may not be what you had in mind.

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Health 2.0: four decades of experience

As I’ve posted before, I’m interested in Health 2.0. I say that from the perspective of someone with nearly 40 years of experience in social science and cancer public health. I hope my long-term perspective can add something to the discussion of this interesting trend, especially the recent discussion kicked off by the Susannah Fox and the infamous “Darthmed” concerning the value of Health 2.0.

If you’ll indulge me a little I’d like to step back to when I studied sociology in the late 1960s. The conventional methodology of sociology was survey research. Surveys as a social science tool go back to the 1940s, and many of the field thought we knew enough to reduce prejudice, poverty, crime and other social ills. I was in a PhD program in sociology and fell in with some rennegrade sociologists who were skeptical. They maintained surveys were not a sound basis for verifiable “scientific” sociology. They argued that the data had too many poorly understood variables in linguistics, scales that were not consistent with statistical mathematics, and data gathering interaction effects to claim it was a verifiable body of knowledge. Also efforts to apply sociology wasn’t getting much in the way of results. I ended up dropping out of the degree program because I realized we didn’t know enough about the platform — about consciousness, brain function, semantics, and behavior drivers — to have a solid scientific theory of human behavior.

I went to work in local public health for a couple years and then entered a school of public health to get an MPH in health education. I remember having debates about the ethics of using what some students though was such powerful behavior change technology that we needed to have rules for using it. You’d think we were talking about nuclear energy! I had to laugh and say, “Look, a year after you get out of here you’ll be willing to hit people over the head with a two-by-four to get them to change their health behavior!” I’d already gotten some experience with how difficult “good” change could be to produce.

When I graduated I eventually went to work for a nationwide cancer organization just as the first smoking cessation programs were being developed. Techniques of education and group support were being used to encourage people to give up cigarettes. It seemed simple: give rational people solid infomartion about how bad cigarettes were for them and they’d be motivated to give them up. It turned out not to be so simple. After years of effort and tweaks to programs it became clear that, as an old friend from Mississippi told me, “the juice ain’t worth the squeezin'”. It became clear we weren’t going to solve the smoking problem one person at a time. Because “activism” in the 1960s and ’70s was associated with confrontational marches in the streets protesting the war in Vietnam, most nonprofit organizations wouldn’t touch anything political like “advocacy” as we know it. Finally, however, some militants began to articulate “non-smoker‘s rights”. Before, the social norm was that smokers had a “right” to smoke in public and it was rude to ask them not to. Eventually the first excise tax on cigarettes was passed in California to increase their cost. Jacking up the price began to get behavior change. The social context began to change as well. People began to recognize that smoke hurt not only the smoker but anybody around, and non-smokers had a right to protest. Eventually higher taxes and laws to restrict smoking in public were passed across the country. It took a couple of decades but the social perception of smoking changed from accepting to negative and mass behavior change began to come about. When I look back over about 35 years of smoking wars I’m kind of amazed that there has been as much change. Because it took so long it seemed for years like nothing was happening. The key, at least for smoking, was monetary disencentives and– after perceptions changed — restrictive laws. So what lessons am I suggesting?

  • Individual change is difficult to get, especially if the society doesn’t have attitudes that reinforce the change.
  • You need to work on societal attitudes and even laws that may positively or negativel sanction the problem you’re trying to solve. Billions will be spent by commercial interests to maintain the behavior.
  • It takes a long time to achieve much change because there’s resistance on the individual, group, and economic levels.
  • Giving citizens more power and authority over their health today is part of a long trend. Another quick example: in the1970s the Women’s Health Collective wrote a book called Our Bodies, Ourselves because women were dissatisfied about how male gynecologists were treating them. It was a signature piece of the feminist movement that produced real change. I think “our bodies, ourselves” is a good slogan for all of us. To my mind Health 2.0 is another step in this tradition.
  • Health 2.0 is oriented to a lot of technology. By itself technology will not produce much change, but over time it can become a great platform to facilitate communication and information but only once social perceptions and attitudes change.

The technology of Health 2.0 is still primitive. It’s mainly, as far as I can see, preliminary, disconnected equipment and software. It needs to mature into an integrated system that works seamlessly for people, has supporting institutions at all levels, has just-in-time information at the user’s fingertips, and is premised on a model where the person is in charge, not the doctor-institutions we’ve adopted for the last couple of centuries. Health behavior change has never been easy. There’s nothing new in that situation. Health 2.0 fans need to keep moving ahead as early adopters and enthusiasts. But really visible results are not likelhy to emerge for years. It may take a new generation to see widespread adoption of someting that would be a real paradigm change. You’ve got to have patience and understand that all this will be in constant evolution. Whatever behavior you’re looking for needs to be well interlocked with complementary systems.

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Have we learned anything from the recession?

In my last post I talked about the trade-off between committing personal and national financial resources to education of the up-and-coming generation versus the end-of-life expenses of the Baby Boom generation. When we Boomers entered the world after WWII it cost US society a lot to expand educational and other systems across the country to accommodate the Baby Boom. But it may cost even more to pay for the exit of this generation at the prices that the last years of life cost through Medicare and family supplements.

I quoted from $123,000,000,000,000*, a recent article by economist Robert Fogel in Foreign Policy. Fogel was drawing attention to the huge commitment to education that China is making. He estimates that as a result of education and other things, the country’s economy will soar to $123 trillion by 2040. The inference is that this will reduce the US and Europe to much lesser financial powers in the world; an outcome that is undesirable if not something to be feared. The implied message is that the US needs to make a similar commitment to education and other economic steps to enable it to compete and grow in the next three decades.

Fogel seems to be in awe of China’s coming achievement, and the article’s subtitle is: “China’s estimated economy by the year 2040. Be warned.” By contrast, Fogel seems rather contemptuous of Europe’s social situation: falling population and low economic libido. He states:

One-hundred fifty years ago, it was considered a sin to enjoy sex, the only legitimate purpose for which was procreation. But today, young [European] women believe that sex is mainly a recreational activity. Behind the fertility trend is a vast cultural shift from the generation that fought in World War II, which married early and produced the great baby boom of 1945 to 1965. The easy availability of birth control and the rise of sex as recreation mean that populations are likely to shrink in many European countries. […]

In another way, Europe’s culture confounds economists. Citizens of Europe’s wealthy countries are not working longer hours to make higher salaries and accumulate more goods. Rather, European culture continues to prize long vacations, early retirements, and shorter work weeks over acquiring more stuff, at least in comparison to many other developed countries, such as the United States. In my observation, those living in most Western European countries appear to be more content than Americans with the kind of commodities they already have, for example, not aspiring to own more TVs per household. Set aside whether that’s virtuous. A promenade in the Jardin du Luxembourg, as opposed to a trip to Walmart for a flat-screen TV, won’t help the European Union’s GDP growth.

Perhaps Fogel is being tongue-in-cheek in this implied criticism, but the inference is that poor Europe is a slacker culture that doesn’t want the benefits of ingesting more goods and boosting its GDP. Shame on them for not wanting a flat-screen in every room!

Let’s see: smaller population, lots of recreational sex, and a population that values taking time for life experiences rather than expending it to have more “stuff,” as Fogel puts it. Future Europe sounds to me like a great place to live. When I imagine 2040 China with  ~1.5 billion people on hamster wheel’s generating $123 trillion worth of “stuff” and activity annually, I can hardly imagine a less appealing place to live. Is an economy of that scale  supposed to be some form of Nirvana, a “worker’s paradise” perhaps?

As I recall, over the last 18 months the media have been telling stories about people in the US  who have learned that it isn’t the end of the world if they can’t afford a 50″ TV, or the latest pair of Nike collectible basketball shoes. When you remodel the kitchen is it really vital to your happiness to have granite counter tops and a professional gas range?Reportedly, some folks have even learned that a simple, less consumption-driven life could be happier than one haunted by debts to get stuff that provides thrills that expire much sooner than the bills.

I suspect that Fogel is tweaking our noses to make his point about China’s imminent ascendency. I’m with him that a nation’s wellbeing is deeply connected to it’s intellectual capital (i.e., ideas and well-educated citizens), but gross GDP is not, to my way of thinking, the best measure.

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