Less is more: make it your new mantra

DRUG BUST Alan Cassels

If you listen closely to the pleas of health advocates and patient groups, those who push for better treatments for specific diseases, such as Alzheimer’s, cancer, arthritis or heart disease, there is a common refrain. That refrain, summed up in a word, is “More.”

We need more drugs. We need more CT or MRI machines. We need more doctors. We need more specialists. We need more access to everything. More. More. More.

And then add the requests for more of everything that supports a decent quality of life. Advocates for the homeless make pleas for more affordable rental housing. AIDs advocates make a very strong case for government-supported safe injection sites. Seniors advocates make demands for more assisted living complexes to support seniors in their frail years. More. More. More. The advocates often feel like their pleas are mere cries in the wilderness.

If you are a health bureaucrat, policymaker or politician, you probably spend a lot of time listening to the competing groups stating their case for More, More, More. You may spend much of your workday trying to satisfy the needs of those who are asking for more. And choosing to make more of one thing accessible to one group inevitably means money that is not going towards a competing claim. After all, there is a limited supply of tax dollars to go around.

The sense of a limited supply of money brings a level of discipline to the way government doles out our collective wealth. Yet I believe it’s occasionally worth putting aside those decisions for a moment and stepping back to take a look at the big picture at the way we manage all our collective resources, of which healthcare is only a single slice.

At the beginning of the year, let’s ask ourselves, “What kind of show are we humans running here on this planet?” Our planet consists of nearly unimaginable health extremes. The poorest billion people on Earth live on less than a dollar a day, a level of deprivation that necessitates being dominated by the issue of survival. More than 25,000 children under five die every day from the most easily preventable diseases: diarrhoea, parasites, malnutrition and malaria. This one billion people lack even the most basic components of health and improving their chances of survival depends on their getting more of almost everything: clean water, decent clothing, adequate shelter, basic healthcare, income, peace and democracy. Even a little more of any of these simple things would produce a huge impact on the lives of these people.

At the other end of the spectrum, where the majority of Canadians live, are another billion or so people for whom survival is almost a foreign concept. These people can easily think of more ways to spend our collective wealth. Nearly half of our provincial budgets are allocated for healthcare and still there is a belief in scarcity – a belief that we need more drugs, more machines, more specialists and more doctors to solve our woes.

That’s not to say that a lot of our collective health spending couldn’t be better managed. There’s good evidence that the way we organize healthcare is so chaotic and irrational that we overspend and underspend in areas that have nothing to do with rationality and equity. What I see at this extreme rich end of the rich spectrum is an absurd level of obsession with avoidance of death at any cost and a collective self-absorption to fight an unwinnable war. Supporting this war is a belief that prophylactic medicine – medicine at any cost, and often against the dictates of evidence, rationality or even common sense – presents nothing but positive contributions to our health. Here we see people plunking down $2,500 to buy a full body CT scan, convinced that it’ll give them the edge they need to save them from the inevitable. Many more get tested and treated, poked and prodded, diagnosed, medicated, swabbed, jabbed, cut and eviscerated, to an extent that sometimes seems quite laughable if it wasn’t so regrettable.

Some beliefs are decidedly bad for your health. Let’s examine some of the more absurd of those beliefs, shall we?

Brand name means better healthcare: How about the belief that brand name drugs are always better than generic drugs? This singular idiocy means that we Canadians collectively spend $2 billion more on drugs than is necessary every year. Don’t tell me we can’t afford to meet even the most minimal levels of foreign aid befitting of a developed country when we allow this lunacy to continue. Buying a patent-protected drug when a cheaper generic exists is a tax on the uninformed. If you believe that a patented treatment always infers some kind of clinical advantage over the unpatented stuff, you should probably be forced to pay for your beliefs. And please don’t expect the taxpayer to pay for your foolishness.

Screen early, screen often: Another absurd belief that many of us have is that it’s a great idea to screen healthy people for disease. Yet screening healthy people can involve insidious and uncounted harms and it is expensive and often terribly unnecessary. There may be dozens of cancer screening programs out there, but only three – count’em three – types of screening programs for cancer have sufficient scientific evidence for authorities to recommend them for the whole population. What are they? Breast screening (mammography) for women over 50, cervical cancer screening (the pap test) and colorectal cancer screening (fecal occult blood test). All the others that we hear about – full body screening, lung cancer screening, PSA or prostate screening, other organ screening, heart screening, (angiography) etc, etc. – are not recommended even though they are heavily marketed and promoted through both the media and private clinics.

Government is protecting us from drug marketing and screening scams:Sadly, that one is wrong too. In Canada, despite all the marketing of both screening and drugs, there is minimal consumer protection from the blatant fear-mongering advertisements you see asking you to take a drug or come on down to the local private clinic for a full body or heart or lung scan. Colleges of Physicians, Health Canada regulators and other professional organizations point at each other when asked who should be minding the store. Even if you believe in minimal government control over your life, you could not disagree with the need for some state involvement overlooking the advertising and marketing of health care products and devices that could hurt you.

Screening and newer drugs are always of incredible benefit: Sadly, this is wrong too. Both the provision of new drugs and preventative health screening are highly controversial because the actual benefit for most people is very small. A new cholesterol-lowering drug might prevent one percent of people taking it from having a heart attack in the next five years. With mammography screening, we’d have to screen 1,000 women with X-ray mammograms every two years for 10 years to prevent about three deaths (compared to a similar group of women not screened). This level of screening will cause about 200 women to experience further investigation (because something suspicious was “found” on their mammogram) or a biopsy. Those women would face the anxiety of having a diagnosis of breast cancer that turned out to be false. It’s very hard to counter the “look early, act early” mantra when it comes to cancer screening, the underlying thought being that if you can find it early, you have a better chance of living.

I think it is time we re-examine our healthcare beliefs. Maybe we need to make a pledge to consider a “less is more” mantra towards health spending. We only need look at the level of per capita health spending in the US, which is more than twice the rate of other industrialized countries, to remind ourselves it’s how we organize healthcare that counts, not how much we spend.

Major advances in world health could be achieved if we collectively took care of everyone’s basic needs – why not start with homelessness in our own cities? – and then worked to ensure we don’t let our collective and irrational health beliefs hold us hostage.

The reason that over-treatment and over-diagnosis are such important subjects to us rich one billion is not just because the excesses of medicine can adversely affect our health, but because such appalling excesses leave so many of our fellow citizens behind.

A civilized society is measured not by how well it takes care of its most privileged citizens, but how well it takes care of those who have nothing. Why not pledge that in this New Year, we work to create a rising tide that lifts all boats, not just those of us who live on yachts?

Alan Cassels is a drug policy researcher at the University of Victoria.

He uncovers the world of cancer screening in a two-part radio documentary, You are Pre-Diseased, airing on CBC IDEAS at 9:05 pm, February 12 and 19. Mark your calendars.

cassels@uivic.ca

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