Part I Million Hearts Limitations of Awareness

One Million Hearts Saved or 160 Million Lives Improved
Part I: Limitations of Awareness

It is not a bad idea to battle against preventable illnesses and deaths. Million Hearts is a campaign designed by top federal and health care experts with the goals of changing people behavior and physician behavior. These behaviors are focused on an increase in the use of aspirin and a decrease in smoking, a decrease in blood pressure, a decrease in cholesterol, a decrease in salt intake, and a decrease in transfat.

When a nation goes to battle, it must know its enemies, the limits of its methods, the strengths of the enemy, the false assumptions that you will make, and the weakness of your own leadership – glaringly apparent in the first months or years of any war.

"It is said that if you know your enemies and know yourself, you will not be imperiled in a hundred battles; if you do not know your enemies but do know yourself, you will win one and lose one; if you do not know your enemies nor yourself, you will be imperiled in every single battle."   Sun Tzu   Art of War (Good timing as this was on Star Trek Next Generation as I was writing this).

We will be imperiled in every battle in Million Hearts as well as in the battle for a Million better child outcomes and a Million of any number of federal, state, or private efforts - because we fail in understanding our strengths, weaknesses, and assumptions.

We demonstrate little understanding of what is preventable or not, the limits of risk factor modification (including the limits in the populations in need of modification), what it requires to accomplish greater prevention and greater proportions with prevention, what can result in fewer deaths (or what can result in more deaths), and

We fail when we focus inappropriately on preventable illnesses and deaths when there are other higher priority areas - balancing budgets, stimulating jobs, reducing health care costs, better children, and health access. We fail when we can accomplish one Million Hearts and much more by improving children and better health access.

And we forget that we cannot win against the enemy of death and many if not most of its causes. Death is inevitable. We all will die. All efforts will fail as death will conquer. – You get the point, but do the experts?
If you do not think something as simple as aspirin can damage or kill, try this illustration. The same computations that indicate lives saved also indicate the substantial group not improved, the one that has a hemorrhagic stroke, those that have bad outcomes anyway, and those that have bad outcomes because of aspirin. There is also the problem of going to the store and finding aspirin at a reasonable cost - one certain to increase because of the retail opportunities afforded by Million Hearts. So even in best case settings, Million Hearts efforts can be expensive and costly – especially in populations that do not actually benefit or that are at higher risk from harm.

Most importantly right now, the nation has a great need to focus on very pressing priorities. Health care leaders must focus on health care in rural, underserved, and primary care settings – health care more endangered with each passing day.

We have a ton of tough high priority problems right now. Yet we have leaders that are spending their political and media and social organization capital in areas that are not going to help the nation right here right now where it needs help, particularly with primary care facing serious problems and health care costs moving to 20% of GDP and beyond.

This bothers me greatly as a primary care physician. Million Hearts interventions all demand more primary care workforce (RN, MD, DO, NP, PA, team members) and a more experienced primary care workforce and a better trained primary care workforce and primary care workforce that is distributed to 30,000 zip codes or adjacent zip codes where 65% of Americans need primary care. Failures in basics such as education, health coverage, and primary care make it difficult for any interventions to succeed. Again I would have to point out that changes in the design that free up primary care nurses from onerous tasks with little benefit (insurance and government requirements especially) and place them back into direct patient care encounters and directing health care encounters - would be one of the best ways to address Million Hearts and health access improvements for 160 million left behind.

SMART designs work to achieve more for less cost with better result. 

Also sending RN, MD, DO, NP, and PA students for long term continuity experiences with primary care health teams would greatly expand primary care services and access and training and outcomes - by design.

The Million Hearts Campaign has been shaped by those leading health care – government, associations, business, and insurance. Million Hearts is not a poor choice in itself. It is what Million Hearts represents that is the problem. Million Hearts represents numerous choices past, present, and future that have not worked for most Americans. These continued choices distract and divert attention from what works. A focus upon diseases and risk factors is quite different when compared to specific focus upon the basic needs of most Americans.

  • One Million Hearts Saved or 160 Million Lives Improved   Million Hearts is another attempt to turn risk factors into saved lives - specifically reductions in heart attacks and strokes. The targets are once again human behavior changes (patient and provider) regarding aspirin, blood pressure, salt, cholesterol, and transfats. The campaign involves a number of federal agencies and health leaders, but the campaign will not address the top issues facing most Americans in their life, death, or health.
  •  Part I Million Hearts Limitations of Awareness  We demonstrate little understanding of what is preventable or not, the limits of risk factor modification (including the limits in the populations in need of modification), what it requires to accomplish greater prevention and greater proportions with prevention, what can result in fewer deaths (or what can result in more deaths).
  •  One Million Part III Higher Priorities A Million Hearts Campaign that hopes to change human behavior should realize that the easiest and best way to change human behavior is changing humans during birth to age 8. To have people decide to improve their health, they must be invested in a better future. Children reduced to growing up in survival mode may never be able to focus on a better future.
  •  Rearranging the Deck Chairs: Death Displacement Saving lives sounds quite heroic, but the reality is that we are at best only displacing or delaying death for a few years. We will all die. We will all die. We will all die…… We spend the most health care dollars at the end of life in ways that are wasted. We spend the most on just a few and the least on the most. We spend so much at the end of life for few that the quality of life is impaired for many.

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D.        Basic Health Access Web    Basic Health Access Blog

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at and he is the author of the World of Rural Medical Education, and Physician Workforce Studies
SMART – Specific, Measurable, Achievable, Realistic, Timely


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