Rearranging the Deck Chairs: Death Displacement

One Million Hearts Saved or 160 Million Lives Improved
Part III: Death Displacements Are Temporary

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.
We spend over $40,000 on 1% of the US pop and less than $800 per person on 50%.
We allow half of medical education economic impact to be sent to a few dozen zip codes in 6 states.

And we steal from future generations to pay for current generations that can contribute less in this life while depriving generations to come.

More cost for little gain has become epidemic. Higher status populations already are maximizing outcomes. Improvements for many if not most Americans are about daily living conditions - conditions worsening as more goes to fewer. Morbidity and mortality are already worsening in ways that the Million Hearts Campaign cannot touch.

Perhaps what is most missing from health leadership (and from government because of health leadership) is lack of understanding of what is preventable or not. After 100 years of solid advances in many areas, we have accomplished the easier and less costly advances for the major gains in life. We are working against
social determinant limitsthe limits of preventable in some and limitations of belief in preventable in othersthe lack of the reality of death in nearly all peoplethe limits of understanding of highly intelligent but lowly aware leaders

You must know what people can do and cannot do to understand how health outcomes can be impacted or not impacted by interventions regarding physicians or patients.

The body has limits as we age and accumulate damage and fixing one part does not mean much gain as other body parts can and do fail. We can fix the body but fixing the mind is still limited.

The perspective of a physician may be helpful. The first time you "save a patient life" by an astute preventive diagnosis such as an aortic aneurism - you feel good. But when your patient dies of a heart attack 6 months later, you begin to be aware of such limitations. Your actions helped take away half of his remaining life or 3 good months out of his last 6.
The family is still grateful that you “found the aneurism in time” but have no real way to grasp what you have figured out.

And you begin to be aware of what can or cannot be accomplished. Once this awareness is gained during training for some, during the early career for others, or later in some who provide direct patient care, even more awareness can be gained. When few gain such awareness, the past mistakes are repeated again and again. Physicians can bring the numbers to life and awareness and they can also help bring the false assumptions to awareness.

One Million Hearts Saved or 160 Million Lives Improved
Part IV: Poor Understanding of Preventable

Taught One Way But Narrowly and Not Globally

We err in a number of assumptions about life, health, and death. We have essentially decided to do more and more as a knee jerk response for decades. More interventions, more workforce, more services, more technology, etc. We have continued to do more even after more has failed to work well, other than to increase costs massively for health care. We are not SMART and this means less specific, more costly, and less efficient - by design.

Being taught one way is a common pathway for health professionals and PhDs and MBAs and JDs but learning to grasp the global concepts necessary for an entire nation to do well is quite another.

Focusing on ever greater technology has not worked well. It is only recently that overall cancer outcomes improved after decades of effort and high cost - and the major gains were made in stopping smoking, something already significantly accomplished with ever less to gain for fewer.

A decent awareness of the relationship of social determinants to health outcomes can indicate that simple changes such as aspirin and reductions of BP smoking, cholesterol, or transfats may not really accomplish what we have seen in past studies. We should understand that interventions are limited in any number of populations where what is predicted may not work.
  • We should understand that nationwide hypertension treatment behavior changes in physicians (UK) did not result in better outcomes for UK patients.
  • We should understand the very basics of "correlation is not causation"  Instead we have more studies that use correlations to predict even with the correlations themselves explain so little of better outcomes - also due to too little known
  • Later blogs indicate the problem when associations claim benefits for innovations that are really just rearrangements of social determinant characteristics - in this case a promotion of the Continuity Medical Home. What Do Medical Home Studies Indicate?

    We should understand that quality improvements may not be possible with basic interventions in low income or underserved populations, as noted by Hong in JAMA with regard to Pay for Performance. We have even more implementations of pay for performance despite known consequences and failures such as UK BP.
But we fail in basic understanding, so we have top leaders propose changes that are not likely to work or will work much less well than predicted.
Priorities in Prevention

We constantly fail to understand what is preventable. We have battled for centuries. Civilizations have risen and fallen and those surviving have passed on the best priorities. We have addressed these areas earliest (by trial and error and other methods). What we have now in the US is the result of centuries of effort. We point to many US advances in sciences but forget about public health and other areas even more basic. We have made the easy high yield low cost efforts such as clean water, sanitation, basic vaccination, and basic drug interventions in areas such as hypertension, antibiotics, etc.

What we must pay to accomplish improved health is more and more and the result is less and less. We have many health leaders that have taken public health 101 but fail to understand the basics of more and more required to move from 80% to 90% to 95% in vaccination, BP, smoking, and other areas.

We are losing these basic battles for clean water, sanitation, and immunization that are high yield and we focus on areas with less potential for improved health.

Populations are limited as much or more by social determinant areas that are often linked to the major causes of death and their risk factors in ways that are difficult to separate

But with poor understanding of preventable, of illness, of death, of the American people, and of  the limits of health care, more battles may be lost than won - and in areas outside of health.
One Million Hearts Saved or 160 Million Lives Improved
Part V: The Case for Basic Health Access not Million Hearts

Health and Human Services needs more from health access and more about health access. Health access is the key to addressing the areas indicated by Million Hearts
  • Aspirin is not a blanket solution and requires consultation with an experienced health professional, preferably primary care or internal medicine in training or nursing. Aspirin does kill and maim at higher rates when used in the wrong way in the wrong people. HHS lists the areas where aspirin can save, but also HHS can save lives by fewer using Aspirin when it is not indicated. Doing no harm also involves expanding use in the right populations according to their risk factors and characteristics without increasing use in the wrong populations.
  • Hypertension successes are failing and hypertension failures are more and more about primary care workforce failures. Clearly more and more with high blood pressure in emergency rooms is just a tip of the iceberg situation – and one going downhill fast. Million Hearts designs can distract from primary care design failures and could contribute to more fragmentation of BP management as new players (pharmacists, retail clinics, Walgreens) enter an already confusing field. Is it a good idea for smokers to go to retail stores that prominently display and sell tobacco products?
  • Smoking interventions that are easy have been implemented. Getting more doctors to confront patients is less likely and the patients are changing as well. Side effects of smoking cessation drugs are significant with many yet to be discovered. Is it a good idea to promote more and more drug solutions to solve drug additions – such as smoking and other areas? The nation has had hundreds of millions of dollars of tobacco settlement money to accomplish smoking cessation and substantial taxation – yet smoking remains prominent and may be making gains in certain younger populations. How will we accomplish more with less, including less awareness, less funding, and more negative influences and side effects of interventions? Also we are moving toward more widespread smoking – with legalized marijuana. More interactions are possible that result in poor health. Higher taxes on tobacco and alcohol products also have consequences on poor, near poor, and lower income populations – so do lotteries.
  • Smoking cessation also may not result in changes in health outcomes. Smoking as a variable represents much more than just smoking. Smoking is not just a simple bivariate representation of a single adverse behavior. Even with smoking cessation eliminated from an individual, the other risk factors remain within the individual (drug use, education, poverty, employment). These and other factors have associations with social determinants. Million Hearts plans for physicians to tell patients to stop smoking. This also requires the workforce that accesses patients at risk. The ability for physicians to tell patients about smoking cessation also depends upon health access for patients and sufficient basic health access workforce. Both areas appear to be set for even greater limitations. How are declines from over 100,000 to less than 50,000 primary care internists going to help with this area? How can family medicine help any more locked at 100,000 with no way to increase since the 1980 design of 3000 graduates per year is still the design 32 class years later.  How can more non-physician clinicians help when expansions of annual graduates are negated by steadily fewer remaining in primary care and especially in family practice – the only choice that results in enhanced distribution to 30,000 zip codes with 65% of the US population and lower to lowest workforce levels – by design.
  • Dietary interventions by dieticians have not worked out well in past studies, yet this did not prevent the Million Hearts proposals regarding salt, cholesterol, and transfat. Basic understandings of the limited food choices facing many Americans left behind have also been left behind. Million Hearts goals are again related to access to basic health services with integration of nutrition, mental health, health education, family, parenting, and other counseling. Stress, diet, risky behaviors, social determinants, health access, and health outcomes are interrelated in many ways that make each difficult to separate. This does not stop the assumptions of various leaders, associations, and corporations, however.
It is too late to stop the Million Hearts bandwagon and we should all hope that it actually works to save lives and make lives better.

But we should not allow Million Hearts to distract from the basic health needs of 160 million Americans left behind in one or more dimensions - and by aberrant designs.

Perhaps more troubling is the tendency to scapegoat behaviors of individuals behind in various health or education or income outcomes - rather than aberrant designs by a nation that send funding more specifically to those with most funds and less to those with least spending already.

And recent events and situations are frightening confirmations of the value of scapegoating and distraction rather than facing real issues and the most important issues.

Both videos are similar as the crowd rallied, led on by selfless individuals, and the group coordinated efforts to save one of their own.

When we all have the same concerns for most of our youth left behind and for most Americans left behind in basic health services, we will have a great nation by the numbers and by what has been considered great for centuries. Civilization requires nothing less that sacrifice by those older for those younger or youngest. Indeed this is the only real progress for those that are still alive – temporarily as are we all.

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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