On the line between patient and population healthBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1408 (Published 29 March 2018) Cite this as: BMJ 2018;360:k1408
All rapid responses
The very real effects of social determinants of population health are gradually making their way into the consciousness of physicians and healthcare administrators. It is hard to know the reach into the thoughts and possible actions of the general population and policy makers in all nations. The statement by the BMJ editor is a powerful one that likely has not received, in the US at least, the attention it deserves.
On the other hand is the scientific issue of whether low socioeconomic status is a cause of ill health and early disability or is it something more like a marker that aggregates those known causes of early death and impairment. The 'burning platform' strategy is certainly one that should be tried to change public policy toward healthcare delivery and the increasing socioeconomic gap in all societies worldwide. As more chronic disease become apparent from lifestyle excesses and other self-inflicted harms (take extreme sport for example, or excess speed crashes on highways) weigh on society, there is a compelling need to do something. But what to do?
Pills and injections are not the answer this time around- though pharma will develop new drugs for appetite suppression, non-absorption of sugars and fats, and now measures for non-alcoholic fatty liver disease. As always the challenge is to meet these newly recognized health hazards while continuing the struggle against the usual large threats of hypertension and hyperglycemia. And, what will the popularized use of cannabis do to a population prone to obesity and hypertension, not to mention pulmonary disease. It ain't going to be easy.
Competing interests: No competing interests
I would like to thank The BMJ and in particular Fiona Godlee for this thought provoking and important contribution and debate. It is true that often times we think of socioeconomic status as a "given", meaning not as a modifiable risk factor for survival, disability and other adverse health outcomes. Nevertheless, these adverse outcomes are in part due to disparities in health service use, including the difficulties for the less privileged for the "maneuverings" required to go throught the right channels and in a timely way that would make the health care provided actually matter (before it is too late)!
Setting aside debates about the role of health care providers as activists or other actors in social change (the tradition going back at least to Virchow), taking socioeconomic disparities as "given" or, what comes down to the same thing, as something extremely difficult to reduce, due to substantial barriers that are in part related to religion and culture, is, in my opinion, ultimately unhelpful. In a manner of speaking, one may represent this view as "our hands are tied" or one can only do so much, etc.
However, I would like to submit that socioeconomic disparities, almost ubiquitous as they are and when- and where-ever we look, they seem to be there, are - forgive the double negative but I think it is called for here: NOT INEVITABLE.
A personal admission: I tried to use this in the title of an article that was published last year in BMJ Open entitled finally: Assessing socioeconomic differences (or lackthereof) in prenatal diagnosis of congenital heart defects: A population-based study, but BMJ has an editorial policy of insisting on "neutral" / "factual" titles, which has its advantages certainly but can sometimes be a bit limiting as well).
Indeed, in the field of prenatal testing, several examples can be cited of the absence of socioeconomic differences, in the right settings, in use and/or effectiveness of prenatal diagnosis for congenital anomalies. A study conducted by the team led by Liz Draper at Leicester University did not find any evidence of socioeconomic differences (measured at the level of place of residence as a deprivation index) in prenatal diagnosis of congenital anomalies (Smith et al, BMJ 2011).
In our own studies on prenatal diagnosis of Down syndrome in France we found that dispariteis in prenatal diagnosis of Down syndrome, which were substantial in the early 1980s, decreased significantly (and not just statistically so) as changes in practice and policies provided widespread, reimbursed access to prenatal testing to all women in France (Khoshnood et al, BJOG 2008). And as noted above, more recently, we found no evidence of differences in the probabiliy of prenatal diagnosis of congenital heart defects across socioeconmic groups defined by maternal profession and geographic origin (Khoshnood et al, BMJ Open 2017).
I do not intend to suggest in any way that socioeconomic differences are not formidable foes - and yes sometimes at least seemingly impossible - to tackle. However, a negative self-fulfilling prophecy is clearly not the way to go either. One way this "sneaks" into discussions about socioeconomic differences in health service use and /or health outcomes is the way culture and particularly religion are used to close the debate as it were. The argument often goes as follows, "Well, obviously prenatal testing that reveals an incurable disease cannot help adverts to X religion because they would not consider a termination of pregnancy for fetal anomaly. Or, "it is not really useful to offer prenatal testing to certain groups because they would be "offended" or even outraged at such a suggestion".
Again, I am not saying that the above scenarios cannot happen or cannot be true but there is at least some empirical evidence that points to the contrary in certain settings. In our study of prenatal diagnosis of Down syndrome for different socioeconomic groups in France, we found in particular that prenatal diagnosis of Down syndrome increased over time MORE for women of North as well as Subsaharean African than for women of French origin, resulting in a DECREASE IN DISPARITY in prenatal diagnosis of Down syndrome in France, a country that in many ways has had and continues to have serious problems in "integrating" minorities. Nevertheless, changes in practice and policy can, and in this cas have had, a major impact on reducing disparities.
I think no one would maintain that women of African origin had a greater increase in prenatal diagnosis of Down syndrome because of cultural changes over a twenty-year period, making them as it were more accepting of prenatal testing. It is much more plausible I believe, to conclude that when a health system provides high quality and reimbursed (free or almost free would be even better!) services to all, disparities can and do decrease. And as Gandalf would say, there is hope in that.
Competing interests: No competing interests
The moral distress amongst doctors that has been pointed out is so real and true ; however it is well known that every clinical decision has its implied costs .There are no clear answers why health inequalities have increased in an era of rising income inequality ; the strong association between socioeconomic status and health is nearly universal (1) . As one asserts that right to healthcare is a critical entitlement , the challenge of social inequality and adversity is simply huge compounded by the numbers (2). Against this backdrop , Universal Health Coverage for everyone and everywhere is indeed a Herculean task. There appear some practical solutions - vaccine disovery and coverage ( despite opposition by groups and cults even for ones of proven efficacy ) , fortified foods , empirical treatments where investigative facilities are scanty. Yoga , sans aberrations can be an immensely preventive and promotive measure for obesity , metabolic syndrome and related diseases / complications. Finally , identification at level of pre.frailty can help tackle many complications in old age .This approach may lessen the feeling that low socio-economic status is always beyond the reach of doctors. References : 1. Chetty R , Stepner M , Abraham S et al. The association between income and life expectancy in the United States 2001-2014 . JAMA 2016 ; 315 : 1750-66. 2. Yeolekar ME. Quality healthcare for the numerous : the challenge of numbers. Journal of International Medical Sciences Academy. JIMSA. Vol 25 ,Issue 3 , July -September 2012 ,139 -40. Dr M E Yeolekar , Mumbai.
Competing interests: No competing interests
Is the BMJ – and the medical profession that it represents – really ‘listening to patients’ and the public?
Fiona Godlee’s recent Editor’s Choice ‘On the line between patient and population health’ (1) refers to research showing that ‘socioeconomic adversity not only shortens lives but also accelerates disability, the very opposite of healthy ageing’. She goes on to mention research that ‘new drugs are not the answer’ and touches on the tensions and moral distress felt by doctors expected to ‘act as guardians of both individual and population health’.
This editorial comment begs another question: what about the role of ‘medication’ in shortening lives and causing long-term ill-health and disability? It is no surprise that antidepressant prescribing is particularly high in areas of socio-economic adversity (2). Patients have for years been trying to flag up very serious issues with ‘lived experience’ of the effects of drugs prescribed for anxiety and depression and this factor will doubtless be contributing to – and indeed exacerbating - the socio-economic issues affecting population health and ageing.
Our Scottish Parliament public petition PE01651: ‘Prescribed drug dependence and withdrawal’, lodged May 2017, is gathering substantial published evidence on its Scottish Parliament web-page (3). This includes many actual patient experiences, as well as government, institutional, professional and individual input. Evidence is being submitted from Scotland and from other countries.
As explained in the ‘petition background’, we had previously already attempted to engage collaboratively with the medical profession and politicians. We have been involved with the British Medical Association (BMA) Board of Science project working on this issue since early 2014. Our Petition calls for recognition of the BMA published findings, 2015 (4) and BMA call for action, October 2016 and updated (5).
We are invited to participate in the BMA Board of Science round-table stakeholder meeting scheduled for 18 April 2018.
Our Scottish petition is being widely shared via Facebook and online patient self-help groups (these are un-funded and non-commercial). The patient-experience petition evidence includes personal accounts from individual men and women of all ages and backgrounds. For those who have had acute adverse reactions, some have been left with severe nervous system damage after just brief exposure to the drug. For others, many years may have elapsed before long-term problems made it necessary to try to ‘come off’ the drug(s) – and attempted withdrawal has been catastrophic. Several cases of life-threatening serotonin syndrome have been missed by doctors and the symptoms further poly-drugged. The accounts describe shattered lives, relentless desperation and deep enduring suicidality, suicide attempts and actual suicides. All accounts have been formally processed by the Scottish Parliament Petition team, according to their official rules, prior to online publication.
Whilst diverse and unstructured, this collected narrative evidence is showing up stark issues: patients’ suffering is variously described in the detail of the individual evidence – devastating effects on lives, relationships, employment and families. The thread running through every single patient account (100 +) is that of doctors prescribing powerful drugs which they believe to be ‘safe and effective’ but which have complex neurological (central and autonomic nervous system) effects which prescribers do not seem to understand. Patient experiences are being disbelieved and discounted. People have no idea that these common medicines ‘taken as prescribed’ are making them so unwell – killing them quickly or slowly.
It is especially alarming to see the number of individual submissions which relate experiences with start dates long after our (and even BMA) attempts to raise concerns – and to realise that all our awareness-raising efforts are simply being ignored and overridden by the medical profession.
This is a very significant public and population health issue. For individuals who cannot metabolise the drugs, suicide or fatal toxicity is a very high risk. For the majority of others, common side-effects of antidepressants include enduring serious sexual problems, weight gain, digestive problems, debilitating fatigue and numbed emotions – as well as other confusing and bewildering symptoms. Clearly these ‘side-effects’ contribute significantly to other health, relationship, social and economic issues – as well as the rising NHS burden of chronic ill-health. The published patient submissions illustrate consistently that the ‘first prescription’ came about at a time of human stress/distress such as study/work/relationship/family issues, new baby, bereavement, traumatic experience or other life transition.
Most worryingly, as time elapses it is becoming abundantly clear that ‘the evidence’ of prescribed harm is being actively attributed to vague psychiatric diagnoses such as ‘medically unexplained’, ‘functional’ and ‘somatic’ disorders. Patients suffering complex, serious and disabling symptoms - from prescribed drug damage and neurotoxicity - are being directed to websites such as http://www.neurosymptoms.org/ and encouraged to engage in (perhaps online) Cognitive Behavioural Therapy (CBT) and acceptance of their mysteriously acquired disability. There is emphasis on locating problems in the patients’ own early life experiences – and socio-economic circumstances - without any reference whatsoever to the all-important life-time ‘medication history’ and its own trail of havoc in the life and health of the patient.
On 18 January 2018 the petition committee took oral evidence from Scotland’s Minister for Mental Health and Principal Medical Officer: despite petition evidence to the contrary, it was asserted confidently that more people should ‘be prescribed antidepressants, at higher doses and for longer’.
On 24 January 2018 Public Health England announced that it was launching a year-long review into prescribing of medicines including antidepressants. Marion Brown wrote to BMJ on the topic of whether ‘action should take priority over further research on public health’ (6).
On 22 February 2018 the Royal College of Psychiatrists (backed apparently by Royal College of General Practitioners) issued confident national press statements about efficacy of antidepressants – and suggested that many more patients should be prescribed them. This was reported in the BMJ news article ‘Large meta-analysis ends doubts about antidepressant efficacy’ (7) and Fiona French, Des Spence, Peter Gordon and others responded. Alyne Duthie wrote to the Herald Scotland that ‘Antidepressants are not at all as benign as we would wish them to be’ (8).
GP Des Spence is publicly supporting our petition and has written in Pulse ‘Time to listen to patients about prescription problems’ (9). Between us we have had many other articles, letters and responses published in the Scottish press and medical journals including BMJ and BJGP over the past year.
A similar public petition, led by Stevie Lewis, is gathering evidence at the Welsh Assembly (11).
A public consultation about ‘suicide prevention’ is being formally conducted in Scotland. Beverley Thorpe has written about this in connection especially with antidepressants and another related Scottish Petition PE01627, ‘Paradoxically speaking … more drugs, more suicides’ (12).
It is becoming abundantly clear that the Royal College of Psychiatrists is vigorously promoting the drugs whilst downplaying the realities of withdrawal (13). GPs are prescribing them and having to deal with consequences which they do not understand. Patients are paying the ultimate price and being passed back to psychiatry and neurology, who have nothing to offer to alleviate the damage sustained.
The BMJ professes to encourage ‘patient engagement’, ‘patient-partnering’ and listening to patient perspectives. The events of the last few months especially seem to make a very sick joke of this. Patients are coming together themselves to try to communicate, via formal public petition, with the medical profession and politicians about the deeply questionable safety of these commonly prescribed medicines – and the devastating effects on patient and population health as a whole.
Fiona Godlee (1) quotes that “NICE guidance asks GPs to act as guardians of both individual and population health”. This is indeed deeply morally distressing for GPs, who carry prescribing responsibility and are obliged to ‘follow professional guidelines’- which seem to be deeply flawed.
We would like to acknowledge the very significant work that is being sensitively undertaken by the Scottish Petition Clerk team in the processing of the large volume of submissions received for PE01651, and sincere consideration by the Petition Committee.
We thank every courageous individual for sharing the immensely painful, personal and harrowing experiences as publicly available personal evidence for our petition.
Professional support is hugely appreciated, especially when risking professional repercussion for publicly expressing views and support.
(1) https://www.bmj.com/content/360/bmj.k1408 BMJ 2018;360:k1408
(2) https://www.theguardian.com/society/2017/apr/14/antidepressants-prescrib... .
(5) https://www.bma.org.uk/collective-voice/policy-and-research/public-and-p... .
Competing interests: No competing interests
Neurology of Socioeconomic Status and Lifestyle Diseases.
In each and every countries socioeconomic status is one of the important factor which influences the health parameters.
Low socioeconomic status is associated with more communicable diseases malnutrition related disorders abd chronic respiratory diseases . High socioeconomic status is associated with Non communicable diseases and life style diseases . Cancers stress psychiatric diseases and accidents are more in both socioeconomic levels.
In brain different areas are responsible for the response to stress. Some areas of brain detect social threats and other areas detect physiological threats. These areas of brain are responsible for activating neuronal pathways in the brain, among them, the hypothalamus and the periaqueductal gray area which then trigger a series of changes in different parameters such as heart rate, blood pressure, inflammation, glucose levels, and fight, flight, or freeze response.
These modified parameters then allow the human to cope up with the acute stress and ultimately allowing the survival of the body. Once the stress is extinguished, the stress response stops.
In humans, especially in modern era, the most common source of stress is socioeconomical conditions. The repeated or chronic activation of a response designed for acute stress can leads to modifications of parameters such as blood pressure, heart rate, sugar level in the blood, and fat deposit in blood vessels and the abdominal viscera. And these modifications then lead to high blood pressure, arrhythmias, diabetes, stroke heart attack and abdominal obesity.
This overuse of the stress response is one way in which chronic stress can lead to pathological conditions which will shorten life.
Another way by which chronic stress leads to diseases has to do with inflammation. It has become clear in the last twenty five years that inflammation plays a key role in most lifestyle diseases.
Neurological and Cardiovascular diseases would be due to inflammation of the arterial wall and cancers would be the consequence of long term inflammation of different tissues, and degenerative diseases of the central nervous system (such as Alzheimer’s disease) would be a consequence of inflammation of the brain.
A paradox arises however when trying to relate stress and inflammation: stress is anti-inflammatory! Stress activates the hypotahalamo-pituitary-adrenal axis leading to a rise in cortisol which is a potent anti-inflammatory hormone: the effect of cortisol on its receptor is to reduce inflammation. When cortisol is chronically elevated however, the cortisol receptors react by becoming "down regulated", i.e. less numerous and less sensitive. This down regulation compensates for the increase in cortisol levels. When the cortisol level (stress level) falls, even temporarily and relatively, the cortisol receptors remain down regulated for a period of time. This is when a problem arises. A relatively lower cortisol level in presence of down regulated cortisol receptors results in a reduced anti-inflammatory effect of the stress system and therefore to a pro-inflammatory situation. This pro-inflammatory state triggers the onset of inflammation which leads to inflammatory diseases.
Socioeconomic status a source of chronic stress. The chronic activation of systems designed for acute threats modifies their basal activity. This modification especially the one involving cortisol and its receptors can lead to a pro-inflammatory state responsible for most of lifestyle diseases of recent days. This hypothesis allows us to postulate a causal chain from socioeconomical status to stress, from stress to inflammation, and from inflammation to diseases.
Competing interests: No competing interests