Society and How We Think About Health PDF

Society and how we think about health Dr Andy Guise Senior lecturer in social science and health April 2024  https://www.youtube.com/watch?app=desktop&v=qZfobvBK6aI Image from wiimedia commons Lecture today Aim: explore how ideas and knowledge of health - including...

Society and how we think about health Dr Andy Guise Senior lecturer in social science and health April 2024  https://www.youtube.com/watch?app=desktop&v=qZfobvBK6aI Image from wiimedia commons Lecture today Aim: explore how ideas and knowledge of health - including medical knowledge - respond to particular social contexts 1 Explore how understandings of health and medical knowledge change over time 2 Recognise the assumptions and histories behind different understandings of health, including medical knowledge 3 Recognise differences between lay and medical knowledge of health Using examples of statins and drug dependency Statins Statins: benefits and side-effects, the evidence (or one perspective on it) https://www.pharmaceutical-journal.com/news-and-analysis/infographics/statins-the-highs-and-the-lows/20205512.article?firstPass=false Statins: timeline of a controversy https://www.pharmaceutical-journal.com/news-and-analysis/infographics/statins-the-highs-and-the-lows/20205512.article?firstPass=false Lancet review: Prof Collins et al “placebo-controlled randomised trials have shown definitively that almost all of the symptomatic adverse events that are attributed to statin therapy … are not actually caused by it.” “exaggerated claims about side-effect rates … may be responsible for its under-use among individuals at increased risk of cardiovascular events.” Collins, R., et al. (2016). "Interpretation of the evidence for the efficacy and safety of statin therapy." The Lancet 388(10059): 2532-2561. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31357-5/fulltext  Dr Malhotra, lead author: “Decades of misinformation on cholesterol and the gross exaggeration of statin benefits with downplaying of side effects has likely led to the overmedication of millions of people across the world.” “The lack of transparency in the prescription of statins is just one symptom of a broken system of healthcare where finance based medicine has trumped independent evidence and what is most important for patients.” https://www.prescriber.co.uk/news/clarity-needed-true-benefits-risks-statins/ It goes on…Fiona Godlee, BMJ editor responds in the Lancet “So despite Horton and Collins and colleagues wanting to shut down the discussion and award themselves the final word, the debate about statins in primary prevention is alive and kicking. It is a debate that needs to be resolved as thoughtfully, objectively, and openly as possible, and not by eminence-based narrative reviews, however extensive, based on meta-analysis of data that only Collins, his fellow trialists, and industry sponsors have seen. This absence of independence and transparency is not unusual in medicine—indeed it is sadly still very much the norm.” https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30721-3/fulltext And it still goes on….May 2020 “…we believe the Collaboration was irresponsible in relaying to the media that 8000 deaths could be prevented each year if all UK citizens aged 75 years or older took statins. Given these gaps in the data, we believe it is wrong to recommend statin therapy uniformly for people aged 75 or older who do not have cardiovascular disease. A far more beneficial public health message is the strong evidence for the cardiovascular benefit of maintaining a healthy lifestyle, especially including routine exercise.” https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31942-1/fulltext https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)33156-3/fulltext And research keeps going on…. Recent review (July 2021) Statins in primary prevention Adverse events are ‘mild and rare’ according to latest evidence base And on…. Study to explore link between statins and severe muscle pains Found no effect of statins and muscle pain compared to placebo https://www.theguardian.com/science/2022/oct/08/placebos- One interpretation: muscle pains as side effects are a nocebo effect? expert-kathryn-t-hall-effect-painkillers-interview  The latest guidance (NICE approved Dec 2021) https://www.england.nhs.uk/aac/wp-content/uploads/sites/50/2020/04/Summary-of-national-guidance-for-lipid-management-for-primary-and-secondary-prevention-of-cardiovascular-disea.pdf The rise of evidence based medicine (EBM) EBM: “The use of current best evidence in making decisions about the care of individual patients” 1970s: argument that many routine clinical interventions had never been tested or evaluated Doctors relied instead on knowledge gained many years before at medical school https://uk.cochrane.org/about-us https://en.testingtreatments.org/wp-content/uploads/2016/11/Evidence-Based-Medicine-Matters.pdf The limits to evidence? EBM and clinical judgement EBM approaches health from a universal, collective position; rather than the needs of a specific, individual patient EBM addresses efficacy of an intervention across a population; not effect for a particular individual (And so can’t address the specific context of an individual patient: e.g. their co-morbidities, poly-pharmacy, social situation) Population level evidence needs to be balanced against clinical judgement for the individual Nettleton, 2006, The sociology of health and illness. Relating EBM to clinical practice in statins “When the NICE guidance appeared last year, it was clear that this would take at least half an hour, potentially for every symptomless adult in the population. The alternative is for lesser breeds of doctor to heed the command of experts and simply tell all these people what to do based on computer prompts about cardiovascular risk, in 10-minute appointments usually made for other reasons. Should people then experience side-effects, they should be firmly told that the trials show they cannot be due to statins. If this was ever the real world, it is certainly not the one we are living in now. Taking lifetime preventive medication is an individual choice and we need to be practical—and humble—in our approach to informing and supporting it.” (Dr Richard Lehman) https://blogs.bmj.com/bmj/2016/09/12/richard-lehman-where-next-with-statins/ What is evidence? What can be evidenced? EBM assumes ‘evidence’ comes from authoritative scientific studies Principally, randomized controlled trials (RCTs) – ‘the gold standard ‘ Patients randomly assigned to two groups One group receives an intervention, the other not Could you do an RCT to understand impacts of….. A new vaccine? A sugar tax? Exercise advice by GPs? EBM and biomedicine RCTs were designed for, and respond best to, clinical and pharmacological interventions RCTs for social interventions are sometimes possible, but very challenging or impossible (how to randomize health system reforms?) As a consequence evidence base – if we assume RCTs only/best evidence - can be built for biomedical interventions, but much less for others (e.g. routine exercise) Our ‘evidence base’ for health is then distorted Nettleton, 2006, The sociology of health and illness. See also: https://www.sciencedirect.com/science/article/pii/S0735109716331370 EBM and the limits on what can be counted : the response to HIV PrEP – Pre-Exposure Prophylaxis is a novel approach giving Anti- Retroviral Treatment for HIV as a prophylaxis Strong evidence base for effectiveness – many RCTs Context 1: relative lack of attention on community based approaches to HIV prevention – e.g. outreach, anti-stigma interventions, empowerment Such interventions not amenable to control and randomization RCTs and so limited evidence base vicious cycle – low evidence, low funding, low attention…. Context 2: mistrust in the pharmaceutical sector Guise, A., et al. (2016). "‘PrEP is not ready for our community, and our community is not ready for PrEP’: pre-exposure prophylaxis for HIV for people who inject drugs and limits to the HIV prevention response." Addiction. https://www.ncbi.nlm.nih.gov/pubmed/27273843 Statins and evidence based medicine Translating an ‘evidence base’ in to clinical care is not straight forward Advocating for wide-spread use of statins can be understood as reflecting a particular biomedical perspective reliant on particular methods (RCTs), with concerns that this particular ‘evidence base’ and interpretations of it act to encourage preventative medication use by millions of people In contrast, other interventions – e.g. exercise – are less amenable to being evaluated and don’t so easily fit with some ways of thinking about health Lay perspectives on statins ‘He said perhaps I ought to think about going on statins, and he showed me a display on his computer screen , of a hundred hearts, you know showing up percentages and telling me that if I took them for 10 years I would reduce my risk by 4%, from 18 to 14%, or something like that … I think those were the figures. So … er … I wasn’t quite sure whether I wanted to — it didn’t seem a huge … er, difference to me, really … the 4%.’ Polak, L. and J. Green (2015). "Using quantitative risk information in decisions about statins: a qualitative study in a community setting." The British journal of general practice : the journal of the Royal College of General Practitioners 65(633): e264-e269. Reflecting on risk https://www.pharmaceutical-journal.com/news-and-analysis/infographics/statins-the-highs-and-the-lows/20205512.article?firstPass=false Points to consider Medical knowledge is not one ‘thing’. We might now think of this as evidence based medicine, but this is quite new, and also contested, and sits alongside other forms of medical knowledge which have different perspectives and assumptions (e.g. clinical judgement). Notions of evidence, probability and risk don’t necessarily have the same meaning to an individual patient as compared to their doctor (and they don’t have the same meaning to different doctors either), as there are different perspectives and values involved. Such ideas and knowledge of health can be influenced by many processes, including evidence, but also industry, the media, and assumptions of what is the best way to support health. Drug dependency Equasy and Ecstasy https://journals.sagepub.com/doi/abs/10.1177/0269881108099672 Understandings of health  A quick history of drugs Drugs part of earliest societies, and trade State backed private sector Opium wars Legal or ignored Global policy now: the war on drugs Criminalisation (less harm reduction) International agreements (early 1900s), UN 1961 convention US declared ‘war on drugs‘ in 1971 Estimated cost p/a of $100bill Not monolithic But linked to poor health and social outcomes for people who use drugs and affected communities Csete, J., et al., Public health and international drug policy. The Lancet. Points to consider Understandings of drugs and drug use and their role in health are contested and have shifted through history, shaped by politics and morality and many other factors How these understandings relate to health, and the knowledge and attitudes of lay and medical groupings, is often filled with tension and little articulated. Particular understandings of what health is can dominate, reflecting particular sets of assumptions (including about morality). Questions, comments [email protected]