Sometimes the clamour coming from the health sector sounds like nothing so much as a bunch of whining kids. My problem’s bigger than yours. No it’s not. Yes it is.
The noise can become deafening when one cancer group competes against another — poor old us in prostate cancer are so badly done by compared with those lucky women in breast cancer — or when the cancer lobby unites to assert its superiority over heart disease.
Of course it’s useful to know the relative costs and impacts of various heath problems, but the competition for the most impressive casualty count is becoming, quite literally, sickening.
This disease-based jockeying for media headlines and policy/funding attention is unhealthy in reinforcing a narrow focus on risk factors for specific diseases. To stress the role of smoking in one particular disease alone is unlikely to lead to sensible tobacco control policies.
While it’s understandable that disease-based groups might want to lobby for better treatments in their particular area, it’s debateable whether this narrow approach best serves the broader community or even their patient group. Often the most meaningful improvements to patient care will come from systemic changes to service delivery more broadly.
As well, many health problems have similar underlying causes – smoking, alcohol, inactivity, poor quality diets or adverse childhood experiences are common culprits — and perhaps we would have more luck in tackling them if the heart disease, cancer, mental health and diabetes mobs worked more in collaboration than competition.
Focusing on risk factors for specific diseases also tends to distract attention from efforts to tackle the broader social and structural factors promoting ill health. It’s so much easier, for example, to make people worried or guilty about what they’re eating than to ensure a healthier food supply.
Too often the media are complicit in the disease wars, happy to amplify the loudest voices rather than taking time to sift the signal from the noise.
One recent example is an Access Economics report funded by The Australian Lung Foundation stressing the toll of chronic obstructive pulmonary disease and calling for widespread screening.
The report was widely and uncritically reported. Most recently, The Weekend Australian repeated its claim that COPD kills 16,000 Australians annually.
No mention was made of Simon Chapman’s recent Crikey article questioning the unprecedented magnitude of these figures. Chapman is not Robinson Crusoe. Here are a few comments from other senior figures in public health and epidemiology.
University of Sydney Professor of Public Health Bruce Armstrong:
I saw coverage of the Access Economics report and the Lung Foundation’s recommended actions on television. My immediate conclusions were those Simon Chapman has reached in his article. The Access Economics numbers for COPD are grossly overstated and the Lung Foundation’s recommendations based on them are not ones that the Australian governments should consider accepting.
The University of Queensland Professor of Medical Statistics and Population Health Alan Lopez:
I would be extremely sceptical of the scientific rigour underlying the Access Economics Report. This may well be a case of good advocates being terrible epidemiologists. That is a scenario that can have significant implications for public policy, as Chris Murray and I discovered when doing the original Global Burden of Disease Study. Our estimates for leading causes of global health interest, including malaria and measles, were much lower than what well meaning advocates had advised WHO. While COPD is a comorbid condition for many other diseases caused by smoking, it is unlikely to cause anywhere the number of deaths that Access Economics attribute. We need to be careful that public policies and programs to control tobacco are based on evidence, not advocacy.
The University of Queensland Professor of Public Health Policy Wayne Hall: “I very much endorse Simon’s recent piece on Access Economics’ report on COPD.”
I also know of at least one other senior figure in the area who has been privately critical of the report but doesn’t wish to go on the record.
Lynne Pezzullo, a director at Access Economics, was most unimpressed when I sought her response to these comments. She stressed the report’s accuracy and her consultancy’s integrity, and also made some disparaging comments about Chapman, including that he is a “troublemaker”, and the “rubbish” that appears on Crikey.
She noted that critics of the reports are associates of Chapman. (For the record, I should declare that I am as well, having an honorary appointment at the University of Sydney).
Pezzullo was also most unimpressed by my analysis of the “disease wars”, describing it as a “tired old line”. Maybe she’s right. But I reckon it’s got more mileage left in it than that other tired old line, my disease is bigger than yours…
Why should concerns about burden of disease end with the dismissal of a report on COPD? Your piece describes a war – the report just presents one assessment of the facts and a means to intervene.
There can be a truce I suppose when Govt attitudes to chronic diseases are based solely on their merits and not on the power, influence and access of lobby groups. The best signal will be when lung cancer and pancreatic cancer are funded at the same level as breast cancer for clinical care, patient support and research and when COPD appears in the above list with its due prominence.
In terms of its attitude to unmet needs in COPD, the next test for the Government and DoHA is the extent to which it responds this month to solicited expert input by extending the revised National Asthma Strategy to address these.
In the meantime, if you want a truce, campaign for that Nirvana on Croakey. I will watch with interest.
Melissa, I smell rank hypocrisy in some of the public comments that have followed the Access economics COPD report. A few questions arise.
Is there a need for the Australian Govt to be more switched on to the burden of chronic disease and mortality from COPD?
Presumably the answer to this is yes if you look at the press release on preventative health – part reproduced below
PRIME MINISTER
MINISTER FOR HEALTH
KEEPING PEOPLE WELL AND TAKING PRESSURE OFF OUR HOSPITALS
The Rudd Government will invest $872 million over six years in preventative health, to help keep people well and take pressure off hospitals.
This is the single largest investment in preventative health ever made by an Australian Government and supports an historic new emphasis on early intervention and tackling disease sooner.
Preventable chronic diseases like cardiovascular disease, type 2 diabetes and cancer are major drivers of the growing burden of disease. With around 670,000 preventable hospital admissions every year, tackling chronic disease will help take pressure off our hospitals too.
Importantly, a proportion of the funding will be reserved for reward payments, which will go to States and Territories which meet agreed targets.
***
Were Access mortality figures necessarily wrong?
This cannot be clear at the moment. If a report questions the conventional wisdom, referring continually back to that convention is no reply at all. The opinions of those that Simon Chapman put on Crikey are not beyond question. Theo Vos wrote in a report for Heart Foundation – The burden of cardiovascular disease in Australia for the year 2003” – updated last year
“A guiding principle of burden of disease methodology is not to accept data at face value. This applies particularly to cause-of-death data. There are potentially several problems with the validity and reliability of cause-of-death data, even those certified by medical practitioners. More to follow.
All I can say is that almost nothing ever gets spent on Crohn’s disease which is what ails me.
Thank God… I always assumed I was being lied to or at least, the figures were being misrepresented. (although I was getting worried they might be right, what with the wheezing an all)
I love the smell of a ciggie in the morning
Now, ha!… smells like… victory 😉
The two most important are:not assigning a specific code, but using senility or some other ill-defined code assigning the wrong code due to diagnostic fashions, carelessness, etc.”
Alan Lopez is excellent but his Global burden study is based on death certificate data that may be flawed or inadequate as Vos suggests. In all my time in Respiratory Disease and Tobacco control I have had nothing to do with Hall.
Is the higher estimate plausible on the basis of known epidemiology?
COPD clearly increases lung cancer and CV mortality – independent of smoking and other risk factors. If you are in the lowest 20% for FEV1 – still averaging a mild abnormality only detectable with spirometry – there is a 4-5 fold increase in cardiac death and lung cancer. This is a very strong effect – akin to more than doubling cholesterol just for heart death risk. The same effect is seen for CV death in the Busselton data Chapman refers to.
Because these effects are seen with mild COPD they are never likely to be reflected in death certificates and will not appear in AIHW data and,currently, these deaths caused by COPD could appear only as cardiac or cancer deaths.
Have the people you quote used Access before?
Not sure when Bruce Armstrong went back from Cancer Council NSW to Public Health at USyd but the cancer council NSW was happy to use Access last year for a cost of cancer report that seems to have created no fuss at all like this one on COPD. Similarly, Access was very recently used by Cancer Institute NSW to project cancer costs. It is for those now complaining, who have close links to both those bodies, to justify this.
Should there be a truce?
Attacking COPD is a cheap shot. The events subsequent are Simon’s posting are more or less what I predicted for an ugly disease and why I asked him not to react in this way