Today we will talk about healthcare! But for once, our debate won't be on covid (thank God!). We will talk about public health, oncology, and prevention. And, about an Economist Impact study on Cancer preparedness that has just released a large paper about the Czech Republic and Czech system of Oncology care. Therefore, I am super happy; I can talk today with Dr. Robert Cook, the Clinical Director of Economist Impact, the research arm of The Economist Group. Dr. Cook lead a team of analysts who have already looked at almost 30 national oncology systems, the Czech Republic becoming the last piece in the puzzle.
Even though most of the focus, when we talk about medicine, shifts toward covid and managing the pandemics, the Czech Republic can be really proud of the quality of its oncological care. According to Dr. Robert Cook, who took part on the Economist Impact study on oncology in twenty nine countries, in which the Czech Republic was ranked 8th, it is remarkable what the Czech oncologists can do having in mind how little money is being invested into oncology in the country.
So, dear Dr. Cook, it's great having you!
Pleasure is mine Jan!
My first question will be about public health: Even though you used to be a general practitioner, you have spent the last twenty years in public health. And public health unfortunately has been a sort of pariah of healthcare, especially in the Western world. For decades it stayed in the closet; not many people had been interested in it and it was underfunded and seen as unimportant. Now covid has changed everything, the media, politicians, and even people drinking beer at the pub are talking about public health. How do you feel about it?
It's a good observation, what you just said; the whole public health field has indeed been seen to wake up. Not only policymakers, but also ordinary people are now truly interested in it. I listen to the BBC regularly, and I am amazed how many epidemiologists are invited guests and how often they appear. Honestly, many are now household names. Prior to this I didn't even know how many epidemiologists there were in the UK.
It is also interesting how much people have started to think about numbers and data when talking about healthcare. Before covid, healthcare was a very individual thing, but now people have begun to understand the population, societal and economic consequences of good health and healthcare.
There is an old saying that generals always prepare to fight their last war rather than the next. From this perspective, maybe the COVID is a sort of wake-up call because this pandemic might be the first among many upcoming societal, complex health issues we will need to deal with. There is aging, instability of health financing, microbial resistance...
This is totally true...
And all those challenges will need our focus, effort, and a lot of money. There is no free lunch in healthcare.
You know, public health has always faced a problem. That is, it frequently needs to take a long-term view on things. This is in contrast to modern societies with very fast news cycles or low attention spans. Politicians in democracies often think about the electoral cycle and their party’s prospects for reelection, for example. Few people were interested in what will happen in ten years or longer. Sad but true. However, there are opportunities to change this, if we recognize the underlying causes of short-termism.
For example, healthcare has become so complex an endeavor that it is now difficult for one person to fully understand it. It is no longer only about access to health facilities or high-quality drugs. Good health, from a personal and societal perspective, is now about our behavior, about stress, food, clean water, and the complex environment around us, including the effects of climate change.
Because politicians come and go, health systems themselves need to consider how to reposition themselves to address new approaches to health and societal needs. Acknowledging that Covid took us totally by surprise, we need to ensure we focus on the future and prepare better for when something similar threatens us again.
Let's take one step down and focus on the intriguing point you mentioned: our behavior and its impact on our health. Thanks to big data and enough computing power, we see, also in a quantitative manner, that our behavior impacts our health by 40%. Then, there are genes, 30%, socio economic aspect & access to health, 15%, the quality of the healthcare system, 10%, and finally environmental exposure, 5%. Therefore, and clearly, our behavior constitutes a critical element of our health.
Thus, do you think the behavioral economy approach, for example in the form of nudges, might be a good strategy for how to positively influence our behavior?
Yes, that's an interesting question. I think it's possible to use them, but first, we need to break down the prevention pathway into separate parts. Not all of them are suitable for nudges and different forms of interventions might be required. For the hardest behaviors that require lifelong lifestyle change, like weight reduction, or smoking cessation, complex strategies are needed. Nudges have been shown to work here, but are probably best combined with public health campaigns, positive social media activism, structural reforms and also financial incentives in some form...
For more straightforward problems, like promoting vaccination against covid, here simple nudges might be helpful. For example, opt-out, rather than opt-in techniques.
Finally, we should not ignore possible inequalities in health outcomes, health access, and broader socioeconomic factors. For behaviors to change, most people need accurate information to make decisions and both the opportunity, and motivation to embrace a healthier way of life.
Some people argue against nudges, saying that they are just pure manipulation.
To a certain extent this is true. My view is that we are often prone to being manipulated all the time and everywhere anyway. Social media, e-commerce, and even product placement in old-fashioned grocery stores are examples. Just think about a candy stall full of chocolates next to every cashier that is waiting for children. Fortunately, this is being changed, at least here in Britain. I find sometimes it's now quite hard for me to find my favorite bar of chocolate in a supermarket. Before, it was next to the cashier!
This, to me at least, seems a positive example of nudging that isn't necessarily manipulation. By reducing the opportunity to pick up a chocolate bar on the way out, I'm not prevented from planning to pick it up when walking around the whole shop, it just reduces my short-term thinking and changes a habit.
How to apply this to more complex and expensive parts of medicine: like diabetes or oncology? To persuade people to live better and also not avoid/miss their check-ups and preventive screenings?
I think there is a place for nudging as well. Again: for example, an opt-out mechanism for health checks and oncology screenings, when people will get their place scheduled automatically in places that suit them and well in advance. To create a seamless pathway and seamless access to care. Also, to apply digital technologies much more to communicate with people more frequently. – People use apps now for everything from payments and groceries; with obvious security and confidentiality safeguards why not use them more when communicating with your family physician.
Maybe let's chunk this oncology pathway into a few pieces. First, there is a problem with our behavior: pollution, junk food, stress, smoking, etc. Here I like public health marketing quite a lot. But in a modern way: KOLs, influencers, social media, gamification, and ideally with some financial nudges to support good behavior. Then, there is the second pot, which is real prevention: checkups, mammography, ultrasounds, colon cancer screenings, and so on. And here, we need a more seamless pathway, as you pointed out. And finally, there is the treatment, which shall be centralized and accessible as much as possible.
Yes, I think it is essential to break it down into a pathway because different pieces need different approaches, and the more upstream we go, it tends to get more complex and complicated. It's not about healthcare only, but also education, employers, environment, including the play of socioeconomic disparities.
Fixing some of these upstream changes is not fast nor easy. Just think about smoking cessation. How quickly, if you do stop smoking do you accrue the benefits of a healthier lifestyle? And the same goes for dietary change. How quickly will a healthy and nutritious diet bring you to a healthy weight and then better health status? The changes can be made very fast, but maintaining them needs more focus. How can they become a habit? So here we come to the role of family and upbringing because it's much easier and better to develop healthy habits as a child.