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The Short Course on Prevention

Interview by Brian W. Simpson

Never one to shy away from sharing his knowledge or opinions, Dean Emeritus Alfred Sommer does both in his new book, Getting What We Deserve: Health & Medical Care in America (Johns Hopkins University Press, 2009). In the slim volume, Sommer, MD, MHS ’73, takes readers on a brisk tour of public health and medicine’s accomplishments and shortcomings. He pauses only to skewer a deserving target like our health care system (“Calling U.S. medicine either ‘health care’ or a ‘system’ is an exaggeration.”) or fads in health care reform (“Market forces are not the best basis on which to build a great health care system!”).

During a recent interview with Johns Hopkins Public Health editor Brian W. Simpson, Sommer riffed on his favorite themes from the book, which one reviewer described as a “thought-provoking and insightful short course on the power of prevention.”

You make some pretty withering assaults on sacred institutions like medicine, health care, insurance, the media.

I heard back from lots of people who very generously have said, “I loved reading the book,” but I must say I haven’t heard back from the health care industry as yet. (Laughs.)

You seem skeptical about genetic research.

I’m skeptical only in that I think the timeframe between the hype that it’s getting now and the benefits that it will eventually provide is totally off. These are complex diseases that are caused by a complex interplay of genes and epigenetic phenomena and all kinds of things that we’re only beginning to understand. Understand them we must. The research has to go on. But the immediate promise in terms of clinical benefit has been hyped far too much.

What should medical journals be doing to more accurately communicate study results?
Medical journals need to be more scientifically robust and stop worrying about getting quoted on NPR and in The New York Times, which unfortunately is what they do. It doesn’t mean they should stop publishing the science they publish, but it does mean they need to be more precise and honest about a study’s implications. The popular media focus on a study’s “discussion” and “conclusions,” about which the journals must become more rigorous.

But the journals are rigorous in the peer-review evaluations.

They’re rigorous in the evaluations, but they’re not rigorous in the interpretation. And the reason they’re not rigorous, I think, is purposeful because it’ll get bigger headlines and they want to be quoted every week in The New York Times. And if you really are rigorous, the number of headlines you can generate is pretty small.

You challenge the value of observational studies.

I challenge their use and interpretation, not their potential value. For instance, observational studies can provide important clues to where we need to do definitive randomized controlled trials. Of course we can’t do randomized trials on everything. You can’t expose otherwise normal individuals and not others to ionizing radiation, just to see what happens. Some things you just can’t do. The role of observational studies has to be, “Does this give me an inkling, a potentially important clue to what might be causing a particular disease?” The problem that I have with observational studies is that’s not the way that many people have been using them in the last 20, 30 years. An observational study can only say that these two things, in this particular circumstance, in this particular population, studied in this particular way, appear to be associated. It never can prove one thing caused the other. That’s why one day you read that coffee kills you, the next day you read that coffee reduces your heart attack rate.

You write about the link between behavior and health. What’s the best way to persuade people to adopt healthy behaviors?

It’s the five “Shuns!”: Education, legislation, litigation, regulation, and taxation …. You start with education because you’ve got to tell people why it’s bad for them. But most people don’t change their behavior simply because you’ve educated them. So then you put positive and negative incentives in place that make people change their behavior. A wonderful example was New York raising the tax on tobacco products quite substantially. Not a little bit but a lot. And you got the biggest fall in usage among teens, which is really where you want to have the biggest impact because that’s when people start to smoke. There is greater price elasticity as people get older because they have more income, so that’s when you outlaw it from public spaces—restaurants, bars—so you’re forcing people to change their behavior for their own good. So some people complain it’s a Nanny State. The same people like to carry guns and claim you can’t keep my gun from me, you can’t keep my cigarette from me. But in fact, that’s what improves health. And there’s a lot of health to be improved.