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Richard Smith on countering the “wicked problem” of the chronic disease pandemic

24 Apr, 09 | by julietwalker

Richard SmithI spent two days last week in the seductive grandeur of Trinity College, Oxford, fretting about the global pandemic of chronic disease, but I left feeling optimistic—despite the pandemic raging as fiercely as ever.

For doctors chronic disease means any disease that keeps going, including AIDS, TB, and other chronic infections together with neurological, rheumatological, and mental health problems. But those of us in what might be called “the chronic disease movement” mean cardiovascular disease, diabetes, chronic respiratory disease, and some cancers. These four diseases are caused by three main risk factors—smoking, poor diet, and physical inactivity—and cause more than 50% of world deaths. Hence the naming of the 3:four:50 website that is a Web 2.0 creation to counter chronic disease where I have placed more blogs on the Oxford conference.

Most BMJ readers are probably aware that although deaths from heart disease and stroke are coming down in developed countries they are shooting up in low and middle income countries. So far very few resources have been devoted to countering the problem, although last year’s World Health Assembly did adopt an action plan. Trying to slow the progress of the pandemic of chronic disease sweeping through the developing world is, a “wicked problem” said David Mathews of the Oxford Health Alliance at the conference. A wicked problem is highly complex, perhaps ultimately insoluble, has no obvious solution and is full of contradictory data; every step forward is possibly a step backwards. Such problems can be tackled only by partnerships devising multiple options for responding and being content with “constructive ambiguity,” whereby partners who may feel uncomfortable with each — like public health practitioners and food companies — concentrate on where they agree and park their disagreements.

One good way to approach wicked problems is to “think big, act small, move fast, and leverage like hell.”  The big thinking is to maintain faith that we can make a difference and to continue to work on a global scale.

Some of the small actions are community interventions for health, where an attempt is made to redesign neighbourhoods so that “healthy choices are the easy choices.” The North Karelia programme that brought down deaths rates from heart disease in that part of Finland can be considered one of the first of the community interventions for health.

The interventions are made in schools, workplaces, health centres, and the whole environment, and ideally the interventions operate not by persuading individuals but by making structural changes like banning smoking in public places, making stairs more accessible, improving public transport, reducing the amount of sugar in drinks, or a hundred other possible changes. Some are large and might require legislative actions, while others are small and easily implemented—like putting notes beside lifts encouraging people to use the stairs.

These interventions require political support and agreement from all the different stakeholders in a community. Indeed, the very act of bringing people together to think how they can redesign their environment is in itself an important intervention. Ideas for change will begin to flow.

These programmes are underway in Kerala, Hangzhou, and Mexico City and are being planned for Leicester, New Haven, Andover, Delhi, and Sousse in Tunisia. Most of the programmes will be rigorously evaluated, although evaluating such programmes is itself close to being a wicked problem.

Another way to prevent heart disease and stroke—but not other chronic diseases–is through the polypill, a pill that combines a statins, antihypertensives, and aspirin. These drugs work in different ways, and so their benefits can be added together. Nick Wald, who spoke at the conference, proposed in the BMJ in 2003 together with Malcolm Law that such a pill could reduce heart attacks and strokes by about three quarters.

Now Denis Xavier, who was also at conference, and colleagues have begun to test the idea, conducting a trial in over 2000 people in India. They have shown that people will take the pill, it is safe, and it does have the expected effects on reducing blood lipids, blood pressure, and platelet stickiness—although the effects were not quite as dramatic as Wald and Law hypothesised. Still, however, one pill that might be available for as little as a dollar a month could prevent more than half heart attacks and strokes.

Tom Marshall, also at the conference, is conducting a trial in Iran and has results similar to those from India.

There seem to be five polypills in the world (three from India, on from Iran, and one from Spain), and all but the Spanish one were represented at the conference—making this an historic occasion.

Anthony Rodgers from Australia has helped Dr Reddy’s Laboratories from India make one of the first pills, but in his talk he regretted the slowness of progress. He attributes the slowness to professional conservatism, regulatory hurdles, and lack of market pull. Nevertheless, I was left with a feeling that we are at last gathering momentum, and polypills may be on the market in Europe and the US within a couple of years. (I’m taking the components already, but it means taking five pills every night.)

Innovation will be essential for tackling chronic disease, but it’s probably less scientific innovation and more innovation in making change happen, getting things done. An example came from Tal Gilbert, head of research and development at PruHealth, a joint venture between the venerable Prudential and the South African company Discovery.

The company offers heavy incentives to people to adopt healthy life styles. Those covered by its policies are given detailed information on what they could do to live healthier lives, guided to companies who can help them by providing healthy foods or access to gyms, and then given “vitality points” for eating healthy foods and exercising. The points become cash benefits.

Academic analysis soon to be published suggests that those who collect many points have much lower claims; interestingly and surprisingly the big reductions are in cancer and mental health. (There is the obvious problem of causation, but Gilbert said that those conducting the analysis were well aware of all the methodological problems.)

“Leveraging like hell” was in many ways the major theme of the conference. Building a jumbo jet was a complex problem but not a wicked one in that there was a clear blueprint. Yet no individual knows how to build a jumbo jet. It depends on many different groups of people with different knowledge and skills, and we are likely to make progress with chronic disease only by bringing together many different stakeholders—politicians, academics, patients, health workers, social scientists, private companies, non-governmental organizations, and many others.

Jonathan Horrell from Kraft Foods UK described the experience in Britain of bringing together government, business, charities, and community organisations in the Department of Health’s Change for Life programme. He is part of Business for Life, and the government’s hope is that industry will contribute some £200m in kind through marketing and creativity. The media and some of the other partners are understandably suspicious that food companies are part of the problem rather than the solution, and building trust among the different groups is proving difficult. “Bilateral trust” among just two groups is not so hard but it’s trust among all that is hard to achieve.

Partnership, ideas, and innovation can achieve little without resources, and lack of resources has always so far been a problem for those trying to counter chronic disease in the developing world. Rajaie Batniji from Oxford University pointed out that about $3 in aid is spent for every death from chronic disease compared with $1030 for every death from AIDS.

Rachel Nugent, an economist from the Centre for Global Development in Washington, described how data from the OECD showed that only around $2m of aid was spent on chronic disease in 1996, but the figure was $56m in 2007, although $31m of that was on “mental health”—in fact, conflict resolution.  In the same year $1346m was spent on infectious disease. Nugent’s survey of donors did, however, suggest that total funding has increased to over $600m by 2008 with about half of it coming from private donors.

Stig Pramming of the Oxford Health Alliance led the conference towards an upbeat conclusion by announcing that June will see the launching of a Global Alliance for Chronic Disease that will include the government research bodies from the US, Canada, UK, India, China, and Australia. It will initially have some $45m to invest in research.

Competing interest: RS is heading UnitedHealth’s Chronic Disease Initiative, which funds eight centres in low and middle income countries to counter chronic disease. The initiative partners with the Oxford Health Alliance, which organized the conference, and helped sponsor the conference.

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  • http://www.femmefractal.com/ Vivian S Rambihar MD and Vanessa S Rambihar, medical student, U Toronto

    Complexity science for complex and wicked problems: a new EBM for health.

    I spent two days in 2000 in the seductive grandeur of Trinity College (Cambridge), and the Isaac Newton Institute for Mathematical Sciences, trying to persuade people that we should use complexity science to solve the world’s complex, or wicked problems. The chronic diseases are eminently amenable to this approach, being a function of complex dynamic interactions. The “chronic disease movement” could use a multilevel and distributed mass movement for change like this, which works best with wicked problems, being what David Matthews calls “highly complex.”

    This is plausible. The new physics of the world is not Newtonian, action and reaction, but complexity with change affecting everything in the interconnected web of physical and social structures and relationships in which we are immersed. Health and chronic diseases are inextricably intertwined in the complex social, political, biological and other interactions of life and nature, hence our BMJ letter proposing complexity science to help in the definition of health (and elsewhere, as the science for health and change) http://www.bmj.com/cgi/content/extract/338/jan09_1/b32. Change today requires a 21st Century approach, beyond Newton.

    There is a track record of this with success: our two decades in a community and global and diasporic project on preventing heart disease, reported as a book chapter in Complexity and Healthcare Organization (Radcliffe Oxford, and available by Googling complexity healthcare organization Rambihar), the Tugela Ferry HIV project in South Africa reported in Joshua Ramo’s 2009 book “The Age of the Unthinkable,” the new model for fourth generation conflict and diplomacy looking at the total picture, and much more. These show that interventions do not have to have political support and agreement of all, like the group of medical students in Toronto, and others starting a global movement for change – globalhearthour.com and at http://www.femmefractal.com/tsunami.htm.

    Stephen Hawking says he thinks complexity is the new science for the 21st century. This should then become the science for health, chronic diseases, and the wicked problems, where complexity resides and a complexity approach to change thrives. Ramo describes this throughout his book as an Effects Based thinking. We can now have a new EBM for health and for chronic diseases, a science based practice for wicked problems, called Effects Based Practice and for chronic diseases and medicine, a new EBM – Effects Based Medicine.

  • Les Simpson

    A major problem which Richard Smith and his United Health’s Chronic Diseases Initiative face concerns the fact that the results from scientific research seem to be categorised as relevant (and therefore discussed)or irrelevant (and therefore ignored).
    For unexplained reasons, papers in the field of haemorheology (blood rheology) fall into the latter category, which means that the involvement of impaired capillary blood flow, because of reduced red cell deformability, are rejected immediately. Any attempt to involve GPs in a discussion of blood viscosity is a waste of time.
    A very extensive literature on the topic is available, for example the 3 books by Leopold Dintenfass, one of which is titled “Hypertension and hyperviscosity.” So by using fish oil at 6 grams daily, to increase red cell deformability and to reduce blood viscosity, it is possible to do without antihypertensive medication. Of course, this would not be popular with drug firms.
    The point is that in general, chronic disorders from arthritis to multiple sclerosis are associated with altered blood rheology – which is potentially treatable. Richard Smith wrote about,”The chronic disease movement” and noted that there were 3 main risk factors – smoking, poor diet and physical inactivity. A common factor is that in all 3 conditions there is increased blood viscosity. Furthermore, it has been shown that cessation of smoking leads to the normalisation of blood rheology, and that regular, low-intensity activity, such as walking, lowers blood viscosity. Fat rich diets are associated with increased blood viscosity, while low fat diets (such as the Swank diet) virtually eliminate multiple sclerosis and provide relief for migraine sufferers. According to Campbell and Campbell in, “The China Story,” a fat-rich, meat-based diet is a risk factor for breast cancer.
    In my book, “Blood viscosity factors – the missing dimension in modern medicine,” published by the Mumford Institute in New Jersey, I have endeavoured to show how the current concepts of modern health problems have been developed by ignoring those reports relating to changes in blood rheology.
    If the UHCDI is to make any progress in the field of chronic disorders, they will need to ensure that the problems of blood flow are recognised, assessed and treated.

  • http://www.bmhegde.com Prof. B. M. Hegde

    I am well aware of Richard’s strong views on the benefits of the polypill to prevent the menace of chronic diseases while he knows mine.

    The interim reports on the studies in India have shown the usual surrogates like the fall in cholesterol etc, but the real audit on the fall in mortality due to chronic diseases and the load reduction on the health system should wait for few more decades!

    In the meantime, reports trickle in on the dangers of those drugs given even in isolation!It is very difficult to believe that they do wonders in combination, that too in very small doses.

    Rachel Witmore and colleagues reported in the JAMA (15th April 2009) that severe hypoglycemic attacks in diabetics were associated with dementia in later life. They rightly suspect that even minor hypoglycaemic episodes could do that. More interesting than that was the fact that even one episode of severe hypoglycaemia was associated with increased incidence of dementia but the incidence goes up exponentially with further attacks of hypoglycaemia. Our usual teaching that an “ideal” control of diabetes should be associated with episodes of hypoglycaemia might be a significant contributor for the higher incidence of dementia in society.

    A population-based sample of 1062 persons from a longitudinal cohort, 60 years and older, free of dementia, who underwent MRI examinations between August 15, 2005, and November 22, 2006. (Rotterdam Scan Study) by Meiki Vernooij and colleagues showed that aspirin in small doses, these days advised to every one above the age of forty to prevent heart attacks, has been associated with cerebral micro-bleeds! What are the long term consequences of these bleeds is for any one to guess? I have a feeling that dementia could be one of the final outcomes. That apart, a large audit on aspirin and its role as a prophylactic measure by John Cleland published in the British Medical Journal did show that while small doses of aspirin might, at best, marginally lower the incidence (statistically insignificant) of non-fatal myocardial infarction, it does increase cerebral hemorrhage significantly. Blood thinners do damage the brain causing amyloid degeneration around those minor bleeds.

    Millions of cerebral micro-emboli were recorded during coronary artery surgery, even when done on a beating heart, by peri-operative scanning. Cognitive changes are seen in around 97% post CABG patients in the immediate post operative stage but settles down to a residual damage of only 47% in the long run. The origin of those emboli is supposed to be the atherosclerotic aortic arch. Immediate post infarction bypass surgery increases the risk even of stroke four fold! Angioplasties are no exception to embolisation, although to a lesser extent.

    To the above list of causes that potentially could result in dementia in the long run we must add many of the blood pressure lowering drugs, some beta-blockers in particular, where the sleep blood pressure could come down to such low levels that cerebral and coronary circulations could be jeopardized. Many of these patients have diffuse lacunar infarcts that predispose to memory loss, an early presentation of dementia.

    With the present thrust to lower the normal levels of BP to below 120/80 mm of mercury in the doctors’ office with heavy drugging, one wonders about the health of the cerebral circulation in these patients. In this list I have deliberately avoided reference to those commonly used panacea for all ills of human kind, the anti-cholesterol group of drugs!

    With millions taking all the above mentioned drugs in combinations most of the time, it is not surprising that we have an apparent epidemic of dementia in the population. While we pride ourselves with our evidence based medical science I know of no evidence based study that showed that a combination of anti-diabetic drugs, anti-hypertensives and aspirin being tried in any RCT to show that they were safe when given together. Most patients in their 40s, who have any of the above “silent killers,” are on a combination of all the three groups of drugs, anyway.

    One wonders what those drugs could do in combination while they are capable of producing cerebral damage even in isolation. Could the combinations have additive effect on the incidence of dementia? There is no evidence as yet! Iatrogenic dementia has come to stay! We have been searching for the causes of precocious dementia while the main culprit is hiding in our own backyard like the woodcutter searching all over the place for his axe on his shoulder.

    Are we adding one more dangerous chronic disability to our long list of chronic diseases by our polypill? I am worried about breaking our Hippocratic Oath-Primum Non Nocere!

    (Bibliography:

    Hadler N. The last well person. 2007. McGill Queen’s University Press.
    Tinnetti M. Stead T. The end of the disease era. Am. J. Med. 2004; 116: 179-183.
    Godlee. F. Measuring quality. BMJ.2009; 338: b1356
    Starfield B. Is US medicine the best in the world? JAMA 2000; 284: 483-485.
    Wilson D. Harvard tries to end industry influence. The Hindu March 4, 2009.
    Rachel A. Whitmer; Andrew J. Karter; Kristine Yaffe; Charles P. Quesenberry Jr; Joseph V. Selby. Hypoglycemic Episodes and Risk of Dementia in Older Patients With Type 2 Diabetes Mellitus. JAMA. 2009;301(15):1565-1572.
     HYPERLINK “http://archneur.ama-assn.org/cgi/content/full/2009.42v1?maxtoshow=&eaf” \l “AUTHINFO#AUTHINFO” Meike W. Vernooij, Mendel D. M. Haag, et. al. Use of Antithrombotic Drugs and the Presence of Cerebral Microbleeds. Arch Neurol. 2009;66(6):(doi:10.1001/archneurol.2009.42).
    Cleland J. Preventing atherosclerotic events with aspirin. BMJ 2002; 324: 103-105.
    Knipp SC, Matako N, Schlamann M, et. al. Cognitive outcomes three years after coronary artery bypass surgery: relation to diffusion-weighted magnetic resonance imaging. Ann Thorac Surg. 2008; 85(3): 872-879.
    Josefson D. Early bypass surgery increases the risk of stroke. BMJ 2001; 323: 185.
    Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary bypass surgery. N Eng J Med 1996;335:1
    POISE Study. http://www.phri.ca/poise.htm
    Shannon B. Why Too Much Medicine Is Making Us Sicker and Poorer Bloomsbury USA; 2007; 343
    Ravnskov U. The Cholesterol Myths. Washington:  HYPERLINK “http://www.NewTrendsPublishing.com” New Trends Publishing, 2000; ISBN 0-9670897-0-0
    Hegde BM. To do or not to do? http://bmj.com/cgi/eletters/336/7656/0#196726, 6 Jun 2008.
    David Wootton. Bad Medicine: Doctors doing harm since Hippocrates. Oxford University Press, pp 320 ISBN-10: 0 19 280355 7 ISBN-13: 978 0 19 280355 9.)

  • http://bmj.com Trish Groves

    I was glad to see Richard’s reference to “wicked” problems in public health; these are problems that morph constantly and won’t respond to linear solutions. Pandemic flu is one example of a wicked problem, obesity is another. Try to tackle wicked problems using traditional strategies and you’ll probably come unstuck. But they can be tamed – if not completely solved – by creative thinking, experimentation, and collaborative working. Essentially, muddling through and playng it by ear may be more effective in the end than trying to implement a grand plan.

    This is a topic that’s intrigued me since buying the Harvard Business Review to read on a long flight last year. I didn’t notice that HBR cost more than £20 till I got to the checkout but, once I’d read John C Camillus’s great article on strategy as a wicked problem, I felt I’d got my money’s worth.

    There’s a summary at http://hbr.harvardbusiness.org/2008/05/strategy-as-a-wicked-problem/ar/1
    which explains
    “Wickedness isn’t a degree of difficulty. Wicked issues are different because traditional processes can’t resolve them, according to Horst W.J. Rittel and Melvin M. Webber, professors of design and urban planning at the University of California at Berkeley, who described them in a 1973 article in Policy Sciences magazine. A wicked problem has innumerable causes, is tough to describe, and doesn’t have a right answer…They’re the opposite of hard but ordinary problems, which people can solve in a finite time period by applying standard techniques. Not only do conventional processes fail to tackle wicked problems, but they may exacerbate situations by generating undesirable consequences.”

    wikipedia has a good summary too http://en.wikipedia.org/wiki/Wicked_problem
    including these definitions:
    “a problem that is difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognize. Moreover, because of complex interdependencies, the effort to solve one aspect of a wicked problem may reveal or create other problems”
    and “A problem whose solution requires large groups of individuals to change their mindsets and behaviors is likely to be a wicked problem.”

    And it lists Rittel and Webber’s (1973) 10 properties of a wicked problem:

    1. There is no definitive formulation of a wicked problem.
    2. Wicked problems have no stopping rule.
    3. Solutions to wicked problems are not true-or-false, but better or worse.
    4. There is no immediate and no ultimate test of a solution to a wicked problem.
    5. Every solution to a wicked problem is a “one-shot operation”; because there is no opportunity to learn by trial-and-error, every attempt counts significantly.
    6. Wicked problems do not have an enumerable (or an exhaustively describable) set of potential solutions, nor is there a well-described set of permissible operations that may be incorporated into the plan.
    7. Every wicked problem is essentially unique.
    8. Every wicked problem can be considered to be a symptom of another problem.
    9. The existence of a discrepancy representing a wicked problem can be explained in numerous ways. The choice of explanation determines the nature of the problem’s resolution.
    10. The planner has no right to be wrong (planners are liable for the consequences of the actions they generate).

    For more on wicked problems in public health, see this report by the Australian Government and Australian Public Service Commission (2007): Tackling Wicked Problems -
    A Public Policy Perspective http://www.apsc.gov.au/publications07/wickedproblems.pdf

  • Les Simpson

    I was intrigued to read Professor Hegde’s contribution because to a major degree it epitomises my previous comment;
    i.e. that there is a general lack of recognition of the relevant published material concerning altered blood rheology.
    Although Professor Hegde shows a clear interest in dementia, I wonder how he would explain the dementia of a patient with myelomatosis. When the myeloma protein was removed by plasmapheresis, the dementia resolved. It is relevant that the myeloma protein increases blood viscosity.
    Diabetes is associated with increased blood viscosity which is exacerbated by hypoglycemia. It is also relevant that the aging process is accompanied by increasing blood viscosity. So in elderly diabetics, during an episode of hypoglycaemia, the viscosity factors will be additive and the consequences may be disastrous.
    Professor Hegde is correct in expressing concern about the effects of blood pressure lowering drugs during sleep. Floras showed that in the early hours of the morning a circadian rhythm was accompanied by a decline in blood pressure. Because blood is a thixotropic system in which the viscosity increases when flow rate is reduced, if there is a drug-related inability to respond to the increase in blood viscosity, then the consequences are potentially harmful. In 1991 the BMJ published a letter in which I drew attention to the risks of prescribing blood-pressure-lowering drugs in the absence of information concerning blood viscosity.
    I reiterate that until their blood rheology problems are recognised, those who suffer from chronic disorders will continue to be disadvantaged.

  • http://www.bmjwa.com Joseph Ana

    Whenever I read about initiatives aimed at countering Chronic Disease- and I mean cardiovascular disease, Asthma, Duiabetes Mellitus, Cancers, mental health,- I feel elated. I felt the same when I was permanently in the UK, and feel the same even since I relocated to Nigeria in 2004.
    But I also feel ‘deflated’ when most initiatives leave out Africa with a population approaching 500 million soon. Malaria, AIDS, TB, and other infectious diseases might be holding back life expectancy for most of the population in Africa, but the rate of increase of Chronic Disease, even in the minority that live to over-50 years is alarming. The reports of ‘sudden death’ in this group is increasing rapidly, and we know it is neither from AIDS nor Malaria, etc. because these ones actually kill the patient ‘slowly’. Anecdotally ( becausde there is not much resources for studying the phenomenon in these parts to give us scientific facts) we know that the sudden death has cardiovascular or endocrine causation. Type 2 Diabetes is rife and so are cancers and mental diseases. And their management is often below par. It is sad to see that Asthma management still largely revolves around xanthine oral and injectables. As is often the case Africa is yet to benefit from the revolution that has happened to Astham Management with inhaled bronchodilators and corticosteroids. The same applies to management of Diabetes Mellitus, Hypertension, etc.
    Therefore, setting up one of these centres which are mentioned in Richard Smith’s blog, in Africa, will benefit the sponsors, the world and ofcourse UnitedHealth Chronic disease initiative. Nigeria where I am based for now, has a population of 140 million people ( every fourth Black African is a Nigerian) and so economy of scale and size-of-cohort benefit will suggest that Nigeria should be considered for locating such a centre.

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