Tomorrow, June 22, 2010, the IOM will convene a two day conference at the request of HHS Secretary Sebelius titled: Assessing the Human Health Effects of the Gulf of Mexico Oil Spill. According to the IOM, “During the first day’s sessions, speakers and panelists will discuss the potential adverse health effects for humans stemming from the oil spill for various populations. Public attendees will also have an opportunity to submit questions to, and engage in dialogue with, the speakers and panelists. The second day’s sessions will explore current monitoring activities, the types of research methods and data sources currently available, and questions to consider when developing short- and long-term surveillance and monitoring systems.” (1)
At the end of the first day, I’ll be moderating a 1 hour open mic session where the audience members will have the opportunity to address the challenges of communicating health information in the middle of a disaster. This specific event represents a misread of historic proportions of the benefits of deep sea drilling over the risks of environmental catastrophe.
Tragedies such as the BP Oil Spill always generate a retrospective analysis of risk/benefit decisions that preceded the event. This is not only to make sense of what has occurred, but also to see what steps might prevent it from happening again. This in many ways is similar to what health professionals and health consumers struggle with in their daily efforts to care for each other. Let’s have look at that relationship and see what lessons might be applicable to our present day national challenge.
Though the health consumer movement is barely 30 years old in the United States, it has already entered its third phase. The first phase was emancipation, the realization and recognition that individuals have responsibility for their own health decisions and health management. The second phase, health empowerment, witnessed a move away from paternalistic patient-physician relationships toward mutual partnership models consummated by patient empowerment through education. Phase three is now underway as, together, engaged patients and family caregivers attempt to reorganize care delivery, moving toward prevention, healthy homes, and team support in both clinical and educational arenas. (2)
This third phase of the health consumer movement has placed the burden of benefit-risk decisions squarely on the patient’s shoulders, and US patients appear up to the challenge. Fully 94% agree that they must be more involved in health decisions, 92% agree that they must be in control of their own health, 89% agree that they need to take more responsibility, and 82% believe that, faced with a health challenge, they should be presented several treatment options with varying degrees of risk.(3)
Perceptions of risk are often overestimated or underestimated by the public. A National Academy of Science study, conducted in 1995, found that accidents, pregnancy, tornados, botulism, cancer, fire, snake bite and homicide were the most frequently overestimated risks, and small pox vaccination, diabetes, stomach cancer, lightening, stroke, tuberculosis, asthma and emphysema were the most underestimated risks.(4)
The point is, we consumers ( and corporations) often get it wrong. The numbers are increasingly clear, if not widely available to the average citizen. For example, the chances of death from heart disease are 1 in 385, from cancer, 1 in 519, from stroke 1 in 1,752, from an accident, 1 in 2,929, from suicide 1 in 9,170, from Alzheimer’s, 1 in 12, 458, from homicide, 1 in 14,857, from fire, 1 in 83,333 and from a bike accident, 1 in 369,881.(5)
But in the field of health consumer risk management, knowing the numbers is not enough, because science and self blend in risk assessments. Professor Paul Slovic, one of the nation’s leading experts on risk, explains it this way, “Patients rarely do an analytic assessment of benefits and risks; they follow their gut instincts about something. We have evolved to deal with risks by trusting our senses, perceptions and feelings about whether a situation looks good or bad or safe or dangerous. This very personal initiative process does not mix well with mathematical formulations of decision-making that we have come to value as rational.”(6)
No doubt, BP was following its gut instincts, cutting costs, focusing on profitability, and hoping for the best. Dr. Slovic’s research points out that our every day risk assessments, including those in health, are affective responses. If an activity is liked, people under-judge its risks and over-judge its benefits. If an activity is disliked, risks are over-weighted and benefits under-weighted.(7) BP liked deep water drilling.
How information is framed can also effect decisions and outcomes. For example, studies show that a “1-in-10” possibility of a poor outcome is seen as much more frightening than a stated “10%” risk of a poor outcome.5 And while air travel, on a per-mile basis, is 50 times safer than automobile travel, it is only five times safer on a per-hour-of-exposure basis.(8)
Finally, the classic experiment with lung cancer patients asked to select radiation or surgery as therapy. When told that 10% die from the surgery, more than 40% chose radiation. Yet fewer than 20% chose radiation when told that 90% survive surgery.(9) It’s unclear as yet whether BP and its outsourcers understood the risk, and if so, whether they emphasized the death or survival of the planet.
Those assisting patients in health decision-making must take care not to bias the patient by how questions or issues are framed. They must be equally aware of problems with health numeracy. (10) Health numeracy is the ability to understand the mathematics and statistics of health. Consider the fact that only one in five high school graduates can convert 0.1 percent to 1 in 1000, let alone comprehend “P value,” a common measure of statistical probability that results are tied to cause and effect, not just to chance.9 A “P value” of less than 0.01 means that there is a less than a 1% probability that the result occurred by chance. A “P value” of less than 0.05 means that there is a less than 5% probability that the result occurred by chance.(11) Communicating risk to consumers requires improvements in health numeracy, and the creation of statistics for non-statisticians.
What do the experts say are the keys to success in communicating risk and benefit? First, drain emotion from words. Attempt to present choices in a neutral format. Second, whenever possible, simplify. Use pictures, images, and simple math. Third, be mindful of your own prejudices. Decisions impact individuals, but they also impact families, communities, societies and the planet. All constituent’s interests must be considered. Fourth, define risk in absolute terms, the actual number of cases or outcomes expected in the target population. Fifth, remember that, while there is a risk to action, there is also a risk to inaction. The question isn’t whether an action is risky. Everything carries a risk. Rather the question is: “Is the risk I am about to take reasonable considering the benefits?” Clearly in the case of the BP Oil Spill, as is painfully obvious to all now, the answer is a resounding “NO”.
For HealthCommentary, I’m Mike Magee.
1.IOM Conference: Assessing the Human Health Effects of the Gulf of Mexico Oil Spill http://www.iom.edu/Activities/PublicHealth/OilSpillHealth/2010-JUN-22.aspx
2.Magee M and D’Antonio M. The Best Medicine. St. Martin’s Press. NY, NY 1999.
3.Magee M. Health Consumer Risk Management: Patients Perceptions of Pharmaceuticals and Health Risks (A Harris Poll). 2000.http://web.me.com/drmikemagee/Site/Publications.html
4.Baruch Fischhoff. Managing Risk Perceptions. Issues in Science and Technology. Fall, 1995: 2 (1) (c) National Academy of Sciences.http://sds.hss.cmu.edu/src/faculty/fischhoff.php
5.National Center for Health Statistics. 2001. Available at: http://www.cdc.gov/nchs/about/major/dvs/mortdata.htm.
6.Solvic P. Assessing and Communicating Risks and Benefits, The Pfizer Journal. Vol 4:5, 2001. p. 12.
7.Finucane ML, Alhakami A, Slovic P, Johnson SM. The affect heuristic in judgments of risks and benefits. J Behav Dec Making. 2000; 13:1-17.http://www.decisionresearch.org/research/affect/publications.html
8.No author listed. Living by the numbers: how to gauge your risks. UC Berkeley Wellness Letter. June 2000:4-5.
9.McNeil BJ, Pauker SG, Sox HC Jr, Tversky A. On the elicitation of preferences for alternative therapies. N Engl J Med. 1982; 306:1259-1262.http://content.nejm.org/cgi/content/full/330/26/1895
10.Schwartz LM, Woloshin S, Black WC, Welch HG. The role of numeracy in understanding the benefit of screening mammography. Ann Intern Med. [serial online.] 1997;127:966-972. Available at: http://www.acponline.org/journals/annals/01dec97/numeracy.htm.
11.Greenhalgh, T. How to read a paper: statistics for the nonstatistician. BMJ. 1997;315:422-425.