From the NYT: “There are not a huge number of side effects here, that’s fairly certain,” said the editorial writer, Dr. Charlotte Haug, an infectious disease expert from Norway, about the vaccine. “But you are giving this to perfectly healthy young girls, so even a rare thing may be too much of a risk.

“I wouldn’t accept much risk of side effects at all in an 11-year-old girl, because if she gets screened when she’s older, she’ll never get cervical cancer,” Dr. Haug said in an interview. “You don’t have to die from cervical cancer if you have access to health care.”  (NYT, August 18, 2009)

That’s all well and good if you live in Norway (or any other place where girls, women and the rest of society have good access to health care), so here’s hoping that Obama and the rest of our government can bring us up to modern standards and provide adequate care for all.

As I have written before, while we in the US like to get as much care as possible, there are situations when more care isn’t necessarily better, and that in many cases, patient factors should help decide the course of treatment. Prostate cancer screening is a prime example of a situation in which screening can lead to a whole host of uncomfortable and potentially life altering consequences (e.g. invasive procedures, impotence), and may or may not lead to a longer life.

While there are certainly many situations in which the best treatments are clear and effective, in cases where the relationship between cause and effect, and treatment and health, are murkier, more may not be better, and in fact may be worse.

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This type of controversy really gets my blood boiling.  Consider the following questions raised:

“Is an ailment a legitimate disease if you can’t test for it? A culture tells the doctor the patient has strep throat. But if a patient says, ‘‘Doctor, I feel hopeless,’’ is that enough to justify a diagnosis of depression and health benefits to pay for treatment? How many therapy sessions are enough? If mental illness never ends, which is typically the case, how do you set a standard for coverage equal to that for physical ailments, many of which do end?”

First of all, many “physical” illnesses also lack a hard and fast test– there is no test to tell the doctor if you have a cold, or in many cases why some people have lower back pain, but in those cases, we expect treatment.  Second, psychiatric diagnosis does not stem from one complaint alone (e.g. “I feel hopeless”), but rather requires a systematic review of patient history, current symptoms, and other factors, just like going to the doctor for physical illness.  Third, while many mental illnesses are chronic, so are cardiovascular disease and cancer, but few people would suggest that just because a disease is chronic, insurance should not be required to cover it. Furthermore, treatment can vastly improve the lives of patients, and make them more functional and productive members of society.

Mental health and physical health are linked, and many so-called mental illnesses have distinct biological bases (genetic, neural).   If anything, I would argue that the fact that we do not understand the biological bases of mental illness provides justification to invest more in research and give more attention to treatment.  Furthermore, I would venture to guess that if we provided adequate mental health services to those in need, we might actually reduce the overall burden of healthcare costs (countries that provide universal health coverage to their citizens often cover mental health as well, because it is the smart thing to do).  As noted by the NYT: “a 2006 study in The New England Journal of Medicine, examining the costs associated with a parity program put into place by President Bill Clinton for all federal employees, found that it actually didn’t increase the use or the cost of mental health services.” 

In the long run, the United States needs to think about prioritizing the health of the population.  This means covering those who need coverage, and it means considering the person as a whole. 

“The genetic variations, which encode nicotine receptors on cells, could eventually help explain some of the mysteries of chain smoking, nicotine addiction and lung cancer that cannot be chalked up to environmental factors, brain biology and statistics, experts said. ”

Similarly, one researcher commenting on the finding suggested: “This is really telling us that the vulnerability to smoking and how much you smoke is clearly biologically based” (psychiatry professor Dr. Laura Bierut of Washington University in St. Louis, a genetics and smoking expert who did not take part in the studies).

However, what both of these sources do not comment on is the fact that more and more evidence suggests that biology AND the environment interact to create health, disease, dispositions.  Certain genetic variations may lead to riskier profiles, given a stressful environment, but in some cases, the same genes that are riskiest under threatening conditions can also be most protective under nurturing conditions.   Following this type of exciting discovery, in my view, what will be even more exciting is to understand the way(s) that the genes identified interact with both the physical and social environment to allow some people with those genes to avoid smoking all together, some to become addicted immediately, and some to fall in between.  To say that genes will explain the “mysteries of chain smoking, nicotine addiction and lung cancer that cannot be chalked up to environmental factors, brain biology and statistics” is to miss the most exciting part of the story– the interactions between all of these factors.

In a recent talk about her work on risky families,  Shelley Taylor mentioned offhand that this work makes her think about recession in a new way– financial stress can place a major burden on families, which may lead to less supportive environments for children.  Is a pending recession a risk factor for depression and other health problems when children born today grow up?

One of the major findings of Taylor’s work is that the early childhood environment really matters.  The question is no longer about nature versus nurture, but rather about the interaction between an individual’s genes and his or her environment.  For example, in the case of the serotonin transporter gene, having two copies of the short allele, in combination with a negative early family environment, confers increased risk for depression and other problems.  In the context of a rich and nurturant early family environment, however, individuals with the short-short combination may actually do the best.  Researchers have conceptualized this in terms of “sensitivity to the social environment” (individuas with the short-short combo are highly sensitive to the social environment, whereas individuals with long-short or long-long may be less sensitive to the social environment and do pretty well either way).  Another good example is the MAOA gene– individuals who are low in MAOA, and who grow up in abusive contexts tend to have much higher probability of showing aggressive behavior (including violent arrests) than individuals who have high levels of MAOA or who grow up in supportive environments (see: Caspi, McClay, Moffitt, Taylor, & Craig: Role of genotype in the cycle of violence in maltreated Children.  Science. 2002).

Back to the question of a recession and its potential impact on children being born now, we don’t have data supporting or refuting this claim, but I have been thinking about the types of markers that might be able to address this type of question.  There is tons of evidence that socioeconomic status plays a major role in health, morbidity and mortality, but what does this mean for people when their financial position changes?   Will a recession now lead to more depression and health problems 20 years down the line?  Will the threat and stress of a potential recession have similar effects?