What Santa Could Bring to Health Equity

Last week, an article I’ve been working on for the past 12 months was published. It was about drug pricing in the US, not my usual focus but an important one. Its authors, Murray Ross and Anthony Barrueta of Kaiser Permanente, wanted to lift the lid on some of the reasons why prices are so high. Their core contention is that not enough policymakers really understand research and development (R&D) – despite all the hysteria – which is partly why policies continue to support an approach to pricing that is converting more and more of the public’s money into private wealth (and creating a few, not many, half-decent drugs along the way).
 
Why, you might ask, does it take 12 months to write a 2000-word article? A big reason is that it takes time to trulyunderstand a topic. You can read articles about it but that’s not the same as genuinely getting into the details. We did that through some research conducted by Knowledge Ecology International. They took drugs that had entered the market with astronomical prices and worked their way back through FDA approval, early clinical trials, the basic science that led to the product that would become a drug, and all of the patent registrations and licensing along the way. It’s only when you work that forensically that you truly understand a topic. 
 
But what value is an article in the so-called ‘peer-reviewed literature’ (in our article’s case, Health Affairs)? In my core work, ‘community and health’, for want of a better name, there is scepticism. Twelve months to write an article seems an insane amount of time to people dealing with the daily crises that are part of living at the sharp end of society. But those crises are constructed by policies, which are based on laws, which are based on ideas – and those ideas often sit in 2000-word articles that take 12 months to write. While I may be a hammer seeing a nail, those articles hold the ‘root causes’ of the daily crises. 
 
Don’t get me wrong, I’m not suggesting that all writing matters. Back when I was a medical publisher, there was an important article written by Doug Altman, an English statistician, in which he said that almost all medical research was scandalously poor. He described how researchers used the wrong techniques, used the right ones wrongly, misinterpreted their results, and drew unjustified conclusions. And yet most of this research gets published in the 40,000 or so medical journals out there, most of which are utterly rubbish. And then those articles are used to inform 2000-word articles that influence decisionmakers. 
 
The challenge – what one spends 12 months trying to do – is to find the signal in the noise. We read a bunch of 2000-word articles with ideas about pharma R&D and drug pricing, many of them in so-called ‘top’ journals, and while they were well-written they were often based on poor research. In essence, the authors were pushing ideas that had no basis in reality, either because they did not have the skills to understand what was real or because they were too lazy to work it out or because reality was inconvenient to their worldview (and, often, their vested interests). 
 
In ‘community and health’, I see this problem all the time – people and organisations are pushing ideas without really understanding them. The most important of these ideas is health equity. Inequities are differences in health outcomes which are unnecessary and avoidable, and considered unfair or unjust (here’s the ‘2000-word article’ that set that out in 1992). To describe something as inequitable, then, the cause has to be examined and judged to be unfair or unjust but rarely do you see this discipline in the use of the term. People are just labelling disparities as inequities without doing the work to find the unfairness or the injustice. 
 
Does this matter? Or is this just the finickity rant of an ageing words-person watching his skill get subsumed by A.I.? You’ll have a view, I’m sure; mine is that it matters greatly. If we’re going to address inequities, we have to do the work. Right now, the majority of people think that work is just to blame racism or the more exploitative forms of capitalism (which US health care is very much participating in, although the solution is not to go about killing its CEOs). But how is racism or exploitative capitalism affecting population health in unfair and unjust ways? 
 
To get into that, you have to go back to the seminal work on the social determinants of health – the 2008 report of the WHO commission. Although most people seem to know that it gave us the idea of the ‘conditions’ in which people live, few seem to have registered that it also said those conditions are created by “the wider set of forces and systems shaping daily life”. It goes on to unpack that further by saying that ‘forces and systems’ are things like “decision-making processes, policies, social norms and structures”. More recent work has, in my mind, superseded that by describing the ‘forces and systems’ as laws, policies, processes and norms.
 
If you want to call a disparity in health an ‘inequity’, show me the law, policy, process or norm that’s unfair or unjust. This level of precision matters because it defines the work that needs to be done. I’m working with some leaders of a health department right now that tell me that for all of the declarations of systemic racism as a public health crisis, there has been precious little follow up work to address it. They think that’s because most people don’t know how to go from the macroscopic observation to the microscopic work, from the big picture to the details. 
 
That’s why we write. While it’s nice to have an audience, the real power of writing is to test if you really understand something. The more we dug into pharma R&D, the more we realised we needed to understand. The more we tried to understand, the more we realised how bad most of the research was and how biased much of the 2000-word writing was. At some point in that 12-month process, we got lost, we wondered if we could really write anything useful. But with perseverance we realised we could. And now, aided by the fact that the article is in a respected peer-reviewed journal, some policymakers will take note and ask themselves how they can regulate R&D so that it isn’t primarily a vehicle for converting public money into private wealth. 
 
Where’s the equivalent work in ‘community and health’? Where’s the rigour that will convince policymakers? How do we move past the sloganeering – health justice! racial equity! resist, resist, resist! – to the focused, detailed work? I’m not sure. But what I am sure about is that it’s going to be hard to get there when a federal agency’s ‘illustrative examples’ of health equity work fail to identify the unfairness or injustice they’re allegedly addressing and when seemingly important public health initiatives focus on conditions without considering the ‘forces and systems’ that create them.

Perhaps Santa can bring a little discipline to the field. 
 
Merry Christmas and ‘see’ you in 2025. 
 
Pritpal S Tamber

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• Krysten Joyce of Kaiser Permanente also helped to create the article
• The image behind the title is by Barry Downard / Ikon Images