Sábado 10 de Enero de 2009

A governor with no money seeks to improve the people’s health
Por Anemona Hartocollis

Snacking on shrimp and carrot sticks, doctors and nurses gathered at N.Y.U. Langone Medical Center to celebrate the opening of a new research center called the Center for Healthful Behavior Change.

They were tapping into the spirit of the times, and now Gov. David A. Paterson has done so as well, turning the familiar call for political change into an appeal for healthful living as he promotes a number of anti-obesity measures, from a sugar tax on soft drinks to posting calorie counts in chain restaurants.

He has joined what has become a movement looking inward, asking people to blame themselves for their bad health. But behind the governor’s agenda there is a truth as constant as failed New Year’s resolutions: Lifestyle changes are easier said than done. Changing ingrained behavioral patterns, doctors say, can be as hard as getting legislators to pass an income tax increase.

At the N.Y.U. opening, in mid-December, Dr. Robert I. Grossman, dean of the School of Medicine, said it was “relatively easy” to define molecules or understand abnormal conditions. But, he added, “Our failure as a society has really been to appreciate the difficulty in modifying behavior.”

It is hard to fault the governor for trying. When there is no money, the challenge for smart politicians is to present an agenda that does not seem to cost anything. His health agenda, much of it needing legislative approval, echoes public health campaigns pioneered by Mayor Michael R. Bloomberg in New York City and Gov. Arnold Schwarzenegger in California.

His most aggressive proposal is to charge an 18 percent tax on sugary soft drinks (but not diet drinks), which he estimates would reduce consumption by 5 percent and raise $400 million in revenue. Following New York City’s lead, he wants to ban trans fats in restaurants, require chain restaurants to post calorie counts, and increase the number of markets selling healthy foods in poor neighborhoods. He also wants to ban junk food in schools and has deputized his wife, Michelle Paige Paterson, to encourage children in middle school in five upstate cities to walk more.

In what may prove to be his most appealing proposal, at least for families, the governor wants to require insurance plans that cover dependents to insure children up to the age of 29. Typically, insurance plans now cover children through the age of 18, or 22 if they are in college, and nearly one-third of New York’s uninsured are 19 to 29 years old, according to the governor. He said the cost would be borne not by employers, but by families, who would be able to take advantage of group rates.

As Governor Paterson summarized it, “Preventing illness is a good investment.”

But experts say that while prevention has intuitive appeal — everyone knows the old saw that an ounce of prevention is worth a pound of cure — its ability to save money and lives may be overrated. The devil, as it is so often, is in the details.

“There’s a lot of buzz about prevention,” said Peter J. Neumann, director of research at the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center in Boston. “In general, I am sympathetic to that, but you have to be careful about what you’re claiming and about the science and the evidence.”

The evidence over the last 40 years has shown overwhelmingly that prevention rarely reduces medical costs, partly because many people who are at risk of a disease may not develop it, said Louise B. Russell, a research professor at the Institute for Health, Health Care Policy and Aging Research at Rutgers University. But, she said, “It’s what people keep claiming when they say we’ll just cover more prevention and that will save Medicare and Medicaid costs.”

While there is good data that links stopping smoking to preventing lung disease, she said that as far as she knew, there was little data on the health value of a soft-drink tax or of banning junk food in schools. This is partly because the value is so hard to measure. People who are deterred from buying soda might substitute other sugary drinks. Students deprived of junk food might still nibble some of the candy they sell for school fund-raisers.

Dr. Russell said that what struck her about the governor’s agenda was that it took health care outside of the medical sector, like food and water regulations. “You don’t go to a doctor’s office, you go to a greenmarket,” she said. “You’re not in a hospital when you get those calorie counts.” To some degree, she said, the governor’s seemingly low-cost proposals represent a subtle kind of cost-shifting, with little recognition of the impediments. It may be hard to walk in suburban neighborhoods with no sidewalks, or hard to leave work early to go to the gym or cook a healthy meal when jobs are scarce. “In fact, time is one of our ultimate scarce resources,” Dr. Russell said.

Ron Z. Goetzel, director of Emory University’s Institute for Health and Productivity Studies, agreed that institutional support, like opening up staircases at work or flexible scheduling, is important when it comes to lifestyle changes.

Still the evidence for the efficacy of lifestyle change may be trickling in, according to Mayor Bloomberg, who recently celebrated a 15-month increase in life expectancy for New Yorkers between 2001, when he was elected, and 2006.

The N.Y.U. center’s director, Dr. Olugbenga G. Ogedegbe, said his own studies showed that patients were turned off by being told that something terrible would happen if they did not take their medicine or eat right or exercise. “Positive psychology can help in the adoption of healthful behavior,” he said.

Of course, the beauty of the governor’s plan is that if you fail, you have only yourself to blame.


  10/01/2009. The New York Times.