Health 2.0

The True Health 2.0 Unmentionables

At the recent Health 2.0 Conference, an unusual session highlighted the health importance of such “unmentionables” as job stress, marital worries and sexual dysfunction. However, despite the moderator’s inexplicable pride in a panelist’s mention of “vagina” – a topic certainly not lacking for Internet attention, albeit under more colloquial synonyms – the truly unmentionable subject was not sex, but the link between social class and health.

Unlike sex, talking openly about age and class distinctions makes most Americans squirm uncomfortably. Still, a number of speakers showed they understood that one of Health 2.0’s biggest challenges is proving itself useful to the population most in need of its help.

To start with, that means the elderly. Age brings an increased susceptibility to disease: half of Medicare beneficiaries are receiving care for one of six chronic conditions. Similarly, income is one of the most powerful predictors of health status. Those in the bottom 80 percent of adult income earners have an adjusted life expectancy almost 6 years shorter than those in the top 20 percent.

From that population perspective, two presentations stood out. The first was the partnership between Geisinger Health System and dLife. The second, for very different reasons, was the unveiling of Sharecare.

Geisinger and dLife are exploring whether online diabetic self-management support paired with the delivery system is more effective than conventional physician counseling for the “sickest of the sick.” About half the study participants are Hispanic, a little over a quarter are African-American and a fifth are white. Thirty-seven percent never finished high school. Literacy and computer skills are low.

“If [Health 2.0] will work in this population, it will work in any population,” said Margaret Rukstalis, a psychiatrist and the lead clinical investigator. By “work,” Rukstalis means a significantly improved outcome (lower hemoglobin A1C) in a randomized clinical trial, a rare form of proof until now in the Health 2.0 world.

Early data are encouraging, says Howard Steinberg, dLife’s CEO and himself a diabetic. He attributes this preliminary success to approaching diabetics “as consumers, not patients, with empathetic connection and practical solutions.”

Which brings us to Sharecare, a new question-and-answer health community created by Jeff Arnold, former CEO of WebMD, and Oprah’s favorite physician, Mehmet Oz. No one in America is more famously empathetic than Oprah, whose Harpo Studios is one of Sharecare’s funders, and no one reaches a demographic more tuned in to health concerns. Sharecare’s content partners also include famous names ranging from non-profits like the American Cancer Society to giant corporations like Johnson & Johnson.

If Geisinger represents the scientific gold standard, Sharecare embodies the commercial one, testing whether celebrity endorsement, brand names and a local/national marketing strategy can make Health 2.0 part of everyday life for the average American.

A variety of other companies are also trying to dismantle the barriers to Health 2.0 still confronting many Americans. As Richard Moore, a physician and member of the MIT Media Lab’s New Media Medicine effort put it, “When you use really interactive technology, if you make things really personalized and dynamic, [patient] education doesn’t matter.”

That and a few other passing references to differing education levels was about as close to mentioning social and class issues as any presenter, including those on the “unmentionables” panel, dared to get. So, for instance, when Richard Tate of the non-profit HopeLab demonstrated Zamzee, a program to engage kids in activities to reduce obesity, he mentioned that the rate of childhood obesity has tripled. What he omitted was the disproportionate surge among Mexican-American and African-American adolescents. You’d have to guess that race and ethnicity are important, and maybe something about socioeconomic status, from the faces on the website.

Similarly, Eliza Corp. president Alexandra Dranecould not bring herself to use words like “unemployed” or “jobless.” Eliza has created a non-profit subsidiary, Eliza Life, that promises a “deep, investigative, real-world approach” to taking on “issues that have historically been too uncomfortable, or too expensive, or too underground to address within our industry.”

Yet under “Basic Needs” in the famous Maslow hierarchy, Eliza lists “crappy boss” as one of the problems linked to survival.” It does not take an “investigative” approach to discover that nearly one in ten Americans is without a job and that having no job is a lot more hazardous to your health over time than a “crappy boss.” On the other hand, Eliza’s customers are corporations and health insurers, so perhaps the company’s “real-world approach” will enable it to discover unemployed and uninsured people.

I understand that Health 2.0 Con is not meant to be a social science seminar, an academic symposium or a political gathering. But just as a panel of venture capitalists at meeting’s end brought an economic reality check to the proceedings, there should be a societal reality check. Economic and social goals alike sometimes require a dash of cold water to replace drinking your own Kool-Aid, if I may be permitted a mixture of liquid metaphors.

Last Fall, I wrote that Health 2.0 could be an “extraordinarily powerful force for the democratization and personalization of information.” I still believe that, and I still appreciate Health 2.0 Con’s consistent effort to mix compassion into its capitalism, which, after all, was Alexandra’s goal and that of Matthew Holt and Indu Subaiya in scheduling the panel.

Nonetheless, no matter how noble your intentions or pure your heart, if you’re going to congratulate yourself on boldly addressing issues others won’t, then either address them boldly or back off from the self-congratulatory back-patting. The reality is that when it comes to health in America, race, income, education and age still count. As some Health 2.0 entrepreneurs start to address that reality, we should be proud to mention it.

Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of Demanding Medical Excellence: Doctors and Accountability in the Information Age .

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Ulrich WirthRichard TateWilliam Steinsmith, MD Recent comment authors
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Ulrich Wirth
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Ulrich Wirth

For an Euro like me it was very interesting to read about the “real unmentionables”, about the impact such social taboos still have in nowadays US. It reminds me of certain “unmentionables” we have in Germany, let’s say the link between educational opportunity and what we call “migration background”. Once it gets mentioned in an outspoken way, there’s always a turmoil in talk shows and in the feuilleton and after the dust has settled people begin to discuss.

Richard Tate
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Great post, Michael – and you’re right, I failed to mention onstage the disproportionate incidence of sedentary behavior and obesity in minority and lower SES communities. But it’s something the HopeLab team and I are keenly aware of – in fact, the socio-economic contexts of our target users have been top of mind for us in developing Zamzee. (And you’re right that our visual communications on our website intentionally acknowledge this.) With more time, I might have shared a slide we often present that overlays some of our own human factors research with young teens overlayed with data from NEJM… Read more »

William Steinsmith, MD
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William Steinsmith, MD

Refreshing to find this lucid outline of the skewed demography of lifespan and medical well-being based on class, race, and ethnicity. Serious systemic reform of the fraying US clinical system is not feasible without accounting these telling disparities.