The Obesity Epidemic and the Rise and Fall of Public Health

David Gratzer (HealthcarePapers, 9(1) 2008: 57-60)

"They don't understand how this could happen. I tell them that they have crushed their knees under their own weight." -----------------------------------------------------

I'm at the annual meeting of the West Virginia Medical Association, and the conversation has turned to obesity. My colleague, an orthopedic surgeon with a local practice, explains how his clientele has grown younger with each passing year. Whereas he used to operate on people in their 70s for hip and knee replacements, he now sees patients as young as 40. How can a 40-year-old ruin his knees? The doctor describes patients with body mass index (BMI) values of 45 - the equivalent of 152 kilograms (335 pounds) for a man with a 1.8-metre (six-foot) frame. No one at my dinner table is shocked. In West Virginia, such stories are too common. The state ranks as one of the fattest in America, ranked second overall for obesity. Whereas obesity rates in America are high, West Virginia is the ground zero of this ailment: 30% of the population has a BMI exceeding 30. And like the rest of North America, this is a new phenomenon: in 1991, no state's obesity rate exceeded 20%. More troubling still is the fact that, on paper, West Virginia seems to have done everything right. For a generation, schoolchildren have learned about good nutrition - it is part of the curriculum. Public officials have gone as far as to study the use of video games such as Dance Dance Revolution in physical education classes. And politicians have implemented a variety of policies favoured by Seeman and Hobbs in their papers: bringing together stakeholders and nudging people in the right direction with everything from taxes on junk food to regulating school lunch options. Yet, it doesn't seem to matter. West Virginia's problems have been getting worse in recent years. Is West Virginia the future of North America? It could be. How are we to avoid this fate? Start by looking at the rise and fall of public health. A Brief History of Public Health Dr. Sara Josephine Baker was a pioneer, helping to save the lives of tens of thousands. She did this without magnetic resonance imaging or even a computed tomography scanner. Like many of the leaders of public health in the early 20th century, she focused her work on the poor. Among her initiatives was setting up a milk station in Hell's Kitchen, thereby enabling poor children to get clean, pasteurized milk. Dr. Baker didn't invent pasteurization, nor did she perfect it. Her work simply aimed at making basic food products safe and available. For much of the 20th century, public health focused on a handful of goals to improve the environment people live and work in: sanitation, clean water and safe food. Across North America, Dr. Baker and her colleagues made it possible to grow up and grow old. Coupled with a long-standing commitment to immunization, public health officials can largely take credit for the incredible leap in life expectancy over the first half of the 20th century. Their methods may have been straightforward, but the results were extraordinary: the expansion of life expectancy during the age of Dr. Baker exceeded the expansion seen during the medical revolution of the latter half of the century. But public health did relatively little to change people's behaviour. That is, until 1964, when a government committee issued a report and saved millions of North American lives. In a balanced review, the Surgeon General's Advisory Committee Report Smoking and Health acknowledged the benefits of smoking (including its relaxing qualities); it also concluded definitively that tobacco is linked to cancer. The report had a profound effect. Today, people widely accept the connection between tobacco and cancer. In the 1950s, people were less certain - in 1958, only 44% of Americans saw the link. Why? It wasn't for lack of evidence: by 1950, the Journal of the American Medical Association (JAMA) had shown in a large sample that 96.5% of the lung cancer patients were smokers." By 1958, JAMA published another landmark study showing that cancer and smoking go hand in hand. But the tobacco industry had been clever, buying advertising and physicians to contradict the evidence. But the report of 1964 was a game changer. The committee members spent 14 months reviewing the world scientific literature and concluded that "cigarette smoking is a health hazard of sufficient import in the United States to warrant appropriate remedial action" (page 33). By the late 1960s, 71% of Americans believed that smoking causes cancer. And so began a decades-long fall in smoking rates. When the report was issued, roughly half of adult Americans smoked; today, the rate is down to one in five. If the surgeon general's report changed America, it also had a profound effect on public health. Gone were the days when it focused on environmental factors in health. Inspired by the success in the war on smoking, public health now focuses on bettering people and the choices they make. Today, public health is as much concerned with safe sex as it is with safe food. But there is a problem with this approach: it applies a 1960s solution to 21st-century problems. The surgeon general's report was issued at a time profoundly different from today - before the Internet and mass health literacy. Indeed, the war on smoking itself has fallen on hard times, with smoking rates remaining relatively stable over the past decade despite a record amount spent by governments on education. How Are We to Address the Obesity Epidemic? In many ways, the solutions outlined in the papers by Seeman and Hobbs simply wish to continue on as public health has for the past four decades, seeking to inform and push people toward better choices. Professor Hobbs, as an example, writes, "As a business owner, for example, I may prefer not to reveal the high level of artery-clogging saturated fat or trans fat in the cookies I market. However, government regulations - the rules - may require me to list on the package label the nutritional content of my product." Later, she argues for some type of government leadership in this field, and I assume that she applauds the efforts of cities like New York to make caloric counts mandatory on some restaurant menus. It's hard to argue against such transparency measures. It's also hard to feel that this is particularly useful. In this day and age, does anyone really consider cookies - heavy with trans fats or otherwise - to be healthy? Speaking of New York, do people really walk into a McDonald's with a milkshake on their mind but not understand that this is a high-calorie snack? Hobbs bemoans the "underfunded educational campaigns" of the Bush Administration, but has it ever been easier for people to get informed about good eating habits? Seeman, too, finds much comfort in education and transparency. He envisions teenagers mentoring children on how to be physically active. Again, it's hard to argue against such a measure. But is childhood obesity really stemming from children who don't know how to run around? Will such programs teach children how to play tag or monkey-in-the-middle? Hobbs and Seeman do of course advocate many other ideas. That said, these ideas seem antiquated. Both Hobbs and Seeman think that it's the government's role to make exercise more available; they have fashioned themselves as modern-day Dr. Bakers, except that they want to regulate sidewalks and parks (Hobbs) or grant tax-subsidized gym memberships (Seeman) instead of building milk stations. The approaches of Hobbs and Seeman differ - between the stick and the carrot - but the goal is the same: to get America off its couch and out of the house. But what to make of the West Virginia experience? The state is one large rolling park. Surely the problem there is not a dearth of green space but people's lack of motivation to use it. In fact, American's have never had more disposable income or leisure time, making it easier than ever to buy a skipping rope from the local Wal-Mart and then use it. How are we to deal with the obesity crisis? First, we can all agree that government policy shouldn't directly foster bad habits. Hobbs is right when she points out that some cheap food, particularly corn syrup-based food, is a consequence of agricultural subsidies. FDR's New Deal may or may not have lifted America out of the Great Depression, but the ongoing subsidies of corn aren't helpful. Second, we can consider the various indirect subsidies of poor health decisions. Many Americans receive their health coverage from Medicaid (the poor) or Medicare (the elderly). Should taxpayers foot the bill for morbidly obese Americans without any restrictions? Non-government healthcare, whose underpinning is the US Tax Code, also indirectly subsidizes the unhealthy with the health dollars of the healthy - the three-pack-a-day smoker two cubicles down from the fit gentleman pays basically the same monthly premiums. Is that right? Ultimately, though, I wonder about the limits of government policy. FDR's corn subsidies existed for decades before America grew fat. For all the indirect subsidization of healthcare, being medically ill seems a more overwhelming deterrent than a good deal on an insurance premium. The recent obesity trend seems to be more about cultural acceptance than government policy. Lawsuits argue that the obese are discriminated against; overweight actors win prized roles and then proclaim their win for the overweight; prominent citizens discuss their inability to lose weight. Even our language has changed - we talk about the "obese" and not the "fat." What then should our politicians do? Legislation will take us only so far. For other major cultural trends - from the decline in divorce to the drop in drinking and driving rates - it has largely been about people speaking up and leading by example. Maybe our politicians can toughen up their language and speak more like this: "We talk about people being 'at risk of obesity' instead of talking about people who eat too much and take too little exercise. We talk about people being at risk of poverty, or social exclusion: it's as if these things - obesity, alcohol abuse, drug addiction - are purely external events like a plague or bad weather. Of course, circumstances - where you are born, your neighbourhood, your school and the choices your parents make - have a huge impact. But social problems are often the consequence of the choices people make." The speaker isn't from West Virginia but from Britain: David Cameron, the leader of the opposition. But his fundamental idea, that one's life is his or her responsibility, is distinctly American. About the Author David Gratzer, MD Senior Fellow, Manhattan Institute One of a series of related papers in the journal Healthcare Papers. References Cameron, D. Speech in Glasgow. Retrieved July 7, 2008. < http://www.telegraph.co.uk/news/newstopics/ politics/conservative/2263705/David-Cameron-attacks- UK-moral-neutrality---full-text.html > . Surgeon General's Advisory Committee on Smoking and Health. 1964. Smoking and Health. Report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington, DC: US Department of Health, Education, and Welfare. Wydner, E.L. and E.A. Graham. 1950. "Tobacco Smoking as a Possible Etiologic Factor in Bronchiogenic Carcinoma; A Study of 684 Proved Cases." JAMA: Journal of the American Medical Association 143(4):329-26. Hammond, E.C. and D. Horn. 1958. "Smoking and Death Rates - Report on Forty-Four Months of Follow-up of 187,783 Men." JAMA: Journal of the American Medical Association 166(11): 1294-1308.

Workplace Rudeness: A New Pandemic?

Neil Seeman

Smartphone addiction (Blackberry or iPhone) during meetings, showing up late for meetings, and a lack of "Thank-yous" are infecting the workplace. Healthcare is no exception.

What can be done to reverse the trend? Equally important, is workplace rudeness a public health issue? There are few legitimate excuses for everyday rudeness. Let's forget about our intensely busy selves; the tough economy; or demanding clients or colleagues. We all know that the busiest people, under the most stressful of circumstances, can be the most polite and responsive in the simplest of ways. Low-tech approaches could help turn the tide. First, my brother, a globe-trotting entrepreneur, has a tag line on his e-mails saying: "Apologies for the curtness of this e-mail; I'm typing with my thumbs." Second, some industry associations now instruct members to respond to correspondence within 24 hours. This is eminently feasible - if you check e-mail even once a day (a policy I recommend for efficiency), and, if busy, say you'll reply at a later date. Last, be tactful if using an out-of-office message. I've seen someone flare in their out-of-office subject line: "VACATION" - nothing more. I asked a former hospital CEO how to get around the problem of email jail and general time crunch, and he advised, "Hire an EA." "What's that?" I asked (seriously). (It's an Executive Assistant). But there may be a simpler, less expensive and more personal solution. I think the social remedy to workplace rudeness is, paradoxically, to be more blunt. Be blunt about being late for a meeting Tai Huynh, a colleague of mine, tells me: "I personally dislike people arriving late to meetings. I think it's rude, disrespectful to colleagues (especially if the late person is the organizer) and eats into valuable meeting time. For me, the rudeness clock starts ticking at about the 5 minute mark. At about 10 minutes, the disrespect factor kicks in and by about the 15 minute mark, I wonder why the person bothers showing up." I figure that toting up the costs to the health system of people being late for meetings - i.e., assessing the waste by reference to the total annual salary of attendees who agreed to come but were late - could save the system significant sums if we are transparent about these costs. Be blunt about meeting unnecessarily According to Glenn Parker and Robert Hoffman, authors of Meeting Excellence, knowing the expense of meetings may be an impetus to make meetings more productive. I believe this could be especially powerful in the culture of health policy, where, to quote one globally renowned physician-researcher, the running ethos is to "to meet to plan to partner." Better to make a decision to partner - or not - at the first meeting, and to start the partnership project (i.e., writing things down) at the first meeting. If you exceed two cancellation notices prior to landing at the first meeting, you know it's not worth it. Messrs. Parker and Hoffman point to a survey conducted at the Milwaukee Area Technical College that recorded the time that members of the college's 130-person management council spent in meetings. The evaluators used salary as the basis to calculate how much this time was worth. Meetings reportedly cost the college more than $3 million US per year. I know managers who charge people money who are late for meetings. I personally don't like this approach. I have young children: I know just enough about psychology to suspect negative incentives generally don't work in this context. People just end up grousing at the boss. Besides, often times the reason for being late for the meeting is because you've had back-to-back meetings all day and the first one started late. After all the meetings conclude, I've been told by some very senior people in healthcare that the day's real work happens "off line" - whatever that means. Be blunt about the use of smart-phones while meeting with someone Personal digital assistants are another curse. So-called "intraviduals" (a term invented by author Dalton Conley in Everywhere, USA) are neither here nor there when tied to their Blackberry. A friend of mine, economist Patrick Luciani, calls this the "excuse-me-your-Highness-I-have-to-take-this-call" syndrome; even when speaking to the Queen, the other call is always more important. I had the pleasure of speaking recently with a wise man who told me that, not long ago, it was the height of rudeness to take another call while speaking to another. Nowadays, it's the new normal. "Of all of the standard irritants, uncontrolled BB use is the largest," writes Borys Chabursky. He tells me of an incident where two individuals came in to interview him for a project. "They asked a question and I would start answering and as I did, they would start checking their emails on their BBs. When I suddenly stopped speaking, they, without looking up said, 'it's ok, we're listening, just keep going.' I couldn't believe it and just stopped the interview." We need leaders in healthcare to rebel against the culture of passive-aggressive behaviour, Blackberry addiction and meeting creep. Several years ago, University of Michigan-Ann Arbor psychologist Lilia Cortina found that 71% of workers had been mocked, taunted, ignored, or otherwise treated uncivilly by their coworkers and bosses. Last summer, researchers at West Chester University in Pennsylvania found that 75 percent of workers are treated rudely by bosses or colleagues at least once a year. I could not find any comparable Canadian data. If you know of comparable data in healthcare, please share. Give incentives for good communication manners When we talk about "a healthy workplace" in hospitals or care facilities, we often refer to policies and protocols that enforce existing health and safety legislation. Innovative initiatives like the Healthy Healthcare Leadership Charter, created by the Quality Worklife-Quality Healthcare Collaborative (QWQHC), are making important strides forward to cultivate healthier healthcare workplaces. Imagine if basic civility were the touchstone for a healthy workplace. That might go a long way to saving money, stopping burn-out, and promoting happiness at work - and at home. Say "Thank You" more often I invite you to express your gratitude and send a "thank you" note to someone who is making a difference to help put a stop to the incivility disorder in the workplace. Thank you for reading this. About the Author Neil Seeman, a Longwoods essayist, is Director and Primary Investigator of the Health Strategy Innovation Cell, based at Massey College at the University of Toronto.

AMA, BMJ, and the Innovator’s Transparency Rule

By Neil Seeman

As of the time of writing, we do not know all of the facts in the current controversy surrounding the Journal of the American Medical Association (JAMA). Reportedly, JAMA editors threatened a researcher, Jonathan Leo, who had criticized the author of a 2008 JAMA research paper. Dr. Leo’s rebuke appeared in an online letter in the British Medical Journal (BMJ).

The American Medical Association has asked an oversight committee to investigate the events. Dr. Leo, a neuro-anatomy professor at Lincoln Memorial University, alleges that senior JAMA editors threatened him and his dean following his publication of the BMJ letter. Dr. Leo’s BMJ letter criticized how results were reported in the 2008 JAMA study that looked at the use of Lexapro, an anti-depressant medication, in stroke victims. Dr. Leo claimed that JAMA did not appropriately disclose the author of the JAMA study’s financial relationship with Forest Laboratories Inc., the maker of Lexapro. Forest disclosed that it had indeed paid the author for speeches, but maintained that his Lexapro research was independent.

According to Dr. Leo, based in Harrogate, Tennessee, JAMA editors insisted that Leo retract the BMJ letter. Further, in an explosive allegation, he reportedly claims JAMA’s executive deputy editor, Phil Fontanarosa, told him, “You are banned from JAMA for life. You will be sorry.” Dr. Fontanarosa has disputed this version of events. Ray Stowers, the dean of Dr. Leo’s faculty, claims JAMA editor-in-chief Catherine DeAngelis told Stowers during a telephone conversation that she would “ruin the reputation of our medical school” unless Stowers forced Leo to retract the BMJ letter and stop speaking to the media. Dr. DeAngelis has denied this.

Further, in an online editorial on the JAMA Web site, Drs. DeAngelis and Fontanarosa accused Dr. Leo of a “serious ethical breach of confidentiality” by wading into alleged problems with the JAMA study whilst the medical journal was investigating the controversy. The JAMA editors said that, in future, anyone complaining of an author failing to report a conflict of interest would “be specifically informed that he/she should not reveal this information to third parties or the media while an investigation is under way.” Here is Dr. Leo's response to the JAMA editorial.

Is the JAMA policy even possible to enforce? Does it serve the interests of innovation and the scientific process? Leaving aside the potential worries about free expression (both for the critic making the allegation, and for the journal publishing it), keep in mind that in the age of health 2.0, most critics of scientific research are not academics. They are patients and their families. In the days since this story emerged, my quick search on Google and online health blogs suggests that at least several dozen bloggers have echoed Dr. Leo’s concerns about conflict-of-interest in the original JAMA article. It can get tricky to try to discipline every research critic on the Web.

The time when editors knew best is passé. Whether or not the army of reader/critics on the Web is right or wrong, they cannot, and will not, be silenced. Transparency governs.

Ignore criticism at your peril

The JAMA controversy reminds me of another industry that failed to heed the transparency rule. When I worked in the newspaper business in the pre-Internet era, we had space for roughly 10 letters, yet 10-15 times that number flowed in by fax or letter every day.

Today, print newspapers are suffering heavy revenue declines (and in some cities, have disappeared altogether) because of not taking criticism and openness seriously. The venerable Rocky Mountain News is defunct. The Tribune Co., owner of the Los Angeles Times and the Chicago Tribune, has filed for bankruptcy. The Seattle Post-Intelligencer is now online only. And just two weeks ago, the San Diego Union-Tribune was sold to a private-equity firm.

Notably, mainstream newspapers such as the Wall Street Journal that were among the first to embrace aggressive reader criticism via blogs, early amid the ascendance of the Internet, are the only ones today that enjoy sustained readership and continued influence. For anyone in the information business, the new mantra is no longer “content is king”. It’s “transparency rules.”

The demise of mainstream newspapers should be a lesson to the titans of research and innovation. Heed the transparency rule: embrace openness or wither on the knowledge vine.

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Neil Seeman, a Longwoods essayist, is Director and Primary Investigator of the Health Strategy Innovation Cell, based at the University of Toronto’s Massey College. He is also an adjunct professor of health services management at Ryerson University and writes the “Second Opinion” health innovation column for the National Post. neil.seeman@utoronto.ca

Privacy has lost its “cool factor”…

Neil Seeman

According to the Talmud, there are two times you’re allowed to boast: when courting a potential spouse, or when looking for a job. In the current recession, many people are searching for a job, and so put their best résumé forward for everyone to see. Scanning the world of healthcare résumés posted freely on social networks such as Linkedin reveals a trend: privacy is out, “publicness” is hot.

As of the time of writing, Linkedin – the leading business professionals’ network online – included the résumés of 653 people working in the “hospital and healthcare sector” who described themselves as privacy professionals. More than twice as many (1,559) described themselves as patient advocates. The largest professionals’ discussion forum dealing with privacy had 867 members; the largest “health 2.0” discussion forum (of which there are many) had 4,888.

A limitation on my analysis: by definition, the very people who use Linkedin to look for employment or to connect with other professionals in their field – 35 million registered users and growing – are people who believe in what author Jeff Jarvis calls “publicness”.

Web 2.0 means social collaboration on the Web. Most “health 2.0” enthusiasts embrace “publicness.” “Publicness” is the new ethic of transparency in all things. Social networking sites such as Facebook, Linkedin, Twitter and MySpace trade off people’s growing willingness to disclose details about their personal lives, accomplishments…and their failures. Twitter, the fastest-growing Web phenomenon, is completely open source. Every entry is searchable on Google.

Contrary to popular myth, the ethic of publicness is much less about vanity than about a fundamental belief that “letting it all hang out” is a value system to be admired. This is part generational (so-called “Generation G”) and partly a function of our loss of faith in Wall Street and its culture of opaqueness. Even Swiss bankers are embracing publicness. Healthcare is not far behind. As the Wall Street Journal’s L. Gordon Crovitz has written, “a right to privacy seems to be transforming into a duty to disclose. We can know more, so we expect to know more.”

…it’s about control

Health 2.0 websites such as patientslikeme – which boasts a heavy contingent of Canadian users – allow members to share treatment and symptom information in real-time in order to monitor and to learn from real-world outcomes. As of March 2009, there were reportedly more than 11,000 users with multiple sclerosis, 8,000 with mood disorders, 3,500 with amyotrophic lateral sclerosis, 3,000 with Parkinson’s disease, and 2,000 users of the site with HIV.

As Jarvis writes in What Would Google Do?, “Privacy is not the issue. Control is. We need control of our personal information, whether it is made public and to whom, and how it is used.” Patients who “let it all hang out” on patientslikeme – name, age, location, symptoms – care more about controlling how their information gets used than about whether fellow sufferers can access it.

The same is true for job-seekers. In the old world, the perfect candidate for the CEO’s office – or for the entry-level position – was someone with an unblemished past. Today, the perfect candidate is someone who has disclosed his or her past missteps online. The superstar healthcare employees of today still boast about their accomplishments, but also about how they have learned from failure and humility.

Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell, based at Massey College at the University of Toronto.

DSM-Twitter: Are We Happy Or Sad Right Now?

Neil Seeman and Carlos Rizo

Sadness is a global phenomenon. It is also challenging to measure in a timely manner. Imagine if we could measure it in real-time and reach out to those in need with more immediacy. We think we can.

March 12, 2029 (CBC.ca) - Canada's happiness index has risen to the level of Denmark's for the first time in two decades, capping a five-year run on the back of booming demand for the nation's improvement in mental health. The Canadian happiness index rose as high as $1,000.800 smiley emoticons before dipping to 998.700 smiley emoticons at 4:16 p.m. on the New York exchange. It has soared 62 percent from a record low of 617.667 smiley emoticons in 2002. The Canadian happiness currency last closed above $1M on Nov. 25, 2008, when Stephen Harper was Canada's prime minister. In other news...

Researchers are accustomed to estimating the prevalence of mood disorders through surveys or through analysis of physician billing databases. The data are disquieting. In any given year, surveys suggest about 8% of Canadians will suffer clinical depression at some point in their lives. Other approaches to measuring prevalence rates include reviewing expert opinion and conducting epidemiological surveys.

Dr. Dan Bilsker and colleagues showed in a 2007 paper in the Canadian Journal of Psychiatry that the physician-treated prevalence of depression in British Columbia grew from 7.7% in 1991-1992 to 9.5% in 2000-2001. More than 95% were seen by family physicians, and in the final year, just 7.5% were seen by psychiatrists. In an alarming statistic just published in the same journal, Mel Slomp and colleagues in Alberta, using physician databases, report a 35% treated prevalence rate for mental disorder (mainly anxiety and depression) for adults seen over a three-year time period.

Introducing DSM-Twitter: A real-time happiness measure
There are roughly 8 million Twitter users, according to a February 2009 report by Compete.com. As the online encyclopedia Wikipedia explains, Twitter "enables its users to send and read other users' updates (known as tweets), which are text-based posts of up to 140 characters in length. Updates are displayed on the user's profile page and delivered to other users who have signed up to receive them."

We were curious as to what Twitter would reveal about the mental health of Canadians. The results are fascinating. So-called "tweets" are often accompanied by "emoticons". In Twitter, the emoticon :) or :-) means happy or joyful. The emoticon :( signifies sad. The double string, :) :), means very happy or :( :( means very sad.

Using our real-time analysis, there were 417 tweets - within 15 miles of Toronto - expressing sadness (or what Twitter calls a "negative attitude") during 17 minutes on March 12 (from 1:06pm EST to 1:23pm EST). During the very same time frame, there were 1,500 tweets from Toronto showing happiness or a "positive attitude." This suggests that the ratio of happy comments to sad comments in the Toronto area was 3.6 to 1.

Is DSM-Twitter "scientific"?
The scientific process is in flux - in large part because the dynamic data available on the Web are growing at a stunning pace. Admittedly, our approach is far from perfect. Among other things, expressions of sadness may result from Twitter service outages, downturns in the stock market, bad sports results, frustrating weather conditions, traffic, or even the playful use of the emoticons. Still, social networking and micro-blogging services such as Twitter are entirely public (to which users consent), increasingly rich - and free! - tools of analysis. This, while the old-world scientific method is under renewed attack because of alleged bias, plagiarism and even fraud, inadequate methodology, and the fraternity-esque culture of peer review. We feel that peer review, critique, replication and validation are essential to innovation. However, we do need to quicken the pace of inquiry in order to enrich our understanding of the fast-changing world.

New paths of investigation
In a 12-hour period on March 12, we found 260 Vancouver-area tweets (connecting from many gadgets, including cell phones and Blackberries) which demonstrated joy. Eighty Vancouver-region tweets expressed sadness during this same time.

It may be unsettling to know that we might be sadder than earlier survey findings indicate. Yet, at the same time, it is exciting that we may have a way of capturing mood trends in real time. With Twitter, we may even have a new device to help reach out directly to the people who are suffering right now. One tweet at a time. :)

About the Author
Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell, based at Massey College, University of Toronto. He is "the Thank you Twitterer" at twitter.com/neilseeman and writes on health innovation for Longwoods and the National Post. Carlos Rizo is the Innovation Cell's Chief Imagineer. He has a Twitter grade of 98/100 (twitter.com/carlosrizo).

Correspondence: neil.seeman@utoronto.ca

A Westjet Health Care System?

Steven Lewis

I fly a lot - too much actually; I am chagrined by my carbon footprint. Most of my flights are on Air Canada (AC), indisputably an international class, full-service airline. You can go pretty much anywhere in the world on AC or its Star Alliance partners. You can pick your fare, frills, seat, and class. I've been an Elite AC member for about 15 years, so I get to wait for my flights in swanky lounges with free food, booze, newspapers, magazines, and business centres. I get free flights from the Aeroplan miles I accumulate and an annual stack of upgrade certificates. I get a special number to call if I need to change a reservation or seek help. Cool, eh?

But I fly Westjet (WJ) whenever I can, and would happily abandon AC altogether if WJ decided to go after the Saskatoon-to-wherever (especially Toronto) business traveler markets. Why? What would lead me to turn my back on the airline that gives me all this stuff, and what accounts for the almost giddy affection for the one that doesn't? Here's my hypothesis: it's because Canada's airlines are akin to the health system we have (AC) and the health system we need (WJ). Here's how.

What do I need? Business class to Kuala Lumpur? Single malt scotch in the lounge? Special meal? AC can do it. WJ? No can do. AC is pretty good at tertiary air care; WJ is the primary care airline. Most travel needs are primary: a reasonably priced ticket, leave on time, decent legroom, a modern aircraft. My own travel life is, well, pedestrian: Calgary, Vancouver, Toronto, Ottawa, Winnipeg (quit smirking - I like Winnipeg). WJ gives me a Boeing 737 with good overhead luggage capacity and a quiet ride - every time, all the time. AC gives me cramped Bombardiers that force passengers to compete for comically little carry-on baggage room. Advantage: WJ for the basic journeys; AC for the continental transplant operation.

What happens when there's a problem? Planes break down and weather mocks schedules. The test of an airline is not when things are ticky-boo; it's when misery descends. AC appears to believe that keeping the passengers in the dark about why the flight is delayed is reassuring, and that parcelling out the delays in two hour increments is comforting. "The 2 o'clock flight that was to leave at 4 is now departing at 6. We can't tell you which gate." WJ makes it a point to tell you what's happening. Call AC with a problem and you almost feel the blame-the-passenger vibes as the agent leafs through the policy manual to confirm your non-entitlements. WJ seems to want to help. AC has done some nice things for me, but WJ has performed truly heroic feasts of creative problem-solving and in one case was generous beyond the call of duty. Advantage: WJ on both comportment and delivery.

Surprise, it's a service industry. Aviation is incredibly safe. Planes of equal size are pretty much interchangeable. The highway up there is the same for everyone and an airport is an airport. WJ offers no business class, no hot meals, no fancy lounges, no air miles of its own. It pursues advantage by other means: the attitude of its people and their capacity to solve problems. Their entire ethos is built around the customer. I used to think the "AC attitude" was the inevitable result of an aging workforce fatigued by the wear and tear of a zillion flights and alienated by repeated labour strife and restructuring. Likewise I was sure that the happy-faced, fun-loving, energetic WJ honeymoon would end.

Well, WJ is a decade old and still no sign of passive aggression; not all their employees are fresh-faced kids. AC actually tries, but there is too much ennui and complexity . Their own agents can't figure out their absurd aeroplan mileage redemption rules and its website produces some legendarily idiotic itineraries. Small wonder they can't reliably produce quality service in the crunch. Pleasantness and can-do are hard-wired into WJ's DNA: I once bought a ticket from a WJ baggage service agent. WJ gives you more while giving you less. It has chosen the right quality indicators. Advantage: WJ.

Simple, reliable, effective, pleasant: whether from an airline or from health care, that's what we need most of the time. And where simple won't cut it, more than ever we need reliable, effective, and pleasant. AC is besotted with complexity and covets the overseas, long-haul market segment. You can tell it doesn't really care about most domestic routes outside the big cities. Though they try their best, it's clear the employees have no great love for the corporation they work for.

AC is to air travel what our acute care-obsessed, high-tech-envy health care system is to health. It's great that we can find the cystic fibrosis gene and separate Siamese twins but not so good that chronic disease management is a national catastrophe. The vast majority of people don't need glitzy miracles; we need sound, evidence-based, timely, respectful, and well-communicated primary health care from a team dedicated to getting it right.

In the end it's about culture, that maddeningly elusive notion that signals what an organization or system is about. The truly successful put the customers first and pay attention to the workforce and the workplace. They get the fundamentals right and understand where their bread is buttered. WJ has mastered primary air care; it makes money where AC bleeds red ink. Health care, take a lesson.

Our Health Policy Contranyms

by Neil Seeman

Smiles, says the old joke, is the longest word in the English language, since there is a mile between the two s's. Whoever thought this up missed the health policy literature - with its long, deliberately obtuse abstractions.

I have worked as a lawyer (where "submit" means "say") and in the large corporate sector (where a "resource" is a "person"). But in health policy we see the increasing use of contranyms, words that contain opposing meanings. A non-health care example of a contranym is "to buckle," which can mean "to fasten" or "to wobble and break." Contranyms can result from what grammarians call polysemy, where one word morphs into different, and ultimately opposing, meanings.

Consider three leading contranyms in the health policy context. One meaning is the word as originally conceived in the dictionary; the other, opposite meaning, is how it has come to be applied in health policy discussions. In each case, there may be an unstated, but rational, method to this linguistic madness.

1. "Stakeholder" is generally used in the health policy lexicon to mean: "a person or organization with a legitimate interest in a given situation, action or enterprise." Since this definition of "stakeholder" is opposite to the original meaning of the word, "stakeholder" - "a person holding the stakes for others," i.e., a lackey - the word has become a contranym.

If we think about it, all Canadians should be "stakeholders" - equal, and equally legitimate - in all matters of health policy (in fact, our Canada Health Act mandates as much). We use the word "stakeholder" to limit, pragmatically, the numbers of individuals whose views we consider when planning policy: in so doing, do non-stakeholders (i.e., "fringe" players) thereby become lackeys?

2. Next time you're at a policy conference, count how many times you hear the word iterative. (Prior to this essay, there were over 100 separate references to the word in Longwoods publications). Its use seems to be growing. "Iterative development" - or common variants, "the next iteration," or "iterative process" - contain a contradiction. "Iterative" means recurring or repetitive, and, yet, "development" or "process" signify advancement. When we use any such phrases, we are unconsciously hedging our bets, insinuating that the "next iteration of the strategy" may veer sideways or even reverse course.

3. To "invest" in an initiative, as understood in the private sector, is to expect a financial return, or profit. And yet, in health policy, there are finite government resources. Policy choices require trade-offs, and a failure to consider trade-offs leads us into the trap of the open-ended fallacy, or what economists consider the failure to think clearly about a policy's knock-on effects. And so, every time you hear the word "invest," consider whether the "investment" is being used in its purist sense (to realistically expect a return) or whether the "investment" will necessarily cleave (itself a contranym) realizable gains from another policy.

To be sure, the US context offers more colourful context for oxymorons, notably "managed care." There may be something uniquely Canadian about the health policy contranym: a deliberate obfuscation of what we aim to say. We care about all stakeholders, but sometimes some stakeholders may be more important to us than others; policy forges ahead in iterative stages, since, perhaps, we are too risk averse to embrace the frontier of innovation; and we may talk a good game about investment, but we may be leery of appearing to endorse the language of profit.

This sort of linguistic muddle is a matter of custom. Is the "custom" a byproduct of "conventional behaviour" or "deliberate design"? That's a conundrum.

About the Author
Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell, based at Massey College, University of Toronto.