Heilsuslfri lokprfs glsur

The McKeown Thesis

McKeown looked at historical records and focused primarily on life
expectancy, which is today the general indicator of human health.
People generally live longer today than before so life expectancy
increased over time. Around 1700 the average age was 40 years but
around 2000 it increased to 80 years old. In the late 18th century
following the industrial revolution (1750) life expectancy doubled.
McKeown looked at the kinds of things that caused death and found
the main cause was infectious diseases whereas TB (Tuberculosis)
was the main cause. Medical innovations, new discoveries and
procedures was considered to be the cause of higher life
expectancy. McKeown proved that was not true, the major scientific
advance was the identification of the TB bacillus (veiran).
Streptomycin was developed around 1940 but the BCG vaccine was
made in 1950s which is the only possible explanation of decreases
in death from then on. With the industrial revolution the three major
historic causes of population gains in health were; 1: Most important
was improved nutrition new methods of transporting foods and more
reliable parts of food and fewer people were getting the disease. 2:
Sanitation was a big factor, clean water and sewerage disposal with
the help of engineering. 3: Ongoing public and social development,
the declining birthrate with improved survival and affluence,
reduction of slums and improved education, literacy, general
hygiene. This started in England and went from there to the US and
is still ongoing in other countries.
Kaplan
Diseases and disabilities are important for two reasons. First, illness
may cause a truncation of the life expectancy. In other words, those
in specific disease categories may die prematurely. Death is a
behavioral outcome. It can be defined as the point at which there is
no observable behavior. Second, diseases and disabilities may cause
behavioral dysfunctions as well as other symptoms. Biomedical
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studies typically refer to health outcomes in terms of mortality

(death) and morbidity (dysfunction) and sometimes to symptoms.
There are only two health outcomes that are of importance. First,
there is life expectancy. Second, there is function or quality of life
during the years that people are alive. Biological and physical
events are mediators of these behavioral outcomes. Individuals are
concerned about cancer, highblood pressure, high cholesterol, or
other problems because they may shorten the life expectancy or
make life less desirable prior to death.
Three Ages by Omran (Epidemiologic Transition)
1. Before the Industrial revolution there was high birth rate, high
death rate (especially among children due to infection an
malnutrition), the life expectancy at birth was low, depopulation due
to epidemics, famine, and war. Slow growth of the overall
population.
2. With the industrial revolution were declines in deaths from
infectious diseases, especially among children. With this the life
expectancy at birth increases and led to rapid growth in population.
3. After the industrial revolution (the first half of the 20th century)
infectious diseases were replaced by chronic non-communicable
diseases, common complex diseases, cardiovascular, cancer and so
on (man-made diseases). Birth rate decreased but life expectancy at
birth increased which led to the aging of the population the
longevity revolution.
In addition three other models were the Classical or Western model
with the high-income countries (western Europe and north America),
the Accelerated Transition Model, which started later but progressed
more quickly (in Japan), and the Delayed or Contemporary Model
which is still in progress or yet to begin as in much of Asia and Latin
America or Africa. More or less McKeowns basics for human health.
The solution is always the same, this happens despite medicine,
people need shelter, clean water, nutrition and so on.

Harper grein:
Transitions can occur at dramatically different paces in different
places. Omrans classic model was developed based on findings in
the U.S. and Western Europe; he estimated that it took about 200
years, from start to finish, though other authors have argued that it
actually began even earlier
Demographic Transistion - 4 stig yfir 1200 r.

Epidemiology is the study of the distribution of disease and

focuses on health whereas Demography is the study of patters of
population, birth- and death rate. These two models of transition
overlap in where they view the same things from different
perspectives.
The Demographic transition is in four stages which all include three
variables; death rate, birth rate, and population growth. The first
epidemiological transition marked rise in deaths do to infectious
diseases following the Agricultural Revolution which was an
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outcome or consequence of changing their way of living. In the first

stage the population was low and stable and birth and death rate
were high. The Second Epidemiological Transition as described by
Omran with the industrial revolution, in stage two the population
was increasing (early increase) where death rates fell rapidly and
birth rates remained high. In stage three the population was still
increasing (late increase), death rate slows down and birth rate
starts to fall. Third Epidemiological Transition, the current
resurgence of infectious disease mortality (dnartni) from newly
emerging and re-emerging diseases, and antibiotic resistant. In
stage four the population is high and stable, death rates low and
stable as well and birth rate is low.
Concepts of health and healthcare
Biomedical Model
Illness is caused by disturbances in physiology, are inherited and
acquired like infection or injury. Something that is in the body
organs, tissues and cells. Dmi: meisli, helsta threat okkar aldri
og aallega blslys. Besta sem hgt er a gera er a sjkrabll
komi og fari me ig bradeildina. kemur medicine helst inn.
Does this suggest a vi ttum a hafa sjkrahs hverju horni?
Nei, er gert r fyrir a allt er laga eftir . Frekar arf a skoa
a sem veldur slysinu sem er yfirleitt human behavior - prevent the
injury in the first place. Have rules and regulations and people have
to go by them.
Biopsychosocial Model
Health is due to an interaction of physiological, psychological and
social causes. These environmental causes that effect individuals
health are diet, cigarette smoking, alcohol abuse, physical activity,
stress, social support, social-economic-political equity and stability.
The burden of disease (a lifa me sjkdmnum)
The pattern has changed; life expectancy has more to do with acute
and infectious diseases. However a less good measure, if you look at
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causes today are non-communicable diseases and common complex

diseases. Diseases are more chronic today. The burden of disease
increases, people have a disease for a long time before they die,
they live with the disease instead of them dying because of
infections from the disease.
Summary measures of health incorporate mortality and morbidity
into a single index by measuring life lived: Without impairment and
with impairment. Their index health as a single number, time spent
being ill while you were alive and how long you live as a fully
functional person. Take account of states of diminished health,
reduced quality of life, or disability.
Two types of measurements: Health expectancy measurements and
health gap measurements. Health expectancy measurements
extend the life expectancy concept by adding information about
non-fatal indicators of health to information about mortality.
Estimated number of years of life lived in full health plus years lived
in a reduced state of health, diminished quality of life, or with
disability. Morbidity is measured in three examples: HALE, QALE and
DALE.
Health Gap Measurements measure lost years of full health
compared to an accepted standard of longevity and standard of
health. It is not a measurement of life itself but how many years lost
do to some health reason.
Judgments of quality of life and disability are made of surveys of
opinions. If you view life with a dichotomous view (alive or dead)
then it doesnt take into account quality of life versus the view that
health is on some continuous scale.

The longevity revolution: are populations healthier now as

well as longer lived?
There are three theories; Expansion of Morbidity, compression of
Morbidity and Dynamic Equilibrium.
Expansion of Morbidity talin vera rttasta kenningin!
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More people live to longer age, they get sick later but the time they
are sick is longer than it would have been before. Makes up the
difference, longer life in sickness according to this theory, taking
into account social and economic differences. Failure of success:
people live longer do to medical interventions (not quit true) but its
not possible to cure the people.
It is presumed the life expectancy from 1990 to 2010 have been
expanded by four years. For each of those years healthy years
increased by 0,8. People lived four years longer but not with full
health (Fyrir hvert r jukust 0,8 r af healthy life af essu fjrum
rum. Lifir fjgur r lengur en ert ekki me fulla heilsu ll fjgur rin
heldur 0,8 fyrir hvert r).
Compression of Morbidity

The same factors that lead to extension of life are the same factors
that lead to compression of morbidity. These factors that lead to
longer life lead to life with better health. The time when we are sick
is minimized but when we get sick we die very soon thereafter.

Dynamic Equilibrium

According to this theory nothing has changed, except people live

longer healthy with slowing of disease progression and from the
time they get sick they stay sick for some time until they die. The
time when people are sick has shifted to further stages of life.
Health-related risk factors
Three possible ways in why there was a decrease in cardiovascular
deaths: Advances in clinincal medicine, genetic differences, and
ways of living health related risk factors. Genetic differences is
an unlikely possibility though.
Risk Factor is believed to be a cause, There is a correlation between
a cause and an outcome. Smoking does cause lung cancer.
Risk marker: correlated may or may not be a cause. There is a
correlation between cause and an outcome but is controversial.
Cholesterol for example may cause death.
Multifactorial: Most mortality and morbidity, not only one factor but
many underlying factors combined that contribute to a disease.
Most cancers and non-communicable diseases are multifactorial
unlike infectious diseases that are single cause.

Biomedical and psychosocial factors

Biomedical interventions are divided into acute, emergency where
everything is done to prevent immediate death (i.e. heart attack),
and secondary actions like bypass that help those that have been
diagnosed to minimize or slow down progression of symptoms and
increase life expectancy. 20% of the decline was due to acute and
80% due to secondary procedures.
Change in behavioral and social determinants: Smoking reduction
and secular (non-medical population) reduced blood pressure, as
primarily due to change in diet. There was less poverty
(socioeconomic deprivation), increased education, and better
housing taking into account the increase of obesity, less physical
activity and diabetes.
The relative contribution of the Biomedical interventions was 32%
(1/3) in reduction in deaths and 66% (2/3) from the change in
behavioral and social determinants. As well the impact of life years
was 21% due to biomedical interventions and 79% due to change in
behavioral. Postponement of death has more impact.
Risk Factor Reduction versus Medical Treatment
1. Risk factor reduction (primary prevention) is asymptomatic
persons is more life saving that medical treatment (secondary
prevention) in patients.
2. The benefits of risk factor reduction versus medical treatment are
greater when measured as life-years than as number of deaths
prevented/postponed. egar gripi er snemma inn veikindi ea risk
factor hefur a betri hrif langlfi heldur en a veita mefer
egar sjukdmurinn er lengra kominn.
3. Prevention delivers superior benefits in quality-of-life (though this
has yet to be quantified). (a hafa ekki sjkdmum contributar a
hafa betri quality of life heldur en a ba og f sjkdm, vera
bjarga en samt lifa me sjkdminn. Biomedical doesnt cure it
just releaves symptoms and prolongs life).
4. In patients, medical treatment contributes more to prolonging life
than risk factor reduction. Why is this?
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It doesnt reverse the pathology, a htta a reykja mun minnka

lkur en a mun ekki laga skaann sem er egar kominn. Reyna a
hgja einkennum og koma veg fyrir progression.
Hj sjklingum er medical treatment betri vegna ess a ert
orin veikur.
Til a vera reykingarmaur og vera komin me lungnakrabba- me
vi a htta reykja getur a hgt sjukdmnum en ekki
afturkalla hann er meical treatment betritil ess a stra og
hafa hrif sjkdminn.
Sjklingar eru ekki mjg gir a breyta eirri hegun sem veldur
sjkdmnum, sumir horfa a etta s of seint g er hvort sem er
komin me krabbamein.
Population focus: Risk factor reduction and disease prevention.
The risk factor reduction comes in early stages. Many social factors
can have effect on risk factors for instance family, community,
education, peers, and economy. If you want to prevent disease it is
better to focus on risk factor in early stages or distal. Distal meaning
far in the distance, risk factors focuses on what is distant from the
disease. For example a 17 year old starting to smoke is a long way
from getting cancer at 50.
Individual focus: Medical treatment and cure. The biomedical
comes in later stages so it is beneficial. If you have symptoms it is
economically profitable to use the biomedical earlier but that
doesnt work, there is a lot of money to be made by selling drugs to
healthy people. But in later stages biomedical focuses on the
symptoms that are treated so they are reduced but it doesnt cure.
Biomedical is proximal meaning immediate conditions (symptoms)
that cause disease.
The distal (early) leads to the proximal (late) influences. The public
health end of Health psychology can be reduced and modified to
slow down and prevent these major causes of death - Preventative
risk factor approach. The major contributions were changes in risk
factors, changes within the public (the domain), which produced a
lot of benefit - reducing the psychosocial factors that lead to death.
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If risk factor reduction is the best way to maximize health and

longevity why is healthcare biomedically-focused? Illness is more
important than health, therefore we are moved to act when
confronted with illness.
We take health as a default but when you get sick it becomes a
preoccupation we act when we see that illness has occurred.
People have higher expectations to medicine and then tend to be
relatively forgiving of medical failure. That is people that get help
although it is not successful they are forgiving. They are willing to
receive medicine if it has immediate effect. The benefit of risk factor
reduction is lost by the time medical intervention occurs. To be
effective risk factor reduction must be long-term and therefor the
reinforcement is delayed. On the other hand medicine addresses
current problems and therefore the reinforcement is immediate.
The population paradox prevention paradox

The population paradox: an intervention that brings large benefits to

the community offers little to each participating individual.
The risk factor operates throughout the paradigm. Those who are at
high risk have a disease or will get a disease so those people get
an intervention. The rest of the community is believed to be low
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risk individuals so they dont profit from any intervention. The idea
is to alter the risk factors for everybody, produce a population shift,
with physical activity and diet. There is a big impact and fewer at
high risk although there is not that much of a change for the
community as a whole.
For example the drug Statins (cholesterol lowering drug), it is known
that they benefit and can provide better longevity. Why than not
proscribe Statins to everybody? That is because of the side effects
of the drug, they can be minimal but can also be very severe. There
is a risk for everybody. If you are at high risk for a disease then the
benefit is more than the harm of taking the drug. For those at low
risk, there is little benefit but the risk for harm of the side effects is
more.

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Medical harm Do no harm

Unintended physical injury resulting from or contributed to by
medical care (including the absence of indicated medical treatment)
that requires additional monitoring, treatment or hospitalization, or
that results in death.
Undesirable healthcare events: We need to distinguish between
the harm of the disease, the harm that is not caused by the disease
and the harm of the drugs. Adverse events: Negative outcomes
are a complication, are often unpreventable, although the use of
best practice there will still be harm. Medical error: Can be
preventable harm do to error and no harm as well despite error
having occured.
The severity of hospital based harmful events can vary, can cause
minor disability (56%), temporary disability (19%), permanent
disability (7%) and death (8%). The rate of harm is much higher
than people generally believe although most of the harm is rather
minor.
Global Trigger Tool
The Global Trigger Tool is an instrument which identifies instances of
medical harm in hospitals. Most hospitals have reporting systems of
identifying medical harm. The trigger tool goes deeper; it takes a
random sample of patients and is not biased. Sampled records are
reviewed by experts (a clinical review team) that identify triggers.
Triggers might be a type of infections, particular diagnoses, the
instances of harm. They look for a sign or signal that gives details
about medical harm and what type of harm has occurred.
Medical harm is very common and a lot more common than people
think. Rannskn Landrigen ofl. Sndi we found that harms remain
common, with little evidence of widespread improvement. Vita er
a medical harm er mjg algengt og getur veri mrgum tilfellum
mjg alvarlegt ar sem a endar daua en rtt fyrir a virast
tilfellin ekki minnka. grein Landrigen kom fram me notkun trigger
tool a meir en 60% tilfellum hefi veri hgt a koma veg fyrir
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medical harm. That still leaves 40% of things that are not
predictable so what should be done with that big problem and
the public grossly underestimates the problem.

Medical harm by type can be categorized into three events;

Medication where drugs are the most common so they cause the
most harm. Types of events can be wrong patient, wrong dosage of
medicine, wrong prescription, and so on. Problems that occur
although diagnosis are made by clinical guidelines and best
practice. Causes are behavioral by the physicians or the patient.
Physicians may not have enough knowledge or have incomplete
patient information. Patients may non be following the doctors
orders. Medical procedures are very severe and can lead to death
or chronic illness. An example of harm from medical procedures are
retained foreign objects. When a patient goes in for an operation
and a tool has been forgotten inside the patients cavity called a
never event. This could lead to an infection, cramping and
sometimes death. To prevent this from happening doctors should
perform a count of the instruments before surgery, before wound
closure and at skin closure although this can be time consuming and
ineffective. Wrong site surgery is another never event that happens
in medical procedures. A doctor performs surgery on the wrong body
part, should operate on the left hand but operates on the right hand.
Hospital-acquired infection (HAI): An infection a patient did not
have when he was hospitalized the patient is deemed HAI if
clinically evident after 48 hours and after having been discharged.
Most common hospitalized infection pneumonia (lungnablga) that
can be lethal. This is said to be due to lack of healthcare personnel
hygiene leading to spread of infection. Personal hygiene or hand
washing is very important to prevent bacteria from being
transmitted between patients (dmi me lknana og
ljsmurnar).
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Poor sanitation causes patients to get hospital-acquired infection

and when they get discharged they take the infection into the
environment and therefrom into the community. Infections from the
community lead back to the hospital and the cycle goes on.

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Medical harm commercial culture of medicine

Alot of money is spent on drug and medicine commercials. Industry
gifts to physicians are very common. Gifts from pharmaceutical
companies to physicians may have huge impact on what drugs they
are prescribing and interfere with clinical decision making. They are
likelier to direct their patients to a drug from certain company and it
can increase the risk of overuse or inappropriate use.
Gifts are biasing whether they are large or small. Physicians do not
feel they are affected by gifts, see themselves as immune to selfserving bias while simultaneously believing most of their colleagues
are susceptible. Self-serving bias is unconscious and unintentional.
Today gift from industry have to be on an educational purpose and
under 100$ a year, otherwise the company will get a fine.
Companies rather take the risk and pay a fine instead of following
restrictions. Receiving gifts is usually treated as an ethical or moral
issue.
Biomedical research and support from industry. Industries are
more likely to fund research when there is a chance of profit. The
odds of getting a favorable result in research are five times more
likely when its for profit than non-profit. Industry is more interested
when the research seems promising and they can influence the
results. The only additional differentiation was non-profit of for-profit
and a mixture of both.
The Cochrane Collaboration
People get sick and get better, doesnt matter what is done.
Cochrane wanted to put medicine on a more scientific basis to
practice medicine and used randomized controlled trials (RCT). He
used RCT to research everything, especially the drugs in clinical
trials on enough participants to find out how well the drugs worked
before they went into sale for the public. RCT is the core foundation
for evidence-based medicine. Most countries have procedures in
which the pharmaceutical companies must do research first and
demonstrate that the drugs works and what harms and side effects
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could may occur, before the drugs go into sale to the public. This
came to be known as the Cochrane collaboration: systematic
reviews, meta-analysis and more research on treatment and drugs
so doctors can use the database and learn how the product has
worked before they decide to use it. It summarizes the idea that you
have low quality evidence and high quality evidence. The lowest is
clinical observation and expert opinion and the highest in the
hierarchy is systematic reviews and meta-analyses. Sadly this is not
that perfect because of the self-serving bias from industry gifts and
so on that effects their decision.
Cochranes hierarchy of evidence: The questions are, Can it
work? Does it do more good than harm in ideal circumstances. Does
it work in practice? Does it do more good than harm under usual
circumstances. Is it worth it? Is the drug to expensive.
The human genome project
To identify and map all of the genes of the human genome.
Personalised medicine: to replace the one size fits all approach of
conventional medicine to deliver the right drug to the right patient
at the right time. The target continues to be to develop drugs that
are specifically targeted to every single persons genome. With new
technology, people could offer their complete genomic information
and then reference against the population and then prevent,
diagnose and treat diseases. Doing this it would change health-care
as we know it today, but it didnt quit work as they expected. Within
personalised medicine the myth is that biological is the fundamental
importance, start with biology and it is the ultimate cause. The most
logical cause is the environment and its shape and other is the
behavior. Complex interaction between genes, behavior and
environment. Though specific genes are in a disease, other factors
have an impact. The solution is to collect data. Data can be
collected in population, in subgroups and then individualized. The
main goal is to use genetic information for screening and testing.
Collecting data was thought to be a solution Big Data collect
more and more data about the problem and be able to solve it with
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the information. With the data they are able to conduct huge
epidemiologic studies with all the geno-information. The
personalized medicine movement is that the government pays for
this which is very costly. The problem is that health is random, there
are chance factors going on at every level all the way in the process,
from the subcellular to biographical. The magnitude of these
chances are major and not minor. Chance explained 65% in the
variation in cancer risk, the environment and behavior explained 2530% and genes only explained 5-10% of the variance. This tells us
that most cancers are due to chance random mutation and other
factors in the genetic process determining whether cancer
immerges.
Inverse care law

The availability of good medical care tends to vary inversely with

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the need for it.

We have Healthcare and then Income, the variance (dreifingin) is
the same accross the world. The majority earns less than the mean
and then there are those that earn more. We then have the
healthcare need, the access to healthcare, and the quality of the
healthcare. Those that have low income, have higher need for
healthcare but dont have as much access to quality healthcare.
Those that have higher income have better access and quality of
healthcare but they are healthier and therefore the need is not as
high.
The more that the healthcare is commercialized the inequalities will
be higher. The inverse care law is most evident where medical care
is most exposed to market forces and less so where such exposure
is reduced.
Inverse benefit law

The benefit law: the ratio of benefits-to-harms. Illness ranges from

low to high, and fewer and fewer that have more symptoms. The X
refers to treatment threshold.
Benefit to harm the more sick you are, the worse the ratio. ll grip
hafa einhverjar aukaverkanir ea negative effects. Erum vi tilbin
a suffera essi negative effect, einhverntman er svo kvei
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hvenr harm er meira en benefit og verur gripi inn .

Sjkdmar eru continuous and vary on a continueum og anna hvort
ertu treated ea ekki. egar einkennin og httan nr kvenu
marki er ratioi meira og gripi inn - medical intervention.
Hva gerist market economy, a er hgt a hagnast lyfjum fyrir
sem arfnast eirra. a er mjg tempting a fra rskuldinn til
og eir eru a fleiri sem f etta inngrip. Flesitr eru associated vi
healthcare industry og v er mikill rstingur a fra til
rskuldinn. Beinynning er t.d. vandaml og evidence sem snir a
lyf hjlpa vi a. a er v veri a tala um a lkka rskuldinn
fyrir njan hp kvenna sem er me pre-beinynningu sem myndu
f essi lyf og aldrei f beinynningu en myndu suffer
aukaverkanirnar af lyfinu kjlfari. a er v minnkun benefit-toharm ratioinu.
Afhverju ekki a fra rskuldinn alveg yfir fyrir allt populationi (Z
stika)? klesterl lyfi Statins en me v a gera a
aukaverkanir geta veri litlar ea miklar - suffer the risk - v
hefir kannski aldrei fengi sjkdminn en munt alltaf suffer the side
effects. Provide treatment before symptoms arise. When you have
sypmtoms, v fyrr sem er gripi inn v betra. Ef sjkdmurinn
nr a progress mun inngripi ekki vera eins effective.
Screening: There should be an accepted treatment for patients
with the screened disease but it is pointless to screen for a disease
that there is no available treatment for. There should be good
understanding of the natural history of the condition, including
development from the latent stage to manifest disease (a vera
komin me einkenni). There should be a recognizable latent or earlysymptomatic (pre-disease) stage.
Type of screening: secondary prevention based on the assumption
that early detection of disease is beneficial. Pro-active screening is
when people voluntarily go and get screened for something specific,
cancer and other diseases. Opportunistic screening targets people
that are in the system, go for some purpose to the doctor and are
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screened for other things as well. Test results can give wrong
predictions of disease.
Issues: Presumed benefit of treatment is an assumption. People
think, if i have a disease i want to know about it and get it treated.
Nna er bi a identifya snemma, mun a contributea til length of
life or quality of life. People presume it will. a sem gerist
venjulega er a flk greinie sig sjlft og presentar a vi lkninn.
Ef ert me einkenni, ertu me einkenni og ess vegna meikar
sense a lta skoa a.
Ef ert me sjkdm, og veist af honum snemma er the treatment
only modestly effective. Er a gott a f treatment einhvern tma
og borga fyrir a ea f ekki treatment og pay some small price for
that later in life.
Ef biomedical healthcare er eins gott og haldi er, afhverju er veri
a screena snemma ef inngripin eru svona g late diagnosis.
Me t.d. krabbamein, er mguleiki a lkna a ef a er greint
snemma en ekki ef a er seint. a er rttltingin sem er oft
notu.
a eru einhverjar lkur a the condition is so slow progressing a
a mun ekki hafa mikil hrif fyrr en mun seinna t.d. eins og
ristilkrabbamein. En san eins og rannskn sndi me
brjstamyndatku til a ath brjstakrabbamein hj konum, a a
finna early stages tti a hafa hrif late stages en a virist ekki
gera a raun. Niursturnar voru r a screening minnkai
aeins ltillega the rate at which women present with advanced
cancer.
Negative side effects: anxiety over abnormal results & years of
uncertainty surrounding treatment outcomes.

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