NON-REFLECTIVE PROCESSES AND HEALTH CARE QUALITY

One viewpoint is that translating research evidence into clinical practice to improve care involves having health care professionals adopting new behaviors and changing or stopping their existing behaviors. As noted in a paper appearing in the April 2022 issue of the journal Social Science & Medicine, however, changing professional behavior can be difficult, particularly when it involves altering repetitive, ingrained ways of providing care. Consequently, an increasing focus is being made on understanding health professionals’ behavior from the perspective of non-reflective processes, such as habits and routines, along with more often studied deliberative processes. Theories of habit and routine provide two complementary lenses for understanding professional behavior, but to date, each perspective has only been applied in isolation.

The objective of a study that was undertaken by investigators was to combine theories of habit and routine to generate a broader understanding of health care professional behavior and how it might be changed. The study involved having a group of experts meet for a two-day multidisciplinary workshop on how to advance implementation science by developing a greater understanding of non-reflective processes. From a psychological perspective, ‘habit’ is understood as a process that maintains ingrained behavior through a learned link between contextual cues and behaviors that have become associated with those cues. Theories of habit are useful for understanding an individual's role in developing and maintaining specific ways of working. Theories of “routine” add to this perspective by describing how clinical practices are formed, adapted, reinforced and discontinued in and through interactions with colleagues, systems, and organizational procedures. The researchers concluded that combining theories of habit and routines has the potential to advance implementation science by providing a fuller understanding of the range of factors operating at multiple levels of analysis, which can have an impact on the behaviors of health care professionals and on the provision of quality care.

IMPACT OF AGE STEREOTYPES ON OLDER INDIVIDUALS’ MENTAL HEALTH

The COVID-19 pandemic that began in the United States early in 2020 has produced many dramatic effects, including fatalities resulting from becoming infected. Another consequence that is attracting some attention is how stigmatization of older individuals has increased as exemplified by extensive press coverage of government officials that appear to devalue older individuals by suggesting they are unworthy of adequate medical care. According to an article published in the April 2022 issue of the The Journals of Gerontology: Series B, recent analyses of Twitter data found that the pandemic has sparked a proliferation of negative-age-stereotype-based comments. These incidents led to an effort to determine whether prevalent negative messaging about aging had a detrimental impact on older individuals’ mental health. The study also considered whether the relatively uncommon positive messaging about aging during the pandemic, such as news reports of older health-care workers who came out of retirement to help sectors overwhelmed by COVID-19, benefited older individuals’ mental health.

Data collection took place between April 23 and May 5, 2020, when stay-at-home pandemic policies were implemented throughout the United States. According to the investigators, this study is the first to demonstrate experimentally that structural ageism, by which societal institutions promote bias against older individuals, can have an impact on their mental health. Specifically, among older individuals, the negative-age stereotype messaging led to more anxiety and less peacefulness than among those exposed to neutral messaging. In contrast, among older individuals, the positive-age stereotype messaging led to less anxiety and more peacefulness than among those exposed to neutral messaging. Interventions in both the negative- and positive-age-stereotype conditions were drawn from actual media reporting about older persons during the COVID-19 pandemic. Study participants exposed to the negative-age-stereotype interventions were twice as likely to report moderate or severe levels of anxiety, compared to those exposed to the neutral conditions. Whereas, those exposed to the positive-age-stereotype interventions were twice as likely to report moderate or greater levels of peacefulness, compared to those individuals exposed to the neutral conditions.

DEVELOPMENTS IN HIGHER EDUCATION

The U.S. Department of Education on April 6, 2022 announced an extension of the pause on student loan repayment, interest, and collections through August 31 of this year. Although the economy continues to improve and COVID cases continue to decline, President Biden has made clear the ongoing need to respond to the pandemic and its economic consequences, as well as to allow for the responsible phase-down of pandemic relief. The extension will provide additional time for borrowers to plan for the resumption of payments, reducing the risk of delinquency and defaults after restart. During the extension, the Department will continue to assess the financial impacts of the pandemic on student loan borrowers and to prepare to transition borrowers smoothly back into repayment. Efforts include allowing all borrowers with paused loans to receive a “fresh start” on repayment by eliminating the impact of delinquency and default and allowing them to reenter repayment in good standing.

Payments and interest accrual have been paused for borrowers with federal student loans since March 13, 2020, at the beginning of the pandemic. The previous pause was scheduled to expire on May 1, following a 90-day extension that was announced as cases of the Omicron variant of Covid-19 surged in December 2021. Approximately 40 million individuals owe about $1.7 trillion in federal student debt, an amount larger than credit card or auto debt. Federal loans make up more than 90% of outstanding student debt. Borrowers with private loans are not eligible for the pause in payments, although some lenders and servicers have offered flexibility.

FY 2023 Budget Proposal Contents Involving Higher Education
The Biden Administration on March 28, 2022 submitted to Congress the President's Budget for fiscal year 2023 that begins on October 1 of this year. As a means of increasing equitable and affordable access to an education beyond high school, the budget would increase the maximum Pell Grant by $2,175 over the 2021-2022 award year, through a combination of discretionary and mandatory funding, helping an estimated 6.7 million students from low- and middle-income backgrounds overcome financial barriers. The proposed increase is a significant step in the budget's comprehensive proposal to double the maximum Pell Grant by 2029. Additionally, the Administration continues to support expanding federal student aid, including Pell Grant eligibility, to Deferred Action for Childhood Arrivals (DACA) recipients, commonly known as DREAMers.

The budget proposal also calls for enhancing institutional capacity at Historically Black Colleges and Universities (HBCUs), Tribally Controlled Colleges and Universities (TCCUs), Minority Serving Institutions (MSIs), and low-resourced institutions, including community colleges, by providing an increase of $752 million over the 2021 enacted level. This funding includes a $450 million initiative to expand research and development infrastructure at four-year HBCUs, TCCUs, and MSIs.

Growth In The Number of Master’s-Degree Programs In Less Than A Decade
Readers of the Chronicle of Higher Education had an opportunity on March 24, 2022 to learn about the rapid growth in the number of master’s-degree programs in the period 2011-12. According to data from the U.S. Department of Education, colleges and universities have added more than 9,000 of these programs. A Chronicle analysis of more than 2,200 public, private nonprofit, and private for-profit colleges from 2011-12 to 2019-20 found that about 60% of those institutions experienced growth in the number of master’s programs they offered. Growth spanned institutions of all types and sizes, including bachelor’s, master’s, doctoral, and four-year special-focus institutions.

Yale University increased its master’s programs by 1.2%, while Gordon College, a small private institution in Massachusetts, went from having two such programs in 2011-12 to 25 in 2019-20, a 1,150% increase. Approximately 160 colleges, nearly all institutions with fewer than 5,000 students, did not have a single master’s program in 2011-12, but had at least one by 2019-20. One institution, the online arm of Johnson & Wales University, ended up with 18 such programs.

HEALTH REFORM DEVELOPMENTS

Access, quality, and cost are the equivalent of a three-legged stool in health care policy. A steady increase in the overall size of the overall U.S. population and dramatic growth in the number and proportion of individuals age 65 and older, a group characterized by increased morbidity, point to a steady escalation of spending on health care. The Centers for Medicare & Medicaid Services (CMS) on March 28 of this year released the 2021-2030 National Health Expenditure (NHE) report, prepared by the CMS Office of the Actuary. It presents health spending and enrollment projections for the coming decade. The report notably shows that despite the increased demand for patient care in 2021, the growth in national health spending is estimated to have slowed to 4.2%, from 9.7% in 2020, as supplemental funding for public health activity and other federal programs, specifically those associated with the COVID-19 pandemic declined significantly.

The NHE has been published annually since 1960. It often is referred to as the “official” estimates of U.S. health spending. These historical and projected estimates of NHE measure total annual U.S. spending for the delivery of health care goods and services by type of good or service (e.g., hospital, physician, prescription drugs), type of payer (e.g., private health insurance, Medicare, Medicaid), and type of sponsor (e.g., businesses, households and federal/state governments). The NHE report also includes spending on government public health; investment in structures and equipment; and non-commercial research, as well as information on insurance enrollment and uninsured estimates.

The report finds that annual growth in national health spending is expected to average 5.1% over 2021-2030, and to reach nearly $6.8 trillion by 2030. Growth in the nation’s Gross Domestic Product (GDP) also is projected to be 5.1% annually over the same period. As a result of the comparable projected rates of growth, the health share of GDP is expected to be 19.6% in 2030, nearly the same as the 2020 share of 19.7%. Selected highlights in national health expenditures by major payer include:

Medicare

Spending growth is projected to average 7.2% over 2021-2030, the fastest rate among the major payers, and also is projected to exceed $1 trillion for the first time in 2023. By 2030, Medicare spending growth is expected to slow to 4.3% as Baby Boomers are no longer enrolling.

Medicaid

Average annual growth of 5.6% is projected for Medicaid spending for 2021-2030. Medicaid spending growth is expected to have accelerated to 10.4% in 2021, associated with rapid gains in enrollment. Spending is projected to exceed $1 trillion for the first time in 2028.

Private Health Insurance And Out-of-Pocket Expenditures

For 2021-2030, private health insurance spending growth is projected to average 5.7%. Out-of-pocket expenditures are projected to grow at an average rate of 4.6% over 2021-2030 and to represent 9% of total spending by 2030 (ultimately falling from its current historic low of 9.4% in 2020).

Impact Of COVID-19 On Employer-Sponsored Health Insurance Coverage

When the COVID-19 pandemic began, there was a concern that millions of Americans could lose employer-sponsored health insurance coverage and become uninsured. Researchers from the Urban Institute released a report in March 2022 based on an analysis of data from the National Health Interview Survey (NHIS), the Current Population Survey (CPS), and the Health Reform Monitoring Survey (HRMS). Among their findings are the following:

• The uninsurance rate among nonelderly adults (ages 18 to 64) remained flat between early 2019 and early 2021, according to all three surveys.

• Gains in public coverage offset estimated private coverage losses on all three surveys, but the CPS showed much smaller public and private coverage changes than the HRMS and the NHIS.

• Administrative data on Medicaid enrollment show substantial changes consistent with the estimates reported on the NHIS and the HRMS.

AVALANCHE OF PUBLIC POLICY ACRONYMS

Official Washington, DC constitutes a paradise for the generation of acronyms that involve public policy initiatives. For example, U.S. involvement in outer space exploration gave rise to the highly recognizable acronym NASA. Public figures, such as the nation’s chief executive have their own designations, e.g., POTUS. The health domain also has its fair share of visible acronyms as evidenced by the existence of COVID, NIH, CDC, FDA, and the ACA, with the latter serving as a shorthand version of the Patient Protection and Affordable Care Act of 2010.

It is not difficult to imagine the average length of time for eyes to glaze over completely when listeners to an oral presentation or readers of a document repeatedly are exposed to an item along lines of an apocryphal Society of Newsletter Editors Who Love Acronyms (SNEWLA). Generally, many periodicals in the health professions prove to be a rich source of additions to a steadily growing verbal mountain of acronyms. A noteworthy example is the Journal of Medical Entomology. An article in the March 2022 issue has a focus on achieving public policy goals to prevent and control the spread of infectious diseases.

Included among this smorgasbord of acronyms are the following: Vector-borne diseases (VBD); West Nile virus (WNV); CDC Epidemiology and Laboratory Capacity (ELC); Mosquito Abatement for Safety and Health (MASH); Pandemic and All-Hazards Preparedness and Advancing Innovation (PAHPAI) Act; Centers of Excellence (COEs); and CDC Southeastern regional center of excellence in vector-borne diseases (SERCOEVBD). These items appear in the article in ways that highlight the importance of sustained efforts needed to achieve legislative goals by collectively identifying specific areas for (1) improvement, and (2) solutions to address national inadequacies in vector-borne disease policy and infrastructure.

An effective vector-borne disease response in the U.S. is a task that requires national policy to fund research and control efforts against both endemic and epidemic diseases. One major opportunity to influence policy authorized to protect against VBD threats is balancing short-term versus long-term goals (i.e., fixing versus preventing a problem). Whereas the story of federal funding in the last 18 years is reactive to emerging VBDs, in recent years there have been efforts to create a proactive system. Emergency funds acquired during the 2016 Zika virus outbreak were used to establish five Regional Centers of Excellence (COEs) in Vector-Borne Diseases with the goal of preventing and responding to emerging vector-borne disease across the United States.

These COEs work to train public health entomologists, vector biologists, and medical providers in VBD-related skills and knowledge; develop and validate effective prediction, prevention, and control methods and tools; and strengthen and expand communities of practice. Conventional wisdom is that there will be additional vector-borne disease threats in the near future, whether in the form of the vectors themselves or pathogens crossing borders. The only way to address future threats responsibly will be through stable, consistent funding. As with many other worthwhile public policy endeavors, such as efforts to enhance the allied health workforce, persistence will be required from one year to the next.

CROSS-FERTILIZATION OF HEALTH CARE INNOVATIONS

Innovative developments that occur in one type of health domain are capable of being transported successfully to related areas. The horrors of war provide a major impetus for the ability to create and implement fast, effective means of treating battlefield casualties. Skills learned and applied in that arena often prove to be highly welcome in the civilian sector. Similarly, capabilities produced in civilian institutions have proven of immense benefit in the military setting.

Beginning in the 1960s with the Mercury Space Program, astronaut Alan Shepard was the first American to participate in a suborbital flight of short duration. Today, the average amount of time for a team of astronauts to be aboard the International Space Station (ISS) is six months. According to an article published in the February 2022 issue of the journal Nature Medicine, spending that amount of time high above the earth can exert an impressive toll on the human body. Bones lose density and their arteries thicken and stiffen the equivalent of a normal decade of terrestrial aging. Over a six-month period, an astronaut’s internal temperature can rise by one degree Celsius upon being exposed to the equivalent of 375 chest X- rays’ worth of radiation. These space travelers also become more susceptible to kidney stones, allergies, and infectious diseases. Even an astronaut’s height changes in space.

Thus, it has become mandatory to consider how to deal with these kinds of ill effects. Fortunately, there have been some successes. Already, technologies have been developed to help astronauts survive, including telehealth, portable ultrasounds, air purifiers, and gravity-compensating bodysuits, to name a few examples of innovations that have made their way down to terrestrial health care settings. Meanwhile, technology developed to help astronauts conduct basic medicine with limited tools and knowledge already has aided in the delivery of health care to remote places, such as Antarctica, ships at sea, or home care settings, which are hard to access and face a shortage of health care workers and supplies.

The all-civilian, four-person crew of SpaceX’s Inspiration4 mission in September 2021 tested out the Butterfly iQ, a handheld ultrasound, taking images of their hearts, lungs, and urinary systems without any ground support. That same pocket-sized device already has been deployed in rural communities around the world where X-ray, CT, and MRI machines are at distances many hours away. Other remote monitoring innovations, such as miniature and body-worn scanning devices can collect and track biomedical data

Moving forward, researchers are investigating ways to equip astronauts so they can serve as their own medical providers: monitoring their own health, diagnosing any issues, and treating them with whatever is onboard. Some researchers have focused on how to augment a spacecraft’s stores by using genetically modified plants as chemical factories so that astronauts someday could grow the medicine they need in space. All these advances offer the prospect of enhancing life for more earthbound inhabitants of this planet.

COLLECTIVE PERCEPTIONS OF AGING AND OLDER INDIVIDUALS

According to an article in the March 2022 issue of the Journal of Applied Gerontology, by 2060 the number of older adults (age 65+) in the U.S. is projected to be more than 98 million, up from 37.2 million in 2006. The American Geriatric Society reports a 45% rise in the demand for geriatricians through 2025 without an adequate workforce supply. Hence, the number of health care professions students entering the geriatric workforce must be increased to meet the imminent and complex needs of this growing population. To attract them, an understanding of the factors influencing career preference and what may prevent students from pursuing geriatric careers is necessary. A mixed methods study design of 864 students from eight healthcare professions (dietetics, medicine, nursing, pharmacy, physician assistant, physical therapy, social work, and speech-language pathology) is described that characterizes social factors that ultimately may influence career choice. The mean age of respondents was 24.0 ± 3.7 years. The majority were female (70.3%), White (63.5%), and represented graduate-level studies (80.3%). Over two-thirds of respondents reported prior experience with older adults through paid work (37.0%) or volunteer work (32.4%). Over half (56.9%) agreed or strongly agreed that they had a close relationship with their parents or grandparents.

Altogether, the results of this study demonstrated students’ variable and paradoxical views of aging and older persons. It may be that students are unable to process and resolve the contradiction on their own, suggesting that earlier intervention with exposure, mentoring, and modeling via positive educator and preceptor attitudes may be necessary to generate positive attitudes. Geriatric training and education programs are critical avenues to correct misperceptions, quell ageism, and address the current shortage in the geriatrician workforce. This investigation provides rich narrative examples of students’ perceptions and understanding of the aging process, as well as myths and misconceptions of aging and older individuals that can be used to inform geriatric curricula across multiple health professions training and education programs.

INTERSECTING VULNERABILITIES AND CASCADING CONSEQUENCES

A separate article in the current issue of this newsletter discusses how the health care sphere in the U.S. can be characterized as consisting of dynamic multiscale systems. Tackling problems effectively in diverse areas will require not only linking vast datasets that encompass numerous components and spatio-temporal scales, but also bringing together multiple disciplines, institutions, departments, and programs. A related way of viewing how to move forward is described in a paper appearing in the March/April 2022 issue of the MIT Technology Review. A case is made for meeting the biggest challenges of today and the future by mobilizing leadership roles across the technology industry, academia, and government so that they act in concert in an innovation ecosystem. A good example demonstrating the power of such a system when mobilized in a crisis is the speed with which vaccines against COVID-19 were developed and deployed.

Vaccines alone have not overcome this pandemic because this disease has revealed weaknesses in the health care system, supply chains, labor markets, social safety net, and even the political system as a way to mount coherent responses to a complex problem. The pandemic also exposed a deeper truth, i.e., that certain triggering events leave the U.S. population subject to intersecting vulnerabilities, with cascading consequences. The appearance and spread of COVID is such a triggering event. In a deeply interconnected world with inherent instabilities that include climate change, inadequate cybersecurity, non-state bad actors, and geopolitical tensions of all kinds, such triggering events are likely to become more frequent if work is not undertaken to forestall them. The risks are not merely economic that hurt both knowledge and a technology-intensive economy, they also are strategic that threaten national and global security. A powerful innovation ecosystem needs to become both more agile and more robust in the face of these risks. Moreover, risk assessments at the federal level must become more holistic and integrated, examining the effect of one danger on another. In conjunction with universities and industry, a government coordinating body should be planning for hazards that could compound other hazards, and offering strategic focus and funding for discoveries and innovations designed to respond to and mitigate them as part of an overall innovation policy.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Structural Racism As A Mediator Of Disparities In Acute Myeloid Leukemia

Black and Hispanic individuals with acute myeloid leukemia (AML) in greater Chicago were more likely to die from the disease than their non-Hispanic white counterparts, with a 59% and 25% greater risk, respectively, according to a new study led by University of Illinois Chicago researchers that was published online January 21, 2022 in the journal Blood. Researchers examined how structural violence, neighborhood disadvantage, perpetuated by social, economic and political systems, can set the stage for poorer outcomes in patients with AML. Strikingly, census tract measures accounted for nearly all of the disparity in leukemia death. Treatment patterns, including induction intensity and allogeneic transplant, as well as treatment complications, as assessed by ICU admission during induction chemotherapy, were additional mediators of survival disparities. The study highlights the need to investigate mechanisms by which structural racism (e.g., segregation) interacts with known prognostic and treatment factors to influence leukemia outcomes.

Suicide Mortality In The United States, 2000–2020

In 2020, suicide was the 12th leading cause of death for all ages in the United States, changing from the 10th leading cause in 2019 due to the emergence of COVID-19 deaths and increases in deaths from chronic liver disease and cirrhosis. As the second leading cause of death for individuals aged 10–34 and the fifth leading cause in the age group 35–54, suicide is a major contributor to premature mortality according to a March 2022 data brief from the National Center for Health Statistics (NCHS). Suicide rates increased from 2000 to 2018, but recent data have shown declines between 2018 and 2020. The leading means of suicide for females in 2020 was firearm-related, a change from previous years, while rates for males have continued to increase. This report presents final suicide rates from 2000 through 2020, in total and by sex, age group, and means of suicide, using mortality data from the National Vital Statistics System (NVSS). This report updates a provisional 2020 report and a previous report with final data through 2019.

HEALTH TECHNOLOGY CORNER

Exposure To Adverse Lead Levels In Early Childhood

Lead is a developmental neurotoxicant in wide industrial use that once was broadly distributed in the environment. The extent of the US population exposed in early life to high levels of lead is unknown, as are the consequences for population IQ. Little evidence is available on the harms past lead exposures continue to hold for yesterday’s children, who are victims of what is termed legacy lead exposures, according to an article published on March 7, 2022 in Proceedings of the National Academy of Sciences of the USA. Investigators estimate that more than 170 million Americans alive today were exposed to high-lead levels in early childhood, several million of whom were exposed to five-plus times the current reference level. These estimates allow future work to plan for the health needs of these Americans and to inform estimation of the true contributions of lead exposure to population health. The researchers estimate population-level effects on IQ loss and find that lead is responsible for the loss of 824,097,690 IQ points as of 2015.

Ants Can Detect Cancer Cells Through Volatile Organic Compounds

Cancer detection is a major public health challenge. Methods, such as MRIs and mammograms available to achieve it often are expensive and invasive, which limits large-scale use. An alternative method being explored by scientists from the CNRS, Université Sorbonne Paris Nord, Institut Curie involves the sense of smell of the species of ants, Formica fusca. As described in a paper appearing in the March 18, 2022 issue of the journal iScience, after a few minutes of training, these insects, which use smell for daily tasks, were able to differentiate healthy human cells from cancerous human cells. Cancer cells are characterized by an altered metabolism, producing unique patterns of volatile organic compounds (VOCs) that can be used as biomarkers. Each cell line had its own smell that could be used by the ants to detect them. The efficacy of this method must now be assessed using clinical trials on a human being, but this first study shows that ants have high potential, are capable of learning quickly, at lower cost, and are efficient.

DEVELOPMENTS IN HIGHER EDUCATION

Another section of this issue of the newsletter describes how omnibus appropriations legislation will increase funding for various government agencies in the health domain. The field of education also will benefit from the availability of added money. The enactment of Consolidated Appropriations Act, 2022 (H.R. 2471) will provide $3 billion for higher education to fund increases for most Title IV programs at the U.S. Department of Education. The maximum Pell Grant will undergo a $400 increase that raises it to $6,895. Although the boost is a welcome development, an aim is to double the grant, an objective that was advocated by some Democrats during the campaign for the presidency in 2020. Compared to funding in FY 2021, Federal Work-Study, Federal Supplemental Educational Opportunity Grants, TRIO, and GEAR UP are among the other programs benefiting from modest increases for FY 2022.

Historically Black colleges and universities (HBCUs), tribal colleges and universities, and other primarily minority serving institutions (MSIs) are highly important entities that will experience an increase of $96 million compared to the previous fiscal year. The overall amount of funding is $885 for these institutions. A related consideration is that HBCUs and MSIs will have more flexibility regarding how COVID-19 relief aid is spent. Another noteworthy feature pertains to the acquisition of real property or construction directly related to preventing, preparing for, and responding to the coronavirus.

While acknowledging these gains, within the education community there is a concern that other unresolved issues warrant additional government action. An example is the necessity of addressing the student debt crisis. Thus far, the Biden administration has approved approximately $16 billion in targeted forgiveness, according to the Education Department. Students who qualify for the total and permanent discharge program due to disability, who qualify for the Public Service Loan Forgiveness program with nonprofit or government work, or who were misled by fraudulent schools have been the beneficiaries of this forgiveness. A partial remedy is that payments on student loans have been paused by the federal government since March 2020 because of the COVID-19 pandemic. Unless further action is taken, payments will resume in May of this year.

The Changing Face Of Federal Regulations

The Higher Education Act (HCE) is a vital piece of legislation that undergirds a great many key governmental activities. Initially passed in 1965, it has been rewritten on eight separate occasions since that year. In its most current version, although originally destined to expire at the end of 2013, the law has been extended by Congress. It remains unclear when the next reauthorization will take place. Until then, however, agencies achieve their respective agendas by using regulations to do so. A concern is that some regulations can be guaranteed to be reversed whenever a new occupant resides in the White House. It used to be more the case that once regulations were formulated, they tended to remain in place for lengthy periods of time. The current pattern is for rules to come and go in cycles that reflect which political party is in control of the executive branch. The result affecting colleges and universities can be somewhat chaotic when they attempt to implement official guidance that experiences constant revisions.

The Negotiated Rulemaking Process

Typically, the Department of Education develops its proposed regulations without public input and then publishes them in the Federal Register for comment by the public. The published document is known as a Notice of Proposed Rulemaking, or NPRM. Under negotiated rulemaking, the Department works to develop an NPRM in collaboration with representatives of the parties who will be affected significantly by the regulations. A series of meetings is conducted during which these representatives, referred to as negotiators, work with the Department to reach consensus on the Department’s proposed regulations. The Institutional and Programmatic Eligibility Committee had its 1st session on January 18-21, its 2nd session on February 14-18, and the 3rd session on March 14-18. Gainful employment is an example of a topic discussed at these sessions. Registration links closer to the start of negotiations are posted at www2.ed.gov/ policy/highered/reg/hearulemaking/2021/index.html, along with recordings and transcripts of the meetings on that site.

OMNIBUS SPENDING PACKAGE APPROVED

Once again, the clock was ticking and a continuing resolution (CR) that provided funds for the federal government to continue operating was about to expire on March 11. With only a single day to go before another CR might have to be created, legislators in both chambers rose to the occasion by producing an omnibus bill, the Consolidated Appropriations Act, 2022 (H.R. 2471), for President Biden to sign into law to furnish money for the remainder of FY 2022. Although the achievement required nearly six months of effort after the current fiscal year began last October, a collective sigh of relief throughout the government accompanied this outcome.

Despite being at loggerheads on many issues in a Congress almost evenly divided between Democrats and Republicans serving in both House and Senate, the results were greeted with general satisfaction by both groups. Weighing in at a colossal 2,700 pages, 1.5 trillion dollars now can be divided in varying amounts among all 12 fiscal year 2022 spending categories. Division H of the bill pertains to the Labor-HHS-Education section. For example, $45 billion is designated for the National Institutes of Health (NIH), representing a $2.5 billion (4.7%) increase over the comparable FY 2021 funding level, the seventh consecutive increase since FY 2016. The CDC has been awarded $8.4 billion, an increase of $582.4 million (7.4%) above the FY 2021 program level. The Agency for Healthcare Research and Quality (AHRQ) will receive $350 million, an increase of $12.4 million (3.7%) above the FY 2021 spending level. The Health Resources and Services Agency (HRSA), an entity that has a major focus on the health workforce, will benefit from obtaining $799 million for Title VII Health Professions and Title VIII Nursing Workforce Development Programs, a $45.1 million (5%) increase above FY 2021 comparable levels.

Disagreements over how much funding to provide for defense and non-defense purposes account for some of the delay that occurs each year in the appropriations process. Democrats tend to place more emphasis on supporting various social programs rather than defense activities, while Republicans generally are more inclined to do the opposite. For FY 2022, the omnibus legislation allows for almost equal increases in defense and nondefense spending from FY 2021 levels, with a $42 billion ( 5.6%) increase in defense accounts and $46 billion or a 6.7% boost for nondefense programs. Democrats originally hoped to double that amount. Another factor that helps to slow down the speed of legislation is an attempt by Democrats each year since 1976 to override the Hyde Amendment, a provision barring the use of federal funds to pay for abortion, except to save the life of a woman, or if her pregnancy arises from incest or rape. That component remains intact.

Appropriations legislation from previous years was famous for including “earmarks” for special endeavors favored by members from each party in both chambers. Senator William Proxmire (D-WI) became famous for creating what he called the “Golden Fleece Award.” From 1975 to 1988, he issued on a monthly basis 168 such honors. His purpose was to expose to public view the somewhat less than noble ways in which the federal government wastes the hard-earned money of taxpayers. Banned 11 years ago, the new round of spending includes some 5,000 separate earmarks at a cost of $9.7 billion.

DYNAMIC MULTISCALE SYSTEMS

The health care sphere can be characterized as consisting of dynamic multiscale systems. Typically, it is viewed as comprising silos that often function independently of one another in ways that lessen the likelihood of achieving effective outcomes. A positive intervention constructed in recognition of this problem is the ongoing creation of activities that place a much greater focus on interprofessional cooperation. One form occurs at educational institutions where students from different professions are given opportunities to learn more about what other disciplines have to offer in the provision of clinical services. The workplace is a related venue where many kinds of clinicians must work together seamlessly to deliver optimal patient care.

Occasionally, this newsletter has apprised readers of other developments that are not viewed necessarily as pertaining exclusively to the health domain, but still have considerable relevance. As an illustration of this wider viewpoint involving the Anthropocene (the current geological period during which human activity has been the dominant influence on climate and the environment), the May 2021 issue of TRENDS featured a discussion of how the insect world is influenced adversely by human activity, such as habitat loss occurring when humans move to previously uninhabited locales and use of pesticides. Insects play a vital role in a terrestrial food web that affects many species of birds, bats, reptiles, amphibians and fish, while also performing essential functions involving pollination, pest control, and nutrient recycling.

Along similar lines, it is worth noting that biological challenges facing the world are complex, multi-factorial, and intimately tied to the future of human health, welfare, and stewardship of the earth. Tackling problems constructively in diverse areas, such as agriculture, ecology, and health care will require linking vast datasets that encompass numerous components and spatio-temporal scales. The December 2021 issue of the journal Integrative and Comparative Biology became available earlier this month. An article in it on the “Axes of Life,” provides a new framework and a road map for using experiments and computation to understand dynamic biological systems that span multiple scales. Theories are offered that can help understand complex systems and highlight the limitations of existing methodologies.

Meanwhile, there are barriers to bringing together all disciplines, institutions, departments, and programs successfully because of disciplinary variations, such as language, terminology, and definition. It also could be due to self-imposed barriers that limit interactions among disciplines. A tendency to gravitate toward like-minded individuals reduces cross-pollination that could bolster advances in interdisciplinary science. Different disciplines may approach similar problems from different perspectives, which causes a separation in focus when disparate groups try to answer similar questions. One remedy might be to produce more journals that are interdisciplinary. ASAHP’s Journal of Allied Health furnishes a positive example of the wisdom of implementing such an approach.

DISABILITY TRAINING FOR HEALTH WORKERS

Steady growth in the portion of the population age 65 and older in the U.S. and other nations is associated with an increase in the onset of various disabilities. As noted in an article published in January 2022 in the Disability and Health Journal, individuals with disabilities often face significant barriers to health care, including lack of accessible transport and facilities; limited financial protection; poor health worker attitudes that result in worse outcomes; or limited health worker training on disability. Moreover, even in countries where there is guaranteed universal access and financial protection, health workers’ unfamiliarity with disability, or negative attitudes toward patients with disabilities, not only could foster an unwelcoming environment, but also contribute to high rates of patient safety issues and lower quality care. A principal aim described in this journal article was to understand the published literature on training health workers about disability.

The investigators searched five databases for relevant peer-reviewed articles published between January 2012 and January 2021. Studies that focused on training health care workers to improve knowledge, confidence, self-efficacy, and competence to support individuals with physical, sensory, or intellectual impairments were included. Data about the details of the intervention (setting, participants, format, impact assessments, etc.) and its effects were extracted. They found that there is an array of highly local tools to train health workers across stages of their training and careers (preservice, in-service, and continuing professional development). Studies involving patients with disabilities in the training, community placements, simulations, or interactive sessions were found to be most effective in improving knowledge, confidence, competency, and self-efficacy. These researchers concluded that as part of initiatives to build inclusive health systems and improve health outcomes, health workers around the world need to receive appropriate and evidence-based training that combines multiple methods and involves people with disabilities. To monitor progress on the impact of training, there also should be a standardized measure of impact on core outcomes. Additionally, while focusing on training by impairment is useful, there also is a need to have holistic disability training. Improving the standardization of core competencies that training on disability should address and measures of impact for disability training can further improve progress in this area.

EXPANDING GLOBAL ACCESS TO GENETIC THERAPIES

Another section of this newsletter includes an item that discusses how supporters of the human genome project advocate probing yet further “beneath the skin” to demonstrate that the massive investment in genome-wide association studies and the coalescence of these findings into polygenic scores will open up new avenues for prevention. As described in the January 2022 issue of the journal Nature Biotechnology, a goal of advancing science and technology should be to solve global health challenges by developing new therapies, treatments, and preventive measures that directly could contribute to the enhancement of the collective well-being of societies. Human genome editing innovations should endeavor to move in this direction, and any that did not, or that were potentially harmful, should not be allowed to continue. Technologies that should not be allowed at all include those attempting heritable germline human genome editing because of the risks and safety concerns surrounding current technology and also because of the new and possibly unique ethical challenges they would introduce.

Instead, somatic gene editing therapies, by contrast, do not present the same risks and challenges, promising to provide treatments for a wide range of diseases and conditions, including cancers, blindness, and hemophilia. The era of genetic therapies, both gene-editing treatments and gene therapies, several of which currently are on the market, has arrived for rare disease. As more of these therapies come online, however, it is time to explore how current business models based on patents and restrictive licensing limit access to treatments. It also is time to explore whether there are other ways in which patents can still reward innovators and protect investments while ensuring that the widest number of patients who need these treatments can receive them. An example of a strategy possibly worth pursuing would be to reduce the cost of premium-priced gene therapies through the use of patent pools, which have been applied successfully in the technology and electronics world.

OBTAINABLE RESOURCES

Integrating Serious Illness Care Into Primary Care Delivery

Approximately 5% of Medicare beneficiaries (2.2 million Americans) are living with serious illness, as are many other non-Medicare eligible individuals. This number is expected to grow rapidly as the population ages and the prevalence of progressive illness increases. In many communities, particularly urban and rural underserved areas, primary care clinicians are the main workforce caring for patients with serious illness, which underscores the need to integrate high quality serious illness care into primary care delivery. As a means of better understanding the challenges and opportunities for integrating serious illness care into primary care settings, the National Academies of Sciences, Engineering, and Medicine’s Roundtable on Quality Care for People with Serious Illness hosted a virtual workshop on June 10 and 17, 2021. The workshop, called Integrating Serious Illness Care into Primary Care Delivery, explored the shared principles of primary and serious illness care, the interdisciplinary teams that power both disciplines, the policy issues that can act as barriers to or incentives for integration, and best practices for integrating primary care and serious illness care. The workshop proceedings summarize the presentations and discussions that occurred during the event. The document can be obtained here.

The Colleges Where Low-Income Students Enjoy The Highest ROI

College typically pays off for low-income students, but not as much as it does for their peers. Low-income students have a lower return on investment (ROI) than all students across public and private institutions and certificates, associate’s degrees, and bachelor’s degrees, largely because they tend to earn less as adults, according to a new report from the Georgetown University Center on Education and the Workforce (CEW). The Colleges Where Low-Income Students Get the Highest ROI finds that overall, these students receive the best financial returns from attending public institutions, where costs are generally lower. Low-income students, whose families earn $30,000 or less per year, comprise more than one-third of college students. Among institutions that primarily award bachelor’s degrees, public institutions generally lead to the highest ROI for these students during a 40-year timeframe ($951,000), followed by private nonprofit institutions ($863,000) and for-profit colleges ($763,000). Although for-profit colleges have the lowest overall returns among institutions that predominantly award bachelor’s degrees, their student bodies have the greatest share of Pell Grant recipients (56%), followed by those of public institutions (36%) and private nonprofit institutions (35%).

The report and rankings can be obtained here.

National Six-Year College Completion Rate For Students Starting College In 2015

The national six-year completion rate for students who started college in 2015 reached 62.2%, according to a new report from the National Student Clearinghouse Research Center. That rate is an increase of 1.2 percentage points over the fall 2014 cohort and 1.5 percentage points over the 2013 cohort. The report tracks enrollment and completion outcomes for all students who entered higher education for the first time in fall 2015, enrolling full-time or part-time at more than 3,600 two-year and four-year institutions, through June 2021. Students from all starting institution types saw increases in completion rates, with the largest increase among community colleges starters (+1.5 pp). Completion rates increased for White, Latinx, and Black students this year, with the largest jump among Black students (+1.9 pp), while Asian student completion rates remained virtually unchanged. Adult learners (older than 24 at first entry) showed the largest completion rate increases, particularly at the public four -year and community college sectors. Traditional college-age students continue to see higher completion rates than older students of both genders. The report can be obtained here.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Self-Related Physical Health Along The Rural-Urban Continuum, United States, 2021

Poor self-rated physical health is strongly associated with morbidity and premature mortality. As indicated in the February 4, 2022 issue of the CDC ‘s Morbidity and Mortality Weekly Report, an analysis used data from the National Well-being Survey (NWS), a national sample of approximately 4,000 U.S. working-aged adults conducted during February and March 2021, to examine differences in self-rated physical health among residents of large urban; medium/small urban; metro-adjacent rural; and remote rural counties. Residents of medium/small urban, metro-adjacent rural, and remote rural counties had significantly higher probabilities of reporting fair/poor self-rated physical health than their large urban county peers. There were no significant differences by sex or race/ethnicity in self-rated physical health. Although there is no single solution to reducing rural-urban health disparities, these findings suggest that reducing socioeconomic disparities is essential.

Demographic Variation In Health Insurance Coverage: United States, 2020

According to data published on February 11, 2022 in National Health Statistics Reports, in 2020, 31.6 million (9.7%) individuals of all ages were uninsured at the time of the interview. This figure includes 31.2 million (11.5%) people under age 65. Among children, 3.7 million (5.0%) were uninsured, and among working-age adults (aged 18–64), 27.5 million (13.9%) were uninsured. Among the under age 65 group, 64.3% were covered by private health insurance, including 56.6% with employment-based coverage and 6.7% with directly purchased coverage. Moreover, 4.0% were covered by exchange-based coverage, a type of directly purchased coverage. Under age 65, about two in five children and one in five adults were covered by public health coverage, mainly by Medicaid and the Children’s Health Insurance Program (CHIP). Among adults aged 65 and over, the percentage covered by private health insurance varied by age, family income level, education level, and race and Hispanic origin.

HEALTH TECHNOLOGY CORNER

Exercise After Vaccination Increases Serum Antibody Level

Researchers at Iowa State University found 90 minutes of mild- to moderate-intensity exercise directly after a flu or COVID-19 vaccine may provide an extra immune boost. In a study published in the upcoming May 2022 issue of the journal Brain, Behavior, and Immunity, participants who cycled on a stationary bike or took a brisk walk for an hour-and-a-half after obtaining a jab produced more antibodies in the following four weeks compared to participants who sat or continued with their daily routine post-immunization. Nearly half of the participants in the experiment had a BMI in the overweight or obese category. During 90 minutes of exercise, they focused on maintaining a pace that kept their heart rate around 120–140 beats per minute rather than distance. A shorter 45-minute workout did not increase the participants’ antibody levels. The researchers found similar results when they ran an experiment with mice and treadmills. These investigators also are tracking the antibody response six months post-immunization.

Smartphone App To Determine How Well Blood Clots

Researchers at the University of Washington have developed a new blood-clotting test that uses only a single drop of blood and a smartphone vibration motor and camera. The system includes a plastic attachment that holds a tiny cup beneath the phone's camera. An individual adds a drop of blood to the cup, which contains a small copper particle and a chemical that starts the blood-clotting process. Next, the phone's vibration motor shakes the cup while the camera monitors the movement of the particle, which slows down and then stops moving as the clot forms. The researchers showed that this method falls within the accuracy range of the standard instruments of the field. The team published these findings on February 11, 2022 in the journal Nature Communications. Tubes of blood used to be rocked back and forth manually to monitor how long it took a clot to form, which requires a lot of blood, making it infeasible to use in home settings. The vibration motor on a smartphone, can do the same thing, except with a single drop of blood.

DEVELOPMENTS IN HIGHER EDUCATION

Previous issues of this newsletter have described developments involving reauthorization of the Higher Education Act (HEA). It is an important topic that does not always receive the attention of Congress it merits. The HEA is the primary law through which the U.S. Department of Education administers a wide range of programs and activities that include financial assistance for students, such as Pell grants, accreditation, and oversight of various rules and regulations. This legislation initially was passed in 1965. It has been rewritten on eight separate occasions since that year. In its most current iteration, although it was destined to expire at the end of 2013, the law has been extended by Congress. It is not clear when the next reauthorization will take place.

The U.S. Department of Education plays many fundamental roles. An example is enforcement in relation to civil rights at institutions that accept federal funds. Another key function is to collect data on colleges and universities around the United States. A valuable resource in that effort is the National Center for Education Statistics (NCES), which produces The Digest of Education Statistics, a comprehensive reference for all levels of education. The 2020 version that was released in February 2022 is the 56th in a series of publications initiated in 1962. A compilation of statistical information covering the broad field of education from prekindergarten through graduate school, the Digest contains data on a variety of topics, including the number of schools and colleges, enrollments, graduates, educational attainment, finances, and federal funds for education.

Department Of Education Releases Updates To Its College Scoreboard

Updates to the Department’s College Scorecard were announced by the Department in February 2022. The effort includes an improved interactive web tool, along with the restoration of several metrics that assist students in gauging how their prospective institution compares to other colleges across costs, graduation rates, post-college earnings, and related metrics. An objective is to have these modifications reflect the Department's priority of supporting and encouraging inclusive, affordable postsecondary programs that provide strong career outcomes for students. Borrowers will be able to use this tool to determine cumulative student loan debt at both the institution-level and by field of study within each institution, as well as federal student loan repayment rates for the institution. The Department is publishing for the first time since 2018, both in the data files and on the consumer site, institution-level earnings data to provide an overall sense of the career outcomes for alumni. Additional information is furnished about graduates who are better off by having attended college, by showing the percentage of those earning more than the typical worker with only a high school diploma.

Renewal Of The Gainful Employment Plan

As reported on February 10, 2022 by Inside Higher Ed, the Department has proposed to impose regulations again to measure the gainful employment of graduates of for-profit colleges and nondegree programs at nonprofit colleges. The proposal was made in advance of upcoming continuation of negotiated rule making on various student aid regulations. The Education Department proposals would return to a system of measuring earnings versus debt of graduates of college programs. They also would require all institutions, including those that aren’t governed by gainful employment, to provide the department with information on completion rates, debt, and other trends by program. This topic has been the subject of intense debate for more than a decade. If the regulation takes effect, it would compare students’ earnings after graduation to their student-loan debts. Programs where graduates earn too little over a three-year period could lose access to federal student aid. Penalties would apply only to programs at for-profit colleges as well as nondegree programs at public or private nonprofit colleges. The Department’s proposals would return to a system of measuring earnings versus debt of graduates of college programs. They also would require all institutions, including those that aren’t governed by gainful employment, to provide information on completion rates, debt, and other trends by program.

HEALTH REFORM DEVELOPMENTS

The COVID-19 pandemic has been instrumental in further exacerbating problems in the U.S. health care realm that have existed for decades. Three principal aspects that continue to be of major concern are cost, quality, and accessibility. With the rare exception of the Patient Protection and Affordable Care Act (ACA) that became law in 2010, most efforts to improve matters have occurred incrementally rather than from a more sweeping perspective. Much progress has been made in efforts to lower costs, enhance quality in the delivery of health care services, and provide adequate health insurance coverage for individuals who lack it. Despite some impressive advances in all three areas, health care expenditures are fast approaching 20% of GDP, serious disparities exist that are harmful for several population subgroups, and substantial differences exist depending on whether individuals live in rural or urban areas. Regarding the latter consideration, as critical as personal genetic codes may be in governing the quality of health outcomes, Zip codes also play a determinative role in the availability and accessibility of essential health care services.

Physician Compensation And Financial U.S. Public Health System Care Developments

Since passage of the ACA, public and private payers in the U.S. have undertaken various payment reforms to improve quality and reduce spending. Alternative payment models (APMs) and value-based payment (VBP) seek to redirect the health system’s focus toward producing value instead of volume. Public and private payers continue to expand use of alternative payment models, aiming to use value-based payment to affect the care delivery of their contracted health system partners. In parallel, health systems and their employment of physicians continue to grow. A good question is the degree to which health system physician compensation reflects an orientation toward value, rather than volume. As reported on January 28, 2022 in JAMA Health Forum, an investigation that was a component of a larger RAND Health System Study was conducted with senior leaders among a purposive sample of health systems in California, Minnesota, Wisconsin, and Washington that were selected because of their advanced collection and public reporting of physician organization performance data through health care measurement and improvement collaboratives, and because they represented diverse market characteristics.

This cross-sectional mixed methods study of 31 physician organizations affiliated with 22 U.S. health systems found that volume was a component of primary care and specialist compensation for most physician organizations. Volume was the most common form of base compensation by a wide margin, being included by more than 80% and 90% of physician organizations and primary care physicians, respectively, and representing more than two-thirds of compensation when included. While most primary care and specialist compensation arrangements included performance-based incentives, they averaged less than 10% of compensation. These study results suggest that despite growth in value-based payment arrangements from payers, health systems currently incentivize physicians to maximize volume, thereby maximizing health system revenues. Increasing the volume of services was the most commonly cited action for physicians to increase compensation, reported as the top action by 22 physician organizations (70.0%) for primary care physicians and specialists. A conclusion is that greater translation of the value-over-volume incentives of payers into physician compensation may be necessary to realize the full potential of value-oriented payment reform.

Adequacy Of The Federal Response To COVID_19

The Government Accountability Office (GAO), the auditing arm of the U.S. Congress that is the equivalent of a federal watchdog, has criticized the Department of Health and Human Services (HHS) for “persistent difficulties” in its response to the coronavirus pandemic and past public health emergencies. For example, HHS still is viewed as having no comprehensive COVID-19 testing strategy, according to a report from the GAO that was released on January 27, 2022. The problems date back more than 10 years to other crises, including the H1N1 influenza pandemic, the Zika and Ebola virus outbreaks, and public health threats posed by natural disasters, such as hurricanes. These failures are viewed as leaving the nation vulnerable to future viruses and weather events, according to the report. In tandem with the release of the document, GAO announced it has added HHS leadership and public health emergency coordination to its list of “high-risk” issues that Congress and the executive branch should address. The list now highlights 37 problems at more than a dozen agencies, with some dating back to 1990.

APPROPRIATIONS RICORSO

Each year, this newsletter serves as a vehicle for describing actions by Congress to appropriate funds that enable the federal government to continue its operations. A movie released in 1993 called “Groundhog Day” is about a television weather reporter who awakes each day and relives it repeatedly while he is in the town of Punxsutawney, PA to film a report about annual Groundhog Day festivities. A proposition is advanced that the appropriations cycle each fiscal year on Capitol Hill is somewhat reminiscent of that same situation.

Fiscal year 2022 began on October 1, 2021 with no permanent funding in place for the next 12 months. Short-term remedies had to be devised in the form of one or more continuing resolutions (CRs). The most recent one expired on February 18, 2022. Legislators had two choices. The most desirable option would be to pass an omnibus bill that encompass 12 different categories of spending. Otherwise, another short-term CR is needed to prevent the government from shutting down. A new CR is in effect until March 11, 2022.

A disadvantage of functioning under a CR is that departments and agencies must operate with last year’s funding levels. An inability to know how much money Congress eventually will provide for a wide assortment of programs means that long-term budget planning is upended. It also remains unclear whether new initiatives either can or should be set in motion. Another serious drawback affects government staffing levels because of the uncertainty of not knowing whether positions will continue to be funded. The Health Resources and Services Administration (HRSA) within the U.S. Public Health Services is an example of an agency influenced negatively by the prevailing uncertainty. Important programs involving community health centers for the delivery of needed services and health workforce training are two of many entities to benefit immensely by having clearer funding signposts in efforts to go forward effectively.

Giambattista Vico (1668-1744) was the author of La Scienza Nuova, a book that he wrote to decipher the history, mythology, and laws of the ancient world. His conception of history is that it unfolds in four stages: theocratic, aristocratic, democratic, and chaotic. In the last phase, everything falls apart, producing a ricorso that results in a return to the theocratic phase where the cycle begins all over again.

Perhaps a way of viewing the annual funding cycle on Capitol Hill might be to consider it as occurring in the following stages:

Dread—Funding finally was approved for this year. Is it really time to begin once again?
Conflict—Why cannot colleagues on the other side of the aisle simply agree with us this time?
Anxiety—Will an omnibus bill ever be passed before the current fiscal year ends?
Satiety—We did it.

Lastly, related to determining if passage of omnibus legislation is achievable, the issue of parity tends to arise every year. If money for social programs is going to be increased, shouldn’t funding for military purposes be increased equally? The same quagmire holds true vice versa.

DUELING IHD “SKIN” NARRATIVES

The genesis of the Framingham heart study in 1948 and the onset of the great era of cardiovascular core risk factor identification (e.g., high lipid levels) are credited with a precipitous decline in ischemic heart disease (IHD) mortality. Rather than lauding this triumph, some epidemiologists have mounted a substantial critique of “risk-factor” epidemiology in IHD, notwithstanding its documented public health value. This critique arises from quite different directions as described in the January 2022 issue of the journal Epidemiology.

Proponents of the social determinants of health argue that it is necessary to move far “above the skin” by examining larger social forces that give rise to the biologic markers conventional epidemiology has treated as causal factors in IHD. Conversely, supporters of the human genome project advocate probing yet further “beneath the skin” to demonstrate that the massive investment in genome-wide association studies and the coalescence of these findings into polygenic scores will open up new avenues for prevention. The two positions to some extent reflect the contrast between the reductionism attractive to molecular biologists and the holism to which social scientists are drawn.

The debate is enriched in the Epidemiology issue by inclusion of a study that brings together genetic and sociodemographic antecedents, providing a welcome attempt at integrating risk factors operating across different levels of organization. Sophisticated mathematical and statistical tools used in the study are indifferent to preconceived causal structures and they have the additional benefit of helping to constrain the prejudices of investigators. The commonality linking the two schools of thought represented is not often recognized. Both argue that it is a mistake to see conventional cardiovascular risk factors as causes. Both agree that they are mere biologic intermediaries determined by factors operating long before they are evident, whether those factors can be social forces or genetic differences.

Both schools also argue that it is necessary to go beyond conventional thinking about cardiovascular risk factors to understand fully the causes of IHD. As has often been noted, causality is not a straight line, but a messy matrix of interacting and intersecting factors operating at different times and at different levels. This consideration especially is true for IHD, which has no singular cause. Although this nexus frequently has been described as a web of causation, that metaphor does not do full justice to the complexity of influences operating on several levels.

Another paper appearing in the January 2022 issue of the journal Nature Genetics complements what is known about cardiovascular disease. Efforts to elucidate causal mechanisms, including large-scale sequencing studies, have resulted in thousands of genes being associated with cardiovascular and cardiometabolic diseases with varying degrees of evidence. The traditional reductionist paradigm, i.e., one disease–one target–one drug, or, if need be, a combination thereof, is insufficient to provide mechanistic explanations and enable actionable subtyping or endotyping of diseases for precision medicine.