Thursday, November 27, 2014

Giving Thanks in a scary world

Let us give thanks.

Let us give thanks that we are not the parents of Michael Brown. One of the more thoughtful and moving pieces on this subject among the thousands to appear is by Charles Blow, Fury after Ferguson.

Let us give thanks, if we do not live in Missouri, that we won’t see the St. Louis County District Attorney running for Governor. Or, if we are, that we can vote against him.

Let us give thanks that we are not in prison, victims of the four-decade old policy of mass incarceration in the US, addressed as a major public health epidemic by the New York Times, Mass Imprisonment and Public Health”, which details the reasons why

…people in prison are among the unhealthiest members of society. Most come from impoverished communities where chronic and infectious diseases, drug abuse and other physical and mental stressors are present at much higher rates than in the general population. Health care in those communities also tends to be poor or nonexistent.

The experience of being locked up — which often involves dangerous overcrowding and inconsistent or inadequate health care — exacerbates these problems, or creates new ones. Worse, the criminal justice system has to absorb more of the mentally ill and the addicted. The collapse of institutional psychiatric care and the surge of punitive drug laws have sent millions of people to prison, where they rarely if ever get the care they need. Severe mental illness is two to four times as common in prison as on the outside, while more than two-thirds of inmates have a substance abuse problem, compared with about 9 percent of the general public.
Common prison-management tactics can also turn even relatively healthy inmates against themselves. Studies have found that people held in solitary confinement are up to seven times more likely than other inmates to harm themselves or attempt suicide.

The report also highlights the “contagious” health effects of incarceration on the already unstable communities most of the 700,000 inmates released each year will return to. When swaths of young, mostly minority men are put behind bars, families are ripped apart, children grow up fatherless, and poverty and homelessness increase. Today 2.7 million children have a parent in prison, which increases their own risk of incarceration down the road.

Oh, yes. Or their children.

Most of us are not. Some of us are. It is simply not ok. And it is not ok to be selfish, arrogant, so-greedy-it-is-not-to-be-believed multi-billionaires. Be successful, yes. Be rich, yes. Do not be obscenely so wealthy that it requires the destruction of the lives of millions of others.

Blow notes that
Even long-suffering people will not suffer forever. Patience expires. The heart can be broken only so many times before peace is broken. And the absence of peace doesn’t predicate the presence of violence. It does, however, demand the troubling of the comfortable

Nick Hanauer, a multi-billionaire, is less sanguine. He warns his fellow 0.01%ers in a post on Politico.com that “The Pitchforks are coming for us…Plutocrats”. It’s a nice thought, that they would get what is coming to them, but I am less than confident that he is correct. It is a nice thought for Thanksgiving, though.

If we have jobs, let us be thankful. If, even better, they are good jobs, let us be more thankful.

If we have family, let us be thankful. If we have lost family, let us be thankful for the time that we had them. If we can still imagine a world with peace and justice, let us be thankful, although it may be just in our imagination.




And then, let us take a deep breath and realize that it is not just going to come, that we are going to have to work for it. Hard, and tirelessly.

Happy Thanksgiving.

Monday, November 17, 2014

Racism, classism, and who we take into medical school: Who will care for the people?

I work in a medical school. I see and teach medical students. They are a smart group. When measured by grades and scores on standardized exams, they are even smarter. Some of them – but not nearly enough – are members of socioeconomic and ethnic groups or geographic areas under-represented in medicine. Sometimes, these students struggle with grades in medical school. Occasionally, this elicits comments, sometimes smug, sometimes rueful, that this is the result of affirmative action, as if this were a negative thing. Given the alternative, the default of taking all people who look alike, who come from the same background, who want to do the same things – in brief, to stereotype, white 22 year old men who come from economically privileged and professional families (many of them medical) who want to be subspecialists in the suburbs – this is pretty scary.

It is affectively, intellectually, and morally scary, yes, to think that we could accept this kind of regression to an archaic, not to say racist and classist past where becoming a doctor was a privilege limited to only a few. It is also scary in very practical terms, because the people who need health care the most are those least likely to be served by the “default” group. Indeed, in fulfilling their personal goals, the result will be to “serve” already overserved communities, largely in specialties in oversupply. There is good data that shows that students from rural areas are more likely to serve rural communities, that students from underrepresented minority groups are more likely to serve members of those groups, that students from less-privileged backgrounds are more likely to serve needier communities. And that all these groups are more likely to enter primary care specialties, those in most short supply. This is what we want. But they represent a small percentage of our medical students. Why? Because we still, despite all the data showing what predicts service to people most in need, stay wedded to incorrect and outdated ideas of “qualified” for medical school that overwhelmingly bring us the same old same old.

Many (although clearly, given the above, not most) of medical students, from all backgrounds, have some difficulty with the first two years of medical school despite being not only smart but are well-educated from top small liberal arts colleges. There is a relationship here; these colleges emphasize thinking and creativity and problem solving, exactly the skills needed to be an effective physician. They teach largely in small and interactive classes, fostering self-confidence and independence and thoughtfulness and sometimes non-conformity, exactly the temperament needed for an effective physician. They grade largely on the basis of essay tests, requiring integration of information, literacy, and demonstrating an ability to think, not on multiple-choice tests, just what we want from physicians. Unfortunately, this is not the best preparation for the first two years of medical school, overwhelmingly consisting of large lectures characterized by a presentation of a huge number of facts, and designed to reward memorization of those facts using massive multiple-choice tests. Good preparation for this: being a science major at a large university whose courses overwhelmingly consisted of large lectures characterized by a litany of factoids and rewarding successful regurgitation of those factoids on massive multiple choice tests. QED.

Not, of course, the best preparation for being a curious, open-minded, thinking, problem-solving doctor. But this is what we get. Yes, it is certainly true that some of our students from large universities, or from professional or high socioeconomic status, or majority ethnic groups, or suburbs, or all, are incredibly committed to making a difference. Many want to enter primary care, many more want to serve humanity’s neediest, in our country and abroad. They are humble, and caring, and smart. We are lucky to have them in our schools and entering medicine. But they, along with those who are from less-well-off families, and ethnic minority groups, and rural communities, remain a minority among all the sameness. And remain more or less in the same proportions over time. We continue to do the same thing, and have the audacity to wonder why we do not get different results. This is Einstein’s definition of insanity.

On November 16, 2014, Nicholas Kristof published his column “When Whites Just Don’t Get It, Part IV” in the New York Times. He discusses the continuing racism in this country, the legacy of slavery, the fact that “For example, counties in America that had a higher proportion of slaves in 1860 are still more unequal today, according to a scholarly paper published in 2010.” And, of course, he discusses the responses he received (from white people) to Parts I-III, saying it is all in the past, stop beating that drum, it is not my fault, I work hard and don’t get the special privileges that “they” do, and why don’t they take personal responsibility, and our President is Black, isn’t that proof that the problem is gone? I won’t begin to get into the question of how much of the vicious attacks on our President are in fact the result of the fact that he is Black; rather while I observe that the fact that he was elected says “Yes, we have made incredible progress,” I note that this does not eliminate “Yes, we still have lots of racism and it has major negative effects on people as individuals and society as a whole.”

Kristof talks about the fact that he and his Times colleague, Charles Blow, are both promoting books. He notes that while he (Kristof) is white and from a middle-class background, Blow is black and was raised largely in poverty by a single mother. But he also makes clear that this doesn’t prove that the playing field is even, but rather that Blow was very talented, very hard working, and also lucky. That some members of minority groups, or people with very disadvantaged backgrounds (or both) succeed is a testimony to them, to their drive and intelligence and talent and luck, and the support that they have had from others such as family or friends which, while obviously not financial, was significant. It absolutely doesn’t prove that those who are from such backgrounds who have not succeeded are at fault. Indeed, the converse is true; how many of those who are from well-to-do, educated, privileged and white backgrounds, who have had all the financial and educational supports all their lives, who are now in medical school or doctors or professors or leaders of industry would have gotten there if they had started as far down the ladder as, say, Charles Blow, or some of our medical students? Some, for sure, but not most. They are folks born on second, or even third, base, who make it home and look at those who started from home and made it around all four bases, and say “why can’t they all do that”? Most of you, starting in the same place, would, like those who actually did start there, never have had a prayer.

It is common for classes of medical students to develop a “personality”, more self-centered or more volunteering, more intellectually curious or more grinding, more open or more closed. I suspect that this probably has to do with a few highly visible people, because most of the students don’t vary that much. I have heard faculty complain about the inappropriate behavior, the lack of professionalism (especially when they get to the parts of school that involve caring for patients), the sense of “entitlement” that many students have. But this is not true (overwhelmingly) of those who are the first in their families to go to college, who are grateful for the opportunity and hard-working, and committed to making a difference in the world. If we think that entitled, unprofessional students are not desirable, why are we accepting those who fit that mold?


We can do better. We can scale up programs to accept caring, humble, committed, smart people instead of self-centered, arrogant, and entitled ones. Indeed, if we hope to improve the health of our people, we must.

Sunday, November 9, 2014

Uber, pricey doughnuts, and health care: serving the needs of the people or the interests of the rich and powerful?

Two articles in the Sunday Review of the New York Times on November 10, 2014 that are not explicitly about health care seem to me to be very much related to the health care system in the US. “Republicans and the puzzle of Uber”, by Josh Barro, discusses the conflicting interests that affect policy making, particularly at the state level, and create an ideological challenge for that party. On the one side, the libertarian wing of the party lauds “the smartphone based car service” Uber as a wonderful example of deregulation, of opening the market to new ideas that nimbly serve the consumer and meet a real need. On the other side are the existing large and small businesses whose owners not only vote Republican but contribute money to Republican coffers, who want to have their interests protected. In the case of Uber, it is licensed taxi owners, but as Mr. Barro makes clear, this extends to many other businesses where profit margins are protected by legal regulations.

Examples that Mr. Barro cites include everything from licensing of interior designers, auctioneers and ballroom dance studio owners in Florida (run by Republicans) to limiting the sale of coffins to funeral homes (in Oklahoma, also very “red”). He notes that this also occurs in the case of very large businesses at the federal level, citing the controversy about the Export-Import bank, which can protect big companies in the US, but is seen as anti-competitive by some in Congress. Other examples which he does not mention include opposition to the presence of food trucks by local restaurants and “blue laws” in some states requiring car dealerships to be closed on Sunday (hey, if it were legal someone would open and then I’d have to also to say competitive, and I don’t want to work Sunday!)

What does this have to do with the health system? A lot, in a lot of areas, but one that is of great interest to me is the recent initiative begun by a collaboration of all of the major family medicine organizations and newly including osteopathic groups called “Family Medicine for America’s Health”. This effort, with the tag line “Health is Primary”, is good and important, calling attention to the fact (and it is fact) that the creation of a cost-effective health system that delivers high-quality care depends upon a strong primary care base (discussed and with evidence presented many times in this blog). It also emphasizes that family doctors are the central specialty in primary care, given the near abandonment of general medicine by internal medicine graduates. The argument is articulately made in a recent article (ironically called, internally, the “über article” as it will be succeeded by other articles addressing components of the problem) in the Annals of Family Medicine, Health Is Primary: Family Medicine for America’s Health”.

However, there has been less-than-sweeping coverage in the media, and a less than enthusiastic reception by other groups in the medical establishment. A generally positive article in the Kaiser Health News by Lisa Gillespie on October 24, 2014, “Family doctors push for a bigger piece of the health care pie”, quotes Atul Grover MD, chief public policy officer of the Association of American Medical Colleges (AAMC), who says “while primary care is important, taking funding away from specialty training isn't necessarily a solution because an aging population will need more specialty care.” This may or may not be true – we need as much training in different specialties as we need, not more or less. It is almost certainly true that we need more in primary care and less in some others – but it reflects Grover’s (and AAMC’s) role in representing the interests of our academic health centers and all of its components even when this may not be in the best interests of the health of the American people. Just like the Republican party, AAMC has constituents that may reflect different interests.

Thus, there is some irony to another quotation from Grover, that “It’s always a question of what motivates groups to do these kind of campaigns — is it looking out for patients or your own interests, and generally it’s a combination of both,” because this is exactly the position the AAMC is in. However, it is a real caution for the family medicine organizations who are working on “Family Medicine for America’s Health”: to the extent that this campaign keeps to the high ground of America’s health (as it generally is, notably in the Annals article) it deserves strong support. To the extent that the self-interest of family doctors is, or is seen to be, the major driver of the campaign, we risk being lumped with other “special interests”: we could become the funeral homes in Oklahoma selling coffins, or at least the AAMC.

The other NY Times article on November 9, 2014, is from Margaret Sullivan, the Times’ “Public Editor”. “Pricey doughnuts, pricier homes, priced-out readers” addresses common complaints from readers that the Times, not only in its advertising but its articles, seems to be addressing an incredibly wealthy crowd. Anyone who reads the paper is impressed by the lack of accessibility of the homes featured often costing not just millions but tens of millions of dollars, the ubiquity of ads for $10,000+ watches, and articles as well as ads for the highest-end consumer items ($160 flashlights and doughnuts costing $20 for a half-dozen). Sullivan notes that these may seem “aimed at hedge fund managers, if not Russian oligarchs”. She quotes Times executive editor Dean Baquet who, adding insult to injury, says of Times readers “I think we have as many college professors as Wall St. bankers”. This is a double insult; first of all there are way more college professors than Wall St. bankers, and the idea that college professors are the economic “low end” is amazing.

Ms. Sullivan’s article cites mixed reviews of the extent to which the Times covers of poverty (the Pew Research Center says 1% of page 1 articles), but it is clear that appealing to the middle class is missing from the Times. Baquet talks about “balance” as if it were reasonable to balance coverage of issues relevant to the 0.01% with those of the 1% or even only the 10% wealthiest Americans, and only an occasional piece addressing the world of the rest of the nation lives in. This, of course, is what parallels the health care system.

Our hospitals seek to attract well-off and well-insured clients, “balancing” them with poor people. But there are way more poor people, and they tend to be sicker and need more care, so justice, equity, demands that there be much, much more care and attention allocated to them than to the wealthy. If the Times makes money from advertisers who want to reach the wealthiest customers, our hospitals are interested in pleasing their wealthiest customers (oh, I mean patients) in hopes of getting big donations. And those donations are almost never used to provide necessary health care for the sickest and poorest, but rather to open new units (adorned with the donors’ names) to recruit yet more well-off patients. Both our health care institutions and the NY Times are about augmenting their income rather than meeting people’s needs.

Ms. Sullivan ends with “In the end, the upscale doughnut and the penthouse apartment — lofty as they may be — have nothing to do with The Times’s highest purpose.”  Good for her. Maybe Mr. Baquet will get the message, but I doubt it. At bottom, however, if the “balance” of whose interests are addressed by New York Times articles seems off, or offends you, or doesn’t meet your needs, you can read your local paper.

If the balance of who our health care system cares for is way off, we have to work to change it.

Sunday, October 19, 2014

Ebola, fate, and appropriately assessing risk.


There has been a lot written about Ebola lately, and lots of talk about it, and fear about it, in the halls of the hospital and clinics where I work, and I would guess lots of other places also. I don’t have any expertise in Ebola, and don’t claim to know what should have been done, or what “we” should be doing going forward, but it is clear that there have been mistakes, or at least major miscalculations, made by the WHO and the CDC and other government agencies. Some of this may be the result of cuts in funding over the last many years, some the result of emphasis on bioterrorism rather than the impact of infectious agents that get transmitted the regular way (“Failures of Competence”, Joe Nocera, October 18, 2014) but has been both sobering as well as a vehicle for administration opponents to attack it. Of course, the attacks may be justified, but there is no reason to think a previous administration would have done better.

First, it is critical to point out that the real problem, suffering, and crisis is in West Africa, in Liberia and Sierra Leone, and Guinea. In countries with little infrastructure and few resources and in the cases of the first two, relatively recent histories of devastating civil wars. The concern about Ebola in the US (so far two home-grown cases, both in nurses who cared for the Liberian man in Texas) needs to be seen in that context. Those countries that are severely affected need major resources, both human and financial, and need them fast. An excellent video analysis of the issues was recently done by Laurie Garrett on a webinar called “The Ebola crisis: the best and worst case scenarios from here”. Thankfully, there is some recognition of the need in these countries among those who are seeking to make political hay of this crisis; my own Senator Jerry Moran has joined others, particularly other Republicans, in calling for closing off flights from the affected countries, but proposes to exempt health workers. Of course, this misses the fact that it is easier to screen folks coming from those countries than people who first travel to other countries and then fly to the US.

What does interest me about the whole discussion in this country around Ebola is the degree to which it illustrates two common flaws in the way people think about problems. One, obviously at play in the case of Ebola, is the fear of the new, unfamiliar, and scary, especially when hyped up by the media. Thus, for example, the reluctance of both patients and staff (encouraged by their families) to come to work in our clinic during the period that a patient at our hospital was being ruled out for Ebola (he didn’t end up having it), even though it is in a separate building and the patient was three layers of isolation deep. This fear is stoked by events such as the revelation that the second nurse to come down with Ebola had been allowed to fly from Texas to Ohio and back on a commercial airliner (although it could just as well be cited as evidence that anyone, working in a hospital or not, might be at risk).

The second is that people often find it easier to worry about, to get worked up about, problems that they are at low risk for but that they cannot do anything about, even when they are not doing what they could do to prevent problems for which they are at much greater risk. I have written in the past about a prototypical patient obsessed by breast cancer, a condition for which she was in fact at no increased risk, who was not doing anything about problems she could act on such as uncontrolled hypertension, cigarette smoking, and unprotected sex with multiple partners. Indeed, my point was that if she was worried about those last three, people would expect her to do something about them since she could – she could take blood pressure medication, stop or cut down on her smoking, and use protection when having sex. But those might be hard. Worrying about breast cancer, something that there was nothing she herself could do to prevent (doctors could order mammograms, at too young an age and far too frequently, but she wouldn’t have to do anything) was, in this sense, easier. Both of these logical flaws were highlighted by comments from the chief medical officer of my hospital, early in the isolation of the possible Ebola patient: “If 20,000 people were dying of Ebola there would be riots in the streets. But every year an average of 22,000 Americans die of influenza, and people still don’t get their flu shots”.

This selective concern is a form of determinism, the topic addressed by Konika Banerjee and Paul Bloom in “Does everything happen for a reason?” in the NY Times, October 19, 2014. They discuss the idea of fate, that things happen that were destined to happen, that experiences of adversity which coincidentally lead to positive outcomes (the man hospitalized for injuries as a result of the 2013 Boston Marathon bombings who falls in love with and marries his nurse) are “meant to be”. They note that while this is most common in people who are religious and believe that God determines everything, it is still a very common belief among atheists. It is an attractive idea, but it is a mis-reading of chance. That is, people pay attention when things seem to fortuitously happen, or a coincidence facilitates something you wanted to happen. (E.g., yesterday morning I heard a part of a 1981 song on the oldies station but couldn’t remember its name; amazingly, when I turned the station back on in the evening, it was playing again! Fated? No, just Rick Springfield’s “Jesse’s Girl”.) We forget how often things do not happen, but remember when they do. Banerjee and Bloom write:
Not everyone would go as far as the atheist Richard Dawkins, who has written that the universe exhibits “precisely the properties we should expect if there is, at bottom, no design, no purpose, no evil, and no good, nothing but blind, pitiless indifference.”
Deists, like Thomas Jefferson I heard yesterday (also on the radio, but NPR this time), believed that the world was so ordered that there must be a creator, although they rejected the detailed instructions that many of their contemporaries took from the Bible or other religious texts. However, the random nature of events, as suggested by Dawkins or by Stephen Jay Gould (“Full House: The Spread of Excellence from Plato to Darwin”) accounts for these just as well.

The same issue of the Times contains a more medically related piece, “Why doctors need stories”, by Peter D. Kramer. I like stories, and I use them a lot (see above for a couple); they make things come alive, tie abstract events to actual lives, create examples in the experience of individual people of phenomena that are harder to understand when we look only at populations. But they can be misused; my story about the woman who was more worried about breast cancer than her smoking or high blood pressure is meant to be an example of how people can choose which facts they believe and which they ignore. It doesn’t prove anything, certainly not that most people act this way, or don’t. It does (I hope) get your attention. We have to be careful how stories are used; “I knew someone who had an abnormal Pap smear and she didn’t do anything and it went away”, while consistent with our most current knowledge about the early course of abnormal Pap smears in young women, is not a valid argument for you to not do anything. Stories tell what they tell; the lessons learned and conclusions reached are up to us.

Banerjee and Bloom end their piece:
If there is such a thing as divine justice or karmic retribution, the world we live in is not the place to find it. Instead, the events of human life unfold in a fair and just manner only when individuals and society work hard to make this happen. We should resist our natural urge to think otherwise.

And, no matter what we think about Ebola, we should get our flu shots.


Thursday, September 25, 2014

Medical futility and the responsibility of physicians...and patients

Ethics is a difficult area. Medical decision making is a difficult area. Both are fraught with ambiguities, conflicting priorities, differing values. Priorities shift with time, as our moral compass tacks back and forth, seeking to compensate for current problems and deficiencies, and sometimes overreaching, require new future shifts in direction. We will probably never get it exactly right, but need to keep working in the right direction.

Barron Lerner makes an excellent start in his NY Times  Op-Ed from September 18, 2014,”When Medicine is Futile”.  He talks about his father, who was a physician leader in “The medical futility movement, which argued that doctors should be able to withhold interventions that they believed would merely prolong the dying process...”. The father was an infectious disease specialist, whose early career was marked by the miracle of penicillin and drugs to treat tuberculosis. However, later his practice, as that of most infectious disease physicians in the US, was being called to consult on infections occurring in hospitalized patients who were otherwise severely ill, often in intensive care units, with terminal diseases and frequently advanced dementia, “…connected to machines and tubes he knew would not help them.”

The younger Dr. Lerner, author of this piece and a professor of medicine at a major medical school, notes that his father “..placed some of the blame for the situation at the feet of bioethics and patients’ rights, two movements that I, as a young physician, had fiercely advocated,” which put them in conflict. And yet, from a longer perspective, he can see a great deal of his father’s concerns. As he point out, the patient’s rights movement and to a lesser extent bioethics
…did not account for one thing: Patients often demanded interventions that had little or no chance of succeeding. And physicians, with ethicists and lawyers looking over their shoulders, and, at times, with substantial money to be made, provided them.

The stimulus for this article is a recent report by the Institute of Medicine (IOM) of the National Academy of Sciences, “Dying in America,” “…that argues that we subject dying patients to too many treatments, denying them a peaceful death.” This report begins the process of reconciling the physician’s responsibility to at least provide accurate information on treatments and the likelihood of their success with the autonomy of patients to make their own decisions about the treatment that they want. This is a welcome effort at reconciliation of these two apparently or potentially conflicted ethical principles, especially given, as Dr. Lerner points out, that “Physicians declaring things to be ‘futile’ sounded too much like the old system of medical paternalism, in which doctors had made life-and-death decisions for patients by themselves.” But any meaningful discussion of this  requires consideration of four powerful issues that always impact upon it.

First, there is trust. Can patients and their families trust the doctors to be advising them in their best interests? This is particularly true for many disenfranchised people who are not like the majority of doctors in background, ethnicity, and certainly income. For the poor and members of minority groups that have in fact in the past been victims of outrageous abuses, there may remain a suspicion of any effort to suggest that further interventions would be futile. People may think “you are only saying this because I (or my family member) is …” and would recommend intervention for a member of your own family, or someone more like you.
Second is the issue touched on above about the “likelihood of success”. Success at what? For patients and/or their families to make intelligent decisions, the parameters of success, or similar words like “help”, “improve”, “make better”, need to be clearly defined in words and concepts that lay people can understand and that physicians are willing to use. I have written in the past about a woman whose daughter worked with me who was dying in the intensive care unit (ICU) of the hospital I worked at. I came to visit and met her 5 children trying to decide whether to approve the use of an intervention in their unconscious, uncomprehending, and terminally ill mother that they were told “would help”. As I was not the treating physician, I went to the ICU doctor and inquired, on their behalf, what the intervention was and how it was expected that it might help. I then cautiously returned to the family to feel them out regarding their understanding of “help”. They thought it meant it would make her “better”. What, I asked, did “better” mean to them? When they appeared confused, I went further, asking if it meant that she would wake up, be able to talk to them, be able to go home, perhaps be able to say goodbye? Yes, they said, that is what it meant to them. I tried to gently say that this would not happen, that this intervention would, perhaps, correct a laboratory value, but would not have any of the outcomes they hoped for. They opted to not have it.

These are not easy discussions, and lead to the third issue. Most people do not have the training and background to understand the ramifications of the decisions that they are asked to make under the rubric of “patient autonomy”. I feel that I am knowledgeable about many areas, particularly medical ones, but it would be ridiculous to ask me how a bridge should be built. You wouldn’t want to drive over it, and I wouldn’t either. Simply citing “patient autonomy” and presenting incomprehensible data and decisions about whether to do something that even the words for make no sense to a regular person is not ethical; it is equivalent to abandonment. Sometimes a doctor or nurse or other health professional with patience can spend the time and effort necessary to help a patient or their family really understand what is going on, what likely outcomes of any intervention or –equally validly – non-interventions might be, so that they can make an informed decision based upon that information and on their own values and priorities. Most of the time the healthcare providers are too busy, and do not have the time and may not have the inclination, and are not paid well, or at all, for that time.

Which leads to the final issue, money. In a quote from Dr. Lerner above regarding procedures that will not be effective, I include “the substantial money to be made from them”. The money to be made by providing them is a profoundly important issue, potentially corrupting any discussion of ethic versus futility. Dr. Lerner notes that the IOM report “…advocates that Medicare and other insurers pay physicians to talk to their patients about end-of-life care”. This is a great idea, but it doesn’t currently happen often, and even the proposal that physicians do it (not to mention be paid for it) was grossly misrepresented as “death panels” when included in the Affordable Care Act (ACA). Even if this time is paid for, it would never approach the amount of money that would come from doing the procedure, or certainly not the money a busy surgeon, for example, might make from operating on someone else.
All people know, intellectually, that everyone dies. What may be harder for many to accept is that they must die, particularly when their time comes. It may be even harder for family members, who are not the actual patient, to accept, and to demand that “everything” be done. For Dr. Barron the elder, as described by his son, “Infections were the way that such frail individuals were supposed to die, the ‘final straw’ in the deterioration of so many of the body’s vital organs and functions.” Yet somehow they had become things that needed to be treated.” 

Everyone dies; what we can only hope for is a death unaccompanied by pain and unpleasantness. Infections like pneumonia which should be treated in an otherwise healthy person in whom a return to health is likely probably should not be in a person who is terminally ill, bed bound, demented. They are nature’s exit door. The same could be said for starvation, a relatively benign way to go, and almost always better than the alternatives of feeding tubes or intravenous nutrition, which carry high risks of complications of aspiration and infection and discomfort.

There must be a real understanding that patient autonomy does not include the right to demand any treatment. We would not assume a person could request a Corvette or a lifetime pension, and yet the latter would probably do more to improve health than any medical intervention, and the former would cost less than many.

Dealing with and overcoming the barriers presented by the first three issues will be difficult but can be done. To really do so means eliminating the fourth issue, the perverse economic conflict of interest that can cloud judgment, decrease trust, and pollute the entire process.

Wednesday, September 17, 2014

Suicide in doctors and others: remembering and preventing it if we can

Recently, SASS-MoKan, our local suicide survivors’ support group, held its annual Remembrance Walk. I have written about these in the past, and have included the fact that my personal interest in the issue of suicide is the fact that my older son, Matt, committed suicide in 2002, just after he turned 24. At the time, everything seemed to be going fine in his life, and it came as a real surprise to his family, his close friends, everyone.

The Remembrance Walk is a lovely ceremony. Following a lap around a good-sized park, there is a ceremony. All the survivors stand on the grass in a circle, and the names of all those they have lost are read; at the end, a flight of doves is released. It is caring, and it is supportive. Of course, the ceremony also brings out the pain and sadness of our losses.

Matt died nearly 12 years ago, but I know others who have lost children very recently. I can tell them that the acute agonizing pain that feels as if it will never ease does, but they cannot and should not believe. It becomes less acute, less sharp, less all-consuming every minute, but it never goes away.

Recently, an Op-Ed in the New York Times by Pranay Sinha discussed “Why do doctors commit suicide?”. Because I am a doctor, and one who many of my colleagues know had a suicide in my family, several people shared this with me, although I’d already seen it. The article provides the perhaps shocking information that the suicide rate among physicians is twice the national average. Beyond this, however, it focuses on residents, doctors in training, and the enormous stresses that they are under, not further discussing the reasons why doctors in general have such high suicide rates. This is not surprising, as Dr. Sinha himself is a first-year resident (at Yale) and is obviously acutely aware of the stresses and strains of residents.

I know that this is true; I was a resident (a long time ago, in the last millennium) and I work every day with residents. It is a hard job; although these people will become, in a few years, full-fledged physicians who will range from very well-paid to extremely well-paid, they are, as residents, working for about the US average wage, but up to 80 hours a week, often with life and death in their hands. That this is fewer hours than residents used to work is good, but is of limited comfort to them. The point is that the residency is a big stress, and it occurs at an age when many people, especially males, are already at risk. The important issues that are addressed in this piece, and in several of the letters written in response to it, are the idea that doctors are supposed to be all-knowing, infallible, unwilling to admit mistakes or weakness. The op-ed and the letters make clear how obviously unreasonable and burdensome that this is, for all doctors and possibly even more for these young doctors who are even more aware, inside, of what they don’t know and are terrified of showing it.

This is National Suicide Prevention Month, which is why the remembrance walk is in September, and why there are such articles appearing. NPR recently ran a program on the increase in the number of suicides in middle-aged men has increased by 50% since 1999; older men have always had the highest suicide rate, followed by adolescents and young men, but this increase in men aged 45-65 is new. Some suggestion is that it is the economic downturn, which hit poor people well before the “official” recession; it is lower-income men who had the highest rates in this age group. Robin Williams’ recent suicide was widely covered; I doubt that National Suicide Prevention Month entered into his decision. Interestingly to me, many of the commentators focused on the “how surprising, he was so funny, he made us laugh, who would have guessed” angle, while others have discussed how he, like many comedians, needed the public attention but was lost when alone. I suspect Williams was bipolar; certainly many of his activities have suggested an ongoing depression while his outer persona was so often manic.

What many of the articles, including the Op-Ed, do not discuss, however, is the fact that most suicides in the US are caused by depression, a disease. It may be unipolar (“just” depression) or bipolar (“manic depression”), but it is potentially fatal.  The stresses of being a doctor, or being a resident, are tremendous and cause people who are depressed to go “over the edge” and commit suicide, but it is important to remember that most people undergoing the same stresses do not. The underlying condition usually needs to be present for the precipitating cause to be fatal. I have previously cited what I consider to be one of the best discussions of this issue, “The trap of meaning: a public health tragedy” by CG Lyketsos and MS Chisolm in JAMA.[1]

National Suicide Prevention Month, and the activities associated with it, are critically important for raising awareness about a condition that kills 40,000 Americans a year, but is often kept secret, through shame. When I became a member of the club no one wants to be in, what are called suicide survivors (although the meaning is family and friends of someone who has completed suicide, rather than those who have personally survived a suicide attempt), I found out lots of people I knew were also members. They had parents, children, siblings, close friends who had committed suicide, but I didn’t know. We often don’t talk about our pain, but the sadness of losing a child seems to many to be more ok to talk about if it was a medical disease, or car accident, or homicide, than if it was suicide. But the loss is the loss; the pain is the pain.

I don’t have the optimism that some do about being able to prevent suicide in specific cases. I do believe that early diagnosis and treatment helps; I believe that being aware of the warning signs is important, and I will never know how many times having those who loved him around might have prevented my son from killing himself before he finally did. I can only hope that more awareness and discussion about this condition will make a difference for some, and perhaps many.





[1] Lyketsos CG, Chisolm MS .The trap of meaning: a public health tragedy. JAMA. 2009 Jul 22;302(4):432-3. doi: 10.1001/jama.2009.1059.

Sunday, September 7, 2014

Ebola, risk, and the public's health

My friend Allen Perkins received a text from his college-student daughter asking if she should be worried about the Ebola virus. His reply, discussed in “Ebola virus and the dread factor” in his excellent blog, “Training Family Doctors” was “Are you considering moving to west Africa?” This was wise and profound fatherly advice, based upon an understanding of the epidemiology of disease. While is it obviously a serious problem in West Africa (particularly Liberia, Sierra Leone, and Guinea), it is not in the United States. Many other things are much more of a threat in the US, including, as Allen points out, “death from bee stings” (100 per year in the US).

Ebola might someday become a significant problem in the US, but it is unlikely and is not now. Many other health problems are. College students like Allen’s daughter should be sure that they have all their recommended immunizations for diseases that can be prevented by vaccine, including HPV and meningococcus, a very serious and often deadly cause of meningitis that can become epidemic where young people live together in close quarters, like college dormitories (and army bases). Yet, many do not receive these immunizations for reasons that range from passively not getting it done (less of a problem in schools where it is required) to having beliefs, or having parents who have beliefs, that vaccines are dangerous and should be avoided (in some cases this can trump school requirements). They are, by the way, wrong. The net benefit far outstrips the risk. Having your child get meningococcal meningitis and die or have serious brain damage, or get cervical cancer, is not something you want.

But focusing on conditions over which we have little or no control, rather than the ones we do, is fairly epidemic in this country (and likely others). Dr. Perkins focuses on the “dread factor”, about how news reports (not to mention thriller movies) whip up fear about these diseases. On the other hand, mostly what we can do is fear them, while the diseases which we individually might be able to have an impact on would require us to have to maybe do something hard: change our diet, start exercising, stop smoking, not drink so much or at the wrong times. I have written in the past about a patient who had a terror of breast cancer, a disease for which she was not at an increased risk based both on her youth and lack of family history. On the other hand, she did not seem particularly worried about the health risks of her uncontrolled high blood pressure, smoking two packs of cigarettes a day, or having unprotected sex with several different men.

Most of us can see that this is not logical, and maybe even snicker a little about her poor decision making. But it is only a little extreme. Many, perhaps most, of us, could do a better job of eating right, of exercising, of not smoking or drinking excessively (which for many people is “at all”). If not Allen’s daughter, many of her classmates are at much greater risk from going out and getting drunk on a weekend night, increasing their risk of motor vehicle accidents, sexual assault, poor judgment in choosing voluntary sexual encounters, and long term habituation for those with a predilection for or family history of alcoholism, just for starters. But taking action to prevent such bad outcomes is hard, requires effort, and often means not doing things we like in the short term, such as eating tasty-but-unhealthful foods, drinking with friends, smoking when we are addicted to nicotine, driving when we (or the driver) is only a “little drunk”, or having to do unpleasant exercise. Or it can conflict with our self-image: wearing a bicycle or motorcycle helmet, eschewing doing things that our friends are doing. Worrying about things that we can do nothing about, like breast cancer or Ebola, may be a little irrational, but it is in some way comforting because if the bad thing happens we are an innocent victim.

In addition, there are actions a society can take, that could make even more of a difference from a public health, population health, point of view, saving more lives, but these require political will. Sadly, this is often more lacking than individual will. Guns are the prime example; many state legislatures and legislators make it a point of personal pride to advocate for there being no restrictions at all on what kind of guns (e.g., automatic weapons) and ammunition (e.g., armor piercing bullets) people can have or where they can carry them (everywhere, open or concealed). Helmets and alcohol regulation are other areas where opportunity for prevention is often missed. Car safety has been increased by car and highway redesign and tobacco has been increasingly regulated (against the opposition of the industry, it should be noted, in both cases) for the benefit of public health, but many opportunities remain.
Indeed, expanding health coverage to all those below 133% of poverty by Medicaid expansion continues to be opposed by those who want to be seen as against Obamacare. This may be irrational from a public health point of view, but in many states it is rational, if offensive, for being re-elected. The most unjust and inequitable part of it all is how the effects of poor public health policies most affect the most vulnerable, poorest, least empowered people in our society, or indeed any society. Public health education campaigns tend to focus on diseases that have well-funded advocacy groups and affect the majority population; a recent qualitative study of African-American women found that they were very aware of the threat of breast cancer, but hardly at all of stroke – a disease statistically more likely to affect them.
Speaking of public health, it is gratifying to see some newspaper coverage of Ebola that is not sensationalist or scary.U.S. Colleges See Little Risk From Ebola, but Depend on Students to Speak Up”, by Richard Pérez-Peña in the NY Times, August 30, 2014, addresses the small but real risk that may affect colleges from students who have (unlike Allen’s daughter) actually traveled to West Africa. Even better is “Leadership and Calm Are Urged in Ebola Outbreak” by Donald G. McNeil, Jr., which presents a rational, thoughtful, public health approach, and discusses public health strategies which have been used in the past in major crises and are beginning to be implemented in West Africa. These strategies center around the use of local, respected experts who can effectively communicate with the people in their countries, rather than international aid agencies. The goal is to help people to utilize appropriate prevention and protection measures rather than panic. Again, as in the case of the other personal behaviors described above, this can be hard for people, especially when it contradicts cultural and religious values (such as how the dead are buried). But having voices who are local, who understand the culture, and have both medical/public health credentials and individual credibility, is extremely important. Of course, unlike the Ebola “scare” articles, these were both on page 8 of the newspaper, but have a more prominent position on that day’s Times homepage.
So what are the lessons? Understanding risk is not always easy, especially when an epidemic with a hugely high mortality rate threatens.  Doing something is harder than not doing anything, and it can thus be tempting to worry more about the things that we can’t do anything about rather than those we could reasonably take action on. The same is true for public health issues that need to be addressed at a societal level.
And, of course, it is always the most vulnerable who suffer the most.



Saturday, August 30, 2014

Decreased need for blood transfusions: bad for business but good for people

The New York Times of August 23, 2014, contains a front-page story by Matthew L. Wald with good news. The use of blood in the US has gone down, because the need has gone down significantly: a decline of almost one-third over the last five years. One big reason is that new surgical techniques, such as laparoscopy and other “minimally-invasive” methods, have replaced many of the traditional “cut someone open” surgeries, so there is thus less blood loss and less need for transfusion. The other reason is that guidelines for blood transfusion have been more standardized and made more stringent, so that only people who really need blood get it rather than it being administered “routinely” to people after certain kinds of surgery. Certainly, in my institution, the physician who is director of our blood bank keeps a close eye on transfusions being ordered for people whose blood counts are above the generally-recommended cut-offs (provided of course, that they are not actively hemorrhaging). Since blood transfusion, like any other treatment, can have negative effects (the transmission of viral diseases like Hepatitis B and C, and HIV are not very significant any more now that we can test for them, but transfusion reactions still occur, especially in those who have multiple transfusions), it is obviously a good idea to limit them to only when they are really needed. Wald notes other reasons:
…new guidelines emphasize treating patients for anemia [my note: not with transfusions but with treatments that encourage the body to make more of its own blood, such as iron] in the weeks before surgery to minimize the need for transfusions. Cancer therapies have also changed in a way that reduces transfusion needs. So has surgery: In a total hip replacement, loss of 750 milliliters of blood, about 1.5 pints, was considered standard; now it is just 200 milliliters.

So it is a little surprising that the title of the article is in the negative: “Blood industry hurt by surplus” in the print edition (a little less negative, “Blood industry shrinks as transfusions decline” in the on-line version), and much of its thrust is about how this decreased need for blood and associated pressure from its purchasers (mostly hospitals) for lower prices is leading to decreased profits, industry consolidation, and worker layoffs. I assume that (based on the fact that the on-line version is part of “Business Day”) that this is in part because it is a business article and that Mr. Wald is a business reporter, not a health reporter. I guess it is indeed too bad for the owners of the for-profit blood banks (as opposed to the non-profit American Red Cross), and it is really bad for the workers, many of whom seem to be represented by the Communication Workers of America, who are losing their jobs. But from a health point of view, the fact that people are only getting blood transfusions when they really need them, and that the frequency of that need is declining, is a very positive development.

One of the more interesting points that Wald makes is the cost of blood products:
Nonprofit organizations collect whole blood from unpaid donors, but hospitals may pay $225 to $240 a unit, according to executives in the business, which covers a variety of costs, including testing. If the unit is billed to the patient, the price can be $1,000 or more.
That’s quite the markup. The markup from unpaid donors to the cost to hospitals is in part explained by the cost “…for storage, management and inventory losses; around a million units a year are discarded, mostly because they are not used soon enough.” Fair enough; these are real costs that must be covered, and the blood banks are bearing them, and hospitals want to pay less for the blood. Less justifiable is the markup by the hospitals, from less than $250 to over $1,000 per unit of blood, although as I have often discussed, this is not atypical for hospital charges. Once again, this is an example of business interest (maximizing profit, even in non-profit hospitals) diverges from the health interest of people (to get their care at a reasonable cost).

The treatment of positive health developments as negative business developments is not new, or unique to blood banking. If more care can be safely and effectively delivered in the outpatient setting, so that hospital admissions decrease, it may be bad for hospital business but it is good for people. If cheap drugs are effective for preventing or treating serious medical conditions (like aspirin to prevent heart attack in men or stroke in women, or folic acid – a vitamin – given to pregnant women to prevent neurologic defects in babies), it may be bad for companies making more expensive drugs to do the same thing, but it is good for people. Conversely, when a previously generic and cheap drug is allowed by a glitch in federal law to be patented, it is good for business but bad for patients (this actually happened in the case of the anti-gout drug colchicine; see the April 16, 2010 guest blog by R. Steven Griffith, VISA and colchicine: maybe the banks and Pharma really ARE in it for the money!). If we have duplication (or triplication, or quadruplication, or whatever) of expensive health care services so that there are more cancer centers, or MRI machines, or transplant centers than a community needs, it may be perceived as necessary for that individual hospital to “compete” but it costs our health system (that is, us all) more money.

What is interesting about this article is the difference in how the cost of health care services are treated by a business reporter (good or bad for business) and how they are treated by a health reporter such as Elisabeth Rosenthal, whose series of NY Times articles (e.g., “The $2.7 Trillion medical bill”) extensively document the high costs and markups in health care. The question for the rest of us is what we feel is more important, business profits or quality cost-effective health care, without unnecessary markups or excessive redundancy in capacity. It is sad when jobs are eliminated because certainly our people need jobs, but that is another question.

I think I am pretty clear on where I stand.

Saturday, August 23, 2014

Caribbean medical schools: "second chance" or serving a real need?

Second chance med school”, by Anemona Harticollis in the New York Times July 31, 2014, is the most recent treatment of the topic of for-profit Caribbean medical schools that train American students who, in most cases, were unable to gain admission to traditional US-based schools. This is not the first time Ms. Harticollis has covered the story; they are also the subject of her article in the Times from December 22, 2010, “Medical schools in region fight Caribbean flow”, which focused on the fear of US schools that these Caribbean schools are willing to pay for the use of clinical teaching spots in hospitals that these US-based schools have been using for free. This most recent piece focuses on St. George’s University in Grenada, one of the more established and better-regarded Caribbean schools. It was briefly famous when protection of its students was one of the justifications for President Ronald Reagan’s invasion of that country in 1983. The article also mentions the other three schools that have been approved for US loans by the Department of Education. However, beyond this, and despite Harticollis’ efforts, the discussion gets murky on two counts: which Caribbean schools are under discussion, and what are the issues of concern.

 Harticollis notes that
There are more than 70 medical schools across the Caribbean, about half of them catering to Americans. A handful — including St. George’s, Saba University, Ross University in Dominica and American University of the Caribbean in St. Maarten, all of which are for-profit — have qualified for federal financial aid programs by demonstrating that their standards are comparable to those in the United States. And they report that high numbers of their test-takers — 95 percent or more — pass the United States Medical Licensing Exam Step 1, a basic science test.
But quality is all over the map in the Caribbean. A 2008 study in the journal Academic Medicine looked at 14 schools and found that the first-time pass rate on the exam ranged from 19 percent to 84 percent. Countries whose schools performed lowest were the Cayman Islands, Haiti, Cuba, Aruba, Dominican Republic, Antigua and Barbuda and, the lowest, St. Lucia, which hosted four medical schools at the time. High performers were in Jamaica, Barbados, Dominica and, the highest, Grenada.
It is irrelevant to the discussion of American medical students going to the Caribbean to look at the national medical schools in Caribbean (or any other) countries; it is only relevant to look at those which were created to educate Americans, and for the purpose of this discussion to limit it to the four that have Department of Education approval. The next thing is to understand that what is “good” or “bad” about any of these schools, or whether they should exist altogether, depends on who is looking and what their interests are. From the point of view of the individuals or companies that own these schools, the motivation is profit, but having a high-quality product increases their enrollment. From the point of view of students enrolling, the motivation is a chance to become physicians and practice in the US. From the point of view of those who are responsible for the academics of the schools themselves, it is to support students, provide a good education, and help them to be successful. From the point of view of many American medical schools, it may be to limit competition, whether that is for clinical teaching spots in hospitals such as those of the New York City public hospitals or for good students.

Most US allopathic medical schools, and their trade association, the Association of American Medical Colleges (AAMC), disparage the Caribbean medical schools in terms of quality of the students that they accept, since the majority of those attending such schools have failed to gain admission to AAMC member schools. However, since most of these AAMC schools have recently or are in the process of expanding their own classes, they must believe that there are well-qualified students who are not currently being admitted, and many of these have ended up in Caribbean schools. When AAMC campaigns to disparage the Caribbean schools, they tend to lump them all together, rather than looking at individual schools or only the 4 listed above. Unquestionably, students even at these four schools have, on average, lower grade-point averages (GPAs) and Medical College Admissions Test (MCAT) scores, and may, on average, not do as well on the USMLE exams as those from US allopathic schools, but there is great overlap. On the other hand, what is perhaps the most concerning part of education at the Caribbean schools is their clinical training – where they learn clinical medicine in the last two years of school. Are the doctors teaching them and the institutions in which they practice of high quality? Is there a well-defined curriculum? Is there standardization of the curriculum so that they can be confident that students are learning what they need to whether they are doing, say, a surgery clerkship in a NYC public hospital or a community hospital in Michigan? However, when AAMC schools are fighting with them about whether they should be able to have spots at the same places US medical schools use – say, NYC public hospitals – this point is also moot.

The most important perspective, of course, is not that of the students, the owners or faculty of the Caribbean schools, or that of the US schools and the AAMC. It is that of the American people and whether they will have access to physicians who will provide excellent care for them. The measures that are usually used for assessing the “quality” of applicants and students – MCAT and GPA and USMLE Step 1 scores – are at best peripheral, since, as I have often argued, they are scarcely relevant to being a good doctor. Does it matter that a doctor didn’t focus when they were a freshman in college and so got C’s, and so even after doing well for 3 years had a lower GPA than another? Should the chance to become a doctor be a reward for having your nose to the academic grindstone your whole life without surcease, or an opportunity for those with skill, passion, and commitment? I have often argued that the way to judge a medical school is by what its graduates do with their lives, and that the percent that enter primary care and practice in underserved areas is a major criterion. It is fine to have some of your graduates doing laboratory research or entering narrow subspecialties, but a school should be judged on its overall output and how well it provides for the needs of our nation.

There is some concern that because of recent agreements between the Accreditation Council for Graduate Medical Education (ACGME), which accredits allopathic (MD) residencies and the American Osteopathic Association (AOA), which accredits DO residencies, that osteopathic graduates will be more welcome in allopathic residencies, tending to crowd out Caribbean graduates. I would doubt that this will be an issue in the Midwest, where osteopathy is strong and most residencies already tend to prefer DOs to Caribbean grads, but it might have an impact in the East, where osteopathy is less present, and where I hear that information pre-med students get from peers (and perhaps sometimes pre-med advisors) is that Caribbean schools are preferable to US-based osteopathic schools.

Like osteopathic schools, Caribbean medical schools, including the 4 DOE-certified schools, place a much higher percentage of their graduates into primary care than do US-based allopathic schools. Is this just a result of the fact that primary care residencies are less competitive than many other specialties, so easier for students from Caribbean schools to get into? Unquestionably, this is part of the explanation, but there is also more encouragement for primary care in these schools, which do not boast a huge research enterprise or maintain tertiary-care hospitals. It also doesn’t change the fact that graduates of these schools, like many international graduates who were not US citizens, are serving the needs of our country because the US schools are not stepping up to the plate. US medical schools are very selective about taking students with high grades, and putting most of them into oversupplied specialties.

The education at Caribbean schools varies, and it would be a mistake to say that they are doing a better job than US allopathic schools. However, US schools are doing a poor job of training the doctors America needs, of ensuring that all people have equal access to quality health care, and the students graduating from Caribbean schools are often filling the holes that they leave.


Those who live in glass houses… 

Saturday, August 16, 2014

Delmar Boulevard, Geo-mapping, and the Social Determinants of Health


The social determinants of health are those factors that affect people’s health status that are the result of the social situation in which they find themselves. Thus, in the well-known graphic from Healthy People 2010 (dropped, for some reason, from Healthy People 2020), which I have reproduced several times, they complement the other determinants such as the biological (genetics), but are represented in most of the other areas. Physical environment and socioeconomic environment, certainly, but even “behaviors” are affected by the circumstances into which one is born and lives. So is biology, actually, as we learn more about genetic coding predisposing some people to addictive behaviors. Certainly it is not all volitional or evidence of weak character.

The social determinants of health can be partially enumerated, and include adequate housing (including sufficient heat in the winter), adequate food, education, and also a reasonable amount of nurturing
and support from your family. In short, they are “the rest of life”, outside and often ignored by the healthcare system. Camara Phyllis Jones, in her wonderful “cliff analogy” (which I have also reproduced before) creates a metaphor in which medical care services are provided for those who need them (or “fall into them”) along a cliff face, while the social determinants of health are represented by how far a person, or a group of people, lives from that cliff face. As such, it illustrates the degree of protection that we all have from falling off that cliff, more for some and less for others.[1]

One of the clearest ways to show the impact of these determinants is by a technique called “geo-mapping” in which certain characteristics (income, educational level, gang violence, drug use, number of grocery stores or liquor stores, public transportation routes, whatever you can think of) are laid over maps of a city, town, or region. We have seen these portrayed on TV or in the newspapers as national and state maps for political events (such as what areas voted for who), but they can also be very useful for understanding the different challenges faces by people living in different areas. The work of Steven Woolf and his colleagues at Virginia Commonwealth University has greatly contributed to this work; in addition to their incredibly useful County Health Calculator, has produced graphs that can be found on the Robert Wood Johnson Commission for a Healthier America site that show how life expectancy can vary dramatically in different neighborhoods, as in the map displayed of the Washington, DC area, mapped along Metro lines for greater effect, or the one of my area, Kansas City, Missouri (which doesn’t have a Metro!)

A recent contribution to this field has been made by Melody S. Goodman and Keon L. Gilbert, of Washington University in St. Louis, who mapped the dramatic differences across Delmar Boulevard in that city, in “Divided cities lead to differences in health”. Their graphic shows the disparities in education, income, and housing value, and, unsurprising, racial composition, on either side of Delmar. This work was covered in a BBC documentary. Dr. Goodman, speaking to a symposium from her alma mater, the Harvard School of Public Health, is quoted as saying “Your zip code is a better predictor of your health than your genetic code.”

This is a pretty sad commentary, given not only the incredible amount of money that has been spent on unraveling the genetic code but the amount of faith and expectation that we have been convinced to have in how this new genetic knowledge will facilitate our health. By knowing what we are at risk for, genetically, the argument goes, science can work on “cures” that target the specific genes. This is a topic for a different discussion, but in brief one problem is that the most common diseases we suffer from are not the result of a single gene abnormality. It is probable that, at least in the short-to-medium term, knowledge of our genetics will be more likely to lead to higher life insurance rates than cures of our diseases. The more profound issue, however, is that there is evidence from the social determinants of health, from the work of Woolf and Goodman and many others, that we do not address the causes of ill health even when we know what they are.


Why is this so? Why is there such great resistance to understanding, believing, that investment in housing, education, jobs, and opportunities will have a much greater impact on people’s health than more and more money spent on high-tech medical care (and, of course, profit for not only the providers, but the drug and device companies and middleman insurance companies)? It is in part because we hope (and, when we are more privileged, expect) that we will be the beneficiaries. And it is also because we choose to believe that those who do not have the benefits we have (of money, education, family) somehow “deserve” it because of character flaws.

The issue of “fault” is articulately addressed by Nicholas Kristof in a New York Times Op-Ed on August 10, 2014, “Is a hard life inherited?” Kristof argues that it is, not genetically but because the circumstances to which one is born and in which one grows up, the presence of caring parents who read to you rather than beat you, who take care of you instead of abusing drugs, as well as adequate food and housing make a tremendous difference in how you turn out.

Indeed, another major study by Johns Hopkins sociologist Karl Alexander, to be published in his “life’s work”, “The Long Shadow: Family Background, Disadvantaged Urban Youth, and Transition to Adulthood”, and covered on NPR, confirms this. Alexander and his colleagues tracked nearly 800 children for more than 20 years, and found that those from less privileged backgrounds with lower incomes and less supportive families did worse. Only 33 of the children moved from the low income to the high income bracket. Problems with drugs and alcohol were more prevalent among white males than other groups, but they did better financially anyway. Some people, rarely, overcome the deck being stacked against them, but most of those who do well after being born with relative privilege would likely not be among them had they been in the same situation.  Kristof writes:

ONE delusion common among America’s successful people is that they triumphed just because of hard work and intelligence. In fact, their big break came when they were conceived in middle-class American families who loved them, read them stories, and nurtured them with Little League sports, library cards and music lessons. They were programmed for success by the time they were zygotes. Yet many are oblivious of their own advantages, and of other people’s disadvantages. The result is a meanspiritedness in the political world or, at best, a lack of empathy toward those struggling…

That lack of empathy leads to a lack of action; we are willing to accept people living in conditions that we would never accept for our family and neighbors, not only across the globe but across town, or even across a street. From the point of view of health, our priorities and investments are misplaced when we do not address the social determinants of health as well as cures for disease. When we do not try to change the known factors of zip code that impact our health as we investigate those of the genetic code.

If there are to be “cures” that come from our understanding of genetics, there is every reason to expect that they will be one more thing that is available to the people on the south side of Delmar Boulevard in St. Louis long before they are to those on the north side of the street.





[1] Jones CP, Jones CY, Perry GS, “Addressing the social determinants of children’s health: a cliff analogy”, Journal of Health Care for the Poor and Underserved, 2009Nov;20(4):supplement pp 1-12. DOI: 10.1353/hpu.0.0228

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