Saturday, July 11, 2020

Other countries invest in the public's health and welfare. We invest in creating billionaires. ???


It’s not just Donald Trump. It would be nice to think it was, and that, if it was far from perfect, everything was much better in the US before him. Maybe it was; certainly many of the horrible things that he and his administration have done were not done by previous administrations, of either party. These include total denial of climate science (or any science), overt (not subtle) racist appeals, gutting most of the federal agencies responsible for the quality of our life (not to mention survival of our planet) in areas such as health, environmental air and water quality, education The administration has replaced of most of the protections we have had with the most rapacious policies we have seen. Oh, yes, and destruction of our relationships with our allies, and moving ever closer to war with – almost anyone, although his friendship and authoritarian bromances with many of the world’s most autocratic leaders might limit that.

And it’s not just his supporters, as nice as it would be to think that they are just stupid (as long as they do not remain the majority, or the effective majority given the intrinsic inequities of the Electoral College). While the most of them may be stupid and have no understanding of where their own self-interest lies, or are at least more committed to racism than their self-interest, there are a minority of them who are smart (if not wise) and very rich people who have been quite pleased with the direction of (most) of the administration’s policies. That is why they fund it.

And it is not even the Republican Party, as much as that party has, at least for 4 decades, been the party of giveaways to the richest, destruction of the environment, bellicosity which has led to several horrible and pointless wars, appointment of right-wing Supreme Court and lower court justices who manage to convince themselves that they know what the “founders” would have thought 250 years later about issues that they could not imagine, and of course racist approaches to almost everything.

But the most important general trend in the United States over the last 40 years, while it has sometimes been accelerated by Republican administrations, has continued under the Democratic administrations of Carter, Clinton, and Obama. It is the increasing, ever increasing – and incredible, at this juncture -- concentration of wealth in the hands of a few, to a degree that has not existed since the days of the “robber barons” of the late 19th century. A recent article in the Guardian, The US has the most billionaires in the world – but here's what it doesn't have’ documents what citizens of other industrialized have that we don’t: low-cost, or even free, college education, universal health coverage, guaranteed paid vacation and paid parental leave. And more. And, of course, we also do not have what the article refers to as an “inhospitable climate for billionaires, one in which they actually have to pay taxes commensurate with their income and wealth. Our climate is definitely hospitable for them. And, thus, if you are both a billionaire and a completely selfish immoral person, you should be happy with US policies. If you are neither, or only one, you should not be.

There is obviously no disconnect in between these two things, the hospitable climate for billionaires and the limited programs that benefit our people. In the 1950s, as our economy and that of the rest of the world, rebuilt from World War II (ours rebuilt faster because, after the bombing of Pearl Harbor, there was not actual war fought on our territory), under the Eisenhower administration, employment, wages, and unionization increased. The wealthy were wealthy, but regular people, workers, found unprecedented economic success, buying houses, cars, and sending their children to college. CEOs made about 30 times what the average line worker made – a lot more. Of course, the growth was not equitable; minorities and particularly African-Americans were still marginalized, but even many of them got decent jobs.

 In the 1960s, mainly under the Johnson administration, the federal government developed programs to help Americans at a level not seen since the New Deal of the 1930s. In addition to passing laws like the Civil Rights Act and the Voting Rights Act, it developed programs to aid the neediest in our country, both Medicare and Medicaid, and the “War on Poverty”. That “war’s” programs are often derided, by the right, as a failure, demonstrating the fatuity of “throwing money at problems”, but in fact this narrative is incorrect. While the US did not “end” poverty, it decreased poverty a whole heck of a lot. Expansion of programs such as Aid to Families with Dependent Children (AFDC) and food stamps and the Fair Housing Act kept millions of children in homes, with food. The development of HeadStart made a real difference in early childhood education. As with most social service programs, the failings were almost entirely the result of not doing enough, not spending enough, and not a result of doing and spending too much.

But the money the government was spending needed to come from somewhere. And relatively more equitable taxes was more than the wealthiest wanted to pay. Of course, most people didn’t and don’t want to pay taxes, but the billionaires had a lot more clout to get what they wanted. So they got tax breaks for themselves and their corporations, and huge expenditures for “defense” (the US spends more than the next 10 countries together), really just another way this country subsidizes its corporations, and this became the order of the next four decades. Beyond not taxing the wealthiest, the US has subsidized them.  This is well-described by Paul Krugman in his recent piece “Why Do the Rich Have So Much Power?” (7/1/2020). Every penny spent on helping the neediest, or kept by the average American, is another penny not in the pocket of billionaires who are apparently possessed by the desire to have endlessly more despite the fact that they will not be able, in their lifetimes and those of their descendants, to buy enough mansions, private islands, planes, and yachts to spend it all.

Then comes a major crisis, like the COVID-19 pandemic. It hits everywhere in the world. Not equally, of course, the poor and the old and minority communities and the disenfranchised are hit the hardest. But a great deal of the first wave was in developed countries. Some were hit particularly hard, like Italy and Spain, and then France and Germany. Some responded aggressively and limited the damage, like the Scandinavian countries (except Sweden). But the US has responded abysmally poorly, with the most infections in the world – 25% of all COVID-19 cases in a nation with 4% of the world’s population. And tens of millions of unemployed people. And hungry people. And, increasingly, homeless people. Because we have not only, over the decades, purposely decimated our public health infrastructure, we have purposely inadequate social infrastructure of any type. While, in this pandemic, the people of other developed countries get cash bailouts, and expansion of the social support systems that we never had, the US expanded (for a little while, we don’t want to go too far!) unemployment insurance and gave folks one-time $1200 checks. Thus the NY Times can report that “Europeans get paychecks. Americans scrounge for food” (7/3/2020). And, thus, as reported by Robin Wright in the New Yorker “To the World, We’re Now America the Racist and Pitiful”. They used to envy us; now they pity us.

Some years back, I was amazed to hear the chair of one of the highest-income departments say they couldn’t afford nurses, and could only have medical assistants in their clinic. Since my department was one of the lowest income, and we did have nurses, I initially didn’t understand. But then it came to me.  Our group hired the nurses and medical assistants we needed to run a quality practice, and paid what was left to our physicians. Their department paid their doctors (i.e, themselves) what they thought they deserved, and then looked to see what might be left to pay staff. A different approach. There are a couple of ways, generally speaking, a society can  allocate resources: one is to spend what is necessary to meet the needs of the people, with the remainder going to profit, or savings, or (if this is the goal) to enhance the wealth of the rich. The other is, well, the opposite – give the rich what they want and see what is left over.

In ancient Egypt, we are told, Joseph advised the Pharaoh to stash away reserves of food when times were good in case they were needed in the future. As the 7 years of plenty wore on, there were certainly those who must have said “Enough!” But then came the 7 years of scarcity, and the Egyptians were glad that they had saved. We haven’t, on purpose, because our purpose has been to make the richest richer and preparing for real problems that might befall the rest of us was not really high on the agenda.

We have not been meeting the basic needs of our people in the best of times. Poverty and racism are key social determinants of health, and for too many of us, our pre-existing health was marginal. We do not have affordable, universal health care. And we have cut resources for public health planning and preparing for a crisis, such as that we face today. For most Americans, that is a double hit, and for the poorest and worst off, it is unconscionable. This needs to change, and it needs to start immediately. Equitable taxation, meeting the needs of our people, and planning and preparation for the future.

Or, I guess, we can just keep funneling money to the billionaires.

Wednesday, July 1, 2020

COVID-19 and the Bighorn Fire: Parallels and the "End Game"


Recently in traditional time, but long ago in COVID-19 time, I somehow got involved in a discussion on Facebook with a person I didn’t know. They had asked a mutual friend what was the “end game” for the pandemic, since people could not put up with the restrictions placed on them indefinitely. I said there was no end game, no one knew when it would end, and the only thing that we could do was continue to stay home, wear masks when we went out and social distance until – whenever. They were unsatisfied, and pointed out to me basic human psychology, which to them meant people will put up with inconvenience, even loss of income, for a period of time but needed to know “until when”.

As I said, that was weeks ago and things have changed, pretty much for the worse in most of the country. For a while you could squint and say that the national infection rate was plateauing, but that was mostly because New York accounted for such a high percentage, and its rate was decreasing. Most everywhere else it was on the rise, particularly in the South and West. I live in Arizona, where over the last week or so the rate of increase of COVID infections has been leading the country. Not the area where you want to be #1! This is mostly the result of early “re-opening” by a Republican governor, Doug Ducey. With the support of the GOP majority in the legislature, he allowed bars,restaurants, hair salons, etc.to open. More than that, he issued an executive order forbidding local government, cities and counties, from having more restrictive rules. This effectively undercut the efforts of the more populous cities of the state, such as Phoenix and Tucson, where I live, which had been requiring masks and social distancing. Tucson Mayor Regina Romero had closed restaurants and bars early on. Ducey’s illogic, characteristic of modern Republicans, was that he favored control at the most local level of government, except in a pandemic. Of course this made no sense; why is the state level better in a pandemic? Following that logic policy should be made at the federal, or even international, level.

More recently, however, he has backtracked completely and allowed local government to make restrictive rules. Tucson and Pima County (much of metropolitan Tucson is outside the city limits) immediately enacted strict closure, mask and social distancing rules. The County is going to allow public health department officials to enforce masks in restaurants when the owners will not (by citing the owners and maybe closing them down). We will see how well they work, if people obey them (way back on June 19, folks were telling CNN -- published in the Arizona Star) that they saw no reason to, and eventually if the new surge in COVID cases and deaths begins to abate. I still cannot say when although I (and of course most people with medical, public health, or epidemiologic knowledge, as well as anyone who was paying attention) predicted the dramatic upsurge in cases. Now we have what is really not a “second wave” but a continuation of the first wave brought on by policies that were (most generously) optimistic, or (more accurately) the result of wishful, magical thinking enhanced by a misplaced desire to “restore the economy”. Dr. Anthony Fauci has just said we might expect as many as 100,000 NEW cases a day! And, of course, economically, things will be much worse (as noted by Paul Krugman) because the increase in disease and death, not to mention the closures, will make the economy tank much faster. And the relief that should have come has, typically, been insufficient for regular working people (how far can $1200 go??) and overgenerous (to put it mildly) to large corporations, many getting millions in bailout relief despite having billions in the bank, and C-suite executives who bathe in greenbacks (not of the $1 variety, either!); in Arizona the governor held on to federal relief funds without distributing them for a long time.



Something else very big is happening in Tucson now. A huge fire (called the Bighorn Fire because it started on about 200 acres on Bighorn Peak after a lightning strike) that started about a month ago has continued to grow despite heroic efforts by firefighters from across the West and indeed the country. It is raging through the iconic Santa Catalina Mountains north of the city; areas of the foothills have been evacuated. When I wrote about the fire in my blog “Life, the Universe, and a Few Things” on June 12, I had to put in an update as in a day it had grown from 3700 to over 7000 acres. As the weeks have passed it grows daily, and the spread is enormous. We have seen it go to 20,000, 30,000, 50,000 acres. Now that it has passed 100,000 acres, the newspaper is now reporting it in square miles – 180 square miles as of today – which, at 640 acres/sq mi is over 115,000 acres. Wildfires, particularly in the arid West, have become more common and more severe (think of the 2018 Camp Fire in California) with climate change brought on by global warming, but they are no less terrible for that. Sometimes, as with Bighorn, the cause is natural (lightning), sometimes the random accidental human, perhaps a camper who builds a fire where they shouldn’t or drops a cigarette, sometimes (as in the Camp Fire) by the criminal malfeasance of corporations (sensing a theme?) The structures most threatened in this, as most, wildfires, are the homes built too close, too high up in the foothills, lovely locations and views (if sometimes offensive to others) but highly at risk.
There are, you may have already noted, some parallels between the fire and COVID. The fire is burning and spreading because the ground is dry and because there is lots of brush that has accumulated in the mountains since the last fires. This is kind of like the people across the nation and the world who are susceptible to the virus. In some ways, it would be a better metaphor for rare severe influenza, or measles before a vaccine, when some (older) people had immunity and those who were younger didn’t, than for a novel virus like SARS-CoV-2, but you get my point. The fire will keep burning until it runs out of fuel, or the summer monsoon rains come, and the firefighters’ efforts keep it from being even worse – while growing, the fire, it is reported, is 45% controlled. The virus will continue to spread until susceptible people are dead or immune (but whether immunity lasts and is protective and for how long is uncertain), or there is a vaccine that is effective and widely applied, and good leadership and government policies can limit it from being even worse.

When there are good government policies, of course. We have seen almost total victories in places like New Zealand, movement back from the abyss in places like Italy and New York City, bright spots in states and cities that have moved as aggressively to limit human interaction, the crucial part of limiting COVID spread, as have firefighters to limit the Bighorn fire. But we have also seen disasters from terrible policy at the national level in the US as well as many states (including, but certainly not limited to, Arizona) and in other countries, particularly those led by arrogant, egotistical autocrats (see also Brazil, Russia, etc.).

The fire-virus metaphor is far from perfect, but it has some relevance. Our response to the fire was hurt by cuts to the funding of national parks and forests; our response to the virus was crippled by devastating cuts to the public health infrastructure. The “end game” for the fire is the summer monsoon rains, which will hopefully come soon. The end game for the virus is the development, manufacture, and VERY WIDESPREAD application of an effective vaccine. That may be on the horizon, but it is far away; even if a great vaccine is developed the application is a humongous undertaking (heck, in most of the US, certainly in Arizona, we can’t even effectively do testing!).

Until then, sorry about the psychology of “human nature”; staying away from people is the only answer.

Monday, June 22, 2020

What are the practical steps that we in medicine can take against racism?


This is a guest post by Seiji Yamada, MD, MPH & Gregory Maskarinec PhD, colleagues from Hawai'i
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In this essay, we discuss what we in medicine in Hawaiʻi can do about racism.



This NY Times opinion piece "It’s Not Obesity. It’s Slavery" by Sabrina Strings, an associate professor of sociology at the University of California at Irvine, decries the victim-blaming attribution of the disproportionate coronavirus risk among blacks to their co-morbidities. The essay starts off as follows: 



About five years ago, I was invited to sit in on a meeting about health in the African-American community. Several important figures in the fields of public health and economics were present. A freshly minted Ph.D., I felt strangely like an interloper. I was also the only black person in the room.

One of the facilitators introduced me to the other participants and said something to the effect of “Sabrina, what do you think? Why are black people sick?”

It was a question asked in earnest. Some of the experts had devoted their entire careers to addressing questions surrounding racial health inequities. Years of research, and in some instances failed interventions, had left them baffled. Why are black people so sick?

My answer was swift and unequivocal.

“Slavery.”



What Sabrina Strings is pointing out here is the importance of history and its legacy of ongoing structural violence. Interviewed by Fareed Zakaria on "Why COVID-19 hit black Americans so hard," Harvard School of Public Health Prof. David Williams notes that for every dollar of income made by white households, black households make 59 cents. For every dollar of assets owned by white households, black households own 10 cents, and Latino households own 12 cents.



The Academic Medicine article "Changing How Race Is Portrayed in Medical Education: Recommendations From Medical Students," outlines how American medicine was historically steeped in racism. We also have the historical legacy of the Tuskegee, a United States Public Health Service study in which 399 black men were observed for decades with their syphilis infections untreated. Who was the first to object? Dr. Irwin "Irv" Schatz, former chair of the University of Hawai`i Dept. of Medicine, in 1965.



Closer to us in the Pacific, we have the legacy of the Marshall Islanders, deliberately exposed to fallout radiation Project 4.1 of the March 1, 1954 Castle Bravo thermonuclear test, then subsequently subjected to human radiation experiments for which they gave no consent. 



That the Marshallese had their human rights denied in this way reflects how they were viewed as less than human. With regard to Utrik Atoll, in a post-Bravo 1956 research planning meeting of the Atomic Energy Commission (AEC) Advisory Committee on Biology and Medicine, Merril Eisenbud, the director of the AEC Health and Safety Laboratory, noted (as quoted by Barbara Rose Johnston 2007, 25):



They had been living on that Island; now that Island is safe to live on but is by far the most contaminated place in the world and it will be very interesting to go back and get good environmental data, how many per square mile; what isotopes are involved and a sample of food changes in many humans through their urines, so as to get a measure of the human uptake when people live in a contaminated environment.



Now, data of this type has never been available. While it is true that these people do not live, I would say, the way Westerners do, civilized people, it is nevertheless also true that these people are more like us than mice. So that is something which will be done this winter.



[Photo: Holly Barker, Bravo for the Marshallese]

 That migrants from Micronesia continue to be denied participation in Medicaid (Med-QUEST) also reflects how they continue to be viewed as the "other" - not deserving of the access to health care as the rest of us. Micronesians also experience racism within Hawai`i's health care system. (See "Discrimination in Hawai‘i and the Health of Micronesians and Marshallese" and "Chuukese community experiences of racial discrimination and other barriers to healthcare.")



The public policy is complemented by more overt racism. One of my Chuukese patients (a man with two jobs, while his wife worked another, but living out of their car) reported to me that he was stopped by the police, told to exit his car, and was slammed against the hood of his car by the policeman.



What are the practical steps that we in medicine can take against racism?

We need to address the systemic racism against Native Hawaiians and Pacific Islanders.

We need to address the distrust that Native Hawaiians and Pacific Islanders have toward the health system and its practitioners to improve access.

We need a health insurance system that includes Micronesians.

We must address the economic marginalization of people who work full-time but cannot afford a home.

We must address the catastrophic on-going military occupation of these islands.



This is a broad outline of the steps that must be taken. We call upon all involved in medicine in Hawaiʻi to make it a reality.



#BlackLivesMatter

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