Wednesday, November 15, 2017

Black men being killed by police: A public health epidemic

“Let’s do it to them before they do it to us,” was the line with which Sgt. Stan Jablonski (played by Robert Proskey) dispatched his troops on the old TV show Hill Street Blues. When Sgt. Jablonski replaced Sgt. Phil Esterhaus (on the death of actor Michael Conrad) they had to come up with a replacement for Esterhaus’ “Let’s be careful out there”. Perhaps the show’s writers felt it was ok coming from the shorter, pudgier actor than the 6’6” Conrad, but it has a very different meaning and very different connotation, an “us against them”.

Presumably the “them” was bad guys, not the regular folks that the police were supposed to be there to “protect and serve” but now, 30 years after the show went off the air, we realize how much this was, sadly, prescient. I am not going to recite the names of all the black men – and children – killed by police in recent years, including Tamir Rice, Michael Brown, Freddie Gray, Philando Castile, but it is an epidemic. Yes, more white people have been killed by police than black in both 2016 and 2017 – about twice as many – but the proportions are way off given that just over 12% of the population of the US is black. And what has been even more graphic is the lack of convictions, and frequently even prosecutions, of the perpetrators.

If these deaths were not at the hands of police, but rather had a different cause – an odd virus that struck down black men when being confronted by the police, or a very selective alien attack, we would not hesitate to call it an epidemic and search for the cause. But this issue is political, it is personal, it is an “us” against “them”, raising the issue is seen by many to be attack on the police, who heroically and at great risk to themselves protect us from evil. Certainly, the Governing Council (GC) of the American Public Health Association (APHA), by far the largest public health association in the nation, did not choose to identify the killing of black men by police as a public health epidemic when it voted, 65%-35%, against a resolution so designating it at the recent meeting in Atlanta. The resolution had been introduced a year before, and sent by the GC back to the authors to make changes to the language, which was done. But it was not sufficient.

If it was the language, felt, for example, to be denigrating to police, that was the issue, members of the group could have introduced and passed amendments to correct it. This point was made (after the vote) by APHA immediate past President Camara Jones, MD MPH PhD. But it was not the issue; the GC (and thus, the APHA) did not want to take a stand identifying the killing of black men by police in the United States as a public health epidemic. Speakers against the resolution cited personal but irrelevant concerns like “my brother is a policeman, and he is a good man”, as well as saying “the data is not sufficient to make the case that it is an epidemic”, which is patently false. The vote was portrayed as a scientific decision, but it was clearly a political one, a decision by the overwhelmingly white group to put their fingers in their ears, their hands over their eyes, and shut their mouths rather than standing up and saying “this is a problem”.

Many of these killings have been of people (usually men, but sometimes women or children) who were not involved in committing crimes. They result from the heightened suspicion police hold of black people in general. If you don’t believe that, you’re probably white. Just before the vote, I was at an session at the meeting discussing police violence against black men. Most of the group was minority (predominantly black) and were relatively young public health professionals, students, and junior faculty in schools of public health. A couple of speakers introduced the issue, but then opened the floor. One by one, in random order, unrehearsed, person after person in the group talked about their fears and their experiences; these were not prepared in advance, but slowly came out, one giving rise to another. A government employee noted that she had two young sons, and worried about their safety. Another woman, a public health professional, noted that her flight to Atlanta departed at 5:30am, so she’d left her home in a mostly-white suburb at 3:30am to go to the airport. She was followed by a police car all the way into the city. Another woman, a professor, talked about driving to a neighboring state and being followed by a police car that eventually stopped her for no reason or violation; in the process the officer asked “if you’re a teacher, why aren’t you in school?” The stories went on and on, from the mouths of professional people, most of them, in fact, women. 

Although many people would disagree, often virulently in with this age of Trump giving loud voice to aggrieved white men, being white in America is a privilege. It is a privilege of not thinking that you will be followed by police, or pulled over by them, or subjected to inappropriately probing questions by them. It creates an illusion, obviously held by the majority of the GC of the APHA, that it is mostly criminals, or “probably-criminals”, or people who look like they might be criminals, who are followed by, stopped by, and sometimes killed by police. But that is not the experience of black people in this country, not the black men shot by a police officer who makes up a story about being threated, nor of the middle-class professionals who told their stories at that APHA session. It is not the experience of the young woman who drove me to the Atlanta airport from the conference; in talking she said she had a 3-year old son and I asked if she feared for his safety not just from gangs but from police. In response she said she did, and pointed to a button hanging from her rear-view mirror and said “my uncle was killed by the police 3 years ago”. I don’t know what occurred with her uncle beyond what she told me, but I suspect it is not fate, coincidence, or Kismet that caused my driver to have her own story to tell, but rather the ubiquity of this experience among black people in America.

What about the police? Don’t we have to worry about the safety of the people who risk their lives each day to protect us? What about the fact that there are many (if not enough) minority police officers? To identify the current situation, not only the killings but the very real sense of most black people in this country that they do not have the same rights as whites, that they are, by definition, “suspicious” because of their color, does not require denigration of all police officers. Indeed, the families (especially male family members) of black police officers, and even the officers themselves when off-duty, experience the same indignities (and worse) as other black people.

It does mean that the idea that a police officer’s first loyalty is to other officers rather than to the community that they “protect and serve” must be very narrowly construed. Rather than a “thin blue line” of brothers (always, it seems, brothers, not sisters), it means that we should have tighter standards for police, excluding those who are overtly and viciously violent and racist. It means better training in identifying a situation in which you see through your prejudice and not through reality, and how to de-escalate. It means that when an officer kills a person innocent of a crime, it is not enough for other officers to have not “done it”; they must, if they were unable to prevent it, disclose it and discourage it and, yes, testify against the perpetrator. Police officers who do so are not “traitors”, they are heroes who allow the force to be thought of as we want to think of them.

The fact that even the most respectable and middle-class black people have to fear interactions with police (even when they are the ones who have called them!) is a societal scandal. The enormously disproportionate killing of black men by police is an epidemic, and like all epidemics we must identify it as such, find the cause, and treat it.

Even the APHA should be able to acknowledge that.

Wednesday, November 1, 2017

Making contraception easy and available: we are going in the wrong direction!

It is 2017. It is more than 100 years since Margaret Sanger advocated for contraception, and more than 50 years since the oral contraceptive pill became available. The last two generations of women – and men – have never known a world where there was no effective form of contraception. They probably do not recall when even condoms, although “over the counter” (in that no prescription was required) were stocked “behind the counter” and required requesting them from the pharmacist often with (if you were young) a disapproving glare, and maybe worse, a raft of questions.

The verbal and physical indignations and worse, including even murder committed on unmarried women who got pregnant and were unable, of course, to have access to abortion should be things of the past. They are, horrifically documented in Dan Barry’s New York Times piece “The Lost Children of Tuam”. The film “The Magdalene Sisters” shows the intolerable treatment of girls who may not have even gotten pregnant but were, perhaps, just a little too familiar with boys. Both the Magdalene laundries and the mother-baby home in Tuam were in Ireland, which was perhaps extreme in the poverty, ignorance, and fast ties to the Roman Catholic Church, but the treatment of women in England and the US were also inexcusably harsh. The British drama “Call the Midwife” tells the story of an unmarried teacher who gets pregnant in the early 1960s and is fired from her job (morally unfit to care for children!), tries to self-induce abortion with a coat hanger, and almost dies. Finally, post-hysterectomy so that she will never be able to have children, she is driven out of town. The most sympathetic characters in the show see it as sad, but none indicate it is horrific, immoral, and inhuman. And this was commonplace, even in the 1960s and beyond.

We should not, in 2017, even be discussing the availability of contraception, not to mention whether it works. Amazingly, we are. Teresa  Manning, appointed by President Trump in May to be the director of the Office of Population Affairs, the main family planning arm of the federal government, is not only a former employee of two anti-abortion groups, but has expressed skepticism of the effectiveness of contraception itself! Manning, a lawyer and not a health professional (although this is not an excuse), is completely wrong. The data is in. Contraception dramatically decreases unplanned pregnancy (regardless of marital status). Time recently ran an article accurately describing the science titled “No, birth control doesn’t make you have riskier sex”. That is the truth, but in fact, even if it is was associated with riskier sex for some people, that would be no reason to restrict access to it. The more contraception is available, the lower the rate of bad outcomes of virtually all kinds. It even, of course, reduces the rate of abortion; in fact, the only two things ever to have been shown to significantly reduce the rate of abortion are comprehensive and accurate sex education and easy and cheap availability of contraception. Indeed, the degree to which contraception is effective in decreasing the incidence of unplanned and undesired pregnancy is directly related to the ease of its availability, including financial availability. Unsurprisingly, reducing the cost of and increasing the ease of access to contraception has the greatest impact on teens and on the poor.

So it is amazing that, in what The Atlantic refers to as “one of its boldest moves yet” (I don’t think that they meant it was positive, but “cowardly”, as well as “stupid” and “reactionary” come to mind as better adjectives) has reversed the ACA’s requirements that employers and insurers provide contraception at no cost to women. Politically, it is part of the administration’s efforts to dismantle the ACA piece by piece, since they were unsuccessful in doing it as a whole. Morally, it is an imposition of a minority’s religious values on the rest of us, and is particularly ironic being spearheaded by Donald Trump. It will cause great harm to individual women (and men) and to the society as a whole. Arguments that the cost of contraception is “only” $50 a month may wash with those in the middle class and up, but for poor women and teens, $50 a month is a lot. The most effective methods of contraception, IUDs and implants (collectively referred to as LARC, long-acting reversible contraception) may have a lower amortized cost over the use period but a high upfront cost that is unaffordable, without subsidies, for many women. (The reason, lack of cash on hand, is the same one that leads many poor families, as described by Barbara Ehrenreich in her wonderful and depressing book “Nickel and Dimed”,  to live in expensive weekly motel rentals – the overall cost may be more than an apartment, but the upfront cost, including deposits, rent in advance, etc., is prohibitive for them.) The impact on the teens who will be denied free access is described movingly by a pediatrician in Vox.

The other important impact of such a policy would – and perhaps will -- be on the economy. This is articulately addressed in a column by Bryce Covert in the NY Times, October 29, 2017. The reasons start with individual women, and the cost of purchasing birth control, money which will not be available for them to spend on other goods – with more than 57 million women using contraception, in one year that is $1.3 billion. But the larger impact is societal – women who cannot control their own reproduction, who do not know when and if they will get pregnant – are in a poorer position to contribute to the workforce and to the economy. Again, going back to the history I address at the start of this piece, we know this empirically, not just theoretically:

… a raft of evidence has definitively found that when women gained greater access to the pill in the late 1960s and early ’70s, they were able to delay marriage and childbirth and invest in careers through education, job training and staying in paid work….Legal access to the pill transformed the economy in that era. It increased young women’s labor force participation by 7 percent….about a third of the increase in how many women attained careers in fields like law and business was due to birth control. Women with earlier access to the pill also made 8 percent more than their peers, and the pill was responsible for about a third of the decrease in the gender wage gap by 1990.

And it is still critical. Perhaps Trump himself is just cynically pandering to his base, and probably much of that base depends upon contraception, women directly but men just as much. Opposition to contraception cannot be justified except by the small minority of religious purists (and of course they are welcome to not use it); opposition to making contraception easily and freely available is almost as bad, as it is completely discriminatory. It is still, as Covert describes,

…still playing the economic role that it did in the 1970s. About half of women who use it say they do so to complete education or to get and keep a job. Contraception is still increasing the share of women who get educated and get paid work, particularly prestigious jobs.

Easy and affordable (affordable for all those who need to use it, not just billionaires or even the upper middle class!) is not a “women’s issue”, it is not a “special interest” issue. It is a core need for people. People with the views of Teresa Manning should not be given center stage, and certainly not given authority over contraception. We need to guarantee permanent access to contraception for all, and for accurate sex education. 


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