Friday, April 29, 2022

Lower life expectancy in the US: A reflection of racism, classism, and social inequity

One of the things that most fuels self-deception is imagining that we should be living, or maybe even still live, in what we imagine was a better past. Of course, the past was not always better – in fact, it was overall, for most people, worse – but our minds repress the bad and remember the good from when we were children, as I have discussed in my other blog, “Life, the Universe, and a Few Things” (Brooklyn Nostalgia, August 21, 2011). Sometimes there is a conscious effort, a movement if you will, to block out the really bad things that have happened in the past not only from our individual memory but from our history books and schools. Clearly, this is happening now with regard to the primary founding evils in US history, extermination of the indigenous inhabitants (Native Americans, Indians) and slavery. That these were real is incontrovertible. That they were horrific, inexcusable, and must be remembered both to honor the victims and prevent recurrence should be obvious. But the effort to suppress teaching of this history, parallel to suppressing teaching about the Holocaust (which is not suppressed in Germany) is ongoing, vicious and wrong. To add insult to injury, advocates are adopting the language of microaggression, justifying their racist efforts to whitewash history with ostensible concern for “making white children feel bad about themselves”.

This is, in addition to every other evil and reprehensible aspect of it, also a way to divert those children – and their parents – from knowing and worrying about the things that they should be worried about, such as climate change and nuclear war. And the incredible inequities in American society (not to mention the world!) that have actually led to terrible social and individual outcomes. For example, the drop in life expectancy in the US. Yes, drop. People living shorter lives than they used to. Due in part to the COVID pandemic, but due in the US more to the vast inequities in wealth, social support, access to health care, jobs, use of harmful substances (such as alcohol, opioids, and tobacco) and every other determinant of health. What this has to do with self-deception and living in the past is the false idea that things are always, automatically, better in this country, the USA, a belief that persists in the face of evidence.

Of course, some things were, in fact, better in this country for earlier generations, some of whose members are still alive and sentient. America may not have always welcomed its immigrants, even those from Europe, and viciously and continuously repressed and oppressed members of many minority groups (particularly Natives and the descendants of Black slaves), but in the first half of the 20th century, major parts of life were often better here for poor people than in many other countries. This was even more so after World War II, when the economies of most of the rest of the developed world were destroyed but the US' was intact, with no wars fought on its soil. This resulted in great success for US manufacturers (no competition!) and other benefits. One was life expectancy, due in large part to better nutrition. In the second half of the 20th century it was widely observed that children of immigrants were bigger than their parents, because from infancy they were better nourished. Then, even later, at the end of that century and into the 21st, some of the major causes of premature death saw a decline, mainly tobacco use.

But the premature death rate in the US is going up, life expectancy is going down. An important paper, published in 2014 in the Annual Review of Public  Health by Mauricio Avenando and Ichiro Kawachi, ‘Why do Americans have shorter life expectancy and worse health than people in other high-income countries?’, provides extensive documentation and discussion, including a supplement with several tables comparing life expectancy among different countries (a representative one, Female Life Expectancy at 40, is reproduced here).


While it has long, forever, been true that the life expectancy of underserved minority populations was less than for white people, the decrease in life expectancy for the “majority” group was shockingly revealed by data provided in 2015 by economists Anne Case and Angus Deaton, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”, and has been demonstrated for larger and larger portions of the US population. As I noted in this blog (Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015) this was a shock for those who held to the belief that it was only true for minorities (and in perverted way, found this reassuring). Indeed, while the life expectancy for Black Americans was and is still shorter than for whites, it was slowly rising while for many whites (of course, especially lower-income whites) it was dropping. Case and Deaton, noting the large increase in mid-life death (kind of an oxymoron, but meaning “middle age”) attributed this to “deaths of despair”, specifically due to opioids and suicide. On November 29, 2019 I wrote about an article by Steven Woolf and Heidi Schoonmaker, “Life Expectancy and Mortality Rates in the United States, 1959-2017” (Decreasing life expectancy in the US: A result of policies fostering increasing inequity), and I noted that, amazingly, women in lower income groups born in 1950 had shorter life expectancies than their mothers born in 1920!

Woolf and his colleagues RK Masters and LY Aron have recently come out with a new publication looking at life expectancy in the US and other OECD countries for 2019-2021. (Note: at the time of publication, the paper, in medRxiv, had not been peer-reviewed). They found that the pandemic shortened the life expectancy in almost all countries, but

US life expectancy decreased from 78.86 years in 2019 to 76.99 years in 2020 and 76.60 years in 2021, a net loss of 2.26 years. In contrast, peer countries averaged a smaller decrease in life expectancy between 2019 and 2020 (0.57 years) and a 0.28-year increase between 2020 and 2021, widening the gap in life expectancy between the United States and peer countries to more than five years.

In addition, ‘The decrease in US life expectancy was highly racialized: whereas the largest decreases in 2020 occurred among Hispanic and non-Hispanic Black populations, in 2021 only the non-Hispanic White population experienced a decrease in life expectancy.’ So while in 2020 the most vulnerable populations took the greatest additional hit from COVID, by 2021 they were slowly recovering, while white populations continued to lose life expectancy.

So why? This may be cognitive dissonance for the self-deluding, or racist, or narrow-minded, or those who think “America is always better”, but it is true. And the reasons for it are the inequities of American life, much of which is detailed in the Avenando and Kawachi paper, as well as Masters, Aron, and Woolf. We do not have universal health insurance, and we do not have universal access to health care. Even many “insured” Americans have very poor insurance, many Americans do not have geographic or physical access to health care services, and thus many people forego health care altogether or until it is too late. Our infant mortality rate is far higher than that of comparable countries. We still have large numbers of people who are “food insecure”, which often means chronically hungry and undernourished, not to mention those who are “housing insecure”, often homeless. And we have phenomenal income inequities which have grown tremendously since the 1980s Reagan assault on the social safety net. A paper by economists Emanuel Saez and Gabriel Zucman, widely covered, shows examples of this: since 1982 the wealth of the 0.00001% (18 families!) has increased from 0.1% to 1.2% of all US wealth.


Just from 2009-2022 the wealthiest American has gone from $40B to $265B, while average income has decreased from $54,283 to $53,490, and the minimum wage ($7.25/hr) has stayed the same! So the US remains an outlier, with great social and economic inequity, poorer health, and shorter (and decreasing) life expectancy. You can believe what you want in terms of political and social theory, but you have to be willing to accept the consequences.

I find these consequences, completely unnecessary, intolerable.

Thursday, April 14, 2022

Burnout and depression in physicians: Not good for them or for the public's health

For some years now, there has been increasing emphasis in the medical community about “physician burnout”. While there different degrees and kinds of burnout, generally it refers to a feeling among physicians from having little or no enjoyment in their work to feeling unable to continue. At this far extent, it contributes to doctors leaving the direct practice of medicine for a less-stressful area where their medical background is useful (administration or insurance work or consulting) to leaving the profession altogether. It can be for a different career, or, if they are older and more financially able, early retirement. In the case of young physicians, particularly residents who are still doing their post-graduate training, working very long hours and getting paid relatively little – and since many have medical school debt exceeding a quarter of a million dollars, it can be actually little – burnout could prevent them from taking on a full career in medicine.

Of course, burnout can affect any profession, or any job, although that term is mostly used for professionals, who have historically counted on some degree of independence and control of their work lives. Feeling burned out, not interested, overwhelmed, and even resentful is common and maybe even normative in much non-professional wage work, where the assumption is often “of course you are alienated”, selling your labor to a boss whose only interest is in profit and to whom you are only a tool to generate it. It is a more recent phenomenon in the professions, particularly as professionals become essentially employees, and the profession I know most about is medicine.

Historically, physicians have worked very hard, long hours, often through the night, taking call to come in and see people (called, in medical terms “patients”), operate on people, deliver babies. In small towns and rural areas, where there were few other physicians with whom to share call, this was often particularly disruptive to home and family life, not to mention sleep. The compensating plusses were considered to be a good income, a high level of respect from the community, a sense of making a contribution and a difference, and some level of control of your practice. Although, often when coming in in the middle of the night, it might not seem like much control, many or most doctors were self-employed, and even when they became part of larger groups they were among the owners.

Over the last few decades, many things have changed in the practice of medicine, increasing the burdensome characteristics and decreasing the positives. These are mostly related to the increased size of medical enterprises and the corporatization of medical care. On the one hand, in the name of “efficiency” the practice of medicine has become routinized, less varied, less interesting, and sped up. Physicians often feel that they are on a treadmill churning patient visits as if they were widgets, not having the time that they would not only like but would be necessary to understand their patients as people, and to begin to meet their more complex needs – and people are complex, with every aspect of their lives affecting their health. They may be paid more, but they have much less control, and often seem to (and do) spend as much time completing their Electronic Medical Records (EMRs) as in patient contact, and it may feel (correctly) that the purpose of the work that they put into the EMR is aimed primarily at maximizing income and profit for their employers rather than maximizing the health of their patients.

The strategies which have been employed to attempt to address burnout have ranged from the individual (support groups, various therapies) to structural (changing the work situation). Many physicians are seeking to achieve more “work-life balance”, with more time for their families and other non-work life. The ameliorations include shift work (work hard but for a specified period of time, and know when you will be off and that you really will be off), limiting scope of practice, and, certainly, increased reimbursement. But because these “solutions” do not work as well for all specialties, burnout does not affect all specialties equally. Shift work is most effective in specialties in which continuity of care for an individual patient with an individual doctor is not seen as important; thus it works well for emergency medicine, anesthesiology, critical care, and a few other areas. It has also been widely employed in hospital work, with “hospitalists” who care for people who they do not see as outpatients working shifts (including for delivering babies), and has extended to generate yet newer specialties like "nocturnists” and “weekendists”. And has even renamed the doctors who do see people in the outpatient setting as “ambulists”. How well this works depends on who you ask; it is “efficient” for the employer, and the hospitalists know their hospital stuff, but for the patient, not only are you not seeing a doctor who knows you but your hospitalist may change every few days (and nights).

Salaries in medicine are still usually tied to how much the individual physician generates for the organization, which is heavily dependent on how insurers reimburse, and that is far more for surgery and other procedures than for “just” seeing, talking with and examining a person, reviewing lab and x-ray information, and coming to a diagnosis and treatment plan. So doctors who do the latter make less money (family physicians, general internists and pediatricians, psychiatrists) than do proceduralists. Thus, the physicians in the highest paid specialties (particularly those not just highly paid but that have the highest income/work ratios) are more likely to be successful in achieving work-life balance and avoiding serious burnout. And those who have to be most available for the greatest portion of time with the least support, rural family physicians, burnout can be highest. Although these doctors also often retain the most degree of autonomy, with time demands coming from their patients, not the corporations that employ them.

It is also worth talking about serious mental health issues that physicians confront, and especially the continued disincentives for them to receive necessary and appropriate care. A March 30, 2022 Op-Ed in the NY Times, ‘Why So Many Doctors Treat Their Mental Health in Secret’, by Seema Jilani discusses this, and in particular how employers and licensing boards feel free to ask about this, contributing to an atmosphere of stigma so that, in fact, many doctors do not treat their mental health issues at all. It would be outrageous for us to expect doctors to not treat their asthma, heart disease, cancer or myopia, but for mental health conditions this remains a real issue. It is one of the two great examples in medicine of the double-edged sword of “you should do this, but we may punish you for it”. The other is in the area of acknowledging mistakes (or even potential mistakes). There is excellent data showing that admitting and examining mistakes at the institutional level absolutely increases the overall quality of patient care (‘every mistake a jewel’, because we can learn from it; see W. Edwards Deming’s “14 points”). However, physicians who do so risk discipline, license loss or restriction, and even lawsuits. These punitive results (except for egregious cases) should not be there, and most of those who wrote letters to the Times in response to Dr. Jilani’s article (and I) agree that these punitive risks should not face physicians who seek treatment for depression or other mental health issues. Burnout and depression are not the same things, but may, and frequently do, co-exist.

Doctors are privileged workers; they are generally highly paid relative to most people, they still earn a great deal of respect, and they have the opportunity for great personal satisfaction through serving others. But they are often held to the standards of independent professionals while increasingly working for corporations, and they not immune from the stresses of overwork, lack of control, speed-up, and negative aspects of how capital treats its workers.

And they are certainly not immune from mental health issues, and should be able to receive appropriate treatment without inappropriate repercussions.


I did not address the issue raised by the recent conviction of a nurse in Tennessee for criminally negligent homicide for accidentally giving a patient the incorrect medication, but obviously this is entirely relevant to the issue of acknowledging errors, and the work situation for health professionals and thus issues of burnout and depression and, indeed incarceration.

A very good discussion of that case, 'Are All Medical Errors Now Crimes? The Nurse Vaught Verdict' appears in Medscape, and I would absolutely endorse this quote from one of the participants:

"A culture of safety is one in which the system that allowed the mistake to happen is changed, not one in which the individual is scapegoated. And a culture of safety correlates with better patient outcomes that we know. This verdict is the opposite." 

Monday, April 4, 2022

Lead poisoning of our children: then and now

Back in 2016 much of the country was shocked to learn about widespread lead poisoning among children in Flint, MI. The cause was lead leached from old lead pipes supplying water to people’s homes after the source was changed from Lake Huron to the more corrosive water of the Flint River (to save money, of course). The identification of this problem was largely due to the great work of a committed pediatrician, Dr. Mona Hanna-Attisha, about whom I wrote on Jan 24, 2016, “Flint, lead, medical heroes, O-rings and guns”. That piece also discusses the shameful – probably criminal – denial of both the problem and its cause by the then-governor of Michigan, Rick Snyder, and his politically appointed state health department, until the evidence became too overwhelming to deny. After all, poisoning children is one thing, but getting negative press is another!

Many of us probably assumed – or at least hoped – that this epidemic of lead poisoning of children, as horrible as it was, was an exception, an outlier, something that should not be happening in the 21st century in the United States. We knew that it was related to the fact that Flint is a poor, largely minority, community, and if we are at all sentient we know that those are the people who suffer the worst from environmental degradation. In the case of lead poisoning, they live in houses that are more likely to have old lead paint, in neighborhoods built closer to heavy automobile and truck traffic areas where the soil (such as, for example, in the playgrounds) has high concentrations of lead. We might have even thought of lead pipes supplying water. But surely this was not something that was happening in many places around the country, even in poor communities?


But it was, and is. All over. More in very poor and minority communities.

A few years ago, [Sean] Ryan, now a Democratic state senator, learned that his constituents in Buffalo were sending bottled water to Flint, Mich., where widespread lead contamination in the water supply had drawn national attention. While respecting the gesture to help, he recalled from a Reuters investigation that there were 17 ZIP codes in Buffalo where the rate of children with high lead levels was at least double that of Flint. (Gabler, NY Times, below)

And it is still happening. And still not being addressed. Flint may have stood out because of the sudden increase in children with high lead levels identified by people like Dr. Hanna-Attisha after the change in water to a cheaper source leached lead from the old pipes, but chronic, ongoing lead poisoning of our children, primarily from lead paint in old houses, continues apace. And there is a lot of resistance to doing anything about it.


This is covered in depth in a recent (Mar 29, 2022) article in the NY Times by Ellen Gabler, How 2 Industries Stymied Justice for Young Lead Paint Victims”. This exposé documents the ongoing and continuing poisoning of America’s children (particularly those of poor and minority people) by lead paint in houses (“about 500,000 children under 6 have elevated blood lead levels in the United States and are at risk of harm”). One of the two industries is the housing industry, which both lies about whether there is lead paint in the homes that they are renting, and, if they are large enough, obstruct those people from finding some sort of (generally financial) justice by hiding the ownership in a web of companies, and fighting culpability.


Without insurance, there is little chance of recovering money for a child when a landlord has few resources. Property owners who do have substantial holdings have found ways to legally distance themselves from problem rentals, increasingly using L.L.C.s to hide assets and identities.


And the other industry? That would be the insurance industry itself, which places clauses in its homeowner’s policy excluding lead. Why? Well, you see, it would cost the insurance company a lot of money if they had to pay for the mitigation of lead paint in these old houses. So they don’t insure the owners, and the owners are either unable to afford to do the mitigation or are large and wealthy enough that they could afford it but choose not to. In fairness, the quote above about property owners legally distancing themselves from “problem rentals” applies to many “problems” (virtually all of which are the owners’ responsibility), not just lead. Property owners want to collect rent but not maintain the property; insurance companies want to collect premiums but not pay out when there is a problem. What could be more American?


Another recent article, in Medscape, documents how most current adults had elevated lead levels as children, and how, as stated in its title, Half of Adults Lost IQ Points to Lead Toxicity. The culprit in this case is primarily lead in gasoline. Added to gasoline beginning in the early 1920s, lead’s phaseout was accelerated by the advent of catalytic converters, which require unleaded gas, in 1975, but it was probably an additional 20 years before it was gone from most gasoline sold.  And, of course, the residual lead in the soil (including places where children play) remains even today. This graphic from the article demonstrates how ubiquitous high lead levels were when today’s adults were children, what age ranges are most affected, and of course how minority children (and today’s adults) were affected with levels far higher than whites (which were bad enough).



So we have a situation where the majority of today’s adults, at lead those over the age of 30, probably had high lead levels when they were children, and have lost IQ points as a result, and where poor and minority children then (now adults) had far higher levels than whites. And we have another situation in which children continue to have high lead levels, and to suffer not “just” a loss of a few IQ points but serious brain damage, because of ongoing lead exposure, now primarily in lead paint that still exists, unmitigated, in many houses. And, of course, these children are disproportionately poor and minority. (Some things, sadly, do not change.) When I was a young physician, working at Cook County Hospital in Chicago, we would not infrequently have to treat (often as inpatients) children with high lead levels. I thought, like measles and chicken pox and rheumatic fever and infections from Hemophilus influenza that this was pretty much history, stories of the “old days” that I could tell medical students and young doctors. I am aghast to discover how common it continues to be.


But there is another part of the story. It is that lead could be cleaned up. Houses with lead paint could have that lead mitigated. If it were, children would no longer be exposed to it and suffer the kind of brain damage described in the Times article. But it isn’t happening, because of the stonewalling, opposition, and outright blockage by the landlord and insurance industries, and their enablers in Congress and state legislatures. Their profits, of course, are more important than the brains of developing children, especially poor and minority children.


You can’t have it both ways — be a big company when it benefits you to generate revenue and business, and then hide behind an L.L.C. when you are sued in an attempt to escape accountability


says the attorney for “JJ”, a South Bend, IN, child with brain damage from lead paint in his home.


But they do have it both ways – this is how the US treats companies compared to children. And as a result we have the article’s final quote from JJ’s mother:


“We know it damaged his brain,” she said. “We know it is irreversible. And we know it is a lifelong thing. No doctor can tell you, ‘This is what is going to be.’”


Somehow, this does not make me proud.

Total Pageviews