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.

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.

Moving to Recovery By Design

The following is a guest post by Robert Bowman, MD, of the A.T. Still College of Osteopathic Medicine in Mesa, Arizona. He welcomes your comments and feedback.

Josh Freeman recently linked to the Charles Blow column in the NY Times, “These Children are our future” (June 14, 2013)  about the past, present, and likely future of the HS Graduating class of 2013 - and those missing from any high school graduation. We were both up into  the wee hours as I also reacted to this with the following:

A classic story taught in most introductory public health classes is of the person who finds the body floating in the river, and pulls it out. Then there are more, and he pulls them out. Then more and more and he gets friends. Then so many that the whole town gets involved, developing a highly efficient system for removing bodies from the river, moving them up and out to the graveyard. Until someone says: "Maybe we should go upstream, and try to find out what is causing all these people to die and fall into the river. And maybe do something about it."

"Upstreamers", then, are those who try to find out why the bodies are getting into the river as compared to those who are focused on addressing problems much later; often too late. Upstreamers recognize social determinant and other barriers that can shape outcomes. For the bottom 30 to 40% of Americans, the outcomes can be shaped substantially by various determinants and not by school, teacher, physician, nurse practitioner, etc. Most of the studies regularly promoted in major journals or reports fail to understand social determinants and patient situations.

Upstream thinking is broken in our nation. Nations with effective social systems have people serving on the front line for health and other social services, who stabilize and support the people of the nation, anticipate their needs, and translate these to national leaders. The role of national leaders is to listen to the people and their translators while acting in the best interest of the nation to make the entire nation more efficient and more effective. When the stabilizing front-liners can no longer support the leadership of a nation, chaos reigns – as we should understand from numerous current examples.

Our leaders are not listening to the upstreamer family physicians, teachers, public health, military, nurses, and front line public servants. Leaders need to listen to those who have the perspectives that can help to better understand normal Americans and those facing numerous dimensions of challenges. This perspective is often shaped because front liners tend to arise from lower and middle income and upper middle income Americans, rather than the top of the socioeconomic heap. Our top leaders, on the other hand, tend to come more from the exclusive sector, and such upbringing  makes it difficult to understand the daily lives of most Americans.

Falling Behind By Design

We are clearly falling behind as a nation. A greater proportion of or nation is falling behind in ways that make recovery more difficult. How we progress as a nation (or not) is about whether we can wake ourselves up to recognize the things that are required. Nations do not recover by economic development, defense, too much spending, or too little spending. Nations recover by investing in the earliest years of life. With progress made year to year or generation to generation, we can recover.

Few want to take responsibility for poor child well being, failures of investment in child development, numerous errors in the production and retention of important health care workforce, health costs that are too high for the outcomes, and other broken designs such as school funding mechanisms. It is easier to blame teachers or physicians rather than to make the investments that can make a difference. It is hard to see how these increasing costs and distractions prevent the investments that we need to make in our children – and our future.

Our education focus is downstream and works for those who do well without any intervention. Designs for school funding and standardized testing and high school and college focus do not work for most children left behind -- almost a tautology. Investments focused downstream insure that school districts in communities with high property values have good outcomes, those with middle property value less, and that even the high performing children from lower property value school districts do less well than those in the bottom portions of the higher property value school districts. Advantages for the advantaged also may retard the needed development of the advantaged children, because they are never challenged by the majority of the population who, if offered the same advantages and opportunity, might spur real competition that pushes all of them further ahead. The result is the lack of social class mobility that worsens in our nation.

How Do Declining Opportunities for Most Americans Shape Lack of Health Access?

Resolution of health access has two multiplier factors – origin shared with the population in need of health access and family medicine choice. Frankly, as Rabinowitz[1] has demonstrated, the effect of origin to help distribute physicians is negated when rural origin candidates do not choose family medicine. This is because their practice location is dictated by their specialty rather than their origin. FM choice facilitates the influence of origin. Social determinants can greatly limit access to medical school, but FM choice is 2 to 5 times as potent a marker for rural choice than medical school training and origins. Only FM physicians, and family NP and Pas, have population-based distribution – the opposite of all other specialties which are more concentrated where health care workforce is concentrated already.

Access to health care is mostly limited by lack of front line health access family medicine. We have insufficient MD, DO, NP, and PA family practice positions supported, offered, and filled.  This is the failed health policy determinant. It fails even more when “flexible” potential sources of family providers can easily choose other specialties; this is seen in NP and PA training programs, which are adding both more specialties and more trainees in each specialty, as well as internal medicine training for physicians.

What I have learned in two decades about family physician origins confirms social determinants and social situations that shape the proportion of providers in family medicine. The same social determinants shape medical school admission and performance as a medical student. After all, those who take -- and in particular do well on -- the tests are more likely to be highest income, most urban, and children of professionals. The standard population for scoring for tests such as MCAT and board exams are the subjects that take the test. Those students whose language, culture, parents, or other origin factors are different will have different scores. Normal origins are associated with different scores because they are normal. Exclusive origin students have exclusive scores. Scores shape opportunity, type of medical school, and even subspecialty. A normal distribution of career choice types is different because it is normal. Normal origins, normal types of medical schools, normal distributions of health spending, and normal career choices such as FM are the recovery vehicles for health access. This is not what our national design dictates. Origins, training, health spending, and career choices favor the concentrated or exclusive.

FM docs arise at 1 per 100,000 people across various types of counties or types of populations. In the populations associated with lower income and other social determinants that have lesser opportunity, about 4 per 100,000 are admitted to medical school per class year (1970 county pop, AMA Masterfile with 90% birth origins). This is 25% family medicine result. In the populations of advantage, about 14 - 20 per 100,000 per class year are admitted. These are areas around DC or NYC or other major metro areas with the highest income, most urban locations with top concentrations of professionals.  When you map concentrations of physician origins it is the same as where physicists, engineers, research and development, colleges, and other concentrations of professionals are found. In these areas most associated with concentrations or combinations of concentrations of high-income professionals, about 14–20 per 100,000 become a physician – about 2 to 3 times higher than average. However, for these populations associated with such concentrations, there is still only 1 per 100,000 found in family medicine per class year. Only 1 in 14 to 1 in 20 enter family medicine (about 5 – 7%). Moreoer, this was data from 20 years ago, at the peak of FM choice. FM choice in all types of origins has declined since this time.

Access is more than FM docs. When I look at rural docs or docs for underserved locations and map them to their birth county, the same 1 per 100,000 applies. Higher proportions of FM doctors arise from locations associated with lower concentrations of people. When there are higher concentrations, the proportions of rural or underserved docs decline. Meanwhile the most subspecialized docs most dense areas (metropolitan) with higher and higher concentrations from origins associated with higher concentrations. A doctor with a sub-specialty such as gastroenterology is 6-8 times more likely to come from a county in the top tier of population concentration as compared to those with lowest quartile income or population density.

Only FM has equitable population based origins and the same 1 per 100,000 per class year distribution, or about 30 FM docs per 100,000, for the current past 30 years of FM graduates. FM will actually decline slightly with population growth as FM is locked at 90,000 due to just 3000 annual graduates dating since 1980.

 

Declining Middle Class and FM

Populations vary in higher education and medical school admission. In the lower income segments, few arise for admission at all. Carnevale[2]and the Century Foundation have demonstrated that only 3% from the bottom quartile were found in the top 146 colleges – the same ones that feed the same types of students to medical schools. About 74% arose from the top income quartile. In the US middle income populations are disappearing, groups that used to be able to access higher education and they also had reasonable FM probability and distribution probability. The highest income segments are lowest FM probability. For example, at the University of Nebraska Medical School, those whose hometown is Omaha and Lincoln and other metro areas have 2% family medicine while those from the rest of the state have 15 - 30% FM choice (4 years of data). Out of state and foreign born components have been increasing and are typically highest income, most urban, children of professionals.

Asian Indian choice of FM was 2% for the 1990s - the population segment most representative of highest income, most urban, children of professionals in census and in AAMC data. All such populations are 3 - 10 times more likely to gain medical school admission in the US compared to the average. Advantages of child well being from the start of life are evident.

It is not about artificial markers of race or ethnicity - it is about highest income, most urban, highest property value, and other characteristics associated with advantage (or concentrations). Those more normal and representative are falling behind of all races and ethnicities. The same is true in studies of college students. Asian and white populations are populations of advantage and as Barr[3] demonstrated at Stanford, for students who planned to go to medical school when they were freshmen, these students of advantage had 100 – 110% actually apply to medical school, while the rate for underrepresented minorities, even in a select school such as Stanford, was only 50% remaining to apply for medical school. Advantage involves concentrations or combinations of concentrations as compared to normal. Those left behind are no small segment of the United States. Most Americans do not have the concentrations or combinations of concentrations needed for better opportunity, better cost of living, better health care quality, or easy health access.

Recovering Health Care Cost, Quality, and Access

The states doing best in health care quality consistently have the best child well being, the best markers of middle class, and the least divisions between rich and poor. Health care quality, access, and to some degree costs are related to child well being as expressed birth to admission in a student or as expressed birth until health care encounter in a patient. Downstream focus, and ever more dollars invested at the high school or college downstream level will not help. Research that attempts to claim better quality without changing Upstream tends to represent distractions from real improvements.

We have models such as Southcentral Foundation in Alaska and Grand Junction that illustrate what can be done - and these are just a start. These are models that recovered from poor designs to optimal designs. As a nation we can also recover from poor designs, by designing well from the earliest months and years of life. Who would deprive a 2 year old or a 3 year old of an opportunity to rise above?

We cannot do better as a nation with so many left behind from the earliest ages by design.

Health professionals such as family physicians can do Upstream work at the community level.

We need similar professionals working entire careers like we do to improve child development.

We need primary care and public health nurses that were trained specifically for primary care and public health - and who remain in such careers.

How we invest in our children and work locally in teams will determine our future.

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[1] Rabinowitz HK, Diamond JJ, Markham FW, Hazelwood CE. ”A program to increase the number of family physicians in rural and underserved areas: impact after 22 years.” JAMA. 1999 Jan 20;281(3):255-60.

[2] Anthony P. Carnevale and Stephen J. Rose, “Socio-economic Status, Race/Ethnicity, and Selective College

Admissions,” in Richard D. Kahlenberg, ed.,America’s Untapped Resource: Low-Income Students in Higher

Education. (New York: Century Foundation Press, 2004),

[3] Barr DA, Gonzalez ME, Wanat SF, “The leaky pipeline: factors associated with early decline in interest in premedical studies among underrepresented minority undergraduate students,” Acad Med. 2008 May;83(5):503-11. doi: 10.1097/ACM.0b013e31816bda16.

Keeping immigrants and all of us healthy is a social task

The Health Toll of Immigration, by Sabrina Tavernise in the May 19 New York Times, documents the decreased life expectancy and worse overall health that accompany immigration to the United States. Focusing on Mexican immigrants in the border city of Brownsville, Texas, but drawing on data about other ethnicities and even time periods, the article provides convincing data that descendants of people who immigrate from Mexico and other, poorer, countries, have, in general, worse health, greater rates of obesity and diabetes, and shorter life expectancies than their parents or those who stayed. The numbers are impressive:  “A 2006 analysis by Gopal K. Singh, a researcher at the Department of Health and Human Services, and Robert A. Hiatt, a professor of epidemiology and biostatistics at the University of California, San Francisco, found that immigrants had at least a 20% lower overall cancer mortality rate than their American-born counterparts. Mortality rates from heart disease were about 16%  lower, for kidney disease 18%  lower, and for liver cirrhosis 24% lower.” It seems to get worse for later generations; “Elizabeth Arias, a demographer at the National Center for Health Statistics, has made exploratory estimates based on data from 2007 to 2009, which show that Hispanic immigrants live 2.9 years longer than American-born Hispanics.”

Some, perhaps most, of this is related to the prosperity of the US, and the easy availability of cheap, high fat, high sugar, high calorie food. One woman, who came to the US at 26 and has since developed diabetes, says she was amazed at seeing hamburgers as big as dinner plates; “I thought this really is a country of opportunity! Look at the size of the food!” Grueling work hours, both parents working (when both are here) make time for preparation of healthful food scarce, and more cash in their pockets allows the purchase of tasty-but-bad-for-you fast food. In addition, there is evidence of increased smoking and drinking as immigrants move into the US underclass, a group particularly targeted by marketing efforts for these substances of abuse.

Traditional diets for most people, including Mexicans, are based on food that is grown or found wild (vegetables, cactus) or bought in bulk (rice and beans). These are high fiber and low in empty calories. Robert Valdez, from the Department of Family and Community Medicine and Economics at the University of New Mexico, is quoted as saying “All the things we tell people to do from a clinical perspective today — a lot of fiber and less meat — were exactly the lifestyle habits that immigrants were normally keeping.” There is some evidence that there may be a genetic predisposition to diabetes in some Latinos, particularly Mexicans, as there is in American Indians; after all, Mexicans are largely a mestizo people with much Indian “blood”. Of course, these observations may be related; the natural diet of native peoples did not provide the environmental  factors (high calories, obesity) needed to trigger clinical diabetes, and so the genes for this did not “die out” as readily as in other groups. The same model is seen in South America; the remote Xingu Indians of the Amazon now have extremely high rates of diabetes where it never existed before the introduction of “white” food (used to refer to the color of the food as well as of the people who introduced it).

The other big factor is physical activity. While many immigrants work in physically demanding jobs, the prevalence of physical activity is not as great as for those living on farms in Mexico. One man talks about losing 75 pounds motivated by the image on the wall of his grandfather, who is 93 and still rides his bicycle every day. Yet, 4 of the 6 siblings of the grandson are obese and have diabetes. Another immigrant talks about walking in her early years in the US and feeling so conspicuous (“a bean in rice”) that she was afraid people would think she was here illegally. This has also been described in African-Americans moving from the agricultural (and very poor) South to a more prosperous, but sedentary, life in the North, and in most families a generation or two removed from farms, whatever their ethnicity. Concepts of what is “enough” food, what is a “good” breakfast or dinner for our children, did not change as quickly as lifestyles did. Our culture does not require physical activity as part of daily life the way farming, including subsistence farming, did, but we fed our children the same number of calories as we did (if we were prosperous farmers) or would have liked to, or more, because it is more easily available. Indeed, these changes are not limited to the US; things are changing for the worse (in terms of health) in Mexico as well; citing the fact that up to 40% of the rural diet in Mexico comes from packaged foods, “Researchers are beginning to wonder how long better numbers for the foreign-born will last.”

These are all factors in the “social determinants of health” – how we eat, how we exercise, how poverty grinds us down and how marketing of harmful substances like tobacco, alcohol, and high-sugar foods take their toll at even greater rates on the poor. This is not to romanticize rural poverty, of people, including children, having to do excessive physical labor in order to survive and thus burn up more calories than they consumed, or to minimize the difference between a rural/farming life which provided enough income to supply those calories and those in which malnutrition claimed lives and health. It is, rather, to point out that some of these terrible conditions ironically protected the health of its victims. This has been observed in the past; beri-beri occurred more in wealthy Chinese who ate hulled white rice than in the poor who ate the rice with hulls that contained the thiamine. In England in the early 20^th century alcoholic cirrhosis was a disease of the rich who could afford highly-taxed spirits, while workers drank watered beer. The image of the wealthy many as obese – and suffering from gout, "The disease of kings1" (all that high-protein food) persists in cartoons.

Dr. Arias, cited above, observes that the health status of immigrant families “…may indeed improve as they rise in socioeconomic status, which in the United States is strongly correlated with better health.” Of course, there is no guarantee that longer time in this country will cause a rise in socioeconomic status; the last decade shows a persistent decrease in the socioeconomic status of most Americans, despite a “recovery” measured by Wall St. stock prices. The answer is not to regress to rural poverty, but it is to address these social determinants. It is to build towns that encourage walking and other physical activity. It should be to make fresh, healthful food widely available. It should involve education in schools about healthful eating, not undercut by junk food available in machines. It should limit advertising for poisons such as tobacco and alcohol. It should make clean air and water a priority, and ensure everyone has access to good health care.

 It should be a no-brainer, but in the politics of the US today, it may not be. Charles Blow in his May 18, 2013 column “Resonance Resistant”, notes that “We all know that anything with ‘social’ in its name activates the conservative gag reflex.” This is crazy; we are social beings. We can do better, and we should.

Unintended pregnancy and health disparities

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In "Health in All" policies to eliminate health disparities are a real answer, August 18, 2011, I discussed the work of Steven Woolf, MD, as it relates to health disparities. The major point of that piece is that the health and mortality differences between groups, particularly racial groups, in the United States accounts for an enormous number of excess deaths. If that gap were closed, and everyone in the US had the same age-adjusted death rate as whites, the number of lives saved would far exceed those saved by all medical care. Indeed, it would far exceed the number of lives saved even by public health interventions, at least as narrowly construed. Many of the social interventions that Woolf and colleagues indicate would be necessary to decrease disparities could be thought of as “public health” in a broader sense, because they would improve the public’s health, but in general eliminating poverty and raising educational levels are not part of the narrower public health construct.

In “Unintended pregnancy in the United States: incidence and disparities, 2006”, published on-line-before-print in Contraception, Lawrence B. Finer and Mia R. Zolna of the Guttmacher Institute report on the disparities in a particular group, women of reproductive age, in relation to unintended pregnancy. They combined data from several sources, “…on women's pregnancy intentions from the 2006–2008 and 2002 National Survey of Family Growth… a 2008 national survey of abortion patients and data on births from the National Center for Health Statistics, induced abortions from a national abortion provider census, miscarriages estimated from the National Survey of Family Growth and population data from the US  Census Bureau,” to assess rates of unintended pregnancy and disparities between groups, and compared  this data to rates in 2001.

 They found that the percent of unintended pregnancies remained high, with a slight increase (from 48% to 49% of all pregnancies) from 2001 to 2006. The actual rate increased from 50 to 52 unintended pregnancies for every 1000 women aged 15-44. There was a significant decrease in the rate of unintended pregnancies in women 15-17 years old, but this group still had the highest rates (79%, down from 89%). While the fact that an increased percentage of pregnancies in such young women were intended is not necessarily a good thing, the overall pregnancy rate per 1000 decreased from 47 to 42 in this group. The rates of unintended pregnancy went down with age, but all other age groups had an increase in their rates from 2001-2006, the largest in women 18-24. To say this again: the rates of unintended pregnancy went up in each age group except 15-17, but that group still had the highest rate, with rates decreased in each older age group.

The most important finding was the disparity in the rate of unintended pregnancy by characteristics other than age: by race/ethnicity, by income, and by educational level. The unintended pregnancy rate for women with less than a HS diploma (80 per 1000) was more than 2.5 times that of college graduates (30); the rates for women who were HS grads and those with “some college” were in between. The rate for Black women (91) and Hispanic women (82) was also 2-3 times that of white non-Hispanic women (36). Income, perhaps, had the greatest disparity: the rate for women at <100% of poverty (132) was more than 5 times the rate for women >200% of poverty (24).

OK. This is a lot of data, and maybe it is hard to follow. But the main point is simple: these are staggering differences, and they are difference based upon the same social factors that Woolf and his colleagues address. The magnitude of these differences overwhelms all the other factors that affect this rate. The women whose resources make them least able to economically provide for unplanned children are most at risk of having them.

The percent of unintended pregnancies ending in abortion also decreased, from 47% to 43%, with the greatest decrease (from 47% to 41%) in women 20-24, but rather than being a positive, this decrease is much more likely to reflect the decreased availability of abortion services than a shift in attitudes toward abortion. That is, a larger number of children are being born as a result of unintended pregnancy to families that will have difficulty caring for them. In addition, these families are getting less and less aid from public sources because the same folks who are against abortion and the protection of the “unborn” are also against social services that will help the families of the born.

This study was also the basis for the excellernt column “Failing Forward” by Charles Blow in the NY Times on August 27, 2011.  He makes these points very strongly, commenting on the policies that restrict access to abortion while effectively punishing the children:

“This is what we’re saying: actions have consequences. If you didn’t want a child, you shouldn’t have had sex. You must be punished by becoming a parent even if you know that you are not willing or able to be one. This is insane.”

As in all of Blow’s columns, he includes a telling graphic, here showing the “States of Child Hunger”, the rate and raw number of children in food-insecure households. There are over 17 million hungry children in the US, or 23.2% of all children. The highest rate is in DC, the lowest in North Dakota. After DC (32.3%), perhaps surprisingly, is Oregon (29.2%). However, after that, unsurprisingly, come the usual suspects , many of the states most commonly associated with poor social supports and frequently conservative Republican leadership: Arizona, Arkansas, Texas, Georgia, Mississippi, Nevada, South Carolina, Florida. Most of the New England states are clustered near the bottom (good) end of the list.

The whole thing is not good. Too many poor and hungry children, too little education, too little opportunity for too many women and their families. Too many people and families caught in the multiple challenges of poverty, poor education, and racial/ethnic minority status, all of which are independently associated with health disparities, and which are synergistic in their effect when found together. This is not a society to be proud of. This is a society that needs great change, and it is the change perhaps we’d hoped for with the election of President Obama.

Frequently, the comic strips (not even the overtly “political cartoons”) capture it best. Here is a link to a “Non Sequitur”, by Wiley Miller. Check out September 4, 2001, with the adventures of super “hero” “CongressMan”. Laugh. And then cry.

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We are moving in the wrong direction: the health care crisis and American hubris

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The passion for democracy and liberation from tyranny continues to spread across the Middle East, with major actions (and reactions from dictators) taking place in Bahrain, Yemen, Libya and even Iran. While decades of US foreign policy has focused on supporting these dictators while talking democracy, the people in these countries are looking at the US as a model, not of foreign policy, but of democracy. They may have economic interests, but -- in Libya, for sure, they are willing to die for freedom. Finally, our President, from whom we (and they) had expected great things, is speaking on behalf of freedom.

However, as I wrote last week, things are moving in the wrong direction in the US itself, where right-wing zealots funded by billionaires have taken over not just Congress but the legislatures of many states. Wisconsin is the prime example of an attempt, which may yet be successful, to strip the basic rights of labor unions to organize and fight for their members, a class war thinly veiled by statements of fiscal responsibility negated by the fact that the unions have already agreed to the financial cuts. On NPR’s Morning Edition on Feb 21, 2011 Steve Inskeep,the host interviewing Senate President Scott Fitzgerald, who is carrying the water for Gov. Scott Walker’s bill, could barely contain his irritation as Sen. Fitzgerald kept dodging the questions, reiterating boilerplate talking points rather than answering.

And we are not doing so well. In Empire at the End of Decadence (NY Times, Feb 18, 2011), Charles Blow provides a stunning graphic chart comparing the United States to other countries in the developed world across a variety of areas on which we do, or should, pride ourselves. We don’t come out very well. Among the International Monetary Fund’s (IMF) 33 advanced countries, we are not in the best in any of the 9 areas. We are dead last in prison population per 100,000 (745, more than twice 2nd place Israel’s 325), and tied for worst, with Korea, with 16% of people indicating that they had not enough money for food in the last year. In the only direct health measure, life expectancy at birth, we are, at 78.24 years, ahead of only 5 of the other 32 countries; Slovakia at 75.62, is the lowest, and Taiwan is jus t behind us at 78.15 (the other 3 are Slovenia, Cyprus, and the Czech Republic).

While Republicans rant about individual mandates and repealing “Obamacare”, the health insurance crisis is not over. In the New York Times, Feb 20, 2011, Donna Dubinsky wrote “Money won’t buy you health insurance”. This “co-founder of Palm Computer and Handspring, is the chief executive of a computer software company” describes the difficulty that she had in obtaining insurance on the private market despite being quite well-to-do when neither she nor her husband worked for a large company any more. After being denied coverage at all because of “pre-existing conditions” (“For me, it was a corn on my toe for which my podiatrist had recommended an in-office procedure. My daughter was denied because she takes regular medication for a common teenage issue. My husband was denied because his ophthalmologist had identified a slow-growing cataract,” she finally found a company that would insure them at a high rate with a high deductible, and the rates have continued to rise although they pay (because of the deductible) most of the bills themselves.

The point is not that she is in tough straits. I am sure Ms. Dubinsky would agree that there are a lot of people who we should have a lot more sympathy for than her; people who are homeless and jobless and hungry, and millions more who are on the verge of becoming so. And yet there are many who continue to see the uninsured as “other”, the “them”, rather than the “me and my neighbors”, despite the fact that many of their neighbors, and relative, and friends, must be in this boat. Ms. Dubinsky’s article points out, if there were any more evidence needed, that insurance companies are greedy and absolutely not to be trusted with the health care of the American people. The Affordable Care Act, (ACA) mandates individuals to purchase health insurance, ostensibly the objection of the Republican right (who are presumably either well insured or healthy and optimists), which was the only way the insurance companies would buy in: they basically said “We can only allow no underwriting (denying insurance to people they assess as too high a risk) this if you make everyone buy insurance.”

Should you even think for a moment that for-profit insurance companies are anything but self-serving, it is worth looking at Jacob S. Hacker and Carl DeTorres’ scorecard, The Health of Reform (NY Times, Feb 17.2011). They grade the ACA in Rollout, Reaction, and Results and give the overall program so far a “B”. The reaction of the insurance companies gets a “C”: “Eager to have millions of new private customers, the big private plans and their lobby are against repeal. Still, they spent tens of millions of dollars supporting the anti-reform candidates in the elections and are fighting key consumer protections and cost controls”.

Paul Krugman is generally a supporter of the ACA health plan, believing that it actually will be a major step to addressing our fiscal problems. “What would a serious approach to our fiscal problems involve? I can summarize it in seven words: health care, health care, health care, revenue. “He continues (Willie Sutton Wept, NY Times, Feb 18, 2011),
“What would a serious approach to our fiscal problems involve? I can summarize it in seven words: health care, health care, health care, revenue….What would real action on health look like? Well, it might include things like giving an independent commission the power to ensure that Medicare only pays for procedures with real medical value; rewarding health care providers for delivering quality care rather than simply paying a fixed sum for every procedure; limiting the tax deductibility of private insurance plans; and so on. And what do these things have in common? They’re all in last year’s health reform bill. That’s why I say that Mr. Obama gets too little credit. He has done more to rein in long-run deficits than any previous president. And if his opponents were serious about those deficits, they’d be backing his actions and calling for more; instead, they’ve been screaming about death panels.”
So, while the President’s plan might be criticized for being a giveaway to insurance companies, the right is attacking it for all the things it actually does well!

Dubinsky ends her article “If members of Congress feel so strongly about undoing this important legislation, perhaps we should stop providing them with health insurance. Let’s credit their pay for the amount that has been paid by the taxpayers, and let them try to buy health insurance in the individual market. My bet is that they all would be denied. Health insurance reform might suddenly not seem to them like such a bad idea.”

Maybe, but some folks have no shame. It is not a bad idea, it is, as Krugman demonstrates, a pretty good idea from an economic as well as health standpoint. And Blow may be right when he says that, rather than confront the realities of developing a population with the health and education to compete in a global economy, too many people “…would prefer to continue to bathe in platitudes about America’s greatness, to view our eroding empire through the gauzy vapors of past grandeur.”

That is not a conceit that we can afford.

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