Killing our children: Guns, mortality and morality

There is really nothing to write about at this time other than the ongoing carnage in our nation as a result of angry young men (always men!) shooting up their schools, most recently (at least at the time of this writing) with the death of 17 students and teachers at Marjory Stoneman Douglas HS in Parkland, FL. It is hard to write through the tears. This should not be going on. Many people have written pieces on the subject -- sad, or angry, or articulate, or all of these. One of the most moving appeared in the New York Times on February 18, 2018, by a man named Gregory Gibson whose son was killed in a school shooting 25 years ago. The online headline, “A message from the club no one wants to join”, is different from, and in this case is much weaker than, the print headline: “Why wasn’t my son the last victim?”

Why indeed? Twenty-five years ago. And since then, countless school shootings, and other mass murders (such as, if we needed reminders, the Las Vegas country music concert, the Pulse nightclub in Orlando and the First Baptist Church of Sutherland Springs, TX) have occurred, and every parent, every family member, wants to know why the most recent prior child to die was not the last, instead of their child. People are terrified; a friend, a rational physician, embarrassedly admits to looking online for Kevlar backpacks for his children. He does international “mission” work and is taking his 14-year old daughter to Africa; when people ask him if he is worried about her safety there, he says “no”, but he is worried about her safety attending school two miles from his home in an affluent suburban community in the US. His day job includes being a leader for the quality program in his hospital, where he searches the actual data for root and contributing causes to problems; he wonders why this country cannot do the same for gun violence. Arizona Star columnist Dave Fitzsimmons expresses similar fears for his children.

This country could, but so far it shows no sign of doing so. Gibson quotes the author Chester Himes commenting on the lynching of 14-year old Emmett Till in 1955 that “The real horror comes when your dead brain must face the fact that we as a nation don’t want it to stop.” Himes was talking about lynching, but it is clear that the same can be said today, more than 60 years later, about school shootings. We don’t want it to stop. Because, if we did, we would do something about it.

Of course, we do, most of us. Various surveys, asking the question in different ways, find different percentages, but always large majorities, of Americans want stricter gun laws, often up to 90%. Even most people who are members of the NRA and/or are registered Republicans want limitations on who can buy guns based on mental illness and other criteria (always “me, and people like me”, but not the people like you) and some kinds of guns or gun modifiers (like “bump stocks”, used by the Las Vegas shooter to turn his AR-15 semi-automatic – and by the way almost all these shootings involve AR-15s) and armor-piercing bullets. No, the “we” who don’t want to stop it, in this case is, beyond a small minority of zealots, the even smaller minority of those who are politicians, in Congress, in the Executive Branch, and in our statehouses.

Why would they do this? Or, rather, not do anything about gun violence? Well, there is a small minority of this small minority who are, themselves, zealots whose interpretation of the Second Amendment is such that our dead children are just collateral damage in pursuit of the higher cause of unrestricted gun ownership. But, for most, opposition to even the most rational restrictions is tied to money, specifically to money from the NRA. A staffer for Jimmy Kimmel, Bess Kalb, looked at how much each of the Senators and Congresspeople tweeting their sadness and condolences took from the NRA, noting that “In the 2015-2016 election cycle alone, GOP candidates took $17,385,437 from the NRA,” (quoting a tweet from Republican National Convention chairwoman Ronna Romney McDaniel), and that “This is NOT counting the $21 million given to President Trump.” Another article documents the individual contributions, led by $4.4 million to Thom Tillis (R-NC, or, excuse me, R-NRA).

These legislators, and sadly even the President, when not crying their hypocritical crocodile tears and then voting with the NRA to kill any sort of gun reform, talk instead about the need to focus on mental health. This, by the way, is a good idea; the mental health system in this country is terrible; insurance companies cover it inadequately, those who are not insured and need public facilities find them cut back yearly, and there is no shortage of news stories focusing on a poor mentally-ill person pushed out of a treatment facility found wandering the street, or worse. Our jails and prisons have become our new mental hospitals, documented, for example, in this comprehensive Atlantic article from 2015, “America’s largest mental hospital is a jail”. However, it is not the diagnosed mentally ill who commit these murders and mass murders. Most such murderers do not have a diagnosis, although they probably suffer from “anger management disorder” (not in the current Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), but “intermittent explosive disorder“ will be in DSM-V). This is important because it is the angry who commit these murders. An article in Slate by Laura L. Hayes from 2014,”How to Stop Violence; Mentally ill people aren’t killers. Angry people are”, contains this persuasive data:

80 to 90 percent of murderers had prior police records, in contrast to 15 percent of American adults overall. In a study of domestic murderers, 46 percent of the perpetrators had had a restraining order against them at some time. Family murders are preceded by prior domestic violence more than 90 percent of the time.

Hayes concludes that “Violent crimes are committed by people who lack the skills to modulate anger, express it constructively, and move beyond it.” Sadly, this also describes many of the most virulent opponents of gun control.

If anything could be even more sad than the fact that the mass killing of our children is tacitly endorsed through inaction by our political leaders, it is that it is only one face of the epidemic that is child mortality in the US. This January, Ashish P. Thrakar and colleagues published “Child Mortality In The US and 19 OECD Comparator Nations: A 50-Year Time-Trend Analysis” in the journal Health Affairs. The picture was bleak. The first sentence of their Abstract summarizes their findings: “The United States has poorer child health outcomes than other wealthy nations despite greater per capita spending on health care for children.” Guns are part of it, and the “social determinants of health”, a sanitized way of saying that in the richest country in the world there are millions of children with inadequate food, housing, warmth, safety, healthcare, and educational opportunities, are ultimately the other causes. We may be the richest country in the world, but we are also the most unequal in the developed world, and the increases in the wealth of the top 0.1% does not “trickle down” to those in need.

Indeed, even the outrageous and disproportionate child mortality rates in this country are not the whole story. As I have noted before (Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015; Tom Petty, the opioid epidemic and changing structural inequities in the US, January 23, 2018) the US is the only wealthy country in which mortality rates are rising, a completely shocking finding since, of course, it didn’t used to be true. And this rising mortality is driven by the white non-Hispanic population (although, it must continue to be said, that the absolute mortality rate of minorities, and especially African-Americans, still exceeds that of whites), and more particularly, poor whites.

In a terrific effort to try to explain to the international community what is happening in the US, Steven Woolf recently wrote an editorial for the BMJ, Failing Health of the United States. He notes the causes of the increases in mortality (more than opioids, more than guns, although these are major contributors), provides data, and proposes solutions. “In theory,” he says,

…policy makers would promote education, boost support for children and families, increase wages and economic opportunity for the working class, invest in distressed communities, and strengthen healthcare and behavioral health systems.

Politicians need to address these issues, and they need to be made to do so. By us, the people they are supposed to work for, not the huge money contributors like the NRA. But we can only do this if we stay angry, and stay organized. We cannot heed calls to “not talk about this now” while families are grieving, because it will, based on history, not be very long before it happens again.

It is our job and we must take it on. 

Does prevention save money? Is that the right question?

Does prevention save money? That is, does increasing access to preventive health care, doing more screening tests on a larger number of people, end up saving more money in the long term by reducing the cost of caring for the diseases that are prevented? This is the question asked in “Conventional wisdom clashes with data on health care savings”, by Margot Sanger-Katz in the New York Times on August 7, 2015. Ultimately, she answers “no”; indeed, in the online version dated August 5 that the link above takes you to, the article is titled “No, Giving More People Health Insurance Doesn’t Save Money”. Although it of course depends upon which preventive test we are talking about; “Counseling on contraception is one [of the preventive interventions that actually do save money] because the costs of prenatal care, delivery and pediatric care associated with an unplanned pregnancy are so substantial. But a lot of the preventive health measures that we tend to value a lot — mammography, screening for diabetes — tend to cost more than they save.”

The motivation for this article at this time is clearly the Affordable Care Act (ACA), which not only resulted in more people receiving coverage but mandated that preventive services be covered with no co-pay. President Obama made the case for it in part by talking about cost savings; Sanger-Katz quotes his 2009 address to Congress: “There’s no reason we shouldn’t be catching diseases like breast cancer and colon cancer before they get worse. That makes sense, it saves money, and it saves lives.”  But, in fact, the discussion on the cost vs cost-saving from preventive services is not new; it has been frequently addressed in the literature. I have written about it several times, including two sequential posts on February 2 and February 9, 2009: Prevention and Cost and Economics and Disease Prevention, that cited two important articles on the topic, by Russell in Health Affairs[1] and by Woolf in JAMA.[2]

Sanger-Katz also cites two studies to support the argument, one old and one more recent. The famous RAND health insurance experiment from the 1970s and 80s that examined the impact of providing free (to the patient) access to health care, and the more recent Oregon health insurance experiment, begun in 2008, where poor people who were not already on Medicaid were lotteried into receiving health coverage or not. As she notes, in both studies, people who got free or low-cost coverage used more care, and thus cost more money. This, she notes, is consistent with basic economic theory, and ”…follows the pattern for nearly every other good in the economy, including food, clothing and electronics. The cheaper they are for people, the more they are likely to buy.”

But, while true, this misses the most important point. I have written about both studies before, I discussed the RAND study in Insurance company profits up and patient care down, May 11, 2011, and also refer to it in my discussion of Oregon, The Oregon Lottery: Far from enough, but at least they are doing something, July 19, 2012. In the latter, I quote from a June 22, 2012 New York Times article by Annie Lowrey, “Oregon Study Shows Benefits, and Price, for Newly Insured” that the study “has found that gaining insurance makes people feel healthier, happier and more financially stable,” and that “The insured were 25 percent less likely to have an unpaid medical bill sent to a collection agency and 40 percent less likely to borrow money or skip paying other bills in order to cover their medical costs.” This is the truly important point; people are getting medical care that they need, and are not having to cut back on their other basic needs (remember, these are poor people who don’t have lots of discretionary income) to do so. It echoes the findings of RAND, which were basically: yes, people who got free health care used more care, and indeed used more care that experts considered “inappropriate” (the classic “going to the ER for a cold” trope). But it also found that, and this is the real take-home message, they used more appropriate care; the corollary trope is going to the ER for chest pain, instead of staying home and hoping it would go away because you’re afraid to incur the cost. Free health care not only saved lives, it improved health.[3]

Ultimately, as Sanger-Katz points out, everyone dies. While provision of preventive services may save lives from one disease “…every time you prevent people from dying from one disease, they are likely to live longer and incur future medical expenses. The patient who benefits from the cholesterol screening may go on to develop cancer, arthritis, Alzheimer’s or some other costly illness.” This may seem obvious, but only if you think about it. In the 1980s, I was the only physician student in a class on Health Administration; the other students were planning on being health administrators but did not have a medical background. In one class, a student reported that we were likely to save money in the future because people were adopting healthier lifestyles – eating better, exercising more, not smoking as much. I pointed out that the opposite was true; this would mean people lived longer, and were more likely to develop long-term chronic diseases leading them to, for example, long hospitalizations and nursing home stays. If you truly wanted to save money, you’d encourage a high-cholesterol diet, no exercise, and 2 packs of cigarettes a day, so everyone would drop dead from a heart attack in their late 40s and be done with the cost.

This may sound macabre, but the point it makes is that cost is not the only issue. Examining the cost of providing free health care, as in RAND 40 years ago, or free preventive care, as in ACA, is a legitimate activity, but it is not the only, or even most important outcome. Access to health care, prevention of premature death, and improvement in quality of life are also critical considerations. Cost is important, but cost control cannot be measured in such crude ways as “does prevention save money”? First, as Sanger-Katz noted, different preventive services have stronger evidence behind them, and have a smaller “number needed to treat” (NNT) to have an impact on either cost or lives saved or quality of life (thus a high priority should be expanding access to contraception and contraceptive counseling). Second, there is the expansion of indications (reasons for doing a test), either through providing preventive services to a larger group of people than those shown to have the most benefit in studies, or by ratcheting down the “goal” for things like cholesterol, blood pressure, or blood sugar. These both have the same effect; they decreases the average long-term benefit while increasing the cost (and, not coincidentally, the profits for the manufacturers of the drugs and purveyors of the tests).

Third, and by far the most important in terms of both cost and justice, is the application of different standards to different populations, based on insurance status, wealth, and race. Performing preventive services for people who are unlikely to benefit is a problem, but performing much more expensive interventions for people who almost certainly won’t benefit just because they want them, and they (or their insurer) can pay for them, and because the providers doing them make money, is a far greater issue for cost. In addition, there is the question of “what is a fair price?” for any service, preventive or therapeutic, indicated or not (well, if not indicated, the fair price is zero!). In The high cost of US health care: it's not the colonoscopies, it's the profit, Jul 28 2013, I cited the work of Elisabeth Rosenthal of the New York Times, on this topic; she presents the wide variation in costs for this and other procedures. Thinking of the myriad types of preventive interventions as if they were all the same and of the same value is like thinking of “cancer” as one disease, rather than hundreds; it is simple and it is incorrect.

Ultimately, the cost issue is addressed by equity. Everyone should have access to all interventions that are likely to help them, and no one to those that will not. 

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[1] Russell, LB, “Preventing chronic disease: an important investment but don’t count on cost savings”, Health Affairs, Jan/Feb 2009;28(1):42-45

[2] Woolf SH, “A closer look at the economic argument for disease prevention”, JAMA 4Feb2009; 301(5):536-8. (9th)

[3] Brook RH, et al., “Does Free Care Improve Adults' Health? — Results from a Randomized Controlled Trial”, N Engl J Med 1983; 309:1426-1434

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

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

The social determinants of health can be partially enumerated, and include adequate housing (including sufficient heat in the winter), adequate food, education, and also a reasonable amount of nurturing

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

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

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

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

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

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

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

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

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

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

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