Drink more? Do more prostate cancer screening? I don't think so. But be careful about falls!

If the malignant lies and disinformation coming from HHS Secretary Robert F. Kennedy, Jr. (RFKJr) and his minions, whom he regularly replaces if they are too inclined to make decisions based on truth and science (see Susan Monarez, head of CDC for less than a month) were not enough, his psycho – but totally dangerous -- baloney regarding vaccines and other health issues provides cover for the re-emergence of other potentially dangerous “health” recommendations. This is par for the course for this administration, which is entirely focused on distracting us from important issues by focusing our attention on other things, brush fires (or sometimes major conflagrations). Trump is quite willing to arrest, brutalize, imprison, and deport people, to start wars across the globe, or whatever it takes to keep the Epstein files – which must contain truly damning information about him – from being made public. 

In the area of health this re-emergence has not been of the major blaze type, certainly nothing compared to the evil of RFKJr’s opposition to, discouragement of, and even blocking vaccines, but more of “well, we have an axe to grind and let’s bring it back out now that we have cover”. Who, after all will worry so much about the issues I address below when they can worry about the return of polio, measles, mumps, whooping cough, H. influenza, Covid, etc. And maybe even smallpox! But there have been several recent articles covering health issues which should be already settled. But, heck, if vaccines are not settled, why should these be?

On Sept 2, 2025, the NY Times Roni Caryn Rabin reports that Reduced Screening May Have Led to Rise in Advanced Prostate Cancer Diagnoses,  and follows that with the subhead “Changes in screening recommendations over a decade ago may have inadvertently resulted in later diagnosis of the most common cancer in men, a new study has found.” It sounds pretty scary, as it goes on to report that Black men are the least likely to be screened for prostate cancer and the most likely to die from it. Prostate cancer is being diagnosed at a later stage and the implication – no, the direct assertion in the article – is that it is because of a recommendation from the US Preventive Services Task Force (USPSTF) which in 2012 began discouraging the use of routine screening with PSA (Prostate-Specific Antigen). The Times article, and the article it is based on, from CA: A cancer journal for Clinicians, and the comments of the chief scientific officer of the American Cancer Society and one of the article’s authors, Bill Dahut, say “The pendulum may have swung too far in one direction, where we were afraid of overtreatment, and now we’re not finding these cancers early on, when they can be treated and are more curable, and we’re more likely to find metastatic disease that is not curable.” 

This conflates diagnosis of cancer at later stages with (implicitly) increase in death from prostate cancer. Well, doesn’t that make sense? Except that what makes sense is not always true. There is no data in the article that says more men are dying from prostate cancer, only that they are being diagnosed with further advanced cancer. Dr. Dahut says that finding the prostate cancer earlier would make it more curable, but if this were true, the decrease in screening would not only have led to cancers being diagnosed at a later stage, but in an increase in deaths from prostate cancer. How come it didn’t? There are basically two types of prostate cancer: the kind that kills you and the kind you die with, but not from. Medicine has yet to be able to find a test that can identify which kind you have. If diagnosing the kind that kills you earlier can make it curable, that’s great – but then we would see more deaths from prostate cancer as a result of not screening, and we don’t. What has historically happened is that the other, more indolent, kind has been treated and physicians have claimed “cures” – even though men don’t die from it without treatment. But they do suffer the morbidity of treatment (i.e., impotence, incontinence, radiation cystitis, etc.) This, along with the poor performance of PSA as a screening test for prostate cancer, is what led the USPSTF to recommend against screening. This issue has been addressed a number of times over the years on this blog (PSA Screening: What is the value?, March 21, 2009, PSA Screening: “One of Medicine's Great Success Stories"?, Oct 27, 2009,  PSA redux: The USPSTF finally recommends NOT getting it!, Oct 14, 2011, Prostate Screening and the Public’s Health, July 12, 2015, as well as other posts on the benefits – or not – of cancer screening), and essentially, nothing has changed. It is terrible that Black men die from prostate cancer. It is terrible that anyone dies from prostate cancer. If screening saved lives we should do it. But this article presents no new evidence that lives are being lost that could be saved.

A few days later (Sept 5, 2025) the Times had an article by the same reporter titled Federal Report on Drinking Is Withdrawn with the subhead “The upcoming U.S. Dietary Guidelines will instead be influenced by a competing study, favored by industry, which found that moderate alcohol consumption was healthy.” Yup. Favored by industry. Not only were the guidelines withdrawn by HHS and thus not, as planned, presented to Congress, but HHS promotes a “competing report” by a panel of the National Academies of Sciences, Engineering and Medicine that “came to a conclusion long supported by the industry: that moderate drinking is healthier than not drinking”. Yay for the alcohol industry! Of course, “Some panelists came under criticism for financial ties to alcohol makers,” but what the heck. It is perhaps surprising, as the article points out, that RFKJr’s MAHA (“Make America Healthy Again”) campaign does not include anything about the use of alcohol – or, even more amazingly, tobacco! When we don’t like the message, we kill the message (and sometimes the messenger), especially in the current administration. But despite the fact that “Science Over Bias, an industry-supported advocacy group, faulted the alcohol intake study for bias: “The Dietary Guidelines should be guided by a preponderance of sound science, not the personal ideologies of a handful of researchers,” it is the industry’s position that is based on bias rather than on evidence. With regard to physical health (not short-term mental health), there is no amount of alcohol that is good for you, and any amount is a little bad. No alcohol is better than moderate alcohol, except for the financial interests of the industry and the scientists on their payroll.

On a somewhat different issue regarding health, not about controversy (screen or do not screen for prostate cancer? Drink alcohol in moderation or not at all?), is the Times article from Sept 7 by Paula Span titled Why Are More Older People Dying After Falls? It doesn’t provide a definitive answer, but strongly implicates prescription drug use (“Some researchers suspect that rising prescription drug use may explain a disturbing trend.”) It’s important. Falls are a major cause of morbidity and mortality in older people. You can break your hip or your head, you can get a concussion or a brain bleed or die. No joke. The association with prescription medication is legitimate, especially certain ones, called FRIDs, or “fall risk increasing drugs”, that are more likely to cause falls though inducing drowsiness, dizziness, drops in blood pressure, etc. Older people are more likely to have more diseases and be on more medications to treat them, and they are also more sensitive to the side effects of these drugs. (Note that drugs do not know which of their effects are “side effects”; we define them as the ones we don’t like!) And they are more likely to suffer serious injuries from a fall. The take-away message is that physicians should carefully review the medications that their older patients (actually all patients) are on, make sure that there is a need for them, and that there is not another less risky (less FRID) drug that could be substituted. Psychoactive drugs “like benzodiazepines, opioids, antidepressants and gabapentin — that act on the central nervous system” should be especially assessed for need, with particular emphasis on the use of more than one drug with similar side effects that can lead to greater risk. The message should not be “stop taking my drugs because the pharmaceutical industry is greedy and trying to drug us all”. Sure, they ARE greedy, and we shouldn’t have to pay so much to them, but that is another issue. They also make drugs that are effective and in standardized doses (unlike “natural” herbs). And often it is the drugs that people like most (because they relieve pain and/or make them feel better) that are most likely to be FRIDs. Exercises to increase strength and balance are important. And, if the risks still cannot be significantly reduced, people may have to modify their lifestyles. For example, it may be necessary to stop walking a big dog.

These are 3 different issues. I included the first two, prostate cancer screening and alcohol use, because they represent efforts to peel back science-based policies that may have been deleterious to the profits of industry, which is like many of the policy changes across the administration over the last 8+ months. The falls issue is a little different; here the concern is to address the risks to the extent possible without overreacting and stopping all your medications!

Medicine and science are complex. But findings can be skewed to fit an agenda, and when that agenda is corporations making more money, a little skepticism is wise.

Self-centered Syllogism: Bad in public health, bad anywhere

I recently met someone who had seen a couple of my blog posts, was interested in public health, and asked a few interesting questions. My answers – or, really, comments – were things I have said and written about before, but his questions forced me to put them together, and in my opinion, the issues bear repeating.

The first question he asked was “why do we put so much emphasis on smoking but not on alcohol? After all, smoking never caused someone to beat their children or spouse, or to drive impaired and have an accident, or get into a bar fight and beat, shoot, or stab someone else.” That is true, and it raises the issue of the impact of substance abuse on the individual versus on the society (although second-hand smoke causes a lot of deaths). But the real answer is the incredible mortality caused by smoking. The CDC page identifies tobacco as the cause of nearly a half-million deaths in the US annually. While the data is from 15-20 years ago, and (hopefully) the mortality rate from tobacco has decreased as its usage has decreased, this is an astonishing statistic. Deaths from tobacco exceeded the total of deaths from alcohol, plus illegal drugs, plus accidents, plus homicides, plus suicides. It remains, even as smoking has decreased, a major health problem. The CDC says, “Tobacco is the leading cause of preventable mortality in the United States”. It was, therefore, the focus of public health efforts because of its tremendous impact on mortality.

However, of course, alcohol is also a major problem, causing both death and severe morbidity (bad outcomes besides death). It is, as my questioner noted, highly associated with violence against both family members and strangers, with automobile deaths, with homicide and not-homicide violence. It also, of course, kills people who use it, from diseases such as cirrhosis and heart disease as well as many cancers that are more common in heavy drinkers. We all have heard someone who did something very bad (commit violence against family members or strangers, have a car wreck, etc.) say “It was the alcohol. I wouldn’t have done it if I were sober”. But they were not sober, they had been drinking, and probably had often been.

The American Addiction Centers alcohol.org estimate that 88,000 people die from alcohol-related violence and abuse and accidents. The site also notes that “The American Society of Addiction Medicine notes that between 28% and 43% of violent injuries, and 47% of homicides, alcohol has been estimated to be involved.” That is a lot, and it could be an underestimate, but it is the closest I can get to quantifying the attributable risk for violence from alcohol. The concept of “attributable risk” in public health can be understood as the percentage of “bad outcome X” that would go away if “risky behavior Y” went away. This is different from the amount that it increases an individual’s risk; some behavior “Y” may increase your risk a lot but, because it is relatively uncommon, account for less attributable risk. Examples include asbestos and lung cancer (very high increase in risk but a lower percent of cases, compared to smoking). Or, looking at it inversely in terms of what disease a risk factor causes, smoking and lung cancer vs. heart disease. Smoking increases the risk of lung cancer more than it does heart disease, but because heart disease is so much more common, the attributable risk from smoking, the number of lives that would not be lost if people didn’t smoke, would be more from heart disease than lung cancer. An example of “smaller percentages of larger numbers can be greater than larger percentages of smaller numbers”.

So what did I say about alcohol? He identified the fact that there is a very large industry of alcohol manufacturers and sellers, which have great influence. I noted that there was (is) also a great industry of tobacco manufacturers and sellers. He said that in addition to the manufacturers, there were also many businesses, restaurants and bars whose existence depended on the sale and use of alcohol. The current emphasis we see in “alcohol reform” is “don’t drink too much”, a common “PSA” from alcohol manufacturers. The implicit message, however, is “do drink!”.

I think most of the members of our society, including many of those still smoking, recognize that any amount of smoking is bad for you, and more is worse, but I do not think that the same is true for alcohol use. The general attitude, even among medical and public health professionals, seems to be “a lot of drinking is obviously bad, for you and for others, but a little – like I do – is not.” What could be wrong with a couple of beers? A couple of glasses of wine? Especially if you’re not driving? Aren’t there studies that show a little red wine is good for you?

There are such studies but they are dated, poorly done, and wrong. Pretty much, while more is worse, there is no amount of alcohol consumption that is good for your health, and any amount is somewhat bad. We disparage those who use other drugs (heroin, cocaine, crack, meth, even still cannabis) for entertainment, but much of our society is actually built around alcohol as the “social lubricant”. Restaurants, bars, parties. Family events like weddings and funerals. Most of such entertainment revolves around alcohol. Perhaps the only place where alcohol is not the key component of “having fun” would be at an AA meeting! This issue is seriously joined by Holly Whitaker in her book “Quit Like a Woman: The radical choice not to drink in a culture obsessed by alcohol”.

The key here is that so many people drink (if “responsibly”, by which they usually mean “not too much” and “not when driving”) that they have to justify themselves by saying it is OK. I call this the “Dirk Gently Phenomenon” from Douglas Adams’ book “Dirk Gently’s Wholistic Detective Agency”. The lead character, who dies on the first page, was a millionaire who made his money by essentially developing syllogisms that took you from the data you had to the conclusion you had foreordained (his biggest client was the US Department of Defense). This is pretty much what we do in lots of areas, including alcohol use; we decide on what we want the answer to be and then look for evidence that supports it.

My new friend noted his son had been in a public health program a few years ago when the big emphasis was on obesity and its health effects. I nodded, but it not so much any more. Obesity has big health effects, yes, but it is also easy to disparage people who are overweight. This is a manifestation of another common tendency among people (including among health professionals): to be critical of people who do (or don’t do) things that come easily to you to do or not do, and conversely minimize the significance of the negative behaviors that you do (or don’t do). If you are naturally thin and have an no difficulty keeping weight off, it is easy to criticize those who are overweight. However, if you like your fancy wine or craft beer or expensive single-malt scotch, you don’t think drinking is such a bad thing. Or, for that matter, being self-righteous.

Public health is good and important. In the US, it is grossly underfunded compared to individual medical care (about 1% of health care dollars). But, like much of medicine it is also subspecialized. To a large degree, public health researchers go where the money is available for grants – in obesity, or smoking, or violence prevention, etc., and become specialists in that area. It is (or should be) different in primary care. As a family doctor, I can measure and counsel you on your blood pressure, but I cannot ignore your diabetes or lung disease and just refer you to another specialist. Similarly, while public health specialists “do obesity” or “do child seats”, this is not an option for the family physician. I need to help you to stop smoking, but cannot ignore that you need to use a seatbelt. Or get vaccinated. Or would have a greater probability of better health outcomes if you lost some weight. Or did not drink so much. Or at all.

Judging others for doing (or not doing) what we find it easy to not do (or do) and minimizing the damage caused by what we ourselves do is a big logical flaw, as is the “Dirk Gently” fallacy. They are not attractive, appropriate, or helpful or good for anyone, and are especially dangerous coming from medical or public health professionals.

Should hospitals and doctors make value judgements about who deserves treatment?

I heard on NPR’s “Here and Now” (Sept 9, 2021) that Jimmy Kimmel, the late night TV host, had expressed anger and frustration with people continuing to refuse vaccination for COVID-19. He noted that many hospitals no longer have available Intensive Care (ICU) beds available, and were going to have to triage who was admitted to them. According to the host, Robin Young, Kimmel said the decision was easy: you have a heart attack, you’re in; you have COVID and didn’t get vaccinated, you’re out. (His monologue is summarized by The Hill, among other sources.) Kimmel is not the only one to express outrage at the unvaccinated -- “shock jock” Howard Stern has responded to those who would cite their freedom to not be vaccinated with “F—k their freedom; I want my freedom to live!”— and is also not the only one called for such “ICU triage”.

Daniel Wikler, a professor of medical ethics from the Harvard School of Public Health was Ms. Young’s guest, and he said that, while he understood the anger that Kimmel and others were expressing, and empathized with it, he did not believe that it was the business of doctors or hospitals to make such decisions. It was the tradition and history of medicine, he said, to treat the illness of the patient if it was treatable, not to decide that someone had done something to themselves to make them undeserving of treatment. As an example, he noted a skier who might ignore all warnings, ski down the back of the hill, and get injured. There are lots of other potential examples, and they are valid.

I agree with Dr. Wikler on both points. First, I understand and empathize with Mr. Kimmel and others who are furious that those who have refused vaccination not only threaten the health of the rest of us but also end up utilizing a huge amount of health resources and services that not only can limit access to these services for others in need, and in any case cost huge amounts in time and effort by health professionals as well as in money. But I also agree that doctors and hospitals have no business refusing to care for these people, and that a core ethical value in medical care has been to provide care, if you are able, to help the illness of the patient, not to judge whether they are worthy of care because of their previous actions. One of the most dramatic and important examples are medical facilities in war zones, which are obligated by the Geneva Convention to treat all injured on the basis of need, not which side they fought on. To treat one’s own soldiers and not injured enemy soldiers who are prisoners is a war crime.

Many of those people who have the heart attacks that Mr. Kimmel thinks should get them into the ICU smoked cigarettes, or ate a very poor diet, or did not exercise, or all of these. While I’m sure that there are some people who are judgmental and smug enough to believe that they should suffer the results of their own life decisions and not receive care, this is not the approach that doctors and hospitals take.

There are certainly many people whose illnesses are at least partly a result of other poor decisions, including use of alcohol – both heavy lifetime use and even one episode which led to the car accident that has them in the emergency room – or other drugs. In addition, while less common than from alcohol, illness and death related to illegal drugs such as opiates and opioids and stimulants is still very common; we have all heard of the “opioid epidemic”. And there are infinite possibilities for blame when you go beyond “sins of commission” – things you did that were bad for you – and enter the realm of “sins of omission” – thing that you didn’t do that are, at least in the view of the one making the judgement, would have been good for you (e.g., diet and exercise).

Back to domestic hospital use, I would like to discuss two examples from my own experience. Suicide attempts are definitely self-inflicted, but the motivation to act is often transient, and many people who attempt suicide and survive do not attempt it again. Guns are very lethal, however, with well over 90% of suicide attempts by gun being “successful”; drugs are less so. My son killed himself with a gun, but if his attempt had been with a less lethal method, I  certainly would have wanted him treated.

On our inpatient services, residents and I have cared for many people who are repeatedly admitted with the effects of their use of alcohol or other drugs. One person I remember well. Regularly admitted for the toxic effects of alcohol overdose, on treatment and release he always pledged to get treatment for his disease, most strongly motivated by caring for his daughter, but never followed through. After many admissions, some residents thought it wasteful to continue to treat him and argued against it. My position was not only was recovery a difficult process, often with many failed attempts, but that our role was to treat his medical condition and refer him for treatment for his alcoholism. We could make the judgement that he was at fault, and each of us might have our own opinion about whether he “deserved” treatment, but that was irrelevant to our obligation to take care of it. It would be a slippery slope indeed. And I would be remiss to not point out the most common reason people are “triaged” to not receive care, at least in the US, is financial: they do not have money or good insurance. That is totally immoral and unacceptable.

There are some differences with those who refused to be vaccinated against COVID or wear masks or distance, but these are variations on a theme. Yes, they put others as well as themselves and their families at risk, but so do those who drink and drive or use other drugs, or who do many other things. It is our job to take care of them to the best of our ability. To do otherwise is to risk great hypocrisy, thinking that those who do the dangerous things we ourselves do are less culpable than those who do dangerous things we do not do and decry. I call it the “Jesse Helms fallacy” after the former powerful North Carolina senator who both opposed treatment for people with HIV/AIDS, who he said were suffering God’s punishment for their homosexuality, and also smoked like a chimney and fought for the tobacco industry. When he had developed heart disease, he sought and received treatment, despite being largely personally responsible for it.

That so many are refusing vaccination and care that there are no beds in ICUs in many states (as a person from Alabama did from heart disease after being unable to get a bed in 43 hospitals in 3 states, and as is occurring across the poorly-vaccinated South) is shameful, discouraging, and incredibly dangerous. These people are misguided, stupid, and many are even evil. But we also hear of those who (because they are dying, to be sure) regret their decisions. We can feel some sense of self-righteousness when we hear about anti-vax personalities who have died. If we are in institutions where there are not enough beds and patients have to be triaged, that triage must be on the basis of their condition and our ability to help them. The social/political fight cannot be waged at the bedside of an individual patient.

As much as we might be tempted to do so.

Tom Petty, the opioid epidemic and changing structural inequities in the US

In October 2017, the rock musician Tom Petty died at the age of 66. Given Mr. Petty’s history of heroin addiction back to at least the 1990s and the frequency with which overdoses seem to cause the death of celebrities, there was some early assumption that it may have caused his. This was confirmed by the coroner, (NY Times, January 19 2018); however, the cause was not heroin but rather prescription opioids (oxycodone plus 3 types of fentanyl), combined with two also-addictive anti-anxiety medicines known as benzodiazepines: “The coroner, Jonathan Lucas, said that Mr. Petty’s system showed traces of the drugs fentanyl, oxycodone, temazepam, alprazolam, citalopram, acetyl fentanyl and despropionyl fentanyl.” (The citalopram is an SSRI anti-depressant). According to a statement from his wife and daughter, he had many ailments including a fractured hip that caused him great pain.

Thus, Mr. Petty becomes another victim of the epidemic of prescription opioid-related deaths. His previous heroin addiction (chronic use of opiates or opioids leads to tolerance, requiring higher and higher doses for relief) and his stature as a rich and famous person (which seems to make it even easier to find doctors who will prescribe such drugs) may have increased his risk, but his death is one instance of a widespread American problem that has been the subject of academic articles, government reports, and opinion pieces from medical providers, patients, and the general range of pundits.

David Blumenthal and Shanoor Servai of the Commonwealth Foundation write in their report “To Combat the Opioid Epidemic, We Must Be Honest About All Its Causes” that “History offers only one other recent example of a large industrialized country where mortality rates rose over an extended period among working-age white adults: Russia in the decades before and after the Soviet Union’s collapse. The economic and social contexts have been eerily similar, and substance abuse has been a dominant factor in both countries: alcohol in Russia, opiates in the United States.” A major study by Princeton economists Anne Case and Angus Deaton in 2015, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century” (which I have previously cited, Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015) posits opioid-related deaths as a major cause of the surprising  increase in mortality rate among white Americans. Blumenthal and Servai note that “Based on weighted estimates, 92 million, or 37.8%, of American adults used prescription opioids the prior year (2014); 11.5 million, or 4.7%, misused them; and 1.9 million, or 0.8%, had a use disorder. The epidemic is spreading so rapidly that it’s likely the numbers are higher now.”

So it’s a very big problem, with many causes, and the solutions are not simple. Doctors play a big role, since they must prescribe the opioids (whether these are taken by the designated patient or illicitly redistributed). While well-known surgeon and author Atul Gawande, in an interview with Sarah Kliff on Vox.com, says “We started it”, I don’t think that is completely true. Certainly doctors have been vehicles for its perpetration but there are other forces at work. One is the movement that began in the 1990s to adequately address patients’ pain, which was seen as insufficient by many critics. In many institutions pain was labeled the “fifth vital sign”, and staff were instructed to ask about pain relief in every interaction. While this is important, especially for acute short-lived pain (such as post-operative or post-traumatic), the use of opiates for chronic pain skyrocketed. The obvious problem is, as cited above, the more you have taken them the more you need; tolerance to opiate and opioid effects often requires increasing doses. The “high” resulting from these drugs (whether intended or not) increases their potential for abuse.

Long-acting opiates and opioids (such as extended release morphine or oxycodone, methadone, and fentanyl patches) are preferred as they can control pain with less of a “high”, but they still lead to tolerance. While addiction is not an issue for people who are dying of their cancer, it is for people with chronic diseases such as sickle-cell and chronic pain syndromes, most commonly in the US back pain. Opiates and opioids have been shown to be poor choices for long-term treatment of chronic back pain, but taking them is often easier and cheaper for patients than complicated (and often expensive) modalities such as physical therapy, and it relieves the pain more quickly and completely until higher and higher doses are needed. So patients, as well as physicians, are part of the problem, and physicians are working to try to help people, while complicating the problem.

Real villains include those who have originated and perpetuated this crisis only to make money. This includes insurance companies, who often deny more expensive treatments such as extended physical therapy or drugs such as buprenorphine, essentially pushing doctors and patients into the use of opioids. They certainly include the pharmaceutical companies who have developed and heavily marketed these drugs, notably the Sackler family who owned Purdue and made and pushed Oxy-Contin®, as documented in the New Yorker article “The family that built an empire of pain” (October 30, 2017). In brief, they acquired the rights to long-acting morphine, but because this was losing its patent protection (and thus its profitability), they developed a long-acting form of oxycodone, which was patented and thus more profitable. Counting on the negative associations that the public and even physicians associated with morphine, they pushed Oxy-Contin, which was at least as addictive and dangerous, for an ever-expanding list of chronic conditions. Back pain, of course, was the target market, and it soon seemed as almost everyone had an indication for opioids. And we have since been paying the price with their deaths.

The flaws of capitalism that directly drove and continue to drive this epidemic through the pursuit of profit should be clear enough. The structural flaws that have and continue to ruin the lives of so many Americans (not to mention people in the rest of the world) may be less obvious but are no less real. The dramatic redistribution of wealth from the vast majority of us to the already-wealthiest, with the concomitant decrease in the quality of life for so many, proceeds apace. The 1%, maybe even the 5%, are doing great, although the biggest benefit (including from the new GOP tax “reform”) law goes to the 0.1% or less. The richest 1% now owns half the world’s wealth and the 8 richest men have as much as half the world’s population!  Worldwide, it is those in the poorest countries that suffer most. In the US, it remains minorities. While the shocker in the Case and Deaton study was the fact that white mortality is increasing, the fact remains that minorities, especially African-Americans, still have far higher mortality rates.

If we wish to decrease this excess mortality, it certainly will be important to address the opioid crisis, by physicians becoming more reticent to prescribe long-term opioids for chronic conditions, patients to accept alternative treatments, and insurers being willing to pay for those treatments. It will also be important to address other chronic addictions, like alcohol (Blumenthal and Seervai observe that while “11.5 million, or 4.7%, misused them [opioids and opiates]; and 1.9 million, or 0.8%, had a use disorder…By comparison, there are 17.1 million heavy alcohol users among adults over 18.” Legal does not mean safer, whether we are talking alcohol abuse or “legitimized” (by prescription) opioid abuse. It most often reflects the relative power of the industries that financially benefit.

The core problem is in the unfair, unjustifiable, and oppressive structural inequities in our society. These are so deeply seated that we often assume they are inevitable, and that there is no other way. There is. We may not be able to eliminate inequality, but if we are to seriously address the epidemic of unnecessary deaths, we need to do more than treat the symptoms; we must grapple head-on with and change our society’s structure. 

Rising white midlife mortality: what are the real causes and solutions?

 A widely covered and important health research study was recently published by Princeton economists Anne Case and Angus Deaton in the Proceedings of the National Academy of Sciences, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”. The main message is contained in the title – mortality rates for white middle-aged Americans are going up – but there are three other important findings that emphasize its significance.

The first is that mortality rates are going down for every other age and ethnic group, as well as for whites of the same age in other developed countries (see graphic). This means something special is happening to this population group in the US. The second is that this increasing mortality rate is not evenly distributed across class, but is concentrated in the lower-income, high-school-educated or less, group of people. This begins to suggest what is special about this group: that they are being hit hard by societal changes that particularly affect them. The third is that the mortality rates for African-Americans, while decreasing, still significantly exceed those of this group of midlife whites. All of these bear further examination.

That these death rates are rising was apparently surprising to the study’s authors, according to the New York Times article “Death Rates Rising for Middle-Aged White Americans, Study Finds” by Gina Kolata on November 2, 2015, which begins with the sentence “Something startling is happening to middle-aged white Americans.” It surprises not only Case and Deaton, but also numerous commentators quoted in the article and in subsequent coverage. An example cited by Kolata is Dr. Samuel Preston, professor of sociology at the University of Pennsylvania and an expert on mortality trends and the health of populations, whose comment was “Wow.”  I guess this is an appropriate comment about an increase in mortality rates of 134 more deaths per 100,000 people from 1999 to 2014, which Dr. Deaton says is only matched by HIV/AIDS in current time.

But the findings are not too surprising to me. After all, Deaton and Case are economists, not physicians or health researchers, and they came upon this data almost serendipitously while studying other issues (such as whether areas where people are happy have lower suicide rates). But others, those who are physicians and health researchers, should know better. Maybe the doctors expressing surprise are those who don’t take care of lower-income people. And the health researchers are those who have not been reading. In a blog piece  from January 14, 2014 (“More guns and less education is a prescription for poor health”) I cite  Education: It Matters More to Health than Ever Before, published on the Robert Wood Johnson Foundation website by researchers from the Virginia Commonwealth University Center for Society and Health, which notes that “since the 1990s, life expectancy has fallen for people without a high school education, a decrease that is especially pronounced among White women.” This was reported over a year and a half ago, and discusses a trend in place for two decades!

Or maybe I am not surprised because I am a doctor, and see these patients both in the clinic and in the hospital. We do take care of lots of lower income people – those not in the 1%, or the 20% or even the top 50%. Yes, the bottom half of the population by income do exist, and many of them are white, and they are not doing well. The study by Case and Deaton indicates that the causes of death that are increasing the mortality rates in this group of people are not increases in the “traditional” chronic diseases such as diabetes, heart disease, and cancer, but are rather due to substance abuse (illegal drugs, prescription narcotics, and alcohol) and suicide. This is not to say that we don’t see much illness and many deaths from those other chronic diseases in this population; we do, and they account for the high baseline mortality among this group, but these other causes are the reasons for the rising mortality rate.

We have seen the explosion of prescription opiate use in people who (like Dr. Case, as it happens) have chronic musculoskeletal pain (despite increasing evidence that opiates are not very effective for such pain). This often results from their work as manual laborers, either from a specific accident or from the toll wreaked by chronic lifting, bending, twisting, and straining. We also see increased use of alcohol, that traditional intoxicant. While sometimes it seems that we hear more about studies touting the benefits of a couple of glasses of wine a day, the reality is that millions of lives are destroyed directly and indirectly by alcohol use: those of the drinkers, those of their families, those of the people they hit when driving drunk. And in both urban and rural areas (people in rural areas were particularly affected by the mortality increase in Case and Deaton’s study) the use of methamphetamine. And as the drop in standard of living for people who used to make their living with their bodies doing jobs that have disappeared or they can no longer physically do becomes clearly irreversible and leads to serious depression, often compounded by chronic pain and substance use, increasing rates of suicide.

What is only alluded to in some of the coverage of this study is the most important point: this is about our society failing its people. It is about the “social determinants of health” writ large. Yes, the direct causes of the increased death rate in this population are alcohol and drug use and depression leading to suicide, and we do need better treatment for these conditions. But to leave it there would be like looking at deaths from lung cancer and chronic lung disease and concluding only that we need better drugs to treat these conditions without considering tobacco. Our society has, for at least four decades, been somewhere between uncaring and hostile to a huge proportion of its people. Where once we were a land of rising expectations, where people who worked hard could expect to have a reasonably good life, this changed beginning in the 1970s. Jobs for those with high school educations started to become rarer, and in the Reagan 1980s, “Great Society” programs that supported the most needy were decimated. (For the record, the “War on Poverty” actually worked; poverty rates went down!)

In the 1990s, economic growth hid the concomitant growth in income disparities. With the crashes of the tech and housing bubbles leading to severe recession in the mid-2000s, the impact of these disparities became apparent. While there were protests in response (e.g., the “Occupy” movement), the banks were bailed out, the wealthy continued to grow wealthier, and working people have seen their jobs, incomes, standards of living, health, and ultimately lives disappear. Only the blind or willfully ignorant could have not seen this coming.

To a large extent, then, this is an issue of class, however much “important people” decry the use of that word. It is also an issue of race, since, as noted, mortality rates for African-Americans (although not for Latino/Hispanics) continue to exceed those of whites; even as they begin to converge, there is still great disparity. Camara Jones, MD, the new president of the American Public Health Association (APHA) uses the term “social determinants of equity” to describe why African-Americans are so over-represented in the lower class.  The current data showing that lower-income whites are moving toward the long-term disadvantaged should not obscure this fact, but rather remind us that white people have had a privilege that is now, for the lowest income, being eroded.

The irony is that many of the people in the groups reported on, and their friends and relatives and neighbors, voted for those in Congress and their states who pursue policies that make their situations worse. That the 1%, or 0.1%, or 0.001% (after all, 153 families have contributed 50% of all campaign donations this year!) like these policies is understandable provided that they are not only rich but selfish, but they alone don’t have many votes. That their money controls votes, both by buying advertising and directly buying politicians, is undeniable. Maybe poor people cannot contribute as much as rich people, but they can vote (most of the time) and there are so many more of them. If we must reject “trickle down”, we must also reject appeals for votes that are implicitly or explicitly racist; lower income white people are not benefiting by voting for the racists.  The lives and health of Americans will be improved by improving the conditions in which they live, by an economy whose growth is marked by more well-paying jobs, not money socked away by the wealthiest corporations and individuals. People, of all races and ethnicities and genders and geographical regions need dignity and opportunity and hope that is based in reality, not false promises.

We need to treat the diseases that affect people and cause rising mortality, but we need to treat the conditions that lead to them even more urgently.

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.