Black men being killed by police: A public health epidemic

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

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

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

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

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

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

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

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

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

Even the APHA should be able to acknowledge that.

United Airlines, health care, and a system designed to privilege the powerful

The spectacle of Chicago Department of Aviation security officers beating and dragging a passenger off of a United Airlines flight was recorded by other passengers and quickly went viral on the Internet, generating outrage across the country (and internationally, particularly in China, where the fact that the passenger was Asian was a source of fury). A series of statements from United and its CEO, Oscar Muñoz escalated from tone-deaf explanation (essentially “well, we told him to get off first”) to most recently apparent contrition, saying it should never, ever, happen to anyone and that United would never, ever, have local police board its planes to take off a legitimate, paying customer.

It is unlikely that this too-little too-late response is going to appease anyone, and it is profoundly to be hoped that United suffers severe financial repercussions; the passenger, who suffered a broken nose and lost teeth, almost certainly will sue. It is not clear how to make this happen to the Chicago Aviation Department. The fury of the public is almost certainly increased by the personal experience of (coach) airline passengers. It also is not limited to either United or to airline travel, as Helaine Olen articulately describes in her NY Times op-ed “United Airlines is not alone”, on April 12, 2017. Ms. Olen goes through the list of issues that were raised by this incident, including not only the concerns about racism (would it have been worse if he were black?), but about the militarization of our police response to relatively minor issues. Although the officers involved were from Aviation Security and not the Police Department, it is understandable that a friend from Chicago posted the question “Was anyone surprised that the Chicago PD used such violence?” on Facebook, given that department’s history of “overreaction” and use of military-type tactics.

But Olen’s main point is that this event (if not necessarily the attendant violence) reflects the vast disparity in treatment provided, not only by United and other airlines but across our society, of people in different socioeconomic situations. She goes through the multiple enhancements to the first class cabins (sleepable seats with Saks 5^th Avenue bedding, better meals, etc.) and compares them to the growing level of discomforts and indignities inflicted on coach passengers, with no food, increased crowding, baggage fees, and the like. The crowding is worse than on a bus, and Greyhound doesn’t charge for baggage. Full-fare first class passengers are a big profit center, but most people in first class are not the 1%ers who can pay these fares, they are business travelers whose companies have bought coach tickets and upgraded to first based on miles earned through an airlines loyalty program. And airlines love that, because it means they will keep flying with them. The rest of us, tough. And don’t believe that they “need” to stay so lean; Olen notes that United made $2.3 Billion in profit last year.

Olen also makes the connection to health, observing that

In a study published in 2014, Martin Gilens at Princeton University and Benjamin Page at Northwestern University found government policy and actions rarely reflected majority sentiment, but instead favored corporate interests and the wealthiest Americans. When congressional Republicans offered up a health insurance reform package earlier this year that would have covered fewer people than the Affordable Care Act, Representative Jason Chaffetz, Republican of Utah, initially defended it by claiming Americans needed to choose between spending on necessary medical care or buying an iPhone. Meantime, the fabled 1 percent would have received an average tax cut totaling $37,000 if the legislation were fully enacted.

And if anyone doubts that this is how the health system functions (although I doubt that many readers of this blog do), I recommend the new book “An American Sickness: how healthcare became big business and how you can take it back”, by Elisabeth Rosenthal (Penguin Random House, 2017). Rosenthal, a former New York Times reporter whose fantastic series “Paying till it hurts” ran in the Times a couple of years ago, is now the editor-in-chief of Kaiser Health News. I have cited her reporting frequently in this blog and in my 2015 book “Health, Medicine and Justice: designing a fair and equitable healthcare system” (Copernicus Healthcare). Indeed, “An American Sickness” overlaps considerably with my book, but is by a much better-known figure, and hopefully will be widely read. Rosenthal, a physician, pulls few punches in this work, saying unequivocally that the US health system is designed and functions to maximize the income and profit of providers (especially hospitals), insurance companies, and pharmaceutical and device manufacturers. (An excellent review of the book by Jacob Hacker, Professor of Political Science at Yale, can be found here.) Rosenthal identifies the ten “Economic rules of the dysfunctional medical market” (which I have reproduced in the figure); all are important but #10, “Prices will rise to whatever the market will bear” is particularly critical, and reflects that the health system bears little or no relationship to a true market, and does not play by Adam Smith’s rules.

ECONOMIC RULES OF THE DYSFUNCTIONAL MEDICAL MARKET

(E. Rosenthal, “An American Sickness”)

1.      More treatment is always better. Default to the most expensive option.

2.      A lifetime of treatment is preferable to a cure.

3.      Amenities and marketing matter more than good care.

4.      As technologies age, prices can rise rather than fall.

5.      There is no free choice. Patients are stuck. And they’re stuck with buying American.

6.      More competitors vying for business doesn’t mean better prices; it can drive prices up, not down.

7.      Economies of scale don’t translate to lower prices. With their market power, big providers can simply demand more.

8.      There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all.

9.      There are no standards for billing. There’s money to be made in billing for anything and everything.

10.   Prices will rise to whatever the market will bear.

Rosenthal supports each of these rules with data and examples. Regarding rules #8 and #9, in an NPR interview with Terry Gross on “Fresh Air” ,she emphasizes the importance of getting an itemized bill from the hospital and going through it line by line, citing a person who found $70,000 in outpatient surgery charges for an inpatient hospitalization, and others billed for circumcisions their newborn sons did not have. But it is not always easy; in the book she tells of a person who demanded an itemized bill rather than the one she received, where the total of $45,000 was simply labeled “Miscellaneous”! The hospital never sent it, despite it being her legal right, but did send her to a collection agency! Rosenthal says we would never tolerate shopping at a supermarket with no prices where they just sent us a $2000 bill every week. We should not tolerate this in healthcare.  Every single service must have a listed, easily accessible public price. It may be fine to discount it for some insurers, and even more for some than for others, but the list price must be as clear as we expect it to be for anything else that we buy.

I learned some things from Rosenthal that had not even occurred to me; for example, the ACA’s 85% limit on “medical loss ratio” (i.e., the percent of premiums that insurers actually have to spend on medical care) ironically helps encourage them to be willing to pay higher prices to providers. Why would they pay $130,000 for a treatment that cost $19,000 only 15 blocks south (the opening example in the book)? Well, they get to keep 15%. And 15% of a bigger number is more in their pockets. And they just pass on the cost as higher premiums! Rosenthal discusses an important conservative health economist who is known for saying the high cost of US healthcare is overblown, but (amazingly) sings a very different tune when confronting the hospital bill for his father!

“Dysfunctional” is the wrong word for our health non-system. It functions just fine to make lots of money for the biggest corporate (including ostensibly “non-profit”) players. For the rest of us, it doesn’t always provide the best, or even adequate care, and it drains our individual and collective pockets, significantly contributing to individual bankruptcies and bad health outcomes when folks go without care. It also results in governments at federal, state, and local levels not having funds for other social programs that might actually improve health more.

Yes, we can change it but it will require resolve and a lot of work, because the opponents of change are rich, powerful, and entrenched. We cannot accept any excuses from our bought-off politicians or “pragmatists” who are the ones who suffer the least. We are least able to fight when we are sick and need care, just as we are least able to object to our conditions when we have a ticket and are on a plane bound for where we need to go. But just as we can fight the latter, we can fight the former; the social media response to United is an example of a good start.

But it is going to take more than a good start to get the thieves and profiteers out of healthcare, and get a system that benefits us all. It is going to take a long fight with a lot of hard work. Up for it?