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.

Gangster capitalism and our health: In the US and in the World

There has been a lot written about capitalism. Karl Marx, for example, wrote a multi-volume study of it just about 150 years ago, and since then a lot of the writing has been about what he wrote, supportive and critical. There is no question that it has remained the dominant economic system in the world; it is the linchpin not only of Western “democracies” and totalitarian fascist states but also ostensibly Marxist governments like China. While capitalism has both its defenders and detractors, it is interesting to me that the defenders spend little time defending the amazingly deleterious effects that it has on the quality of life (and even existence of life!) of people, the environment, war, and (to the point of this blog) health.

The problem is that, in pursuit of profit, industries will do and have done almost anything, with no moral compass or conscience, and, worse, with no concern for future generations or the planet. Some of the most obvious and egregious examples in the US at this time include their (largely successful) lobbying of the current administration to roll back on rules to ensure clean air and water and the overall environment so that they (in this case, extraction industries like oil and mining) can further increase their unconscionable profits without worrying about the damage it does. So we have mining and extraction in and near our national parks (“near” is important; air and water do not respect boundaries!), scaling back of national monuments so extraction can take place, poisoning of the water through leaks in oil pipelines (such as Keystone), and poisoning of the air we breathe when fossil fuels are burned. Oh yeah, and the increase in global warming which has already permanently altered the climate and will eventually wipe out life on earth (starting with the lowest lying areas) if nuclear war doesn’t first.

Our health and safety is also constantly at risk from aggressive efforts by corporations to increase their profits. This can take the form of producing unsafe products either because it saves money (e.g., dangerous child toys) or costs a lot to not do (e.g., not having lead in our water or asbestos in talcum powder), or by making important and beneficial (and hopefully safe) medications unavailable to many people because of incredible price increases (for the tip of the iceberg, see “Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?, September 3, 2016). We of course know about the ongoing – and largely successful efforts – of the tobacco industry to increase their profits by promoting a product that kills 400,000 people a year in just the US (mainly from cancer and heart disease), including through promoting it to children (e.g., the cartoon character “Joe Camel” – see Fischer et al, “Brand Logo Recognition by Children Aged 3 to 6 Years: Mickey Mouse and Old Joe the Camel”, JAMA 1991;266(22):3145-3148, December 11, 1991).

One of the most vicious and insidious efforts to compromise our health in the interest of profit has been carried on for more than a half-century by the sugar industry. For decades, under the table, sugar producers funded scientific research into the negative effects of a high-fat diet while ignoring the almost-certainly more detrimental effects of a high-carbohydrate, especially simple carbohydrate – sugar – based diet. Soda pop became the national beverage with incredible impact on the rate of obesity, in the US and internationally. A 12-oz can of Coca-Cola® has 140 calories, so what about that 40oz fountain drink at the convenience store? A 2-liter bottle has 812 calories. That’s a lot. So most health professionals, like doctors, tell people to not drink it, or not very much of it. This is, however, competing against the messaging of the industry, which pushes it a lot, and gets the cooperation of many nutritionists through the use of – wait for it – money! I have written about the corruption (or conflict of interest, to put it nicely) of health organizations like the American Academy of Dietetics and Nutrition (AADN) and the American Academy of Family Physicians being funded by Coca-Cola® and other sugar purveyors and having their ads on their websites (The AAFP, Coca-Cola, and Ethics: Serving the public interest?, August 20, 2010). The ads are no longer there, but you can read about the AADN at the fooducate blog, and if you search sugar on the current AADN website, you will find some pieces on limiting sugar, but as many on the potential risks of artificial sweeteners (which, whatever your beliefs,  the FDA rules as safe) and fats.

Of course, as with the case of tobacco, efforts to limit the sugar market in the US (such as Mayor Michael Bloomberg’s failed attempt to limit the size of sugary sodas in NYC), have led the industry to branch out and increase its efforts to profit in the rest of the world, particularly the developing world. While many countries can be targeted, the biggest markets, China, India, and Mexico, have received special attention. The NY Times has an important exposé  on January 9, 2019, ‘Research details how junk food companies influence China’s nutrition policy”, citing work published in BMJ (“Making China safe for Coke: how Coca-Cola shaped obesity science and policy in China”) and the Journal of Public Health Policy (“Soda industry influence on obesity science and policy in China”) on the role of the International Life Sciences Institute (ILSI):

…a worldwide organization with a Washington headquarters, funded by many of the biggest names in snack foods, including Nestlé, McDonald’s, Pepsi Co. and Yum! Brands as well as Coca-Cola. It has 17 branches, most of them in emerging economies like Mexico, India, South Africa and Brazil, and promotes itself as a bridge between scientists, government officials and multinational food companies.

But in China ILSI is so well-placed that it runs its operations from inside the government’s Centre for Disease Control and Prevention in Beijing. In fact, when asked to comment on the studies, the ministry emailed a statement not from a government official but from ILSI’s China director.

Thus China’s health policy, which almost entirely focuses on exercise like “Happy 10 minutes” (good for you!) and ignores the dangers of high-calorie sugar-laden foods for obesity (and there is excellent evidence that diet is probably about 80% of the issue, with exercise critical for the other 20%).

There are those who will argue that it is not capitalism itself, but “unfettered capitalism” that is the problem. There is a lot of truth to that. The blind pursuit of maximal profit with no attention at all to the negative impacts on the world around them is not a necessary part of any profit making endeavor. Indeed, the “Wealth of Nations” by Adam Smith cautions strongly against this sort of excess, and “the only responsibility of business is to make profit for its stockholders” guru Milton Friedman sort of assumed that they wouldn’t do it.

But they do, and “unfettered” – or corporate gangster capitalism – is what is running the world. And it is not good for our health.

Health Insurance on Demand: radical idea or just another scam?

 “It’s a radical idea.”

I like that. Oooh, what? Radical ideas are often good, even necessary. What is this one?

“On-demand insurance that lets customers buy some of their coverage only if and when they need it, similar to how TV viewers might rent a new release from Amazon instead of paying every month for a pricey cable package they rarely use.”

Huh? Could this be real? If it is such a good idea, why did no one think of this before? Maybe it could be the solution to the problem of the “individual mandate” that has folks so worked up. The argument for that mandate to buy health insurance, a key part of the Affordable Care Act (ACA, also known as Obamacare), was that, to work, insurance requires a lot of people who are healthy have to pay in (via premiums) in order for those who have need to have their bills paid when they need it. This is the central principle of insurance underwriting. If not enough people who do not need to use the insurance buy coverage (in the case of health insurance, are healthy, at least that year), or if too many sick people buy it, rates have to be a lot higher. This is true for all types of insurance to work – car (most people have to not have accidents), homeowners (most people have to not have fires), life (most people have to not die in any given year). The practice of assessing risk, called underwriting, is very mathematically complex and there is an entire profession of actuaries who figure it down to the finest detail, but the general concept is simple: there needs to be enough money collected to pay the claims and pay the overhead costs of the insurance company – and, of course, in a for-profit system like the one we have -- make a healthy profit.

Health insurance on demand, buying insurance only once you get sick, is the subject of an Associated Press article that appeared in the NY Times on December 17, 2018. It sounds really exciting: ‘"It's the sort of thing we need entrepreneurs to be doing," said Robert Laszewski, a health care consultant and former insurance executive. "We haven't had a new idea in managed care in I don't know how long.”’ Yes! Finally a new idea! Based on the idea of picking the shows you want instead of subscribing to cable TV! Sort of the same thing. Except, really, not having TV doesn’t kill you.

Or maybe it’s not so new. After all, we have had something like this forever. It’s called “not buying insurance”. Then, when you get sick, you get billed for the whole thing. Of course, this is more than almost everyone but the richest people can afford, thus the key reason for health insurance. Back in the old days – before WW II – health insurance, or really illness insurance – was much less common. It was more like accident, or fire, or life insurance where you paid premiums in case something you really didn’t want to happen actually did happen. On the model of all insurance, you only “won” if you “lost” – if something bad happened to you. This “sickness insurance” came to be known as “major medical”; people paid for their doctor visits in cash (or chickens, or apple pies, or doing chores), but when they got really sick and needed surgery, needed to be hospitalized, then insurance kicked in.

Then, over the next couple of decades, several things happened that together made health insurance, not just “major medical”, a virtual necessity for everyone. More treatments became available for diseases that used to be untreatable; often these were very costly to treat, and required hospitalization and expensive drugs, imaging, and surgery. The causes of many diseases began to be elucidated; perhaps the most significant was the impact of smoking. The first paper identifying smoking as a cause of lung cancer appeared in 1950; in 1964 the Surgeon General’s report made this connection, and warning labels began appearing on cigarette packages in 1965, becoming Surgeon General’s warnings in 1970. High blood pressure (hypertension) only became identified as a disease, a risk factor for heart attack and stroke, in the late 1950s and 1960s. Remember that President Franklin Roosevelt died as a result of a stroke caused, we now understand, by his extremely high blood pressure – but in those days even the President didn’t get treated for hypertension, because it wasn’t recognized as a disease (and there weren’t any drugs for it).

People began to want not only the treatment for diseases that were formerly untreatable but also for early diagnosis of, and treatment of, conditions (like hypertension) that might be asymptomatic but might put them at risk for “the big one”. New diseases, and treatments for them, began to be discovered; indeed, a cynic (me) might say that yesterday’s ‘crock’ (medical slang for a person with imagined symptoms) became today’s sick person once their symptoms were associated with a disease – usually because someone found a diagnostic test for it or drug to treat it, and now could make money selling it.

On July 30, 1965, President Johnson signed the Medicare Act, providing health insurance to those over 65 and the blind and disabled; Medicaid, providing (limited) insurance to a (limited number of) poor people soon followed. Despite vigorous opposition to Medicare by the AMA before it was passed, doctors quickly warmed to this program, since a large portion of the sickest (because of being oldest) population now had health insurance, and they (and their hospitals) could get paid for providing care. Costs skyrocketed. In 1972, Congress declared end-stage renal (kidney) disease to be a Medicare-qualifying condition. Renal dialysis went from being an uncommon intervention (which required consensus of nephrologists, psychologists, ethicists, etc., to determine that an individual’s future prospects made them deserving of it) to available – and paid for – for everyone with kidney failure. It turned dialysis centers into money machines, and nephrologists (who ran and owned many of them) from esoteric specialists to among the highest-earning physicians. It now costs Medicare over $30 billion a year, and some are questioning its ubiquity.

Let me be clear: Access to medical care, particularly prevention, early diagnosis and treatment, as well as kidney dialysis, is a good thing. People should have it. This includes the people who resist the most valuable of medical interventions such as not smoking and getting vaccines. The problem with medical care is the incredible cost, because no one who is making money on it is cutting prices, and the cost of insurance to employers and individuals (including premiums, copays, deductibles) is out of the reach of many. So now we have suggestions like “insurance on demand”, kind of a retro-solution. If it is a solution.

So how does Bind Benefits, the company featured in the article, do it? I don’t know – maybe they can do enough volume of business that they can negotiate lower rates with health care providers, thus meaning the customer pays less. But, then, this is how the insurance market already works – insurance companies work out deals with providers to pay less than the ostensible price. Only the poorest, without insurance, actually get billed the full retail price. And then, unsurprisingly, they can’t pay it, even with repayment plans. Many of their bills get sent to collection agencies that pay cents on the dollar to the original creditor for the opportunity to ceaselessly harass those with the greatest need.

Maybe it is a gimmick to attract the relatively healthy younger crowd. But it will still leave out the most vulnerable, the sickest, oldest and poorest, and the people who need it the most. This has always been the American way, sadly.

Here’s an idea: How about we put EVERYONE in the US on Medicare, and then fund it adequately? It costs more (but not as much more as you might think since the oldest and sickest are already in it), but we STOP paying insurance premiums, copays, deductibles. We limit the profit for the biggest parasites – drug companies, insurance companies (which might administer aspects of Medicare as they do now), health systems, some physicians? We stop pretending health care is like a fire in your house, something you want to be protected against but hope doesn’t happen, and recognize that it is something everyone needs. Not partial measures, like lowering the age for Medicare to 55, or asking people to buy in, or such. Just everyone in the same system, funded by our tax dollars (and a lot less of them than we are spending now). THAT would be an idea.

Everybody in, nobody out!

Ebola, risk, and the public's health

My friend Allen Perkins received a text from his college-student daughter asking if she should be worried about the Ebola virus. His reply, discussed in “Ebola virus and the dread factor” in his excellent blog, “Training Family Doctors” was “Are you considering moving to west Africa?” This was wise and profound fatherly advice, based upon an understanding of the epidemiology of disease. While is it obviously a serious problem in West Africa (particularly Liberia, Sierra Leone, and Guinea), it is not in the United States. Many other things are much more of a threat in the US, including, as Allen points out, “death from bee stings” (100 per year in the US).

Ebola might someday become a significant problem in the US, but it is unlikely and is not now. Many other health problems are. College students like Allen’s daughter should be sure that they have all their recommended immunizations for diseases that can be prevented by vaccine, including HPV and meningococcus, a very serious and often deadly cause of meningitis that can become epidemic where young people live together in close quarters, like college dormitories (and army bases). Yet, many do not receive these immunizations for reasons that range from passively not getting it done (less of a problem in schools where it is required) to having beliefs, or having parents who have beliefs, that vaccines are dangerous and should be avoided (in some cases this can trump school requirements). They are, by the way, wrong. The net benefit far outstrips the risk. Having your child get meningococcal meningitis and die or have serious brain damage, or get cervical cancer, is not something you want.

But focusing on conditions over which we have little or no control, rather than the ones we do, is fairly epidemic in this country (and likely others). Dr. Perkins focuses on the “dread factor”, about how news reports (not to mention thriller movies) whip up fear about these diseases. On the other hand, mostly what we can do is fear them, while the diseases which we individually might be able to have an impact on would require us to have to maybe do something hard: change our diet, start exercising, stop smoking, not drink so much or at the wrong times. I have written in the past about a patient who had a terror of breast cancer, a disease for which she was not at an increased risk based both on her youth and lack of family history. On the other hand, she did not seem particularly worried about the health risks of her uncontrolled high blood pressure, smoking two packs of cigarettes a day, or having unprotected sex with several different men.

Most of us can see that this is not logical, and maybe even snicker a little about her poor decision making. But it is only a little extreme. Many, perhaps most, of us, could do a better job of eating right, of exercising, of not smoking or drinking excessively (which for many people is “at all”). If not Allen’s daughter, many of her classmates are at much greater risk from going out and getting drunk on a weekend night, increasing their risk of motor vehicle accidents, sexual assault, poor judgment in choosing voluntary sexual encounters, and long term habituation for those with a predilection for or family history of alcoholism, just for starters. But taking action to prevent such bad outcomes is hard, requires effort, and often means not doing things we like in the short term, such as eating tasty-but-unhealthful foods, drinking with friends, smoking when we are addicted to nicotine, driving when we (or the driver) is only a “little drunk”, or having to do unpleasant exercise. Or it can conflict with our self-image: wearing a bicycle or motorcycle helmet, eschewing doing things that our friends are doing. Worrying about things that we can do nothing about, like breast cancer or Ebola, may be a little irrational, but it is in some way comforting because if the bad thing happens we are an innocent victim.

In addition, there are actions a society can take, that could make even more of a difference from a public health, population health, point of view, saving more lives, but these require political will. Sadly, this is often more lacking than individual will. Guns are the prime example; many state legislatures and legislators make it a point of personal pride to advocate for there being no restrictions at all on what kind of guns (e.g., automatic weapons) and ammunition (e.g., armor piercing bullets) people can have or where they can carry them (everywhere, open or concealed). Helmets and alcohol regulation are other areas where opportunity for prevention is often missed. Car safety has been increased by car and highway redesign and tobacco has been increasingly regulated (against the opposition of the industry, it should be noted, in both cases) for the benefit of public health, but many opportunities remain.

Indeed, expanding health coverage to all those below 133% of poverty by Medicaid expansion continues to be opposed by those who want to be seen as against Obamacare. This may be irrational from a public health point of view, but in many states it is rational, if offensive, for being re-elected. The most unjust and inequitable part of it all is how the effects of poor public health policies most affect the most vulnerable, poorest, least empowered people in our society, or indeed any society. Public health education campaigns tend to focus on diseases that have well-funded advocacy groups and affect the majority population; a recent qualitative study of African-American women found that they were very aware of the threat of breast cancer, but hardly at all of stroke – a disease statistically more likely to affect them.

Speaking of public health, it is gratifying to see some newspaper coverage of Ebola that is not sensationalist or scary. “U.S. Colleges See Little Risk From Ebola, but Depend on Students to Speak Up”, by Richard Pérez-Peña in the NY Times, August 30, 2014, addresses the small but real risk that may affect colleges from students who have (unlike Allen’s daughter) actually traveled to West Africa. Even better is “Leadership and Calm Are Urged in Ebola Outbreak” by Donald G. McNeil, Jr., which presents a rational, thoughtful, public health approach, and discusses public health strategies which have been used in the past in major crises and are beginning to be implemented in West Africa. These strategies center around the use of local, respected experts who can effectively communicate with the people in their countries, rather than international aid agencies. The goal is to help people to utilize appropriate prevention and protection measures rather than panic. Again, as in the case of the other personal behaviors described above, this can be hard for people, especially when it contradicts cultural and religious values (such as how the dead are buried). But having voices who are local, who understand the culture, and have both medical/public health credentials and individual credibility, is extremely important. Of course, unlike the Ebola “scare” articles, these were both on page 8 of the newspaper, but have a more prominent position on that day’s Times homepage.

So what are the lessons? Understanding risk is not always easy, especially when an epidemic with a hugely high mortality rate threatens.  Doing something is harder than not doing anything, and it can thus be tempting to worry more about the things that we can’t do anything about rather than those we could reasonably take action on. The same is true for public health issues that need to be addressed at a societal level.

And, of course, it is always the most vulnerable who suffer the most.

Drugs, Tobacco, Doctors and the Health of the Public

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Drugs (the legal prescription type) and drug safety seems to continually return to the news, most recently with reports of serious side effects from a new oral contraceptive pill (OCP), featured on NPR’s "Morning Edition”. With regard to OCPs, it is important to note that virtually all the side effects of oral contraceptives, including the serious ones, are the same as the ones women are at greater risk for from being pregnant. The fact that pregnancy is a “natural” event does not make it risk free; complications such as clots in the veins of the legs (deep venous thrombosis, DVT) do occur, associated with the higher levels of estrogen in pregnancy, and occur more frequently than they do for women taking oral contraceptives. Whatever one’s level of risk for OCPs, a risk that increases with increasing age and dramatically if one smokes, that risk is greater from being pregnant.

However, because the probability of getting pregnant (and thus having serious “side effects” from it) decreases with increasing age while the risk of serious side effects from OCPs goes up, it makes sense for older women who are still fertile to use alternative types of contraception – but, unless they are actively trying to get pregnant, to use contraception. The fact that OCPs can have significant benefits (mainly: preventing unwanted pregnancy) does not make them benign, but neither is pregnancy itself.

The choice to use or not use drugs for any condition (or for prevention of a condition), whether they are prescribed by a health care provider or, in the case of many nonprescription drugs, chosen by the person him/herself, is influenced by number of factors. The best one is that a person has a condition that puts them at risk for bad health outcomes (the “patient important outcomes” of premature death or decreased quality of life; see Calcium, Heart Attack and Osteoporosis, August 2, 2010; Rosiglitazone and the "Holy Grail" July 16, 2010; Statins and scientific integrity, July 6, 2010), and the probability that a drug will decrease that risk is significantly greater than the probability that the drug’s effects will cause a problem. There are sometimes other reasons; a person (patient) will hear from a friend that a drug worked for them, or see on it advertised on television or elsewhere, and decide to try it (if non-prescription) or ask their doctor for it (as so often urged on TV commercials). Depending on a number of factors (whether the drug is in fact useful or potentially useful for something the person has, whether it might create increased risk for the patient, how persistent, or even demanding, the person is) the doctor might in fact prescribe it.

In general, it is fine if you ask your doctor about a medication that you have reason to think might benefit you, but probably not such a good idea to persist/insist if s/he suggests it would not be advisable to take it. A few cautions and things to think about, some of which I have previously discussed (“Conservative” Drug Prescribing March 11 2009):

• Not everything is effectively treatable with a drug. Taking a pill may be easier than changing your diet or exercising or doing other hard or proactive things, but without those other activities it may not work or work as well, and may well be worse;

• Not all drugs are “bad”. Some are really helpful for the right people with the conditions that they are effective in treating, and the potential side effects are far less than the benefits.

• Because some drugs do not require a prescription this does not make them “safe”. They should still only be used when the same criteria are fulfilled: scientific evidence demonstrates that the probability of benefit significantly exceeds the probability of harm. The same applies to any “nutritional supplement”. Because it is not called a “drug” doesn’t make it safe. Everything has potential for harm in the wrong people, the wrong circumstances or the wrong dose (Dietary Supplements can be Dangerous for your Health, October 31,2009)

• If a little is good, more is not necessarily better. Nor is less necessarily better. The right amount is: the right amount!

• Despite our culture’s fascination for the “NEW!!”, new is not necessarily better. Frequently it is worse. Drugs are not cars or cell phones. Newer drugs may have side effects that have not become apparent in the necessarily limited testing that is done before they are marketed, but do manifest when many times more people take them. They sometimes have therapeutic benefit for some people that is greater than old drugs, but often they do not. The only reason to even consider a drug that is new on the market is if your old drug, and the other available old (=”well established”) drugs don’t work adequately or have intolerable side effects, and there is reason (=”evidence”) that the new one will (work better), or won’t (have those side effects).

• Advertising drugs, whether to physicians or to patients, is pretty much a bad thing. As in all advertising, the goal is to sell stuff; it is not (despite pharmaceutical company slogans) improving people’s health. This is highly tied to “NEW!!” because it is the new drugs that are the ones that are advertised. This is because they are the ones that cost the most, that have the highest profit margin, and that the companies need to develop a market for. They also have to amortize their research and development costs, as they will often point out. This would be a less offensive claim if most of the drugs that came out and are heavily marketed were not “me too” drugs – modifications (often quite minor) of existing drugs that are no longer under patent and are being sold generically. Drugs that the doctor may have in his/her “sample closet” will always be these same drugs – the newest, highest cost (and highest profit) options. In health care, if something is being advertised, whether a drug or a procedure available at a local hospital, the meaning is “we would like it if you would buy this because we will make money” and not at all necessarily “this will be good for your health”. By the way, in the case of advertised procedures that you may see on billboards for a hospital or clinic, it means also “if you have insurance”.

The issue of advertising to physicians is addressed in an excellent editorial by Matthew Anderson in the current issue of Social Medicine. It examines the historic and current collaboration by medical organizations with big corporations. In addition to the AAFP/Coca-Cola alliance that I have recently written about, it examines the relationship between the American Academy of Pediatrics (AAP) and infant formula manufacturers and the tight involvement of the AMA with pharmaceutical companies. It is eye opening. In addition, the journal contains a powerful piece by Alan Blum introducing two classic articles about physician activism around tobacco written by the same Dr. Blum when he was, 20 years ago, editor of the New York State Journal of Medicine: “Cigarette smoking and its promotion: Editorials are not enough” and When “More doctors smoked Camels”: Cigarette advertising in the Journal” . The introductory quotation to the first article, from Ira Gershwin of all people, cannot be repeated often enough “One man's death is another man's living”.

And, for those who doubt that, given the current shameful practices, sometimes, given enough time pressure and public awareness, progress is possible, it is worth just looking at the Social Medicine’s cover to see how far we have come, in at least the relationships between doctors and tobacco.
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The Public’s Health: Smoking and Salt

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People pretty much know that smoking is bad for you. You, the smoker, and you, the person exposed to secondhand smoke. Smoking accounts for over 450,000 deaths a year in the US, more than alcohol, accidents, homicides, suicides, and illegal drugs. It is good for people’s health – both the smokers and those who are exposed to that smoke in their homes, workplaces and places of recreation – that people are smoking less; fewer people are smoking and those who do are, on average, smoking fewer cigarettes. Most of the people who have quit have done it on their own, rarely the first time that they tried (“Quitting smoking is easy,” said Mark Twain, “I’ve done it hundreds of times.”) Others have had help – from support groups, physicians, therapists, drugs.

But more important than individual efforts to change individual behavior is the positive impact public policy can have on public health. Mandatory immunizations for school, seat-belt laws, laws governing the safety of manufactured automobiles, helmet laws etc., have all had measurable and significant impact on our health. The two most common and important public policy initiatives regarding smoking are taxing tobacco and banning smoking in public places. In the January 27, 2010 JAMA, Mohammed K. Ali and Jeffrey P. Koplan look at “Promoting health through tobacco taxation”.[1] They show that increasing tobacco taxes decreases tobacco use, especially in young people, and thus the morbidity and mortality that comes from tobacco.

The beneficial effect of smoking bans is so enormous it suprises even tobacco control advocates. “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis”, published by David G. Meyers, John S. Neuberger, and Jianghua He in the Journal of the American College of Cardiology, September 29, 2009,[2] examined 11 studies of smoking bans done in 10 different locations and found that there was a 17% overall reduction in acute myocardial infarction (AMI = heart attack) when these bans were implemented, and that the risk incrementally decreased 26% for each year that the ban was in place. In Helena, MT a smoking ban instituted in June 2002 and resulted in a 40% decrease in AMI by the time the ban was suspended by a court order in December. After the ban was lifted, the AMI rate returned to baseline within 6 months. The impact on AMI is in addition to any effect on other diseases, such as cancers, which were not examined in this study (and would take many more years to have an effect). While much of this improvement in the public’s health comes from reducing the impact from second hand smoke on non-smokers, such bans also unquestionably encourage smokers, especially younger ones, to stop smoking. This is particularly true when quitting is something that the smoker had wanted and planned to do, with the smoking ban or increase in the tobacco tax acting as the “final straw”.

Ronald Bayer and Matthew Kelly, in the New England Journal of Medicine January 28, 2010 discuss “Tobacco control and free speech”[3] and look at how the courts are likely to decide on cases brought to them on tobacco control. While not, so far, opposing tobacco bans, the American Civil Liberties Union is supporting objections to limits on tobacco advertising on the basis of their restriction of free speech: “Burt Neuborne of the New York Civil Liberties Union told Congress that the proposed bans represented ‘a vote of no confidence in the capacity of ordinary Americans to judge for themselves how to react to tobacco advertising”. Bayer and Kelly cite the Posadas decision, written by former Chief Justice Rehnquist in 1986, that limited the advertising for a casino. The quote his opinion “It would surely…be a strange constitutional doctrine which would concede to the legislature the authority to totally ban a product or activity [such as gambling] but deny to the legislature the authority to forbid the stimulation of demand for the product or activity [advertising]”. I would argue that it is unreasonable to suggest that we can outlaw products (such as heroin, marijuana) or activities (gambling) but not restrict others (e.g., smoking in public places) and thus most often bans have been supported.

However, the Supreme Court is moving away from the Posadas position, Bayer and Kelly tell us, in the 2001 case of Lorillard Tobacco Company v. Reilly, and given the 2010 Citizens United decision in which the Court has made the bizarre declaration that corporations have First Amendment rights to give money directly to political candidates, it is far from certain that they would support tobacco bans, taxes, or restrictions on advertising in the future. Clearly, these justices who have previously styled themselves as “strict constructionists” looking at original intent”, have clearly demonstrated that they have no such belief, radically making new law and reading their own beliefs into the Constitution. But what is certain is that all these restrictions, without directly forbidding any adult from smoking, have a dramatic positive impact on the public’s health.

Another article in the New England Journal of Medcine, published on-line January 20, 2010, by Kristen Bibbins-Domingo, et. al., looks at the “Projected effect of dietary salt reductions on future cardiovascular disease”, and notes that reducing dietary salt by 3g per day (or about 1/3) would reduce the annual number of deaths from all causes by 44,000 to 92,000, and new cases of coronary heart disease by 60,000 to 120,000, stroke by 32,000 to 66,000 and AMI by 54,000 to 99,000. This is important, because in recent years the emphasis on salt reduction as a method of treating hypertension (high blood pressure), one of the big vehicles for these bad outcomes, has diminished with the marketing of large numbers of anti-hypertensive drugs. We, as physicians and the public, need reminders of the dramatic efficacy of this sort of dietary change.

The article does not address how that reduction might be accomplished; clearly, as with smoking, the effect could occur if people as individuals just reduce their salt intake. But the probability of this happening is again low. Programs such as labeling the salt/sodium content on foods in both grocery stores and restaurants, especially “fast-food” restaurants, have been implemented in a number of cities. Further regulation, actually requiring lowering of the amount of salt in these foods, would have an even greater impact. Unlike smoking bans, which have a great part of their effect through elimination of exposure of non-smokers to secondhand smoke, the benefit of salt restriction is mostly to the individual consumer. However, this does not mean that societal impetus for this change is not a critical part of changing people’s behavior. Indeed, as noted by Mark Doescher, Director of the Rural Health Research Center and the Center for Health Workforce Studies at the University of Washington in his comments on the important new textbook Community Based Health Interventions [4], “…environmental factors, such as safe streets, healthy food choices, and smoke-free establishments govern individual behavior.”

Experts in occupational safety have long recognized that changing individual behavior is the least effective way of increasing safety. If we want to prevent people from slipping on a factory floor and going through a plate glass window, the first choice is architectural (don’t put a plate glass window next to a shop floor where substances may be spilled that people can slip on). The second choice is engineering, or retrofitting (put a steel mesh over the window). The least effective choice is changing human behavior (telling people to be careful!). The dramatic reduction in deaths from car accidents over the last 30 years has had virtually nothing to do with people driving more safely, and everything to do with car manufacture (engines that collapse down instead of into your lap, air bags, etc., all of which were resisted by the automobile industry) and safer road construction. With regard to the health of the public, the same rules apply. Tobacco bans, tobacco taxes, and efforts to reduce salt intake by honest labeling are much more likely to have a salubrious impact than efforts to get people to change their behavior individual by individual. We need to encourage the latter, but because Doescher is correct, we must also implement the policy changes. We must no longer allow the economic benefit to special interests to continue to endanger the public’s health.

[1] Ali MK, Koplan JP, “Promoting health through tobacco taxation”, JAMA 27Jan10;303(4)357-8.
[2] Meyers DG, Neuberger JS, He J, “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis”, J Amer Coll Card 29Sep09;54(14):1249-55.
[3] Bayer R, Kelly M, “Tobacco control and free speech”, NEJM 28Jan10; 262(4):281-3.
[4] Guttmacher S, Kelly PJ, Ruiz-Janecko Y, eds., Community-based health interventions, Jossey-Bass, San Francisco, 2010.