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.

Structural racism, structural violence and COVID-19: We must fight both epidemics

The novel coronavirus which causes COVID-19 does not discriminate. Despite the common human error of teleologically imputing motivation to organisms – or even inanimate objects – this virus, like other viruses, like other microorganisms, does not choose its victims by conscious intention. Like other microorganisms, it is opportunistic, attacking people who are available and do not mount an immune resistance against it. In the case of COVID-19, that was, at least initially, everyone who was exposed, so that while it began in China it was brought to other countries by international air travelers, generally among the more economically privileged.

But it didn’t stay that way. While the virus does not discriminate, human societies do, and poor people always suffer more. In many countries, including the US, the UK and Brazil it is minority populations, people of color, and especially Black people who have borne the brunt of the epidemic. This disparity is particularly dramatic in countries with long histories of racism that have vicious right wing leaders. The Guardian describes Enormous disparities': coronavirus death rates expose Brazil's deep racial inequalities. In the US, another country with these two characteristics, the disparities are so large that they should be shocking, except we are used to them now. This graph from the NY Times shows the disparity in COVID cases based on income, (the graphic shows NYC and Chicago, and clicking on the interactive link lets you look at the specific but similar patterns in many major cities), but the disparity based upon race is layered on top of that.

Study after study demonstrates this disparity.  They are revealed in hearings in the House of Representatives, and have been demonstrated for many chronic diseases. The cause is Structural Racism, which systemically has placed Black people in lower-paying jobs with much less hope for advancement and the accumulation of wealth, more blighted and polluted neighborhoods where access to basic services (food, transportation, recreation) is worse, segregation of schools either by law (de jure) or de facto in which education is worse, and more limited, and the incredible chronic stress of racist practices in society. This clearly manifests in the fantastically high rate of police brutality against Black and other people of color in the US, as has been demonstrated again and again, and with the murder of George Floyd has led to what (we hope) will be sustained and sustainable demands for change, and in the psychological stress that the ever-present danger of such acts along with less lethal racist treatment wreaks on the people experiencing it. All of us are worn and depleted by acute stress situations (“fight or flight”, with the exhausting secretion of adrenergic hormones) and need to rest to recover, but the chronic condition of stress experienced by oppressed and repressed people leaves no room for recovery, weakens resistance, increases chronic disease and shortens lives. Medical students (at least that large majority who are white) sometimes find this the “soft” stuff, not like the cellular level biochemistry and physiology, that sounds more “real”, but this is not so. There are studies that demonstrate, concretely, cellular level indicators of longevity (leukocyte telomere length) are shorted in people undergoing chronic stress, overall,[1] and in many specific conditions, including PTSD, chronic lung disease, Alzheimer’s disease, and chronic racism.

Our healthcare system is responding, but much of it not in a way that will help stem the epidemic. Recently, I wrote about ‘Rich hospitals get the bulk of government bailouts: It's the American way!’ (May 26, 2020), and more recently information comes to light that shows many systems are doing even less to help America confront the virus, laying off thousands of actual healthcare workers, and more to line the pockets of their C-suite executives! While these egregious and unforgiveable abuses are worst in for-profit hospital systems such as HCA, they are also occurring in many large and prosperous “non-profit” systems.

The NY Times comments on Anthony Fauci, the NIH’s top virologist:

He described the pandemic as “shining a very bright light on something we’ve known for a very long time” — the health disparities and the harder impact of many illnesses on people of color, particularly African-Americans.

The coronavirus has been a “double whammy” for black people, he said, first because they are more likely to be exposed to the disease by way of their employment in jobs that cannot be done remotely. Second, they are more vulnerable to severe illness from the coronavirus because they have higher rates of underlying conditions like diabetes, high blood pressure, obesity and chronic lung disease.

Philip Ozuah, the CEO of Montefiore Medical Center in the Bronx, very hard hit by the virus, writes of the deadly combination of racism and COVID-19 writes that “I fought two plagues and beat only one”,

America has changed its behavior in such profound and fundamental ways to mitigate the coronavirus, from self-quarantining and working from home to wearing masks and literally risking our lives to care for the sick. As our streets fill every night with protesters demanding a change that has been too long in coming, I dare to hope that we as a people can summon the same selfless courage and determination to change our behavior to address the endemic racism and brutality that plagues our country.

Then finally we may rid ourselves of that deadly virus as well.

For a clear, angry, and cogent description of the roots, causes, current manifestations of, and discussion of what we might do, a recent entire episode of John Oliver’s ‘Last Week Tonight’ is  a must-view.  He starts with the horrific and (finally) increasingly known statistics – such as that in Minneapolis, people of color are 7 times as likely to be arrested as whites, and the incredible fact that in the US 1 in 1000 Black men can expect to be killed by the police! Toward the end he quotes Kenneth Clark commenting on uprisings in the 1960s. Clark describes how after each previous crisis, from 1919 on, the powers-that-be say the same things and nothing really changed. The stark reality that this is still true 50 years later is unavoidable. Oliver insists that things must change, that we need to direct address and change the way that police to their jobs, and indeed redefine what the role of the police should be. He states that ‘It’s about a structure built on systemic racism that this country built intentionally and now needs to dismantle intentionally.’

Some have suggested that the risk of spreading the coronavirus from people gathering in mass demonstrations is high. These demonstrations have even been compared to the right-wing “anti-mask” demonstrations.  The risk of infection is likely heightened, but care can be taken; the important point is that whatever is necessary to finally confront and end racist violence in this country, particularly by the police, must happen and must happen now. Bassett, Buckee, and Krieger from the Harvard T.H. Chan School of Public Health take this on directly and strongly in a recent Op-Ed in the NY Daily News, ‘Racism is a deadly virus too: a public health defense of these mass protests’. They contrast the risk of COVID-19 infection by demonstrators consciously and purposely not wearing masks to the anti-racist demonstrators who are doing their best to wear masks and practice physical distancing.  They conclude that:

Protesters are in the streets demonstrating against police brutality and white supremacy not because they are indifferent to the risk of COVID-19. They are doing what they can to protect themselves and their communities precisely because the institutions that are supposed to protect and serve them have been killing black people in this country far longer than the coronavirus has.

The evidence is in and is clear. Indeed, it has been in and clear for many generations. Racism exists, not merely in the beliefs and attitudes of some or many people, but in the intrinsic structure of American society. It is structural racism and structural violence. It continues to kill and harm people at intolerable rates. In the midst of a terrible global pandemic caused by the SARS-CoV-2 virus, we finally and thoroughly must fight and erase the epidemic of structural racism in the US.

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[1] Olveira BS, et al., Systematic Review of the Association Between Chronic Social Stress and Telomere Length: A Life Course Perspective, Aging Res Rev. 2016 Mar;26:37-52. doi: 10.1016/j.arr.2015.12.006. Epub 2015 Dec 28.

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Health status in the United States and State Health Performance: The Commonwealth Fund report and potential solutions

The Commonwealth Fund has recently issued its 2018 Scorecard on State Health System Performance. This scorecard has data for each state (+ DC, so 51 spots), measuring performance against a variety of metrics evaluating access to health care, quality of care, efficiency in care delivery, health outcomes, and income-based health care disparities. Because the Scorecard has been issued 2013, Commonwealth can compare the current year’s rankings and performance to previous ones, seeing how states get better (or worse) on these individual measures as well as on overall performance.  

There is not much change. The Top 5 in performance remain Hawaii, Massachusetts, Minnesota, Vermont, and Utah, in the same order as last year. The Bottom 5 (47-51) are Arkansas, Florida, Louisiana, Oklahoma, and Mississippi, and are close to the same, the only change being Florida dropping 5 spots to join the group and displacing West Virginia, now at 46. Hawaii at the top and Mississippi at the bottom are not only unchanged, but remain far ahead or behind of their nearest competitor. The top regions are still the Northeast and Upper Midwest, with the West dragged up by Hawaii and Utah but otherwise an average to low average group.

Commonwealth also ranks the states on degree of improvement of their scores in each of 43 different indicators. More indicators improved than went down, which in itself is a good thing, but there are a lot of caveats. For one thing, it doesn’t measure amount of improvement, or how much less a state might have improved compared to others. For example, Oklahoma joins the list of the top 5 states with improvement on the most indicators (17, to rank it #4), and yet dropped two places in the overall ranking, from a dismal 48 to 50^th! This is not good. More important, however, were the areas in which indicators fell for many states and for the nation as a whole. This include rising death rates (a really big one!), including a 50% increase in deaths from suicide, alcohol, and drug use since 2005, rising obesity, and gaps in care with a rising disparity between and within states.

Many of the improvements are in areas that have been focal points of public health policy, like decreasing smoking. This is good, but this long-time-coming advance over the tobacco industry’s heavily funded effort to get people to continue to smoke, and young people to take it up, has still not been entirely won. More important, the lessons from the anti-tobacco campaign have not yet transferred to the other well-funded high-profit threats to health, notably sugar and guns, as well as alcohol and pharmaceuticals. Unfortunately, each of these struggles seems to need to rise up almost as if the others hadn’t been joined; activists can and do learn from the previous ones, but so do industries that manufacture unhealthful commodities. These industries replicate the strategies that tobacco used to delay change for so long. The main one, of course, is the liberal application of money to politicians. The same lobbyists who worked for tobacco work for sugar, and guns, and alcohol; the color of their money is still green, and politicians still enjoy receiving it.

While it is true that many politicians from both major parties have been recipients of such largesse, the retreat from reality-based policy that is the hallmark of both the Trump administration and the Republican Party in Congress has major impact on the causes of illness and will continue to do so into the future. One good example of the latter is the aggressive retreat from environmental regulation, personified by EPA administrator Scott Pruitt, rolling back auto-pollution emissions standards (a decision currently being challenged by a coalition of states led by California). Another is the firm resistance to common-sense regulation of guns, which result in over 30,000 US deaths a year, a tiny fraction of which are from foreign terrorists. Limitations on semi-automatic weapons and high-capacity magazines, waiting periods and background checks, absolutely would decrease the number of these deaths (the majority, by the way, are suicides), but are blocked by legislators feeding from the gun-industry funded NRA trough.

Not only politicians are recipients of graft; a recent New York Times exposé provides evidence of pharmaceutical companies using ostensible “speaker’s fees” to actual provide kickback payments to physicians who are big prescribers of their drugs. The article emphasizes payments to doctors who practice pain medicine and are in a position to prescribe large amounts of the opioids manufactured by these companies. Sadly, this is almost as unsurprising as the graft going to politicians to compromise our health. What we should be is outraged about it, and working to combat it. Certainly the politicians do not seem to be. In the conclusion to her “controversial” speech at the White House Correspondents’ Dinner Michelle Wolf noted that: “Flint still doesn’t have clean drinking water.” It is harsh, it is true, and it is almost as bad as the news that the government of Michigan will no longer be providing free bottled water, even though the tap water is still unsafe.

Flint, of course, is a majority minority and overwhelmingly poor city. It has long been clear that its struggles with lead-poisoned water is not coincidental with the makeup of its population, and it not a coincidence that it is in Michigan. The Commonwealth Report illustrates a wide divide between those states that have better and those that have worse health status. Largely, the map is geographic with northern states better and southern states worse, but there is a tongue of northern states in the worse group, heading up from Kentucky and West Virginia into Indiana, Ohio, and on up to Michigan. What these states have in common with most of those in the south is control by Republicans who in most cases have not, in most cases, expanded Medicaid for their citizens. Expansion of Medicaid was a central part of the Affordable Care Act, but a Supreme Court left the decision on whether to do so optional for the states; those that have not done so have worse population health status. This is exacerbated by changes in federal policy that have increasingly made access to health care worse and more expensive in most states, with the impact felt most in states that have elected Republican government and that voted for President Trump.

In another blog post, First Look at Health Insurance Coverage in 2018 Finds ACA Gains Beginning to Reverse, the Commonwealth Fund notes that*:

·        About 4 million working-age people have lost insurance coverage since 2016

·        The uninsured rates among lower-income adults rose from 20.9 percent in 2016 to 25.7 percent in March 2018

·        The uninsured rate among working-age adults increased to 15.5 percent

·        The uninsured rate among adults in states that did not expand Medicaid rose to 21.9 percent

·        The uninsured rate increased among adults age 35 and older

·        The uninsured rate among adults who identify as Republicans is higher compared to 2016

·        The uninsured rate remains highest in southern states

·        Five percent of insured adults plan to drop insurance because of the individual mandate repeal

This is also not good news. Much of the problem is because employer health insurance costs (much of it passed on to workers) have been rising as Medicare and Medicaid control costs. A Washington Monthly article (excerpted by the great Don McCanne in his Quote of the Day) calls for price controls, noting that much of the cost (in lower wages) that workers bear for higher health insurance is not obvious to them, and they would thus have sticker shock from a Medicare for All program. Dr. McCanne notes that a current California bill, AB 3087, calls for price controls, and is supported by unions but opposed by industry and the California Medical Association so it has little chance of passage, suggesting that this solution is not more palatable to the powerful. He calls for well-thought out Medicare for All program, saying:

Now would it be that difficult to let people know about the hidden costs of health care that they are already paying? Do people really prefer being kept in the dark by an opaque financing system rather than being enlightened by the transparency of financing through an equitable tax system, especially if the amount being spent is somewhat less for all but the wealthiest of us?

I do not think so. It is time to do something to change a status quo that is unacceptable for the health of so many as well as unaffordable. It is time to do the right thing.

*Also summarized by Dr. McCanne