Abortion is health care. It must be safe and legal.

Quite a number of years ago, before the murder of George Tiller, MD in 2009 (see my post In Memoriam George Tiller, May 31, 2009), the Students for Choice group at the medical school where I worked had a forum with a speaker who was the minister that counseled potential abortion patients in Dr. Tiller’s practice. (Yes, he had a minister to do counseling. He was murdered while acting as an usher in his church. Don’t forget that!) During the discussion, one student stood up to identify himself as a person who was adopted as a baby, and how he was so glad that he had not been aborted. He talked about the wonderful love and support he had gotten from his adoptive parents, and how it had made it possible for him to get to medical school.

I was very happy for him, but it is a specious argument in two important ways. First, one can never know what “might have been”, and who a baby born would have been. In addition, this in no way begins to address the pregnancies with fetuses who have conditions incompatible with life, or the trauma of giving birth to a 12-year old who is the victim of incest, or indeed any pregnant person. A person carrying a baby to term is 14 times more likely to die than one having an abortion, and in some circumstances (Black women in Mississippi) 118 times more likely to die! (cited by Michelle Goodwin in an excellent piece in the NY Times, June 26, 2022, “No, Justice Alito, Reproductive Justice is in the Constitution”).  

The second flaw in his argument, personal as it was to him, is that all children are not guaranteed such an outcome if they are born and adopted. It would be incredibly wonderful if all children had terrific, loving, supportive parents, when biologic or adopted or of any other combination, especially if they also have the financial and emotional capability of raising a (or another) child. But this is far from always the case, for any kind of parent. It is a romantic pipe dream of the  “pro-life” movement that being given the opportunity to be born means anything is possible for the child. This is the position taken recently by, for example, the Cornell Republicans, who tweeted '“Hundreds of thousands of children will now have the opportunity to live life to their fullest potential” (Cornell Daily Sun, June 26, 2002). This is nonsense; having that opportunity requires more than being born. It requires love, and safety, and food, and housing, and education, and nurturance. The kind of things that the medical student above apparently had. The kind of things that millions of children born already do not have access to. And, clearly, the kind of things that many Republicans (and others, likely; I didn’t want to make this about political party, but it was the Cornell Republicans who issued the statement) have completely refused, continuously, to support for children born in the US. The meme that “pro-lifers” love only unborn, not born, life, is sadly, the effective truth. (Note that I do not mean that all, or even most, people who identify as “pro-life” feel this way, but it is the effective practice of those they elect to Congress and state legislatures. Of course, if we were going by what most people believe, over 60% of Americans believe abortion should be legal in all or  most cases.)

People who are pro-choice also use specific examples, individual stories, and they are also gripping. A post making the rounds on FB since the Dobbs decision says: ”Overturning Roe does not stop abortions, it stops SAFE abortions!” and this is absolutely true. As much as the anti-abortion forces would like to prevent all abortions (they think), abortion have been part of human life since...forever. But they have not always been as safe as they have become since the Roe decision, and now they are about the safest procedure that can be done, and even safer when done with medication. I thought I’d include a few of those stories, anecdotes, that accompany these posts because they are each as real as the story of that medical student, written in the voice of one who says that they are not “pro-abortion” but “pro-life” as in:

·        I'm pro-Becky who found out at her 20-week anatomy scan that the infant she had been so excited to bring into this world had developed without life sustaining organs.

·        I'm pro-Susan who was sexually assaulted on her way home from work, only to come to the horrific realization that her assailant planted his seed in her when she got a positive pregnancy test result a month later.

·        I'm pro-Theresa who hemorrhaged due to a placental abruption, causing her parents, spouse, and children to have to make the impossible decision on whether to save her or her unborn child.

·        I'm pro-little Cathy who had her innocence ripped away from her by someone she should have been able to trust and her 11-year-old body isn't mature enough to bear the consequence of that betrayal.

·        I'm pro-Melissa who's working two jobs just to make ends meet and has to choose between bringing another child into poverty or feeding the children she already has because her spouse walked out on her.

·        I'm pro-Brittany who realizes that she is in no way financially, emotionally, or physically able to raise a child.

·        I'm pro-Emily who went through IVF, ending up with SIX viable implanted eggs requiring selective reduction to ensure the safety of her and a SAFE number of fetuses.

·        I'm pro-Jessica who is FINALLY getting the strength to get away from her physically abusive spouse only to find out that she is carrying the monster's child.

·        I'm pro-Vanessa who went into her confirmation appointment after YEARS of trying to conceive only to hear silence where there should be a heartbeat.

·        I'm pro-Lindsay who lost her virginity in her sophomore year with a broken condom and now has to choose whether to be a teenage mom or just a teenager.

·        I'm pro-Courtney who just found out she's already 13 weeks along, but the egg never made it out of her fallopian tube so either she terminates the pregnancy or risks dying from internal bleeding.

The post concludes:

You can argue and say that I'm pro-choice all you want, but the truth is:

I'm pro-life.

Their lives.

Women's lives.

You don't get to pick and choose which scenarios should be accepted. It's not about which stories you don't agree with. It's about fighting for the women in the stories that you do agree with and the CHOICE that was made.

Women's rights are meant to protect ALL women, regardless of their situation!

Overturning Roe does not stop abortions, it stops SAFE abortions!

Abortion is healthcare.

 

It is health care. And it is critical that be available. To all.

Technology and other obstacles to getting health care: it’s capitalism, of course!

I saw this cartoon posted recently on Facebook, and am sorry that I can find neither the cartoonist nor the original site of publication. It is, as is the case with most good humor, both funny and sad, in that it cuts close to the reality of the lives of people seeking health care. This particular cartoon emphasizes the technology obstacles to receiving care, which represent another layer of obstruction beyond insurance, distance, availability of providers, and, generally, a system that favors the corporations involved in health care over the people (also known as ‘patients’) seeking it, or the clinicians who provide it. One of the biggest complaints and stressors (and reasons for physician burn-out) is the Electronic Medical (or Health) Record which consumes enormous amounts of clinician time inputting data (many clinicians report at least a 1:1 ratio of charting on-line to seeing people).

It take so much time and is so onerous in large part because it involves, in addition to charting the note recording what the person was complaining of (“Subjective”), what was found on exam, lab, imaging (“Objective”), what was diagnosed (Assessment) and what was done (Plan), many click boxes have to be filled out to record specific data digitally. While this includes things that are sensible because they enhance easy retrieval (e.g., a flu shot), and things that are otherwise ostensibly documenting preventive care for certain issues (e.g., alcohol or tobacco use), they also include many things that ensure compliance with specific government regulations or insurance companies rules, and extensive and complex documentation and clicking to ensure that maximum reimbursement is received by the employer.

There are benefits to having data stored in a searchable and easily retrievable digital format. However, on balance, patients find their access to medical care, already strained by financial, time,  and distance constraints, further limited by technologic obstacles, and doctors find them terribly burdensome and of less utility,  but yet they proliferate. Patients do not usually want to blame their doctors or other clinicians, most of whom they value and trust, but cannot understand why those obstacles have been put in place.

Let us go back to “maximum reimbursement is received by the employer”. Most doctors and other clinicians are no longer in solo or small-group practices, but rather are employed by corporations (both for-profit and ostensibly not-for-profit) or by large groups that, even when physician owned or managed, have the same incentive to maximize reimbursement, even at the cost of efficient use of the clinician’s (not to mention the patient’s!) time and effort. Of course, for the corporation, the most efficient use of a physician’s time is that which generates the greatest reimbursement, which is not necessarily the same as that which generates the greatest marginal health benefit for the patient. This is an issue I have written about many times before, but it bears repeating. People who are willing to vote against an administration because gasoline prices are high, even though that is a result of corporate greed and is most supported by the administration’s opponents, are not always ready to think deeply. Indeed, physicians and other clinicians retain a great deal of respect and admiration despite the violence done to people in their name (usually not, of course mainly physical violence, although making it difficult or impossible for folks to access health care can certainly result in physical damage!)

People often want to take credit for what is seen as good, and to deflect blame onto others for what is seen as bad. This is a particularly common trait in those called “leaders”, although they are often just bosses, not leaders. It is so common in this group, in fact, that we are often shocked when a person in a position of real authority takes responsibility for their – and their subordinates’ – mistakes, and gives credit to others for accomplishments; this is why Harry Truman’s sign “The Buck Stops Here” became so famous. In the case of health care, such duplicity by the “leaders” often takes the form of the corporation wrapping itself in the mantle of “caring for and about your health”, while actually creating obstacles (including those technological ones) to accessing care, particularly if you are not a high-profit-margin patient, and even blaming those doctors, nurses, and others who actually do provide care for the problem.

In a different context, this theme has been replicated in Mexico, by the government rather than the corporation. Doctors (and their patients) in rural areas are being kidnapped, killed, and otherwise abused by drug gangs, as reported in the NY Times. In a cynical political move to seem to address this problem, the government is talking about bringing in 500 Cuban doctors. ‘“They [that is, the rural physicians] forget about a patient’s primary right, which is to be cared for wherever they are, and it’s because of this that we needed to resort to contracting foreigners,” Dr. Jorge Alcocer Varela, Mexico’s secretary of health, told reporters at a recent news conference.’ Safe in his cabinet office in Mexico City. This generated an appropriate response: ‘The announcement about the Cuban doctors provoked outrage among many Mexican doctors, who said the problem was not a lack of physicians or an unwillingness to work in rural communities, but the life-threatening conditions they must work under.’

The lower your own risk, the easier (but more ignoble) it to criticize those who are at risk. The less value you (as, say, a CEO) bring to the actual provision of health care, the more you can feel free to blame those who do, or who criticize the way that you have organized systems to maximize your profit, not to improve people’s health. Such CEOs love to brag about their great programs that bring highly-reimbursed care to well-insured people, but are rarely willing to spend much on high-value (as opposed to high-profit) care for the most needy.

Healthcare is scarcely unique in having been seemingly overtaken by systems that have the goal of limiting human-to-human interaction and replacing it with often difficult-to-navigate (especially for the older or less computer-savvy person) human-to-machine systems. “They” want you to download their app (after upgrading your operating system), go to their website, and do anything that does not require them to pay a person who can actually help you. Almost no actual people prefer that, but we’re usually stuck. When they can’t force you off the phone and on to the computer, they can sure make you wait – at your doctor’s, at the pharmacy, at the airport – and maybe you’ll give up. It does not just happen in health care, but when stakes are your life and health, it seems particularly bad.

Just remember who and what is at fault; usually not the doctors and other clinicians, who actually want to help you, but corporate capitalism, motivated by greed.

Where has all the caution gone? COVID infection is still common!

Most infections diseases in people get passed from one person to another, although sometimes animals and insects are the vectors. More rarely (as in the case of COVID-19) an ‘enzootic’ infection (one that resides in animals) can ‘make the jump’ to people, although after that the transmission continues to be primarily person-to-person. If there is an outbreak of an infection it can spread rapidly among ‘susceptibles’ (people who do not have immunity through either prior exposure to the infection or from vaccination against it), particularly in crowded conditions.

Many of us are aware of this from our children. In winter, young children in school and day-care bring home infections that can make them sick and often infect other members of the family. Luckily, most of these are minor and transient (the ‘common cold’), but in the past included many serious and potentially fatal diseases such as polio, measles, mumps, whooping cough, rubella, diphtheria, Hemophilus influenza, chickenpox, and others. The frequency of these diseases has gone down dramatically as a result of vaccines that have been incredibly effective. Outbreaks still occur in places and populations where an insufficient percent of the children have been vaccinated to result in ‘herd immunity’. In the US, this is, sadly, most common not in communities which do not have access to vaccinations, but in which large numbers of people have, for whatever their reasons, chosen to forego vaccination for their children.

 

Dave Caverly, Speedbumps

 

The way that outbreaks of any infectious disease, from colds to influenza to chickenpox to sexually-acquired infections to COVID-19, occurs depends upon the route through which that organism is transmitted – sometimes by respiratory droplets (cold, COVID, pneumonic plague, polio), sometimes through fecal-oral contamination (think young children), sometimes through sexual contact involving exposure to blood or other body fluids, sometimes by more than one of these. Respiratory transmission is particularly great in crowded indoor environments, such as schools, concerts, restaurants, clubs, and family gatherings. And gyms, where people working out are breathing heavily. And singing (such as the karaoke sessions enjoyed by the NY State judges before many came down with COVID). Sexual transmission is, of course, less likely to be incidental and requires close and often prolonged contact.

But there is a similarity. This is that we are at risk for exposure not only from symptomatic individuals with whom we have contact, but often from those who are not, or not yet, symptomatic but who have been infected by someone else. In the case of sexually acquired infections, the idea that when you have sex with someone you are not only having sex with them, but potentially anyone else they have had sex with, or the people those people had sex with. Monogamy, is of course, protective, provided, of course, that it is actually practiced. It does not necessarily take many outside episodes to introduce an infectious disease.

In the case of COVID, we are not talking about sex, but about high-risk exposures. And also about what we assume should have been low-risk exposures but were to people who themselves may have taken greater risks. You may be pretty careful, not go out much, wear your mask if you are indoors with groups of people that you do not know, but be less careful if you are with close family members, especially those in your home. But just as a child can bring home a cold from daycare, or a sexual partner can bring home an STI from a relationship that you did not know they had, a family member can bring home COVID from a concert, club, restaurant, airport, social gathering, or other event in which others, who you (and maybe they) do not know were infected, unvaccinated, unmasked. If you happen to be more vulnerable: older, sicker, immunocompromised, and especially (because this is usually fixable) unvaccinated, the outcome can be not just infection but hospitalization and even death.

Minority communities have higher rates of all of these problems – infection, hospitalization, and death. Some of this can be tied to greater prevalence of chronic disease, some could possibly be lower rates of vaccination, and much may be related to having a higher rate of low-income and jobs that require actual presence and cannot be done from home by ‘Zooming it in’. It can also be true that poorer families may be more likely to have multiple generations living in the home, with various sources of infection (school, work, social activities) increasing the likelihood of COVID being brought into the home and infecting family members who are more at-risk.

Most of us want to see and interact with our family members. But if those family members have contracted infection, whether by “choice” (adopting higher-risk behaviors, not wearing masks, especially not being vaccinated) or by bad luck despite taking precautions, seeing them puts us at greater risk. Some of that risk may be unavoidable, but some can definitely be mitigated. COVID is NOT gone, but people are taking more and more risks, including me. I returned from a trip to Europe a few days ago, and while I wore an N-95 mask on the plane and in the airports, it was risky (the line for passport check in the Madrid airport crowded despite ironic signs on the floor asking people to maintain a 2-meter distance, between which were many people, was surely a potential super-spreader event). But I seem to be one of the few people worried about it. In the gym, no one else is wearing a mask, even as they huff and puff on machines which definitely increases the likelihood of spread, and I take no reassurance from their carefully wiping them down, since this is not really how COVID is spread. The front desk has even taken down the plastic barrier that has long been in place.

If all this were occurring because the rate of infections, and thus hospitalization and death, were down, this could be a good sign. Unfortunately, it is not. A recent headline in my local paper, the Arizona Star, on June 3, 2022 is “AZ COVID numbers continue to rise”, and daily published an update on number of cases. Yes, vaccination has definitely reduced the rate of hospitalization and death among those who have been infected, but the greater the number of infections the greater the risk of those really bad outcomes.

Death is now less likely, at least among the vaccinated. Be vaccinated. But COVID is still there, and in many places cases are increasing. Continue to exercise caution, and try to not take unnecessary risks.

 

The Fourth Surge? The Fifth? Guess what: It’s still not safe out there!

The US recently passed a million deaths from COVID-19. There have been a lot of articles marking this dubious milestone, notably in the NY Times as in this Briefing by Jonathan Wolfe, and this Daily podcast.  The Wolfe piece includes two important graphics, one showing the number of new cases by day. It also contains shows hospitalizations and deaths, and makes the several “waves” very clear. And that this Spring’s wave is huge. The second graphic shows deaths, by time and by race/ethnicity in the key non-child, not old, age range of 25-54. A lot of deaths, and while the particular minority group that is most affected varies among the different surges, Blacks and Latinos are disproportionately dying.

A million people is a lot of deaths. It is, as Wolfe points out, more Americans than have died in all the wars in our nation’s history. It is more people than have died in any other country. It remains about 20% of the world’s deaths. I have often written about how the US healthcare system is far inferior to that of many other countries, particularly the wealthy ones that are our appropriate comparison group. It is unfortunate that this area, where we are but certainly should not want to be #1, demonstrates our lack of an effective public health system and the inadequate coverage for healthcare of so much of our population.

 

It demonstrates more than that, as anyone can tell you, regardless of the group that their political position demands be blamed. People are getting out more, mingling more, interacting more, going to physical workplaces more – and getting infected more. Not a day has gone by recently where I have not heard from a friend or relative about something that they did for the first time in a long time – go to a concert, or to an indoor restaurant, or get together with a group of people in someone’s home. And every single one of these stories has ended with someone, the friend or relative or one of the people that they interacted with, getting sick and testing positive (and possibly, likely, others to follow). I have learned more than I ever expected to about the unreliability of home test kits, which have sometimes been falsely negative two or three times in a sick person before the result of a more definitive test came back a couple of days later. The amount of virus (“antigen” if you want to be cool) that you need to make you sick is less than that required to generate sufficient antibody (what your body makes to fight the virus) to turn these tests positive.

It is tempting to say people are behaving badly or stupidly, but what is true is that people’s behaviors – tentative or full-throttle efforts to move back to a “normal” pre-pandemic life – have increased the number of infections. And that the increase in the number of infections leads to an increase in the number of hospitalizations and deaths. These are sometimes, but not always, in the people adopting the “risky” behavior. Sometimes they are in the people (often older, sicker, more vulnerable) that they live with.

Both my wife and I have traveled abroad recently, and it makes us nervous. She went to India, and we both are now in Europe. We tried to be as safe as we could on an airplane where the pilot and staff announce regularly that “you are not required to wear a mask, but please respect the decision of other people to mask or not mask”. I guess that means that there have been at least arguments, and likely fights, on planes over this issue. A federal judge in the US, in the middle of this current surge in infections, ruled that the government could not require people to wear masks on planes, and the administration did not appeal it. Thus, in traveling from India, through Dubai, everyone was masked until my wife got off at O’Hare – and most people were not. There are legal scholars who disagree with this judge’s ruling, but the key point, whether you agree with it or not, is that she ruled that the Constitution does not give the federal government the right to require people to wear masks on planes. She did not rule (and of course, could not rule!) that not wearing a mask was safe. This distinction seems to be lost on many people.

Including judges, of course. We just learned that 70 New York State judges went to a retreat in Montauk, NY, and that (as of May 19) 20 of them have tested positive for COVID, and many are sick. And there will likely be more. The fun of that retreat included a big karaoke party, a really effective way to spread the droplets that cause the infection. And these are the people who issue the rulings about what is allowed and what is not. Makes me feel really secure; how about you?

On a more chilling note, a close relative just told me about a longtime friend who has not been vaccinated,  won’t do it, and refuses to wear a mask. But he does not refuse to travel or to go out and interact with others, even in settings where evidence of vaccination is required. He lies and says he is vaccinated. “Luckily” for him (and, of course, unluckily for the rest of us!) he shares his father’s name, so he uses his father’s evidence of vaccination to access these venues. Think about that. Think about how reassured you are when you are with a group of acquaintances and “everyone” is vaccinated or tested negative. Or are on a plane where “everyone” has had to present proof of vaccination. Do you feel secure? You should, actually, at least feel more secure. The odds are very much lower in these settings. And in private groups, of course you trust your friends and relatives. On the other hand, it might not be everyone. One of them might be this guy. Or one of the thousands, probably millions, like him.

Recently, a ruling by a federal judge has blocked the federal government from ending Title 42, a public health regulation invoked by Trump to keep migrants coming from Mexico out of the US  based upon the possibility of their bringing in COVID, which has been continued until now. But it is not migrants who are spreading COVID; it is infected Americans who have not been vaccinated, will not wear masks, and openly mingle in public (and private) places.

In small villages in India everyone is wearing a mask. At O’Hare, or your local restaurant, or even on an airplane or in a convocation of judges, people are not. Luckily they are vaccinated. Unless, of course, they’re not. Since people’s desire to “open up more” began, early in the pandemic, I have been saying “opening = death”. Vaccines have helped a lot, and there area lot fewer deaths and hospitalizations when folks are vaccinated even when they are infected.

Sadly, there are too many people who are doing their best to try to make it worse.

SCOTUS, Roe, Reproductive Rights, and All Our Freedoms: We must act

 

Politico, and now other outlets such as the NY Times,  have reported on a 98-page draft opinion from the Supreme Court that, in no uncertain terms, overturns both Roe v Wade and Casey and removes federal protection for abortion rights. While it is true that this is a draft and individual justices’ final decisions could change, the fact that 5 of the justices (Alito, who wrote it, Thomas, Gorsuch, Kavanaugh, and Coney Barrett) signed on to it makes it unlikely that the final decision will change. The only uncertain vote is that of Chief Justice Roberts, but he is no longer the swing vote he once was; the only difference is whether the vote to say that women have no Constitutional right to control their own bodies would be 6-3 or 5-4.

And, absolutely, let us be clear: that is what overturning the 50-year old Roe decision would mean, that the majority of the justices on the Supreme Court will have ruled that the control over a woman’s body, on whether she has to continue a pregnancy regardless of the circumstances, is in the hands of others. It may be Congress, state legislatures, governors, husbands or other relatives, churches that they may or may not belong to or believe in, petty pettifoggers, vicious misogynists, non-vicious misogynists (?), and folks with their own right-wing agendas, but not the women themselves. When Roe was decided, Justice Blackmun, who wrote the opinion, said abortion should be a decision made by a woman and her doctor. That was itself a bit paternalistic, but it was 50 years ago; I think the way that still should be read is “with adequate medical advice”, understanding the potential (or likely) risks involved in the decision that the woman makes. And ONLY the woman whose body involved should be able to make!

The majority of justices on the Supreme Court obviously do not believe this, along with a substantial minority – but definitely a minority – of the American people (most polls put support for Roe at about 70%). Their anti-abortion movement, well funded by multi-millionaires and billionaires, and supported by both the Catholic Church and many fundamentalist Protestant sects, seems to have finally won their cause after 50 years of reactionary fighting to impose their will on everyone else. It is a coup, be certain of that. It was, most immediately, made possible by the fact that Donald Trump got to name 3 Supreme Court justices, through the hypocritically evil behavior of Mitch McConnell the GOP Senate majority, which decided both to block President Obama’s appointment of Merrick Garland, not even holding hearings, 9 months before his term expired, and then approving Trump’s appointment of Amy Coney Barrett just weeks before the election he lost! This alone should be enough to make everyone who cares about reproductive rights, women’s rights, LGBTQ+ rights, voting rights, any rights, pull out all stops to make sure that the predicted Republican victory in November does NOT happen, that McConnell (and I make no analogies since anything you might compare him to would be insulted by the comparison) does NOT again become Majority Leader. The Democrats are far from perfect, but every justice who voted to repeal was appointed by a Republican, and it was the Republican majority in the Senate that facilitated the appointment of the last three. The SCOTUS opinion will say that the decision is Congress’ and there is no possibility that legislation maintaining women’s rights will get 60 votes in the Senate, or even 50 given Joe Manchin. The pundits and pollsters are all predicting a big INCREASE in GOP seats in November. Unless we do something about it.

Make no mistake: this SCOTUS decision is that the opinions of some people are worth more than the lives of others. No one who is opposed to abortion has ever been required to get one by the decision of Roe. Of course, there were many “mental disabled” people or others judged incompetent who were required to get them in the past, vicious abuse in itself. Ironically, the issue is that the same logic is now being applied to ALL women; they do not have the Constitutional right to make their own decisions about their own bodies.  As Susan Matthews in Slate writes, Justice Alito could not find a justification for the right to abortion in the Constitution because “The Constitution was not written for women”. It didn’t even give them the vote!

Although it does not change the core issue, the choice of words in the debate has been unfortunate; anti-abortion people use the term “murder” of “babies” while abortion rights advocates have used the term “choice”, as if it were a matter of convenience, or what color bedspread to get. It isn’t. It is about the decision to carry a pregnancy, something that is medically risky even in the lowest risk people (but a risk that most people who want to have a baby gladly accept), to give birth, to probably raise a child, to completely change their life, to possibly be unable to care for already-born children, to give birth to a child of a rapist (perhaps incestuous rapist), to give birth to a child already unable to survive because of genetic or other malformations occurring in utero, etc., etc., being only the right of the woman who is pregnant, and not that of anyone else. Consulting them – family, friends, doctors, is fine, but the decision needs to be that of the woman alone, not the state legislature.

This decision, if it stands, will not end abortion in the US, as it will send us back to pre-Roe times when the decision was left to the states (indeed, several states had legalized abortion before Roe). So, abortion will likely remain legal in states like NY, CA, MA, IL, etc. But other states, including of course TX and FL, which have already passed draconian restrictions on access to abortion, will almost undoubtedly make it illegal again, along with many others. It has been estimated that abortions will decrease by 14% (“only”) but if this is true, it has to be taken in the context of geographic access. Women with money from TX, FL, and other states that severely limit access to abortion may be able to travel to another state, but poor women, on whom the burden always falls the hardest, will find it much more difficult or impossible, as will teenagers, including those who are pregnant as a result of incestuous rape (see “Who gets abortions in America”, by Sanger-Katz, Miller and Bui, originally published in the NY Times Dec 21, 2021 and republished on May 3, 2022). Health and healthcare are already incredibly inequitable in the US, and this decision will make it much worse. Jill Filipovic, writing in Substack, provides a number of other concerning likely outcomes,  including that there will be a 21% increase in maternal mortality!

And if that were not enough – more than enough – to get your blood boiling,  get you out to the streets, the likelihood that this will end with abortion approaches zero. Many of the opponents of abortion rights also oppose other reproductive rights, including cheap and easy access to contraception and sex education in schools. This would be illogical if preventing abortions were truly their goal, as it is precisely access to these two factors that are universally associated with lower abortion rates – see ‘Scandinavia’. When abortions were illegal in countries such as Ireland, sex education and contraception were also severely restricted – and the abortion rate was higher than in say, Denmark. But the women receiving these abortions, illegally, were at much higher risk. These arguments, however, get little traction, since those who would restrict all reproductive rights are doing it for other reasons – maybe they hate sex, maybe they hate women, but they surely believe that they know better and freedom is not important to them. If this is hypocrisy – they will fight for the right to own and carry a gun or not wear a mask – hypocrisy is not important to them either.

And it will not end with reproductive rights and contraception. Certainly the rights of LGBT+ people will be even more infringed. And our rights to read books and have our children learn science and history. And our right to vote. Listen to the far-right carry on about restrictions on their freedoms, but think about the freedoms that are at the core of the US and on which we depend.

And most important, these are freedoms we can no longer can passively depend on. If you don’t fight for them, they won’t be there.

Lower life expectancy in the US: A reflection of racism, classism, and social inequity

One of the things that most fuels self-deception is imagining that we should be living, or maybe even still live, in what we imagine was a better past. Of course, the past was not always better – in fact, it was overall, for most people, worse – but our minds repress the bad and remember the good from when we were children, as I have discussed in my other blog, “Life, the Universe, and a Few Things” (Brooklyn Nostalgia, August 21, 2011). Sometimes there is a conscious effort, a movement if you will, to block out the really bad things that have happened in the past not only from our individual memory but from our history books and schools. Clearly, this is happening now with regard to the primary founding evils in US history, extermination of the indigenous inhabitants (Native Americans, Indians) and slavery. That these were real is incontrovertible. That they were horrific, inexcusable, and must be remembered both to honor the victims and prevent recurrence should be obvious. But the effort to suppress teaching of this history, parallel to suppressing teaching about the Holocaust (which is not suppressed in Germany) is ongoing, vicious and wrong. To add insult to injury, advocates are adopting the language of microaggression, justifying their racist efforts to whitewash history with ostensible concern for “making white children feel bad about themselves”.

This is, in addition to every other evil and reprehensible aspect of it, also a way to divert those children – and their parents – from knowing and worrying about the things that they should be worried about, such as climate change and nuclear war. And the incredible inequities in American society (not to mention the world!) that have actually led to terrible social and individual outcomes. For example, the drop in life expectancy in the US. Yes, drop. People living shorter lives than they used to. Due in part to the COVID pandemic, but due in the US more to the vast inequities in wealth, social support, access to health care, jobs, use of harmful substances (such as alcohol, opioids, and tobacco) and every other determinant of health. What this has to do with self-deception and living in the past is the false idea that things are always, automatically, better in this country, the USA, a belief that persists in the face of evidence.

Of course, some things were, in fact, better in this country for earlier generations, some of whose members are still alive and sentient. America may not have always welcomed its immigrants, even those from Europe, and viciously and continuously repressed and oppressed members of many minority groups (particularly Natives and the descendants of Black slaves), but in the first half of the 20^th century, major parts of life were often better here for poor people than in many other countries. This was even more so after World War II, when the economies of most of the rest of the developed world were destroyed but the US' was intact, with no wars fought on its soil. This resulted in great success for US manufacturers (no competition!) and other benefits. One was life expectancy, due in large part to better nutrition. In the second half of the 20^th century it was widely observed that children of immigrants were bigger than their parents, because from infancy they were better nourished. Then, even later, at the end of that century and into the 21^st, some of the major causes of premature death saw a decline, mainly tobacco use.

But the premature death rate in the US is going up, life expectancy is going down. An important paper, published in 2014 in the Annual Review of Public  Health by Mauricio Avenando and Ichiro Kawachi, ‘Why do Americans have shorter life expectancy and worse health than people in other high-income countries?’, provides extensive documentation and discussion, including a supplement with several tables comparing life expectancy among different countries (a representative one, Female Life Expectancy at 40, is reproduced here).

 

While it has long, forever, been true that the life expectancy of underserved minority populations was less than for white people, the decrease in life expectancy for the “majority” group was shockingly revealed by data provided in 2015 by economists Anne Case and Angus Deaton, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”, and has been demonstrated for larger and larger portions of the US population. As I noted in this blog (Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015) this was a shock for those who held to the belief that it was only true for minorities (and in perverted way, found this reassuring). Indeed, while the life expectancy for Black Americans was and is still shorter than for whites, it was slowly rising while for many whites (of course, especially lower-income whites) it was dropping. Case and Deaton, noting the large increase in mid-life death (kind of an oxymoron, but meaning “middle age”) attributed this to “deaths of despair”, specifically due to opioids and suicide. On November 29, 2019 I wrote about an article by Steven Woolf and Heidi Schoonmaker, “Life Expectancy and Mortality Rates in the United States, 1959-2017” (Decreasing life expectancy in the US: A result of policies fostering increasing inequity), and I noted that, amazingly, women in lower income groups born in 1950 had shorter life expectancies than their mothers born in 1920!

Woolf and his colleagues RK Masters and LY Aron have recently come out with a new publication looking at life expectancy in the US and other OECD countries for 2019-2021. (Note: at the time of publication, the paper, in medRxiv, had not been peer-reviewed). They found that the pandemic shortened the life expectancy in almost all countries, but

US life expectancy decreased from 78.86 years in 2019 to 76.99 years in 2020 and 76.60 years in 2021, a net loss of 2.26 years. In contrast, peer countries averaged a smaller decrease in life expectancy between 2019 and 2020 (0.57 years) and a 0.28-year increase between 2020 and 2021, widening the gap in life expectancy between the United States and peer countries to more than five years.

In addition, ‘The decrease in US life expectancy was highly racialized: whereas the largest decreases in 2020 occurred among Hispanic and non-Hispanic Black populations, in 2021 only the non-Hispanic White population experienced a decrease in life expectancy.’ So while in 2020 the most vulnerable populations took the greatest additional hit from COVID, by 2021 they were slowly recovering, while white populations continued to lose life expectancy.

So why? This may be cognitive dissonance for the self-deluding, or racist, or narrow-minded, or those who think “America is always better”, but it is true. And the reasons for it are the inequities of American life, much of which is detailed in the Avenando and Kawachi paper, as well as Masters, Aron, and Woolf. We do not have universal health insurance, and we do not have universal access to health care. Even many “insured” Americans have very poor insurance, many Americans do not have geographic or physical access to health care services, and thus many people forego health care altogether or until it is too late. Our infant mortality rate is far higher than that of comparable countries. We still have large numbers of people who are “food insecure”, which often means chronically hungry and undernourished, not to mention those who are “housing insecure”, often homeless. And we have phenomenal income inequities which have grown tremendously since the 1980s Reagan assault on the social safety net. A paper by economists Emanuel Saez and Gabriel Zucman, widely covered, shows examples of this: since 1982 the wealth of the 0.00001% (18 families!) has increased from 0.1% to 1.2% of all US wealth.

 

Just from 2009-2022 the wealthiest American has gone from $40B to $265B, while average income has decreased from $54,283 to $53,490, and the minimum wage ($7.25/hr) has stayed the same! So the US remains an outlier, with great social and economic inequity, poorer health, and shorter (and decreasing) life expectancy. You can believe what you want in terms of political and social theory, but you have to be willing to accept the consequences.

I find these consequences, completely unnecessary, intolerable.