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 P�rez-Pe�a 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.

Treatments that don't cure the disease; we are spending money on the wrong things

In �Heralded treatments often fail to live up to their promise� (Kansas City Star, May 17, 2014), Alan Bavley, writing with Scott Canon, continues to demonstrate that he is one of the excellent health journalists � excellent journalists � in the US, along with Elisabeth Rosenthal of the New York Times. The common practice in the news media (and, thanks to a typo, �medica�) is to hype the new, exciting, dramatic, expensive, and hard to believe even though you want to. In politics, we often see the media acting as flaks for the government, the rich, and the powerful (sometimes, of course, these can be in conflict). Bavley and Rosenthal  and their ilk actually do investigative journalism, trying to the best of their ability to find out the truth rather than to reprint press releases.

The article begins with a review of a surgical procedure that was designed to control high blood pressure (hypertension) without drugs, by cutting some of the nerves to the kidneys. It made sense, it was seen as a big breakthrough (�The potential benefit was huge,� said a cardiologist). Unfortunately, when actually subjected to appropriate scientific study, it didn�t work. Or, rather, it worked just as well as placebo, a sham surgical procedure. The same cardiologist remarks ��This could be considered the biggest disappointment in cardiology of this century, but �the medical community went about it right.� 

Science worked. Unfortunately, the authors add,

�If only that were always the case. A combination of industry marketing, overly eager doctors, demanding patients and news media ready to cheer on anything that sounds like a breakthrough is popularizing many drugs, surgeries and other treatments long before they�re adequately tested. Far too often, they�re ultimately proved ineffective, no better than older, cheaper therapies, or even hazardous. Billions of dollars are wasted and tens of millions of patients are put at risk�

Yup. They go on to cite the Vioxx scandal, in which Merck concealed evidence of its biggest-selling drug causing an increase in heart disease. But that was taken off the market; many other unproven (or worse, proven to be ineffective) treatments are not. They talk about arthroscopic knee surgery, still often being done for conditions for which it has been shown to be no more effective than a sham procedure. They discuss surgical robots, costing upwards of $1.5 million, and proton-beam radiation treatments (those babies, the machines, really cost a lot!) for which the evidence of effectiveness compared to more standard and much cheaper treatment is mixed, at best. But hey, if you�re a hospital, and the competition has robots and proton-beam accelerators, who�s going to come to you if you don�t have one? Poor people? Heaven forfend!

And it is all about getting the advantage on the competition to make more money. A good argument can, and should, be made that competition in hospitals helps no one. That if there were an expensive item that there were an actual medical need for one of in the community, there should be one, not one at every hospital. But that would presume that the goal of the health system was to increase the health of the American people at the lowest effective cost. It isn�t. It�s to make money. If I can get your patients to come to me instead, it is seen as a victory (from a competitive business sense). It is really a loss for the health of our people and the pocketbooks of us all.

It is particularly depressing because that money is not buying us health. If you still harbored the belief that �we have the best health care system in the world�, it�s time to acknowledge that you are wrong (although we forgive you given the hype!). We should all know how expensive our health care system is, that we spend way more than any of the other developed countries (members of the Organization for Economic Cooperation and Development, OECD). The attached graph, from Steven Woolf, MD, PhD, who was a plenary speaker at the recent Society of Teachers of Family Medicine Annual Conference, shows a comparison of spending and life expectancy for the OECD countries. That�s the US way off to the right, spending more than anyone by far, but having a life expectancy close to the Czech Republic. Better than Mexico, Poland, Slovakia, Hungary and Turkey, but at enormously greater cost!

Woolf was the lead author of the Institute of Medicine�s (IOM) recent report �Shorter Lives, Poorer Health� , which presents depressing, but unfortunately accurate, data on our health status. We are among the �leaders� in death rates from communicable and non-communicable diseases and from injuries. Only for a few causes are our death rates better than the average. Our life expectancy at birth is worse than any of the 17 comparison countries for men, and second worst for women. Our probability of survival to age 50 is lower than any of 21 comparison countries. At any age until 75, we are never better than 15 out of 17 in terms of life expectancy. We do have better survival rates once we reach age 75, but there is no information on how much of that is keeping people alive despite poor quality of life.

Want more? In case you think it is only the minority populations (although that would be part of our population), non-Hispanic whites rank no higher than 16 of 17 at any age below 55. And the only portion of our population for whom mortality rates have risen is non-Hispanic whites with less than 12 years of education. From 2005-2009, the US had the highest infant mortality rate of the 17 countries and the 31st highest in the OECD. Non-Hispanic whites and mothers with 16+ years of education also have higher infant mortality rates than those in other countries. Among the 17 peer countries, mortality from transport accidents decreased by 42% in the OECD between 1995 and 2009, but by only 11% in the US. The same trends hold for child and adolescent health � and ill-health and mortality.

And then there are the areas where we really shine, particularly health issues related to guns.

• In 2007, 69% of US homicides (73% of homicides before age 50) involved firearms, compared with 26% in peer countries.
• A 2003 study found that the US homicide rate was 7 times higher (the rate of firearm homicides was 20 times higher) than in 22 OECD countries.
• Although US suicide rates were lower than in those countries, firearm suicide rates were 6 times higher.

We have the highest child poverty rates in the OECD, our preschool enrollment is below most countries, and the ratio of social services spending to medical spending is below almost all other OECD countries.

This is insanity. We are spending enormous amounts of money, but we are spending it so that our hospitals can compete with each other, so that we can deliver the most expensive and high-tech care whether it benefits people�s health or not, and we then do not have any money left to do the things that would really enhance health: expanding education, creating jobs, decreasing poverty, ensuring that people had homes and enough to eat.

Not to mention the guns.

More guns and less education is a prescription for poor health

Within the span of one week, my state of Kansas was headlined in two pieces in the New York Times, unusual for a small state. Unfortunately, neither was meant to be complimentary. �What�s the matter with Kansas Schools?� by David Sciarra and Wade Henderson appeared as an op-ed on January 8, 2014, and �Keeping Public Buildings Free of Guns Proves Too Costly for Kansas Towns�, by Steve Yaccino, was a news article (middle of the main section but top of the web page!) on January 12. Both are political and social issues; for example, the thrust of the �guns� article is that Kansas municipalities (like Wichita) that want to keep guns out of public buildings (like the library) are financially stymied by the cost of the security requirements the legislature has put in place in areas where carrying guns is not permitted. Like abortion (and neither of these pieces addresses Kansas� virulent anti-abortion laws), guns are a very hot-button issue that inflames deep-seated passion in places like Kansas, and so is (sometimes) education. I will, however, focus my comments on the health impacts of these laws.

First, guns. Guns are, very simply, bad for people�s health. (Obviously, even when used as �intended�, for hunting, they are bad for some animals� health, but this is not my focus.) Having guns around increases the risk of death or injury from them. Having guns intended for hunting stored locked and unloaded is the safest, but this doesn�t work for guns intended for self-defense since that renders them less available for that purpose. Carrying guns on your person, in your car, in public, on the street, and into businesses, public buildings, schools, and health care settings increases the risk. This is not what gun advocates, and concealed-carry advocates believe. Their idea is that there are bad guys out there carrying guns, either criminals who might want to rob you or crazy people who might want to shoot up your school or post office, and that carrying a gun allows one to protect oneself, and possibly others, by shooting down the perpetrator before more damage can be done. Thus, it protects your health, and that of others.

Nice idea, but completely unsupported by the facts.  Guns kill lots of people, injure many more, and virtually never save lives. This is the case even when used by police, and even more true when use of guns by police officers is excluded. It is true despite the widely-publicized, often repeated on the internet, and frequently invented stories about a virtuous homeowner shooting an armed robber. I have no doubt that such cases occur, but with such rarity as to be smaller than rounding error on the number of deaths and serious injuries inflicted by guns.  Suicides and homicides are among the leading causes of death in the US, most are caused by guns, and almost none of the homicides are �justifiable manslaughter� from a person protecting him/herself from an armed invader. The mere presence of easy-to-access guns in the environment increases dramatically the risk of successful suicide (see my blog, Suicide: What can we say?, December 12, 2013, with data from David Hemenway�s �Private Guns, Public Health�[1]). In addition, the number of �accidental� deaths (where someone other than the intended victim was shot, or someone was shot when the intent was �just� to threaten or show off, or by complete accident, sometimes when an unintended user � say a child � gets hold of a loaded gun) from guns is way ahead of any other method of harm (knives, bats, etc.)

When we go beyond having guns to carrying guns in public places, the data is less well collected. However, the trope of the heroic law-abiding, gun-carrying citizen drawing down on the evildoer in a public place, like say a movie theater or the waiting room of your clinic, is a terrifying thought. First of all, almost none of them are Bat Masterson or Wyatt Earp or Annie Oakley (except maybe in their own minds) and the idea that they will hit who they are aiming at is wishful thinking; the rest of the folks are caught in a gunfight. It is scary enough when this involves police officers, but if half the waiting room pulls out pieces, the results will be, um, chaotic. Harmful. Not to mention what happens when the police show and don�t know who to shoot at (maybe if you are a gun-toting good guy you can wear a white hat�).

So, having guns around, and the more easily they are available, is absolutely harmful to the health of the population, and generally you as an individual. If people, including legislators, and Kansas legislators in particular, want to encourage gun carrying for other reasons, they should at least be aware of and acknowledge the health risks. But what about education? The cuts in state education will, quite likely, harm the education of children (or if, as the article notes, the state Supreme Court forces the legislature to fund K-12, the education of young adults since the money will likely come from higher education), but what about health?

There is a remarkable relationship. More education leads to better health. Better educated people are healthier. The relationship is undoubtedly complex, because better educated people also have better jobs and higher incomes, which is also associated with health. This is addressed with great force in a recent policy brief �Education: It Matters More to Health than Ever Before�, by the Virginia Commonwealth University Center for Society and Health sponsored by the Robert Wood Johnson Foundation; for example, while lifespan overall in the US continues to increase, for white women with less than 12 years of education, it is currently decreasing! The RWJ site also includes an important interview with Steven Woolf, MD MPH, Director of the Center. �I don�t think most Americans know that children with less education are destined to live sicker and die sooner,� Dr. Woolf says. He discusses both the �downstream� benefits of education: �getting good jobs, jobs that have better benefits including health insurance coverage, and higher earnings that allow people to afford a healthier lifestyle and to live in healthier neighborhood,�and the �upstream� issues, �factors before children ever reach school age, which may be important root causes for the relationship between education and health. Imagine a child growing up in a stressful environment,� that increase the risk of unhealthy habits, poor coping skills and violent injuries.

In several previous blogs I have cited earlier work by Dr. Woolf, one of the nation�s most important researchers on society and health, notably in "Health in All" policies to eliminate health disparities are a real answer, August 18, 2011. I included this graph, in which the small blue bars indicate the deaths averted by medical advances (liberally interpreted) and the purple bars represent the potential deaths that could be averted if all Americans had the death rates of the most educated. I also included a link to the incredible County Health Calculator (http://chc.humanneeds.vcu.edu) which allows you to look at any state or county, find out how the education or income level compares to others, and use an interactive slider to find out how mortality and other health indicators would change if the income or education level were higher or lower.

In the US, the quality of one�s education is very much tied to the neighborhood you live in, since much of school funding is from local tax districts and wealthier communities have, simply, better schools. (This last is completely obvious to Americans, but not necessarily to foreigners. A friend from Taiwan was looking at houses and was told by the realtor that a particular house was a good value because it was in a good school district. She called us an asked what that meant; �In Taiwan, all schools are the same; they are funded by the government. No one would choose where to live based on the school.�) This difference could be partially compensated for by state funding for education, which is why cuts in this area are particularly harmful, including to our people�s health. In fact the most effective investment that a society can make in the health of its people is in the education of its young.

An educated population is healthier. Wide availability and carrying of guns decreases a population�s health. Unfortunately, the public�s health seems to carry little weight in these political decisions.

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[1]Hemenway, David. Private Guns, Public Health. University of Michigan Press. Ann Arbor. 2007.

Suicide: What can we say?

On Sunday, September 8, 2013, we participated in the annual Suicide Remembrance Walk in Kansas City�s Loose Park, organized by Suicide Awareness Survivor Support of Missouri and Kansas (SASS/Mo-Kan). An article previewing the walk and interviewing Bonnie and Mickey Swade, our friends who established SASS/Mo-Kan, ran in the Kansas City Star on September 7: �What to say, and not, to those left behind by suicide�. Bonnie and Mickey became our friends because we are members of a club none of us would wish to be in: suicide survivors. Their son Brett completed suicide about a year after our son Matt did, and we were in a support group together before the Swades started their own. Matt�s suicide was on December 13, 2002, which I never thought of as being �Friday the 13^th� until I realized that because of the vagaries of leap years, this year, 11 years later, is the first Friday December 13^thsince then. Thus, this post several months later.

The Remembrance Walk around Loose Park in Kansas City was well-attended on a hot morning, and culminated in all of us standing in a very large circle holding long-stemmed flowers as a distressingly long list of names was read. We counted 7 times when two (and in one case 3) last names were repeated; the list was not in alphabetical order, so this was not coincidence. As much pain it is to have one person you love having committed suicide, two or more is unfathomable. Finally, white doves were released, and the ceremony ended to the strains of �Somewhere over the rainbow�.

I have written about suicide before (July 29, 2009, �Prevention and the �Trap of Meaning�), in which I discussed an article that had recently appeared in JAMA by by Constantine Lyketsos and Margaret Chisholm titled �The trap of meaning: a public health tragedy�[1] ). The thrust of that piece was that people -- families, lay persons, psychiatrists, psychologists, philosophers, and others -- search for �meaning�, �reasons� for suicide, and that this is, essentially, pointless at best and, devastating at worst. Suicide is the fatal result of the disease of depression, a disease which is very common and not usually fatal, but can be. It may often be precipitated by a specific event or set of events (as the final episode of chronic heart or lung disease is often preceded by a viral infection) but those are not the cause. The strongest prima facie evidence is that most people in the same circumstances (whether victims or perpetrators of bad things) do not kill themselves. But enough do to have made a long list to have read at the ceremony in Loose Park.

Like everyone else, each person who kills themselves is unique, and their histories differ. Some have made previous attempts, often many times; others gave no clue. Some have been hospitalized, often many times; others never. Some have family who were sitting on the edge, awaiting the suicidal act, trying their best to help to prevent it but helpless to really do so. The families and friends of others had no idea it might happen. While those who attempt or complete suicide are depressed, some very overtly manifest that depression and some not so much. While many people who have depression never attempt suicide, some complete suicide when things are looking, to others, good. Overall, access to effective weapons increases the probability of �success�; the �lethality� (the probability that you will die from an attempt) is about 95% from guns, and only 3% from pills. Therefore, easy access to guns is associated with a higher successful suicide rate; in young men 16-24 the success rate is nearly 10 times higher in low gun control states than in high. I doubt these young men are more depressed, but they have quick and effective methods of turning what may have been relatively transient suicidal thoughts into permanent death. Of course, not all suicides are classified as such; while it is often obvious, sometime it is not: how many one-car accidents, for example, are really suicides? And, because �unsuccessful� suicide attempts are grossly under-reported, the lack of an accurate denominator makes �success� rates very hard pin down.

On one hand, the fact that most suicide attempts are not hospitalized and given intensive treatment seems to me to be a bad idea. Since the greatest predictor of a suicide attempt is a previous suicide attempt, if there is any likelihood that a suicide can be prevented it would be best to intervene at that time and try to treat the depression. On the other hand, I am not sure that there is any good evidence that treatment is terribly effective in preventing suicide. Yes, there are many people who have attempted suicide once and never again, but this may be a result of treatment or the natural history of their disease. There are people who are under intensive treatment when they complete suicide, often when least expected. Indeed, there is evidence that treatment of depression may sometimes paradoxically increase the risk of suicide by getting a person whose depression was so severe that they were unable to act better enough that they can. And, conversely, there is no way of knowing how many times, before a suicide is completed, a planned attempt was put off by an intervention that may not have even been intended, by demonstrating love and letting the person know they were needed.

It doesn�t always work. If the person is unwilling to share their symptoms and is determined to complete suicide, there is no prevention that is effective. My son was 24, deeply loved, lived in a state with strict gun control laws and probably never held a gun before. But he was able to drive to a low gun-control state, buy a carbine and bullets, and complete his suicide. He took his time and planned it, and it is unlikely to have been preventable. But many suicide attempts are not as well planned, are more impulsive, and efforts to prevent these might be successful in many cases. In a classic 1975 article in the Western Journal of Medicine[2] David Rosen interviewed 6 survivors of jumps from the Golden Gate bridge. The emphasis in these interviews is on transcendence and �spiritual rebirth�, but all agreed that putting a �suicide fence� in place might have deterred them and might deter others.

For all of us who wish mightily to prevent disease and death, suicide may be seen as the greatest affront because the death is seen as �unnecessary� and often involves people who were �healthy� (except for their depression), young, and had a future before them � sometimes (as I like to think of Matt�s) a truly promising future. But too often we, in our desire to prevent death and disease, choose to focus on the least effective interventions to do so. We will take unproven drugs (especially if they are �natural� or non-prescription), and clamor for our �right� to have marginally useful or even ineffective screening tests, but there is a vocal movement against immunizations, one of the few preventive interventions that are known to be effective. We decry mass murders in school after school, and bemoan the loss of our young people to both suicide and homicide, but resist regulation of the most effective instruments of death, guns. We all take our shoes off each time we fly because of one failed �shoe-bomber�, but ignore the thousands of deaths on our city streets.

I wish my son had not killed himself. I wish I knew how to have prevented it. I wish I could tell those of you who worry about a loved one how you can prevent it. I wish even more that I could tell those of you who don�t suspect it that you can be secure because in the absence of definite warning signs you can feel safe. I can�t do that. When there are warning signs, take whatever action you can, but the reality is that it may not be effective. When there are no signs, hope that it is because there is no risk.

As individuals, we hope and do what we can. As a society, we should decide on our priorities, and we should be guided by the evidence, not by our fantasies, hopes, or magical thinking.

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[1]Lyketsos CG, Chishom MS, �The Trap of Meaning: A Public Health Tragedy�, JAMA. 2009;302(4):432-433. doi:10.1001/jama.2009.1059.

[2] Rosen DH, �Suicide Survivors: A Follow-up Study of Persons Who Survived Jumping from the Golden Gate and San Francisco-Oakland Bay Bridges, West J Med. 1975 April; 122(4): 289�294. PMCID: PMC1129714