Moving On Up

February 12, 2019

When it comes to health and wellness, we are learning that your Zip code is at least as important as your genetic code.  Differences between neighborhoods in access to education, transportation, open space, food, etc. lead to differences in health outcomes including life expectancy.  And since we can’t do anything to change the genetic code (at least not much), efforts at improving the social determinants of health are a reasonable target for reducing health disparities.

One market-based approach has been the use of housing vouchers.  Providing rental subsidies for low-income families should allow them to move to neighborhoods with more resources.  Such relocations have been shown to provide long-term benefits to children.  Unfortunately, important barriers remain according to a new study from the Center on Budget and Policy Priorities, reported in the Washington Post.  In nearly all the 50 largest US metro areas, families with housing vouchers were located primarily in low-opportunity neighborhoods, despite enough affordable housing in higher-opportunity areas.  Overall, while 18% of all voucher-affordable rentals were located in high-opportunity neighborhoods, only 5% of families with vouchers lived in those areas.  Moreover, minority families with vouchers are more likely to live in concentrated minority neighborhoods, even though most of the affordable housing units are located in more mixed neighborhoods.  In most of the metro areas studied, this racial gap was on top of the income gap.

In other words, money does not equate to access.  This is not dissimilar to health care: while Medicaid has markedly improved health insurance coverage for low-income children, many have trouble accessing health care due to a paucity of medical facilities in urban neighborhoods, among other factors.  The research on housing vouchers does not elucidate the barriers, but several possible causes stand out, including historical patterns of racist housing policies, and local policies that do not tie the value of the voucher to local markets.

For the Twin Cities metro, there is a little bit of good news.  We have among the highest percentage of low-income families living in high-opportunity neighborhoods (17%, 5th of 50 metro areas), one of the lowest percentages of voucher families of color living in minority-concentrated neighborhoods (50%, 7th lowest of 50), and a smaller than average gap between voucher-affordable housing available in higher-opportunity neighborhoods and the actual use of such housing.

Nevertheless, as cities face an increasing problem with affordable housing, we need to be aware that, as is so often the case, the market is a useful but imperfect tool, especially for eradicating ingrained disparities.  It’s almost as if inequity is in our genes.

A Rising Tide Lifts Some Boats

January 23, 2019

“A rising tide lifts all boats.” This phrase, attributed to John F. Kennedy but actually coined by a regional New England chamber of commerce, is a common way to express the notion that economic growth is by definition good for all.  It’s certainly an appealing metaphor, and when thought of literally appears unassailably true.  But is it?

A recent study from the National Bureau of Economic Research and reported by the Washington Post, suggests not.  In an earlier era, the basis for this “rising tide” analogy was that growing businesses generate more jobs and higher wages, which help the people who have those jobs.  However, experience in the past few decades has shown that business growth does not necessarily translate to growth in either jobs or wages, and corporate profits have grown markedly faster than wages for workers.  Another rationale for the rising tide lifting all boats arose in an era where, thanks to the prevalence of defined contribution retirement plans like 401(k), the majority of households own stock.  Corporate profits are returned to shareholders in the form of dividends and higher stock prices.  One way to increase profit is to raise prices.  Such higher prices that could hurt consumers should be offset if those same consumers were also shareholders.

Again, facts trump theory.  Using data from several US government sources, researchers found that because consumption and equity ownership are unequally distributed, rising prices serve to shift resources from low- and middle-income individuals to the wealthy.  Lower income consumers pay far more in the higher prices than they get from any equity increase.  The net effect of this reverse Robin Hood effect was a shift in 3% of national household income from poor to rich in 2016.

Think about that the next time a pharma company jacks up the price of an Epi-Pen or some other life-saving drug.  Watch how much higher the corporate yacht floats.

Kids in America

January 2, 2019

I always look forward to the holiday issue of BMJ, one of the foremost medical journals in the world, which typically includes light-hearted and satirical articles such as the recent randomized controlled trial of parachutes to prevent death from jumping out of airplanes, and my all-time favorite article about comparing apples and oranges.  However, this year my enjoyment was overshadowed by an anything-but-satirical article in the holiday week New England Journal of Medicine.  (Thanks to my colleague Yoav Messinger for alerting me to it.)

Researchers at the University of Michigan published a study of the major causes of death in US children and adolescents over the past 20 years.  Given the omnipresent collection boxes to support St. Jude’s Research Hospital, you’d be tempted to think that cancer is at the top of the list.  Not so much.  In 2016, the most recent year for which data are available, it came in a distant third, accounting for 9% of deaths in children age 1-19 years.  Leading the list are motor vehicle crashes and firearms.  All injuries, both intentional and unintentional, make up over 60% of all childhood deaths.  Moreover, among injuries, unintentional injuries were most common (57%), but almost half of injured kids were victims of suicide (21%) or homicide (20%).

Let that sink in for a minute.  In 2016, 2560 children took their own lives, and 2469 were killed by someone else.  That’s 97 dead kids each week, or one every 104 minutes.  Each year in this country we lose some 750,000 person-years of life due to childhood injuries alone.  If we really want to save lives, you would think gas stations would have those little plastic coin boxes with pictures of shot up or strangled children.  I haven’t found one of those yet.

Reading the article, it’s hard to know what is most upsetting: how much worse we in the US are compared with other wealthy countries (and many poor ones), or the enormous disparities within our own nation, or the notable lack of progress in reducing these deaths over the past two decades.  Motor vehicle crashes are a major exception, with the death rate in 2016 just about half that in 1999.  However, for both motor vehicles and firearms, death rates have actually increased in the past 3 years.

An accompanying editorial points out that the problem is not about deficiencies in medical care.  It is about the sickening prevalence of nearly universally preventable traumatic injuries.  I recently wrote about firearms specifically, but the notion that we need to pay more attention to preventing injuries if we want to save children’s lives is clearly broader (suicide by suffocation, for example, is slightly more common than suicide by gun).

Now, I have nothing against St. Jude’s or any other children’s charity.  But when it comes to causes of death, we need to focus efforts and resources where they will have the greatest impact.  In this context, comparing cancer to injuries is like comparing walnuts and elephants.

The Gun Theory of Disease

November 13, 2018

In the mid-1800s, cholera outbreaks were common in much of Europe.  They tended to occur in poor neighborhoods.  As a result, many people assumed poverty was a cause; specifically, that the indifference of the poor to hygiene and the associated dirty and crowded conditions created a miasma, or atmosphere, that produced disease.  In 1854, John Snow, who is now considered the founder of epidemiology, proved that cholera in fact came from contaminated water.  (It wasn’t until the subsequent work of Louis Pasteur and Edward Koch, leading to the germ theory of disease, that the specific cause was determined to be bacteria in the water.)  Water treatment then led to the eradication of cholera in developed countries.

In the late 20th century, when a mysterious immune deficiency arose in certain high-risk populations such as gay men and IV drug users, some people also postulated that it was caused by their lifestyle.  Of course, the discovery of the HIV virus debunked this notion.  Appropriate preventive measures again led to sharp decreases in the spread of AIDS.  Cholera, tuberculosis, HIV – these and many other infectious diseases which were previously attributed to moral factors are now recognized as public health issues.  Trying to eliminate such ailments by proselytizing among the poor or “curing” homosexuality would be foolhardy at best.  Rather, they have been addressed successfully through public health interventions such as water treatment, immunization, and risk education.  What were once the most common causes of death in children have been nearly eliminated in the developed world.

Unfortunately, a new scourge has arisen to fill that void, at least in the US.  From 2000 to 2016, almost 49,000 children 0-19 years died from firearm injuries.  (No, that is not a typo.)  That is 2868 boys and girls every year, 8 per day, one every 3 hours.  They are shot at home, at school, on the playground.  Firearms are one of the leading causes of death in childhood, accounting for 3% of all deaths ages 1-9, 9% of all deaths in children age 10-14, and an astonishing 21% of deaths in 15-19 year olds.  Some of these are accidental, but in the 10-14 year olds half are intentional and one-third self inflicted, while almost half the deaths in the teens are suicide.  (Note that guns are not the most common method of self-harm in youth, just the most lethal.)

As with cholera and HIV, there are those who argue that this is a moral issue: guns don’t kill people, bad people kill people.  Or at best it’s a mental health issue.  But it’s not, and least not primarily.  It’s a public health issue.  And only public health methods will be successful in controlling it.  There are 3 main elements: surveillance, mitigating risk factors, and promoting protective factors.

Now, my gun theory of disease states that guns are the primary cause of gun injury.  That should be obvious.  But just as with the germ theory, that doesn’t necessarily translate into eliminating all guns.  After all, our bodies are filled with good germs.  We just need to take steps to understand how to keep guns from causing harm.

First, surveillance.  Successfully combatting firearm injuries in children requires much more data on the risk and protective factors, which means more research.  The Dickey amendment, promoted by the NRA and part of federal budgets since 1996, prohibits the use of federal money for research that could be used to advocate for gun control.  As a result, federal support for firearm research has been negligible; just this year, the NIH awarded its first grant for pediatric gun research.

Second, we know some of the risk factors for firearm injury.  Mental illness is certainly one.  So is weapon design.  The AR-15 is the HIV of guns, incredibly lethal.  Finally, we know some things that can protect against injury.  Smart technology that prevents firing by anyone other than the owner, or accidental firing, is a highly promising approach to reducing the risk of injury.  Safe storage is another: keeping guns unloaded and locked up greatly decreases the risk of both accidental and intentional injury in children.  Yet an incredible 4.5 million children live in homes where guns are stored loaded and unlocked.  Parents need to know the one question that can save their child’s life: is there an unlocked gun where my child plays?

It is possible to have society where guns are legal yet safe.  Finland and Canada are 2 countries with similar levels of gun ownership as the US, but death rates around one-quarter of ours.  It will take both legislation and education, both key pillars of successful public health strategies.  And those of us who advocate for kids need to help with both.  (Dr. Sheldon Berkowitz wrote a nice column on this in the November MN AAP newsletter.)  84% of pediatricians surveyed agreed that gun injury is a public health issue.  Yet only around half thought it was their role to discuss or counsel families about guns.  That is absurd.  It’s like saying it’s not our role to give vaccines, or discuss smoking at home.  That’s what the NRA thinks, too.  They recently tweeted that with regard to gun issues, physicians should “stay in their lane.”  Well excuse me, Mr. LaPierre, but when it comes to public health, physicians have the whole damn road.

In a country where there are more gun stores (64,417) than bookstores (23,753) and grocery stores (38,571) combined, there is much work to do.  But anyone who was around in the 1980s can recall the sense of doom about HIV.  Germs can be tamed.  So can guns.

Another letter to my nieces

September 28, 2018

I was thinking about you again today as I watched something that brought me to tears: a woman describing, in a room full of mostly men and to a television and Internet audience of many millions of people, how she was sexually assaulted as a teenager. You may remember when I wrote you about my fears for you and other girls in the wake of an ugly 2016 presidential campaign that brought the issue of sexual harassment into the spotlight and revealed persistent attitudes toward women’s status and rights that were at best prehistoric.  At the time, I told you I hoped things would get better.  I’m not so hopeful today.

There are a lot of things that made me sad – and angry – as I watched a terrified and distressed Dr. Ford tell her story, but I’ll focus on two. The saddest moment for me was learning why, after 30 years of keeping this to herself, she finally told her husband and therapist what had happened.  When they were remodeling their house, she insisted on having two front doors.  Two front doors – who ever heard of that?  She finally had to explain that when she was 15, two older boys got drunk, locked her in a room, climbed on top of her, grabbed her all over and tried to take off her clothes, and clamped a hand over her mouth to keep her from screaming for help.  She thought she would be raped; she thought she might be killed.  When they finally gave up and stumbled back downstairs, she had to go back past them to escape from the house, and she was afraid she would be trapped.  I can’t imagine going through something so scary that 30 years later I would literally tear my house apart so that I would have a way to escape if anything like that happened again.  Many people have said what happened to Dr. Ford was just “horseplay,” and have wondered what the big deal is.  The president even opined that if it was really “that bad,” she would have called the police.  After hearing her, I now know it wasn’t that bad; it was worse.  I want to keep a copy of the video to play for anyone who ever dares to wonder if sexual assault of any kind is really “that bad.”

What made me angry is the fact that she had to sit in that intimidating room and answer questions from a prosecutor in the first place. She is the victim – why is the prosecutor questioning her?  Even more widespread than the sense that sexual assault isn’t a big deal is the attitude that it somehow reflects on the victim.  Everything from “she was asking for it” to “she’s unreliable” to “she’s making this up for personal gain.”  I have no doubt that some people have fabricated stories of this kind of assault, just like people commit insurance and banking fraud.  But most people don’t.  Why if a man calls the police and says his car was stolen he is automatically believed, but if a woman says she was sexually assaulted, she is automatically doubted?  And after seeing the disruption in Dr. Ford’s life, the threats to her and her family – after seeing the raw fear and anguish on her face in front of that crowd of (mostly male) senators and others – who can any longer wonder why someone might hesitate to say anything, even if it is “that bad”?

So back to you. You are only 3 years younger than Dr. Ford was when this happened, and there are a lot more things that could happen now than back then.  (If you can believe it, we didn’t have cell phones or Instagram or even the Internet.)  I worry about you, and your friends, and all girls.  Fortunately, thanks to brave women like Dr. Ford and many others, it’s no longer a secret that these things happen a lot.  I don’t know if that makes it easier to stop, but it’s a start.  Don’t accept anything that makes you uncomfortable as just something that guys do.  They don’t, not the good ones.  The good ones are going to do what we can to raise awareness and call the creeps out.  And know that if you ever need to talk about anything like that, you have people you can talk to: your mom, your aunt, me.  People who will listen.  People who will believe you.  As I’ve told you before, never think you are less capable, or strong, or smart, because you are a woman.  You are strong.  As strong as Dr. Ford.

This Is What Remarkable Looks Like

July 18, 2018

My medical school roommate would travel all the way across Durham, to North Carolina Central University, to get his haircut. “There are no barbers on this side of town who know how to cut black people’s hair,” he told me.  Now historically the city was fairly segregated, but that was no longer the case; there were plenty of African-Americans at and around the Duke campus.  In a truly free and unbiased market, businesses should have arisen to meet that demand.  But it didn’t happen.

There are far more consequential examples of such systemic racism in the healthcare system. We now have large numbers of adults living with diseases that used to kill people in childhood: cystic fibrosis, hemophilia, and of course sickle cell disease.  In the past, few adult physicians knew how to take care of those conditions, but now, a growing number of specialists serve those patients.  Except for those with sickle cell disease.  In the Twin Cities, there are almost no adult hematologists for the burgeoning number of adults living with sickle cell disease, which disproportionately affects people of color.

Fortunately, as reported on MPR recently, there are those advocating for this unmet need, especially Children’s own Rae Blaylark, sickle cell patient health advocate in our Center for Cancer and Blood Disorders and President and Founder of the Sickle Cell Foundation of Minnesota.  She knows from personal family experience the struggle to find care for adults with sickle cell disease.  Her advocacy highlights the significant disparities in care for those adults. Not only do they lack access to specialists in this community, but they face barriers and biases in the health care system as a whole.

While I lament this example of health inequity, I am so proud to have someone like Rae here at Children’s, working to address systemic racism and improve health and justice in the community. Thank you, Rae!

Happy Doctor’s Day 3/30/18

March 28, 2018


I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;

THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;

I WILL RESPECT the autonomy and dignity of my patient;

I WILL MAINTAIN the utmost respect for human life;

I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient;

I WILL RESPECT the secrets that are confided in me, even after the patient has died;

I WILL PRACTICE my profession with conscience and dignity and in accordance with good medical practice;

I WILL FOSTER the honor and noble traditions of the medical profession;

I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;

I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;

I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;

I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;

I MAKE THESE PROMISES solemnly, freely, and upon my honor.

Many of us recited some version of these words of the Hippocratic Oath upon entering the profession of medicine. When I read the copy hanging on my office wall, I am reminded of the awesome commitment we all make, and of the profound trust that is placed in us.  Medical education and training are not a pathway to status and wealth; they are a covenant obliging us to serve our fellow beings.  Not many physicians can live up to the example set by our colleagues in Doctors Without Borders.  But in everything we do, whether in direct practice, or doing research, or in administering the health care system, we need to ask whether we are living up to this oath.  Did I respect the autonomy and dignity of those who seek my help?  Did I treat them with compassion and authenticity?  Did I consider the health and well-being of patients first and foremost?  It would be easy to feel daunted, but instead I feel grateful – grateful for the privilege of being able to serve, and for the honor of being part of a community of individuals who share that call to service.

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