Keeping a Finger on the Pulse of America's Dangerous Epidemics

Advocates for sensible gun legislation had it right when they framed the epic number of individual and mass shootings in this country as public health issue. Public health professionals and organizations like the American Public Health Association and the American Medical Association have continued to push for addressing gun violence as a growing epidemic, and so they should.

According to the Brady Campaign, 318 people in America are shot daily in murders, assaults, suicides, suicide attempts, unintentional shootings, and police intervention. Every day 96 of them die from guns. No wonder. In this country, 1.7 million children live in a home with an unlocked, loaded gun and millions of guns are sold every year in “no questions asked” transactions.

Part of the gun violence epidemic we face resides in the growing, almost contagious episodes of police brutality and unnecessary use of weapons, primarily against people of color.  This year over 430 people have been shot and killed by police and the year is barely half over. Last year’s total number was 987. Some of the names we remember are Michael Brown, Trayvon Martin, Eric Garner and Tamir Rice. Among those whose names we may not recall are Danny Ray Thomas, an unarmed black man clearly suffering from a mental health crisis, who was killed by a Texas police officer, and more recently, Stephon Clark, another unarmed black man who was shot eight times, six of them in the back, by Sacramento police while simply holding a cellphone in his grandparents’ backyard.

We are clearly facing a growing number of public health crises involving guns, but gun violence, no matter who commits it, isn’t only contributing to a crisis that involves instant death or disability.  It is also leading to an epidemic of crises in mental health among survivors and victims’ families. Where is the discussion of that issue?  It’s telling that a search for information on this invisible crisis led me to myriad articles ruminating on the idea that gun violence is perpetrated by people with mental health problems, but not one link deliberating on the mental health toll gun violence takes on survivors or family members appeared.

Yet, just think what it must have done to Tamir Rice’s mother to learn that her child, simply playing with a toy, had been shot to death by police.  Or to Stephon Clark’s grandparents as they saw their grandchild gunned down in their backyard. Or to Eric Garner’s family, not only left to deal with economic worries, but with the lifelong sorrow of a husband and father being choked to death by police. Think about what Michael Brown’s family, Trayvon Martin’s family, Sandra Bland’s family and the multitudes of other family members of the unknown victims of violence– spouses, children, siblings – will have to live with for the rest of their lives. It is possible that there are worse things than death, like living with despair, and dread.

There is another epidemic of violence that needs attention as we appear to descend into a dark place while struggling with a new, unfamiliar reality grounded in our current political environment. America has always had an incipient underbelly, but unlike those who survived the fascism of Europe preceding and during WWII, Americans have been fortunate (until now) to avoid the punishing life of autocracy and dictatorship.

Now come Donald Trump et.al., and along with his followers, a dramatic increase in hate crimes not unlike the ones seen in many countries during the 1930s and 1940s and emerging once more. America has seen a growing number of hate crimes in recent years but they are proliferating even more as racists and white supremacy groups feel emboldened to openly spew their contempt for others. That contempt is aimed first at Jews, and then at Muslims, according to the FBI. Hate crimes are also on the rise as perpetrators target the LGBTQ community.

According to the Southern Poverty Law Center, the number of hate groups has increased along with the growing number of hate-filled violent acts.  These crimes range from vandalism in synagogues and cemeteries to graffiti messages and Swastikas on buildings, to threats to religiously affiliated schools. Many hate crimes are perpetrated against individuals. In 2014 a man killed three people at two Jewish centers near Kansas City, and recently a Muslim man was beaten in the Bronx by attackers calling him a terrorist. In another incident in New York, a man shoved a Mexican immigrant onto the subway tracks after dragging him off a train. He narrowly escaped death.

All the growing violence we’re witnessing, whether manifesting as verbal abuse or escalating to hate crimes and murder, even at the hands of police, can appropriately be seen as epidemic. And epidemics, seen through the public health lens, call for controls and eradication. None of us can be inoculated against the diseases of hatred in our zones of relative comfort and safety, because “no man [sic] is an island.”  As another famous quote reminds us, “Together we stand. Divided we fall.” 

The pain of a potential fall looms large, and it is likely to be more than any of us could bear.

 

           

Back to Barefoot and Pregnant Politics

 

In the late 1970s as I was beginning my career in women’s health, one of the first feminist icons I met of was a flamboyant, passionate, and deeply committed woman named Perdita Huston.  She had made her mark internationally working as a journalist and a Peace Corp professional, but what put her on the feminist map was her 1979 book Third World Women Speak Out

 

Huston’s book was remarkable because she was the first person to give women in the developing world a chance to tell their own stories. She gave them voice, and with that voice what they proclaimed most loudly was that they wanted fewer children, and they wanted those children to be educated.

 

It was a radical moment with far-reaching ramifications because it coincided with the early days of family planning becoming a goal of international funding agencies like the U.S. Agency for International Development (USAID). With the help of the Women in Development movement, spawned in large part by the Women’s Movement at large, donor organizations had begun to realize that family planning was key to a country’s economic and social development and that women’s reproductive health was an issue that mattered.

Subsequent years revealed that family planning was, indeed, a wise investment. Countries like Egypt and Bangladesh showed that once women controlled their fertility, families, communities, and countries benefited, whether by increasing educational opportunities for girls, widening agricultural opportunities for women, or bringing women into decision-making at some levels of society.

None of this happened quickly or easily; there are always naysayers and development “specialists” willing to argue against innovation (and empowering women), no matter how simple and effective an intervention may be. But gradually the world saw how important family planning was to the healthy development of nations, let alone women and their families.

Now fast forward to Trumpian times, in which the president has reinstated Ronald Reagan’s Mexico City Policy of 1984 – revoked by Bill Clinton, restored by George W. Bush, and revoked by Barack Obama - in which nongovernmental organizations are forbidden to receive U.S. federal funding if they perform or promote abortion in other countries. 

Trump goes even further. His administration, including the Departments of Health and Human Services, Treasury and Labor, wants to make it easier for employers to deny contraceptive coverage to their employees if the employer has “a religious or moral objection” to doing so. The administration also wants to make it harder for women denied birth control coverage to get no-cost contraception directly from insurance companies, as they have been doing.

In an attempt to rush this through, the administration made the absurd claim that taking time to seek public comment would be “contrary to the public interest,” and went so far as to say that coverage of contraception could lead to “risky sexual behavior,” a nod to those who believe women’s sexuality is evil.  Not only is that one huge misogynistic insult to women; what is riskier than setting women up for unwanted pregnancies while trying to eliminate safe abortion and shut down Planned Parenthood?

 These actions are a setback of huge proportion. They affect not just American women, but women around the world.  In Madagascar, for example, the change in policy is forcing dramatic cutbacks by the largest provider of long term contraception in the country, Marie Stopes International (MSI), which receives millions of dollars from USAID for its work there. Ironically, abortion is illegal in that country, but MSI cannot receive American aid because it will not renounce abortion as part of reproductive health services in other parts of the world.

Hundreds of women and girls flock to remote MSI clinics where they receive everything from malaria prevention to HIV treatment to contraceptives. It’s a scene repeated all over the developing world no matter who is providing services. What is to become of all those women?

The policy, already making its way to the courts, is clearly aimed at mollifying organizations like March for Life and Real Alternatives, anti-abortion groups that don’t qualify for religious exemptions but claim to hold strong moral convictions unrelated to a particular religion.

In his long string of lies, Trump and his administration have claimed, absent of any evidence, that its new rules won’t have an effect on “over 99.9 percent of the 165 million women in the United States,” while simultaneously arguing that low-income women will still be able to get subsidized or free contraception through community and government health programs. All this while the administration plans to substantially cut government spending on such programs.

The President’s attack on birth control, safe and accessible abortion, and the Affordable Care Act is low on intelligence and high on lies. It is spiteful, vindictive, woman-hating, and downright mean. It will hurt millions of women and their families. There are only two ways to describe it: utterly inhumane and grossly misogynistic. Everyone should be resisting mightily.

America's Rural Health Care Crisis Grows

Not long ago I received a call from my doctor’s receptionist. My long-time primary care physician and partner in healthcare decision-making was retiring her practice, she said, along with two other doctors in our small town. Together they would be leaving 4,000 patients to find care in a community where most physicians are not taking new patients because they are already overwhelmed by their caseload.

I felt especially troubled by the news since I don’t go to just any doctor, even if one is available. As a proactive health consumer, I research providers carefully because I want to work with someone with proven competence, a compassionate heart, and a philosophy of primary health care that supports my own. Finding a doc like that is not easy. It’s especially challenging when there are too few physicians available.

I also realized that I had become part of the troubling landscape of rural health care. I was suddenly caught up in a picture represented by facts and statistics like these: Disparities in access to healthcare for people who live in rural areas of America continue to widen. Recruiting physicians willing to work in isolated areas has also become more difficult, and is not helped by Donald Trump’s plans with respect to work visas and travel bans. Rural hospitals are closing at an alarming rate. In the past six years, 80 of them have closed and if the rate of closures holds, 25 percent of rural hospitals are predicted to close in less than a decade.

The number of doctors per 100,000 residents is 40 in rural areas compared to 53 in urban environments. That’s not counting specialists, where the comparison is 30 to 263. More than half of our counties have no practicing psychiatrist, psychologist or social worker while opioid-related addictions and overdoses are disproportionately higher in rural areas.

In addition, America’s rural population is older, makes less money, smokes more, is generally less healthy, and uses Medicaid more frequently.  Diabetes and coronary heart disease are more prevalent in rural areas and the death rates for rural white women have increased as much as 30 percent in recent years, reversing previous trends.

Studies published in the British Medical Journal recently revealed a severe lack of resources at rural hospitals, sparse staffing and limited access to specialist consultations and diagnostic tools. An attempt to reduce emergency department admissions for cost-cutting is also putting patients at risk.

The situation is complex and challenging due to economic factors, social differences, educational shortcomings, lack of understanding and political will among legislators, and the isolation of living in remote areas, according to the National Rural Health Association.

Some health care analysts and managers advocate for increased use of technology to help solve the growing problems in rural health care delivery, arguing that while technology won’t solve all the problems, it can make a discernable difference. For example, the Institute of Medicine believes that telemedicine can allow rural hospitals to “cut down on the time it takes rural patients to receive care, particularly specialty care.”

That’s all well and good, perhaps, when it comes to hospitals reducing costs and meeting their other needs. But where does it leave me, and other rural patients, when we’re sitting in our johnnies waiting to (literally) see our doctors?  Where is the comforting face-to-face communication and the physical observation so vital to a clinician’s assessment of a patient’s condition and emotional state? Where is the Q&A necessary for shared decision-making? I once left a practice because my doctor, who had previously looked me in the eye when we talked, listened carefully to what I said, and talked to me like a peer, suddenly couldn’t get his face out of his computer screen long enough to greet me when I entered the room.

As I search for a new doctor – the right doctor – in the coming days, I recognize that like many others, I have a big challenge ahead. For me that challenge goes beyond numbers - something the profession includes in discussions of “accessibility.” It involves trust, proven skills, two-way communication - often around intimate issues or possible critical life decisions - and mutual respect.

Such a partnership for health is not easy to find no matter where one lives. In rural America, it is becoming even more difficult. Patience and perseverance in selecting, hopefully, from a crop of good new physicians, may be just what the doctor – and this community -need to order.

 

Getting Real About Guns

Post Orlando, let’s get real. The latest massacre in America, and its worst to date, was not about ISIS. It was not about Muslims or Islam. It was not about mental illness.

It was about guns and how easy they are to obtain in this country. It was about our incredible inability to effect legislation that would do something about what is now recognized as a national embarrassment as well as a continuing national tragedy, one that is finally acknowledged to be a major public health issue.

The shocking numbers support that claim. Last year 469 people died as a result of 371 mass shootings. So far this year at least 288 people have died in 182 mass shootings. Since Orlando, more than 125 people have been killed by guns, 269 were injured, and five mass shootings have occurred. We don’t even hear about most of these events, or the fact that nearly 10,000 American children are killed or hurt by guns every year.  Nationally, guns kill twice as many children and young people as cancer and 15 times more than infection according to the New England Journal of Medicine. Let that sink in.

Here’s another startling statistic. In 2010 there were 3.6 gun murders per 100,000 Americans.  In Canada and Portugal there were 0.5. Many other countries ranked even lower than that, including Australia at 0.2.  (Does anyone seriously think they have fewer mentally ill people per capita than we do?)

Lat month a story in Seven Days revealed that a reporter bought an AR-15 semiautomatic rifle in South Burlington, Vt. for $500 cash with “no paperwork and no background check. [The seller] had no idea who I was or what my intentions were,” Paul Heintz wrote. “Nine minutes after I met the man, I drove away with the sort of weapon used 39 hours earlier to slaughter 49 people in Orlando.” A woman in Philadelphia reported a similar experience, beating Heintz’s time by two minutes.

Sadly, my home state of Vermont has the nation’s most permissive gun laws, so what took place when Heintz bought his gun, the same kind that killed all those children and their teachers in Newtown, Ct., was legal. The same kind of gun, by the way, also killed the people in Aurora and the people in San Bernardino.

What will it take to end the madness? One answer comes from a grassroots movement in Vermont, where gun laws have been nearly nonexistent and its politicians have waffled over the issue for years.

Gun Sense Vermont (GSV), an example for others, has been effectively moving reluctant politicians and prospective candidates toward action. Since startup three years ago, GSV’s track record is impressive. It first began a conversation about guns in the Statehouse. Then last year state senators received 1400 letters from constituents along with 12,000 petition signatures calling for action, all from Vermonters. Two Senate committees seriously considered gun-related issues and gun-owning groups announced a plan to lead a Vermont version of the suicide-prevention New Hampshire Gun Shop Project. The Vermont Senate Judiciary Committee voted unanimously to send a bill to the full Senate making it a state-level violation for felons to have guns, and to require court records of dangerous individuals be submitted to the National Instant Background Check System. And the governor signed into law a bill to prevent gun violence.

“Gun Sense Vermont is a growing, bipartisan, grassroots organization that focuses on closing gaps in Vermont’s gun laws that make it too easy for guns to fall into the wrong hands,” says Ann Braden, founder of GSV. “We come from all walks of life and 160 Vermont towns and every voting district. We are united in our call for common sense action that protects the rights of individuals as well as those of our communities.”

After Orlando, Vice President Joe Biden sent a letter to people who signed a petition calling on the government to ban AR-15-type assault weapons from civilian ownership. In it he addressed the thriving gun culture in this country that allows gun violence to continue.  “The President and I agree with you,” he wrote. “Assault weapons and high-capacity magazines should be banned from civilian ownership. … These weapons have been used to commit horrific acts. They’ve been called ‘the perfect killing machines.’”

Then he explained that the 1994 bill that banned assault weapons expired two years ago and was never renewed. How can that be, we might ask. The answer, in two words, is Republican Congress.

The vice president discussed other legal measures that could be taken which were debated and defeated in the Senate last month, a shameful event that resulted in a sit-in by House Democrats demanding action.

Faith leaders, law enforcement officials, businesses, public health experts, the majority of gun owners, and some legislators are calling for legislation that will help put an end to death by gun violence in this country. All over America millions of people are marching, pleading, praying, weeping for gun control. But pleading and prayers won’t do it. Neither will stigmatizing the mentally ill or spewing rampant Islamophobia or fear-mongering about ISIS.

Voting will help do it. That’s why this year is so important.  If we want to confront the gun culture that is ripping our nation apart, now is the time, once and for all, to get real about guns.