Sunday, May 7, 2017

Public Health Policy and Social Class

How does social class prejudice reveal itself in public health? Among conservatives it might be the attitude that low income people deserve to be sicker, and we don’t need to help them, because they are lazy. Liberals have their attitudes, too. For example, “we are experts and know best what you poor folks need,” although that, too, is often not true. I’ve been thinking about this in connection with public health programs that just don’t work the way they should: transportation benefits that people have too much trouble using, mental health coverage that is inadequate for the problems many people face, cuts to programs that have worked well; and yet public health tolerates these situations! Why? Let’s explore one concrete example how social class works in public health: efforts to reduce tobacco smoking. 

Tobacco is the drug of choice for low income Americans. For example in Gratiot County we found that 31 percent of adults who earn $20,000 or less smoke compared to 9 percent of adults who earn $75,000 or more. Twenty-nine percent of mothers smoked while pregnant!  This is a really big deal. In another blogpost I wrote about how heart disease deaths are increasing in rural Michigan. 

Today, public health in Michigan has two favorite ways to try to help people quit. First, you can sign up to get friendly text messages that encourage you to keep trying; second, Michigan like other states has jacked up taxes on cigarettes to high levels (not high enough for some) in hopes of making smoking too expensive. You can find lots of research that says these two approaches are effective in getting people to quit, but they aren’t, at least among low income people. The reason public health says texts and taxes get people to quit smoking is because that’s all we’ve got left. Our general fund budgets are far less likely to support tobacco cessation programs than they once were, and health insurance, including Medicaid, doesn’t reimburse enough for us to support cessation programs by billing insurances—but still, we want to be able to say we’re doing something.

The Campaign for Tobacco Free Kids publication “Tobacco Tax Increases Benefit Lower Income Smokers and Families” reflects the official consensus stating “increasing price is proven to reduce smoking, especially among kids and among those with low incomes.”

But not everyone agrees. In “Poor Smokers, Poor Quitters, and Cigarette Tax Regressivity” appearing in American Journal of Public Health, Dahlia Remler found, “cigarette taxes heavily burden poor smokers who do not quit, no matter how tax burden is assessed.” In another study in the Journal of Policy Analysis and Management, Remler said, “Very high cigarette taxes, however, have a dirty little secret: their regressivity. Overwhelmingly and increasingly, smokers are concentrated among the poor. Moreover, our era of rising cigarette taxes is also an era of dramatically rising income inequality and possibly lower purchasing power for the poor.” 

The public health community has rallied behind the taxes. The Campaign for Tobacco Free Kids says, somewhat snarkily, “it is smoking itself and its health harms that are hurting the lower-income population,” not the taxes. Therefore the Campaign is not responsible for the harms of the taxes. The social class bias in this attitude is somewhat breathtaking. You can almost hear someone huffing “if they are too stupid to quit, screw them.” The Campaign is a left-leaning progressive public health organization, but here, their attitudes are similar, for example, to Republicans in the House of Representatives who think it is OK to get rid of health care benefits for low income people because they “made bad choices.”

But evidence is mounting that tobacco taxes are harmful to the poor. Katherine T. Hirono and Katherine Smith published a review of the literature and concluded that “very large cigarette tax increases unintentionally harm the most vulnerable in society: smokers who are homeless, very low income, and/or suffer from mental illness… Low-income smokers who either can't or won't kick the habit following large tobacco tax increases face increased financial hardship, and so do their families.”

But surely low income people don’t give up food or other necessities just to keep smoking? Remember that tobacco is very addictive. A study by the Research Triangle Institute showed that low-income smokers in New York, which had the nation's highest state cigarette tax, spent nearly a quarter of their household income on cigarettes. Nationally, those with the lowest incomes smoke less, but still spend just over 14 percent. 

In raising these issues, I want to challenge my colleagues to think about how social class influences our response to the unintended consequences of our liberal policies. In 1920, in the face of rampant alcoholism, who could have imagined that prohibition would cause alcohol-related mortality to soar out of control? But it did. But that wasn’t the worst failure of public health at that time. The real failure was refusing to support the repeal of prohibition once it was understood that the law had made things worse. The public health community supported prohibition to help people avoid the harms of excessive alcohol consumption, but couldn’t change course even after it understood prohibition was making things worse. 

Yes, it bothers me that Michigan’s Mackinac Center, which opposed the Affordable Care Act, also opposes tobacco taxes. And I worry my musings may be mistaken when I see that my own public health association, the Michigan Association for Local Public Health, strongly supporting increased tobacco taxes. But we need to remember that real human beings are the objects of our policy prescriptions. I remember meeting a low income woman at a community event where Chantix, a drug that helps people quit, was being distributed. She began crying. A tobacco cessation counselor hugged her and said, “You’re afraid you won’t be able to quit” and the woman sobbed, “I’ve tried so many times and nothing works.” I didn’t know people cried about not being able to quit smoking until I saw it. 

Think about this: it is difficult to argue that we raise cigarette taxes because we really want to help low income people quit, given that we do so little else to help them do so. If we wanted to help people quit we would use the tax increases to address the problems in people’s lives that keep them smoking. But we don’t. In Michigan we have used tobacco tax revenue for things like scholarships, school aid and debt service. I agree those things are important, but so little tobacco tax revenue goes for smoking cessation in Michigan that the State gets a grade of F from the American Lung Association for its paltry tobacco prevention efforts. The real reason for the taxes is to plug budget holes, and we don’t lose sleep thinking about the woman who spent her last dollar on cigarettes and doesn’t know what she will eat tomorrow.

Thursday, January 5, 2017

Obamacare and Local Public Health

A lot of times I ask my wife, Debra Bennett, among other people, to read potential blog posts. Her comments help me communicate more clearly.  This time she told me this post is too complicated, and I should concentrate on explaining to people, in clear simple terms, how repeal of the Affordable Care Act would impact them directly. I haven’t taken her advice and the reason for that is I want to use this blog, not for simple advocacy, but to expose the real challenges faced by local public health.  There are probably 6,000 people working in local public health across the State and the purpose of this blog is to show others what we see every day.  The vast majority of local public health departments are located in rural parts of Michigan. These are places where heart disease mortality rates for low income people are rising, where suicide and heroin overdoses are surging. Local public health departments are madly trying to figure out what is happening and what can be done about it.  This is also Trump country. We spend much of our time, whether it is talking about a contaminated well or helping a mother get respite care for her handicapped child, loving on people who decided to use their votes to “shake things up”, and because of the election things are likely to get that much more difficult for everyone. The details of this story are complicated and technical, and what I’m trying to do here is let people see some of these details--details that are ordinarily invisible to most people.


When Donald Trump was elected people became concerned that the next Congress would repeal the Affordable Care Act (ACA or “Obamacare”). However, some pundits reassured people that Congressional action would not be too extreme. For example, well-informed commentators appeared on Politico’s Pulse Check (It’s the episode entitled “Obamacare Endangered”) and said that while Congress may repeal the ACA, it would actually retain important parts of it, because Congress would not want to take away people’s health insurance, and because the ACA is actually good for the health care industry.

But the incoming Congress is not behaving so rationally.  Now journalists are writing that the next Congress is likely to repeal many of the most important and beneficial parts of the law, including the expansion of Medicaid. What does this mean for public health? Sure, people will lose their health insurance, but that won’t impact local public health directly, will it?  Sure it will.  Repeal of the ACA would unravel much of the innovative work to strengthen preventive services that local public health has been engaged in for the past six years.  And understanding this helps show how repeal of the ACA could literally be deadly to those whose lives have been changed by it.

This isn’t just about protecting programs. Any time legislatures attack health care or public health people get sick and even die as a result. A contemporary example is what happened in Texas after their legislature cut funding for family planning services in 2011.  You might be surprised that cutting family planning funding could have a big, negative impact on health.  In fact, family planning is counted among the ten great public health achievements because when women acquired the ability to control their fertility both infant mortality and maternal mortality plunged. MMDHD is the only public provider of family planning services in our three counties (Cherry Health provides services to people for whom they are the primary care provider). These services include comprehensive personal health services--not just birth control—for people who might not be getting care anywhere else. The Texas legislature cut funding for family planning in order to close down Planned Parenthood clinics because some help women get abortions, and did not consider the impact losing access to their other services would have on women’s health. As soon as the funding cuts went through maternal mortality doubled!*  

Yes, I am afraid Michigan could be facing something similar, soon, not necessarily because of cuts to Planned Parenthood—the Michigan legislature made a lot of noise about doing that only to discover Michigan gives no money to Planned Parenthood—but because of the impact that repeal of the ACA could have on public health.

There are three major ways that repeal of the ACA could impact public health. The first would result if repeal leads to the elimination of the Healthy Michigan Plan (expansion of Medicaid) or the Health Insurance Marketplace ( or “Obamacare”). More than 640,000 additional people have gotten health insurance through Healthy Michigan and an additional 313,000 bought health insurance through the exchange.  Nearly one million Michiganders will lose health insurance if these plans are eliminated.

But it isn’t the loss of the ability to go to the doctor that is the issue. The reality is that primary care doctors don’t necessarily do a very good job of serving low income, vulnerable people who tend to have complicated problems that extend beyond their specialty. Health insurance enables these people to access other preventive services such as mental health and substance abuse treatment, smoking cessation and rehabilitation. Losing health insurance means people will lose all this other stuff, too, and these services are the ones they really need the most, that help them recover their health.

The second way that repeal of the ACA would impact public health has to do with new, innovative public health programs that have been stood up over the past six years leveraging opportunities in the ACA which could be swept away. The ACA has changed the environment in which providers of preventive services are operating so that they are encouraged to create and experiment with new ways of finding at-risk people and meeting their needs. Elsewhere I have written about activities like the diabetes prevention program, co-location of mental health and physical health services and community health workers (CHWs) which are directly aimed at enabling the sickest and most vulnerable people to receive services they need to recover their health. To provide just one concrete example of how this has worked in Michigan, Medicaid health plans are now required to support community health worker (CHW) programs. This requirement was enacted as part of the Michigan’s State Innovation Model, its implementation of the ACA. CHWs meet peoples’ non-medical needs (housing, food, transportation, etc.) to get them to the point where they can begin to focus on health. For example, MMDHD has created a CHW program that focuses on adults with chronic diseases.  In Saginaw there is a CHW program that focuses on people with mental health problems and Muskegon has a program for women with risky pregnancies. Michigan’s CHW programs were evaluated and shown to improve health outcomes and reduce costs, but our elected leaders may decide that’s no reason to keep them around.

For an employer, writing on-line about the challenges your operation is facing can be fraught. Yes it is good to try to attract attention to potential threats. Maybe advocacy can change the outcome. But your employees may read what you write and think “Oh my god! That’s my job he’s writing about!” So to any MMDHD employees who read this, I want you to know we are working on a Plan B (and C in fact) to sustain our programs in case the ACA is repealed in a way that affects us.

The third way repeal of the ACA would affect public health could result from the elimination of the Prevention and Public Health Fund (PPHF). The PPHF is one of the best parts of the federal budget you never heard about. It was established under the ACA to ensure that the ACA focused as strongly on public health as on health care. Michigan has received nearly 100 million dollars from the fund which has been used for obesity reduction, tobacco programs, heart disease prevention, cancer prevention and other activities.  Funds have gone to health care systems, tribal governments, universities, community groups like YMCAs, and yes, local public health. Unfortunately the fund has been embattled since it was created and much less has been appropriated by Congress than was hoped for. Nearly a billion dollars have been shifted from the PPHF to support existing, inadequately funded CDC programs, too.  This detail is important because it means the fund is also supporting our existing, routine local public health programs (for example family planning) through the CDC. If the PPHF was eliminated due to a repeal of the ACA it would mean more than simply losing the special programs mentioned above, but it could mean a reduction in local public health’s regular operating budget.

So for example, suppose a million Michiganders lose their health insurance and lose access to family planning services through their primary care doctor.  They might turn to local public health for family planning as they did before the ACA.  But just at that moment support for local public health could be reduced because of elimination of the PPHF.  This could be a real train wreck.  

And don’t think Planned Parenthood will be there to fill the gap.  Legislatures that don’t fund that organization and trying to shut them down by saddling them with bogus regulations that make it too expensive for them to operate. Since Michigan doesn’t fund Planned Parenthood there is no stream of dollars that could be shifted to other providers, like local public health, if Planned Parenthood leaves the State.

And we are only talking about the impact in one area:  family planning!  Now think about the impact across the suite of programs local public health offers: communicable disease, outbreak investigation, immunizations, WIC and home visiting programs, children’s programs, hearing and vision programs, oral health, community health workers and care coordination programs with mental health.
Could Michigan experience as spike in maternal mortality in the near future?  It’s something we need to take very seriously, but it’s likely next time the damage will be spread even further.

* The story of what happened in Texas is complicated. Maternal mortality rates have been rising in many places in the United States, not just Texas. One reason is that vital statistics agencies are getting better at identifying cases of maternal mortality. Increases may also be linked to the general increase in mortality among low-income people that has been evident lately. You should also know that Michigan is also, like Texas, a state with high maternal mortality. Still the sudden, enormous jump in Texas is hard to explain without understanding that many women lost access to family planning services there. 

Tuesday, July 12, 2016

St. Louis, Meet Flint. Part 3: What Does Race Have to Do With It?

On MSNBC on Martin Luther King Day, Governor Rick Snyder was asked whether environmental racism had anything to do with the Flint water crisis. His response was “Absolutely not. Flint is a place I’ve been devoted to helping.”

In fact, environmental racism has everything to do with it, the Governor’s clean conscience notwithstanding, and every Michigander needs to understand how it does so we can understand the problems of our struggling cities as well as our poor rural areas.

A very popular narrative about the problems of Flint, Detroit and other Michigan cities goes something like this: These communities were economically ravaged by their voters who elected leaders who they knew would finance unsustainable contracts, payrolls and benefits, and now that the party is over and the cities are bankrupt, regular, hardworking Michiganders are being stuck with the tab.  This is often thinly concealed code for “Black people create problems that White people have to clean up”.

A similar narrative is increasingly being used to describe the poor, rural (mostly White) areas of Michigan where despair is leading to sharp increases in suicide, drug abuse, chronic disease and rising overall mortality rates—and where hope of economic recovery is vanishing. I described these chilling trends in the first part of this series. Stereotypes that poor, rural Michiganders are self-destructive slackers who deserve their fate are growing stronger.

Before I come back to what's happening in our rural areas, I’m going to pose an alternative history of Flint, one that blames environmental racism for the crisis. I will do so in a very personal way. I’m going to tell a story about my family. I’m going to talk about my two grandfathers.  These two men loved me a great deal, and gave many gifts to our family.  Strangely, one of the most influential things that came to me from them happened because my parents made an effort to learn about our family’s attitudes and behaviors toward Black people. Because of my parents’ efforts and what I learned about my grandfathers, I have a strong, personal sense how White Americans limited the economic opportunities of Black Americans, laying the foundations for the disaster in Flint.

My father’s father, Richard, who had an eighth grade education, rose to become a vice-president of his Mississippi town’s bank. In the 1950s, like virtually all White people in his town, he actively participated a social system that systematically crushed the aspirations of Black people. He became a prominent member of the White Citizen’s Council, the organization that worked to maintain school segregation and prevent Blacks from voting. In 1955, the White Citizens' Council published in the local paper the names of 53 Black signers of a petition for school integration. Soon afterward, the petitioners lost their jobs and had their credit cut off. Richard was deeply involved in a notorious incident in which the first Black social worker hired in the area was fired as a warning to other Black professionals.  He wasn’t the worst person to have walked the earth, but the fact that he was my grandfather makes me understand that White racism is part of my family’s legacy in this country.

In the middle of the 20th century, in the Great Migration, Black people fled the South to get away from people like my father’s father. They moved to places like Flint, and also Oakland, California. Unfortunately, there they ran into people like my mother’s father, Herbert.

Herbert was an architect and conservationist who lived in Oakland. But, like almost all White people of his generation, he was also a segregationist. In the mid-fifties, almost all White American home owners agreed to discriminate against Blacks and Jews by not selling their homes to them, doing their part in the cluster of practices known as “red-lining”. Real estate associations, city planners and federal government policies on financing home ownership excluded minorities as part of their official policies. When he purchased his home in Oakland, Herbert signed a memorandum stating that he would not sell to a Black person or Jew. The foothills remained almost exclusively White until near the end of the 20th century while the flatland seethed in poverty.

So Blacks fled the South to get away from racists and came to places like Flint or Oakland where they ran into segregation. In their new homes they often did not get the best jobs, were the first fired when globalization devoured industrial jobs starting in the 1980s, and were never able to buy good homes. Most never acquired wealth. When the economy of Flint imploded, the well-to-do fled, but the poor, many of whom were Black, were left without the means to sustain themselves or their community. When the tax base collapsed so did the capacity of the government.

But many aspects of this story are actually strikingly similar to the recent history of rural Michigan. This story has been told for Montcalm County, one of the places in which I work today, in an award-winning documentary. In Montcalm, divisions in the community fell along social class rather than racial lines. But these divisions meant that some residents did not acquire wealth in the form of valuable property, even though Montcalm had both prosperous agriculture and industrial sectors. Then globalization shuttered most of the factories in the area right around the turn of the 21st century. Many of the residents tumbled from what felt like the middle class into poverty. What had once been a landscape of family farms and factory jobs became a landscape of factory farms and rural slums. I believe this was the beginning of the trends that led to the spiraling health problems we saw in the first part of this series. And, similar to Flint, the erosion of the tax base in Montcalm has led to drastic reductions in government services threatening the ability of residents to protect themselves and their health.

I am writing about this because I have noticed during conversations about race in Mid-Michigan, that feelings about racial justice are often used as reasons to deny social justice to rural Michiganders. Feelings about racial justice can block action on problems facing rural communities.  For example, you may hear people say that we can’t create a potentially beneficial social program that could help rural Michiganders (this was used as an objection to the expansion of Medicaid), because of the risk that undeserving [Black?] people could possibly benefit from it. Sometimes people seem to worry more about their fears of others milking the system then about putting policies in place that would truly promote health and well-being. But of course an objective reading of history shows that neither urban, mostly Black Michiganders, nor rural, mostly White Michiganders created their circumstances. They were both victims of forces beyond their control and they can’t move forward without progressive policies designed to hem in the power of the wealthy and create new opportunities for the majority. Pitting people against each other just blocks changes that would improve lives and holds everyone back.

I started this three part series with a disturbing tour of statistics showing increasing mortality rates in rural areas.  I have tried to show that these trends make sense when you realize rural Michigan is subject to the same kinds of social forces that have affected other rural areas like Appalachia, but also urban parts of Michigan, like Flint. We used the story of pollution in St. Louis, Michigan and the economic collapse of Montcalm County to illustrate this point. My hope is that Michiganders will one day see that we all share an interest creating the conditions that promote health and well-being for everyone, and will seize every opportunity to do so.

Monday, July 11, 2016

St. Louis, Meet Flint: Part 2: Environmental Justice

In my last blog post I showed that northern and central Michigan has a lot in common with the coal country of Appalachia in terms of mortality due to chronic disease, drug overdoses and suicides: that is, we are among the worst places for those killers in North America.  The problems are so severe that for low-income Whites mortality rates are actually rising for the first time ever.

I do not claim to understand fully why this is happening, but one concept that may be useful is that of environmental justice. The concept of environmental justice seeks to explain why health problems are concentrated in some places.  It says that in some places there are imbalances in power so large that people cannot successfully advocate for themselves. Coal country is a good example. People in
Appalachia were so dependent on the coal industry for jobs that they could not successfully demand safe working conditions, reasonable compensation and a clean environment. They were never able to diversify their economies so that when the coal industry declined and jobs disappeared families were wiped out and the tax bases of communities collapsed.

Communities where there are high levels of environmental injustice tend to have three characteristics:
  • Dependency. Residents are economically dependent on a powerful industry and are forced to tolerate abuses to survive. 
  • Powerlessness. Efforts to demand justice are unsuccessful because of the imbalances in power. 
  • Voicelessness. When residents speak out or try to tell their story they are told they are wrong or ridiculed. 
The concept of environmental justice is often applied to post-industrial cities with large communities of color like Flint, Michigan.  Flint is the city in which a government-appointed emergency manager changed the water supply to save money (good idea) without ensuring that it was treated it properly (bad idea), resulting in widespread exposure to lead. In Flint people were dependent on the auto and other manufacturing industries which began to collapse under pressure from globalization in the 1980s. Housing segregation was either legal or tolerated right into the 1970s, meaning African-Americans in Flint did not acquire wealth in the form of valuable homes at nearly the same rate as Whites. When the economy collapsed, those who could afford to do so moved, leaving mostly vulnerable low-income people behind.
The tax base shrank setting the stage for the water disaster.  Why did it take the Genesee County Health Department 18 months to figure out there was lead in the water?  The Department’s budget and staff had been more than cut in half meaning the community was powerless to protect itself.  The residents of Flint were virtually voiceless even though the protested loudly that there was something wrong with the water.  During the run up to the disaster I was in a meeting with a DEQ official who told me people in Flint didn’t know what they were talking about. “They keep showing up at meetings with bottles of brown water. The water is brown because it has iron in it!  But they won’t listen!”  He called Dr. Mark Edwards who had data that proved there was lead in the water a “Kook” and heads nodded.

Are there rural communities with widespread environmental injustice in central and northern Michigan? It is easy to think of examples. Towns in the Upper Peninsula were dependent on iron and copper mining, for example.  But I’ll write about what I know: the environmental disaster in St. Louis, Michigan in the geographic heart of the Lower Peninsula.

Beginning in the 1930s the Michigan Chemical Company produced a variety of chemicals on the banks of the Pine River in St. Louis, including DDT and a flame retardant PBB.  It was widely known as a very dirty business, encouraging employees not to worry about exposure to toxics, and dumping waste in the river and several sites in the community. But people were dependent on the company and so it got away it.  In 1978 PBB was accidently mixed into animal feed that was shipped to cattle, hog and chicken facilities throughout Michigan.  When Michiganders consumed meat, milk or eggs they were exposed to the PBB. Many farm families who ate their own animals became very ill. Today Michiganders who are tested are still found to have PBB levels six times higher than the national background level.

When farmers complained that something was making their cattle sick they were told there was nothing wrong, or that it must be due to their own bad farming practices.  Later when the real extent of the problem was discovered Michigan Chemical was allowed to pay a small settlement, and bury the plant site under a clay cap.  People in St. Louis complained that the company should be forced to pay for a clean-up but they were powerless to influence the government’s decisions, and the company was allowed to leave the state without doing so.  A few years later residents discovered that the clay cap was leaking but their voices were ignored until it was found that PBB and DDT levels in the river were actually continuing to rise.  Finally, forty years after the PBB was mixed into the animal feed the EPA declared Super Fund sites in St. Louis and began working on remediation.

Urban, mostly Black Flint, and rural, mostly White St. Louis share some unfortunate traits.  They have been dependent on industries that didn’t love them back, they have been powerless to influence decisions about their fates, and when they tried to speak out their voices were not heeded.  They share some other things too: both culminated in environmental disasters that have been incredibly expensive to clean up and both ruined the reputations of moderate republican governors who wanted to leave legacies as environmentalists but weren’t willing to put the systems in place that would truly protect the environment (Milliken for St. Louis, Snyder for Flint).

With this kind of history to unite us, Michiganders should band together to fight for environmental justice, but often we don’t. Often we feel like we are pitted against each other. Can that change?  I witnessed something recently that says maybe it can, at least for some of us.  At a community meeting at Alma College I saw this exchange between two people who I will call Bob and Betty (not their real names).  Bob burst out with “So these people in Flint don’t take care of themselves, and they mess up their water supply, and now other people like me are supposed to pay millions of dollars to bail them out?”  Betty turned to Bob and put her hand on his arm and said, “Bob, when you talk that way it makes me sad. Remember, we have been working for decades to get the government to pay millions of dollars to clean up our mess, and now they are finally, and we are glad, and people in Flint are paying their share of that, too.”  Bob thought a minute and said, “Thank-you Betty, you are right.”

I managed to go on for hundreds of words here talking about Flint without really talking about race.  In my next blog post I am going to write at length about how race influences our thinking about environmental justice, including in rural areas.

Sunday, July 10, 2016

St. Louis, Meet Flint. Part 1: Rural Mortality

I want to kick off a set of three blog posts that explore the causes of some of our most serious public health problems. Today I want to look at alarming trends in health in rural Michigan and ask what is happening to us? What I will do in the next two posts is ask whether rural Michigan is a victim of the same kind of forces that cause public health crises in other rural areas like Appalachia, but also in some urban areas, like Flint.

I’m going to show you three maps. The maps show the distribution of some serious health problems in the Midwest. What you will see is that rural central and northern Michigan is in trouble.  In fact we look like some of the sickest parts of North America. What you will also see is that even though the maps represent different public health problems, the distribution is the same in each case. This provides evidence about what those forces causing our public health crisis might be.

This map is from a well-known analysis of the distribution of heart disease deaths originally done by the CDC and reproduced many, many times.  First notice the legend. The disparity in heart disease deaths is enormous. The places with the highest rates of heart disease death (red) have rates eight times higher than those with the lowest (white)!  Then look at northern Michigan.  Excluding the prosperous communities around Grand Traverse and Charlevoix, northern Michigan tends to have high heart disease mortality rates.

I do not understand why, but Minnesota and Wisconsin, which I think of as being similar to us, fare much better.  But look at big cluster of mortality centered on Kentucky and West Virginia; our heart disease death rates are like theirs.

The next map is of the opioid overdose death rate, again from the CDC.  Opioids include prescription painkillers and illegal drugs like heroin.

Opioid overdoses have recently shot up in some rural areas, especially in Kentucky and West Virginia, and also in northern Michigan. Opioid use has been identified as a risk factor in the spread of HIV in rural areas.  Again, Minnesota and Wisconsin seem to be spared.  New York is spared also, because of policies ensuring access to drugs that aid in recovery from addiction.

The last map is of the gun suicide rate (sorry about the poor quality reproduction). It was made by the digital magazine Braid using CDC data. Suicides have increased sharply in some parts of rural North America. Again we see the same pattern, with northern Michigan, Kentucky and West Virginia having very high rates and other places being lower.  My conclusion:  Northern Michigan has something in common with coal country!

These problems—chronic disease, drug abuse and suicide—are part of a cluster of health problems befalling low-income, rural communities in some parts of North America that are so severe, they are actually causing measurable increases in the overall mortality rate.  For background on that look here and here.

And these unprecedented mortality rate increases are happening in low-income, rural parts of Michigan. You can see it at the local level. This line chart is for Montcalm County but you get the same results in many counties in Michigan.

The chart shows the heart disease death rate; the blue line is for Montcalm. For years heart disease death rates had been trending down locally just like everywhere else in North America due to reductions in smoking and improvements health care, but in the past few years the trend locally has reversed.

There are many factors that are contributing to rising mortality rates. Some of these factors, like stagnating rural economies, involve complex public policy and political issues. Other factors, like the pushing of opioids by pharmaceutical companies, are specific and narrow.  But low-income, rural communities seem especially vulnerable and are being hit harder than other areas. In my next two blog posts I want to explore why they are so vulnerable.

Thursday, December 31, 2015

New Year’s Resolution: Making Ethical Choices

I’ve had the pleasure of spending a great deal of time reading really interesting stuff over the holiday break. My reading has inspired me to help the Mid-Michigan District Health Department make a New Year’s resolution to take additional steps to avoid ethical lapses in the future. Let me explain.

The Atlantic magazine has a great article by Jerry Useem on how ethical lapses happen in organizations called What was Volkswagen Thinking? (in reference to the automaker’s installing software in their vehicles to defeat emissions tests). Useem explores other well-known examples including the decision by Ford to keep making Pintos even after it was shown they were prone to exploding; Morton-Thiokol’s vote to launch the Challenger even after they knew the O rings were leaking in cold weather; and B. F. Goodrich’s sale of aircraft brakes to the Air Force that they knew would overheat and fail.

Useem shows that often ethical lapses happen even though otherwise good and intelligent people are involved. He says that one thing organizations can do to reduce the chances of ethical failures is to have an explicit code of conduct that empowers people to act to prevent abuses. He uses the example of Johnson & Johnson’s “Credo”—their code of conduct—which guided their decision to immediately recall every bottle of Tylenol capsules at a cost of $100 million when they learned that someone had contaminated a few with a deadly poison. In Useem’s telling, the CEO was on an airplane when the news broke, and by the time he landed the recalls were already in motion.

Of course these are all examples from business. But there are plenty of examples from public health and the CDC has even developed a course on ethics in public health which is here.

I am thinking about how organizations can fight ethical lapses because Michigan is wrestling with a big one of its own right now: The failure of the responsible State government agencies to alert the residents of Flint that it was likely their water was contaminated with lead over the past spring and summer. Unlike many of the cases explored by Useem in which it took years for the facts to come out, you can read in detail about what really happened right now, because has posted FOIAed documents on its website. I personally know many, perhaps most, of the people whose emails are there. I know them to be good and intelligent and consider many close friends. But in their emails you can see them struggling to understand what to do when data emerge that seem to show that lead levels are increasing. At the time, they believe there are contradictory sets of results. We now know with hindsight that wasn’t the case—all the data showed that lead levels were increasing. But at the time, they hadn’t figured that out yet. It took weeks, but you finally see more emails asking what it means if there is a chance the high lead results are correct? (It would mean we should sound the alarm.)

But none of this prompts me to throw rocks at the State, it makes me worry about where, in my own organization, we might be at risk of making similar mistakes.  And, it makes me wonder how we can strengthen our code of conduct (we call it our Guiding Principles—page four of this document) to make it clear employees are empowered to warn against ethical lapses.

There are some things happening that could turn into ethical lapses if we don’t watch it. For example, are we doing enough to raise the issue of ground water quality? After all, I am sitting on a mountain of data that says there is potentially disease causing human poop from failed or non-existent septic systems in our rivers and streams, where people canoe, fish and even swim. But there is only a little bit of activity going on to do anything about it. Of course our situation is different from Flint, because while we do have citizens on one side of the issue clamoring for a clean-up, we have just as many on the other side clamoring for nothing to be done because it could raise costs to real estate and agriculture. So we are on the horns of a political dilemma, and that means things will only change very slowly.

Another threat of a lapse could be coming from some of the innovative new clinical projects we have started that are costing us money, without as of yet having generated much new revenue. One example is the project in which we are supporting primary care services being offered to patients of Community Mental Health in one of the counties we serve. I love this project because really sick people are getting good physical health care for the first time. But I have had staff come to me and ask me to shut the project down because of its costs and the strain it places on our billing “department” (one person—go Bonnie!) while it hasn’t generated the expected income. I’ve asked them to keep going because I think we are learning things that will help us innovate in the future, and I think the money will come.  But maybe I’m just NASA not listening to Morton-Thiokol and there will be a financial explosion. Okay, it isn’t completely like that because our partner in this project is committed to it and is covering most of the cost overruns. Or am I just rationalizing a threat away?

And then there is another set of lapses that are created by omission rather than commission. For example, how can we do more to reach out to the growing migrant laborer population in our district? Why can’t the Collaboratives in our counties do more to address stagnating incomes and stubbornly high poverty rates? Why do I always seem to be too busy to spend more time just hanging out with staff and getting to know them better? (That’s the advice Coach Dantonio would give me I’m sure--see the 10th paragraph of this.)

Clearly I can’t foresee all the potential ethical lapses on my own.  Co-workers will know about others that I am unaware of. What I want to do is encourage everyone in the organization to take the threat of ethical lapses seriously.  When I wanted to get staff to stop collecting data on paper (which cost us a lot of staff time which means money) and always automate data collection projects I “branded” the concept with the phrase “Let the robots do the work” which seemed to create a helpful picture of where we wanted to go. I’d like to do something similar with the concept of avoiding ethical lapses.  I’m having trouble coming up with something. I don’t think any of these work:

If it could explode—that’s a bad thing.
It’s been _____ days since anyone was poisoned.
Not losing our jobs because of ethical lapses is job one!

Did you laugh?  I hope so. I think one thing that is wrong with these is that they are negatively phrased; they talk about what is to be avoided rather than what to do.  How ethical lapses happen is an important question, but the solution ought to be phrased positively as making ethical choices.

So help us out here. If you can think of some way to brand the concept of making ethical choices that works in a public health setting please send it along.

Saturday, December 12, 2015

Gripped by Fear

This post was inspired by a question my mother, Barbara Cheatham, of Issaquah, Washington asked me. 

According to the media we are all gripped by fear. The media is focusing on terrorism in particular right now, but we also have guns, mass shootings, police violence against minorities, violence against people thought to be Muslim, and lots of other things to be fearful of, apparently. I am not going to pick apart all the trends in this short article. I just want to quickly make the point that violence overall, including gun violence, is not increasing.

When Barack Obama was elected president gun sales shot up, apparently because people thought gun laws were about to be tightened up.  I thought it would be enlightening (in a dark kind of way) to see if gun violence increased as  a result. More guns = more shootings, right? I waited for a few years to pass and then made the following chart for my state of Michigan.

Gun violence had not increased even though there were more guns out there!  Many years each of the three counties I work in have no homicides at all, even though the air is filled with the sound of gunshots throughout the fall (Thank a hunter for saving you from a car-deer crash).

Curious about what this meant I then graphed the number of assaults. The chart below is for Montcalm County, one of the counties I work in, although you'll get similar results for most, if not all, communities in the country.

Assaults are actually going down! This is a nationwide trend. We just don't beat on each other like we used to.

Remember when looking at these data on homicide and assaults that people mostly shoot or otherwise kill or maim their own family members, friends and acquaintances. Of 532 homicides in Michigan last year, 52 victims were strangers to their killer (in 204 cases the relationship could not be discerned from the report). The rest of the victims were family members, friends or acquaintances. Strangers are not attacking us at an increasing rate in public places. This is not happening. The chart below is the overall homicide rate for Michigan going back to 1980. The homicide rate has been cut in half.  But not our fear.

I've done a little bit of reading on this, and I do not think there is a good explanation for this decline. Obvious candidates like the aging of society don't survive statistical tests. For whatever reason, overall, we are a more peaceful people than we have ever been. This is a wonderful thing and we need to avoid messing it up by over-reacting to the bad things that are happening.

It is true that the United States has a higher homicide rate, especially for gun homicides, than many other places. And it is true that while gun homicides are declining, gun suicides are increasing. And, yes, terrorism is real.  So there are many serious problems related to violence with which we must wrestle. But lets do so while understanding that overall we are safer than ever before.