Tag: gun violence

Out of Control Health Costs or a Broken Society

Oct 9, 2023

Flawed Accounting for the US Health Spending Problem

By Jeff Goldsmith

Source: OECD, Our World in Data

Late last year, I saw this chart which made my heart sink. It compared US life expectancy to its health spending since 1970 vs. other countries. As you can see, the US began peeling off from the rest of the civilized world in the mid-1980’s. Then US life expectancy began falling around 2015, even as health spending continued to rise. We lost two more full years of life expectancy to COVID. By the end of 2022, the US had given up 26 years-worth of progress in life expectancy gains. Adding four more years to the chart below will make us look even worse.

Of course, this chart had a political/policy agenda: look what a terrible social investment US health spending has been! Look how much more we are spending than other countries vs. how long we live and you can almost taste the ashes of diminishing returns. This chart posits a model where you input health spending into the large black box that is the US economy and you get health out the other side.

The problem is that is not how things work. Consider another possible interpretation of this chart: look how much it costs to clean up the wreckage from a society that is killing off its citizens earlier and more aggressively than any other developed society. It is true that we lead the world in health spending. However, we also lead the world in a lot of other things health-related.

Exceptional Levels of Gun Violence

Americans are ten times more likely than citizens of most other comparable countries to die of gun violence. This is hardly surprising, since the US has the highest rate of gun ownership per capita in the world, far exceeding the ownership rates in failed states such as Yemen, Iraq and Afghanistan. The US has over 400 million guns in circulation, including 20 million military style semi-automatic weapons. Firearms are the leading cause of deaths of American young people under the age of 24. According to the Economist, in 2021, 38,307 Americans aged between 15 and 24 died vs. just 2185 in Britain and Wales. Of course, lots of young lives lost tilt societal life expectancies sharply downward.

A Worsening Mental Health Crisis

Of the 48 thousand deaths from firearms every year in the US, over 60% are suicides (overwhelmingly by handguns), a second area of dubious US leadership. The US has the highest suicide rate among major western nations. There is no question that the easy access to handguns has facilitated this high suicide rate.

About a quarter of US citizens self-report signs of mental distress, a rate second only to Sweden. We shut down most of our public mental hospitals a generation ago in a spasm of “de-institutionalization” driven by the arrival of new psychoactive drugs which have grossly disappointed patients and their families. As a result, the US has defaulted to its prison system and its acute care hospitals as “treatment sites”; costs to US society of managing mental health problems are, not surprisingly, much higher than other countries. Mental health status dramatically worsened during the COVID pandemic and has only partially recovered.

Drug Overdoses: The Parallel Pandemic

On top of these problems, the US has also experienced an explosive increase in drug overdoses, 110 thousand dead in 2022, attributable to a flood of deadly synthetic opiates like fentanyl. This casualty count is double that of the next highest group of countries, the Nordic countries, and is again the highest among the wealthy nations. If you add the number of suicides, drug overdoses and homicides together, we lost 178 thousand fellow Americans in 2021, in addition to the 500 thousand person COVID death toll. The hospital emergency department is the departure portal for most of these deaths.

Maternal Mortality Risks

The US also has the highest maternal mortality rate of any comparable nation, almost 33 maternal deaths per hundred thousand live births in 2021. This death rate is more than triple that of Britain, eight times that of Germany and almost ten times that of Japan. Black American women have a maternal mortality rate almost triple that of white American women, and 15X the rate of German women. Sketchy health insurance coverage certainly plays a role here, as does inconsistent prenatal care, systemic racial inequities, and a baseline level of poor health for many soon-to-be moms.

Obesity Accelerates

Then you have the obesity epidemic. Obesity rates began rising in the US in the late 1980’s right around when the US peeled away from the rest of the countries on the chart above. Some 42% of US adults are obese, a number that seemed to be levelling off in the late 2010’s, but then took another upward lurch in the past couple of years. Only the Pacific Island nations have higher obesity rates than the US does. And with obesity, conditions like diabetes flourish. Nearly 11% of US citizens suffer from diabetes, a sizable fraction of whom are undiagnosed (and therefore untreated). US diabetes prevalence is nearly double that of France, with its famously rich diets.

Let’s Do Public Health Better

Feb 28, 2023• 1

BY KIM BELLARD

Eric Reinhart, who describes himself as “a political anthropologist, psychoanalyst, and physician,” has had a busy month. He started with an essay in NEJM about “reconstructive justice,” then an op-ed in The New York Times on how our health care system is demoralizing the physicians who work in it, and then the two that caught my attention: companion pieces in The Nation and Stat News about reforming our public health “system” from a physician-driven one to a true community health one.

He’s preaching to my choir. I wrote almost five years ago: “We need to stop viewing public health as a boring, not glamorous, small part of our healthcare system, but, rather, as the bedrock of it, and of our health.”

Dr. Reinhart pulls no punches about our public health system(s), or the people who lead them:

…the rot in public health is structural: It cannot be cured by simply rotating the figureheads who preside over it. Building effective national health infrastructure will require confronting pervasive distortions of public health and remaking the leadership appointment systems that have left US public health agencies captive to partisan interests.

Matthew’s health care tidbits: Hospital shooting reveals so much

Jun 13, 2022

Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

In this edition’s tidbits, the nation is once again dealing with an epidemic of shootings. Now a hospital joins schools, grocery stores and places of worship on the the recent list. I was struck by how much of the health care story was wrapped up in the tragic shooting where a patient took the life of Dr. Preston Phillips, Dr. Stephanie Husen, receptionist Amanda Glenn, 40; and patient William Love at Saint Francis Health System in Tulsa.

First and most obvious, gun control. The shooter bought an AR-15 less than 3 hours before he committed the murders then killed himself. Like the two teens in Buffalo and Uvalde, if there was a delay or real background checks, then these shootings would likely have not happened.

But there’s more. Hospital safety has not improved in a decade or so. Michael Millenson, THCB Gang regular, has made that plain. And that includes harm from surgery. We know that back surgery often doesn’t work and we know that Dr Phillips operated on the shooter just three weeks before and had seen him for a follow up the day before. Yes, there is safety from physical harm and intruders–even though the police got there within 5 minutes of shots being heard, they were too late. But there is also the issue of harm caused by medical interventions. Since “To Err is Human” the issue has faded from public view.

Then there is pain management. Since the opiate crisis, it’s become harder for patients to get access to pain meds. Was the shooter seeking opiates? Was he denied them? We will never know the details of the shooter’s case, but we know that we have a nationwide problem in excessive back surgery, and that is matched by an ongoing problem in untreated pain.

And then there are the two dead doctors. Dr. Husen, was a sports and internal medicine specialist. Obviously there are more female physicians than there used to be even if sexism is still rampant in medicine. But Dr. Phillips was an outlier. He was black and a Harvard grad. Stat reported last year that fewer than 2% of orthopedists are Black, just 2.2% are Hispanic, and 0.4% are Native American. The field remains 85% white and overwhelmingly male. So the chances of the patient & shooter, who was black and may have sought out a doctor who looked like him, having a black surgeon were very low in the first place. Now for other patients they are even lower.

The shooting thus brings up so many issues. Gun control; workplace safety; unnecessary surgery; pain management; mental health; and race in medicine. We have so much to work on, and this one tragedy reveals all those issues and more.

No More Empty Desks

Nov 18, 2019• 1

By ROBIN COGAN, MEd RN NCSN

Forced absence from gun violence has created a literal and metaphorical void in schools across our country that may impact students and staff for decades to come. The students are referred to as “Parkland kids,” “Sandy Hook students,” or “Columbine survivors.” These labels are sadly reflective of a new reality for American schools, as students, teachers, and staff no longer feel safe. America’s students feel vulnerable as the facade of schools as a safe place is no longer true. The Center for American Progress recent report revealed that 57% of teenagers now fear a school shooting.[1]

Often, perpetrators of gun violence leave a trail of “red flags” for years, as they are troubled youths. This was the case in the Parkland shooting. Tragically, multiple agencies failed to respond to the signs the troubled young man was leaving, including specifically writing online that he aspired and planned to be a school shooter.

In the aftermath of the Parkland, Florida tragedy, parents and school districts turned to security experts demanding a plan of action. Sadly, the information provided was substandard and lacked evidence to support the strategies as efficacious. Lives weigh in the balance and there is no more tolerance for guessing.

Research is needed to guide the creation of evidence-based frameworks for school communities to address prevention as well as protection. Threat assessment teams are a strategy to assess for potential threats, but more importantly is that an intrinsic safety network is woven into the fabric of the educational system. Exposing the root cause of the contagion of violence impacting our youth is key.

Physicians Should Play a New Role in Reducing Gun Violence

Aug 29, 2019• 3

By MATTHEW S. ELLMAN, MD and JULIE R. ROSENBAUM, MD

What if firearm deaths could be reduced by visits to the doctor? More than 35,000 Americans are killed annually by gunfire, about 60% of which are from suicide. The remaining deaths are mostly from accidental injury or homicide. Mass shootings represent only a tiny fraction of that number.

There’s a lot physicians can do to reduce these numbers. Typically, medical organizations such as the AMA recommend counseling patients on firearm safety. But there is another way to use medical expertise to help reduce harm from firearms: physicians should evaluate patients interested in purchasing firearms. The idea would be to reduce the number of guns that get into the hands of people who might be a danger to themselves or others due to medical or psychiatric conditions. This proposal has precedents: physicians currently perform comparable standardized evaluations for licensing when personal or public safety may be at risk, for example, for commercial truck drivers, airplane pilots, and adults planning to adopt a child. Similar to these models, a subset of physicians would be certified to conduct standardized evaluations as a prerequisite for gun ownership.

As a primary care physicians with decades of practice experience, we have seen the ravages of gun violence in our patients too many times. A 50-year-old man shot in the spinal cord 30 years ago who is paraplegic and wheelchair-dependent. A 42-year-old woman who sends her teenage son to school every day by Uber because another son was shot to death walking in their neighborhood. A teacher from Sandy Hook who struggles to cope with post-traumatic stress disorder.

Physicians can contribute their expertise toward determining objective medical impairments impacting safe gun ownership. These include undiagnosed or unstable psychiatric conditions such as suicidal or homicidal states, memory or cognitive impairments, or problems such as very poor vision, all of which may render an individual incapable of safely storing and firing a gun. In this model, the clinical role would be limited in scope. The physician would complete a standardized evaluation and offer recommendations to an appropriate regulatory body; the physician would not be the final decisionmaker regarding licensing. An appeal process would be assured for those individuals who disagree with the assessment.

If Gun Violence is a Health Epidemic, Can We Quarantine It Like a Virus?

Oct 20, 2013• 4

By Mike R. Weisser

At least two-thirds of the perpetrators and victims of gun violence are males under the age of 30. What else do they have in common? They live in neighborhoods with high crime rates and low family incomes, they knew each other before the violence broke out, they usually aren’t employed.

But there’s another commonality these young people share which isn’t often mentioned in discussions about gun violence and crime.

It turns out that the part of the brain that controls processing of information about impulse, desire, goals, self-interest, rules and risk develops latest and probably isn’t fully formed until the mid-20s or later. And while adolescents and young men understand the concepts of ‘good’ versus ‘bad’ as well as older adults, they tend to let peer pressures rather than expected outcomes guide their behavior when choosing between risks and rewards.

Take this neurological-behavioral profile of males between ages 15 to 30 and stick a gun in their hands. The brain research clearly demonstrates that kids and young adults walking around with guns understand the risks involved. Whether it’s the NSSF’s new Project ChildSafe, the NRA’s Eddie Eagle or the grassroots gun safety programs that have expanded since Sandy Hook, nobody’s telling the kids something they don’t already know.

So what can we do to mitigate what President Obama calls this ‘epidemic’ of gun violence when the population most at risk consciously chooses to ignore the risk? I suggest that we look at what communities have done to protect themselves from other kinds of epidemics that threatened public health in the past.

And the most effective method has been to quarantine, or isolate, the area or population where the threat is most extreme. It worked in 14th-century Italy, according to Boccaccio in The Decameron. Why wouldn’t it work now?

Last month the city of Springfield, Mass., recorded its 12th gun homicide. If the killing rate continues, the city might hit 15 shooting fatalities this year, a number it actually surpassed in 2010. This gives the city a homicide rate of 10.2 per 100,000 residents, nearly three times the national rate. Virtually all the violence takes place in two specific neighborhoods bounded by Interstate 291 and State Route 83, and all the victims are between 15 and 30 years old.

Drugmakers May Win Big in Effort to Curb Gun Violence

Feb 13, 2013• 2

By Matt Barry

Reducing gun violence by increasing access to mental health services may cost billions of taxpayer dollars and give drugmakers that help treat mental illness a revenue windfall. But will it reduce gun violence? The answer is uncertain.

In the wake of the tragic shooting at Sandy Hook Elementary School, there have been repeated calls to increase access to mental health services as a way to reduce gun violence in the U.S., even though the evidence is weak at best that those services actually reduce gun violence.

Absent from these calls to action is any sense of how much that policy would cost. Many argue that any cost is worthwhile if it prevents just one needless death due to gun violence. But we live in austere fiscal times and knowing the price tag before taking action makes sense (click on the image above to enlarge).

A just-published Bloomberg Government Study estimates that the potential impact on the federal deficit due to increased spending on mental health services could exceed $260 billion from 2014 to 2021.