Sunday, February 18, 2018

Killing our children: Guns, mortality and morality

There is really nothing to write about at this time other than the ongoing carnage in our nation as a result of angry young men (always men!) shooting up their schools, most recently (at least at the time of this writing) with the death of 17 students and teachers at Marjory Stoneman Douglas HS in Parkland, FL. It is hard to write through the tears. This should not be going on. Many people have written pieces on the subject -- sad, or angry, or articulate, or all of these. One of the most moving appeared in the New York Times on February 18, 2018, by a man named Gregory Gibson whose son was killed in a school shooting 25 years ago. The online headline, “A message from the club no one wants to join”, is different from, and in this case is much weaker than, the print headline: “Why wasn’t my son the last victim?”

Why indeed? Twenty-five years ago. And since then, countless school shootings, and other mass murders (such as, if we needed reminders, the Las Vegas country music concert, the Pulse nightclub in Orlando and the First Baptist Church of Sutherland Springs, TX) have occurred, and every parent, every family member, wants to know why the most recent prior child to die was not the last, instead of their child. People are terrified; a friend, a rational physician, embarrassedly admits to looking online for Kevlar backpacks for his children. He does international “mission” work and is taking his 14-year old daughter to Africa; when people ask him if he is worried about her safety there, he says “no”, but he is worried about her safety attending school two miles from his home in an affluent suburban community in the US. His day job includes being a leader for the quality program in his hospital, where he searches the actual data for root and contributing causes to problems; he wonders why this country cannot do the same for gun violence. Arizona Star columnist Dave Fitzsimmons expresses similar fears for his children.

This country could, but so far it shows no sign of doing so. Gibson quotes the author Chester Himes commenting on the lynching of 14-year old Emmett Till in 1955 that “The real horror comes when your dead brain must face the fact that we as a nation don’t want it to stop.” Himes was talking about lynching, but it is clear that the same can be said today, more than 60 years later, about school shootings. We don’t want it to stop. Because, if we did, we would do something about it.

Of course, we do, most of us. Various surveys, asking the question in different ways, find different percentages, but always large majorities, of Americans want stricter gun laws, often up to 90%. Even most people who are members of the NRA and/or are registered Republicans want limitations on who can buy guns based on mental illness and other criteria (always “me, and people like me”, but not the people like you) and some kinds of guns or gun modifiers (like “bump stocks”, used by the Las Vegas shooter to turn his AR-15 semi-automatic – and by the way almost all these shootings involve AR-15s) and armor-piercing bullets. No, the “we” who don’t want to stop it, in this case is, beyond a small minority of zealots, the even smaller minority of those who are politicians, in Congress, in the Executive Branch, and in our statehouses.

Why would they do this? Or, rather, not do anything about gun violence? Well, there is a small minority of this small minority who are, themselves, zealots whose interpretation of the Second Amendment is such that our dead children are just collateral damage in pursuit of the higher cause of unrestricted gun ownership. But, for most, opposition to even the most rational restrictions is tied to money, specifically to money from the NRA. A staffer for Jimmy Kimmel, Bess Kalb, looked at how much each of the Senators and Congresspeople tweeting their sadness and condolences took from the NRA, noting that “In the 2015-2016 election cycle alone, GOP candidates took $17,385,437 from the NRA,” (quoting a tweet from Republican National Convention chairwoman Ronna Romney McDaniel), and that “This is NOT counting the $21 million given to President Trump.” Another article documents the individual contributions, led by $4.4 million to Thom Tillis (R-NC, or, excuse me, R-NRA).

These legislators, and sadly even the President, when not crying their hypocritical crocodile tears and then voting with the NRA to kill any sort of gun reform, talk instead about the need to focus on mental health. This, by the way, is a good idea; the mental health system in this country is terrible; insurance companies cover it inadequately, those who are not insured and need public facilities find them cut back yearly, and there is no shortage of news stories focusing on a poor mentally-ill person pushed out of a treatment facility found wandering the street, or worse. Our jails and prisons have become our new mental hospitals, documented, for example, in this comprehensive Atlantic article from 2015, “America’s largest mental hospital is a jail”. However, it is not the diagnosed mentally ill who commit these murders and mass murders. Most such murderers do not have a diagnosis, although they probably suffer from “anger management disorder” (not in the current Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), but “intermittent explosive disorder“ will be in DSM-V). This is important because it is the angry who commit these murders. An article in Slate by Laura L. Hayes from 2014,”How to Stop Violence; Mentally ill people aren’t killers. Angry people are”, contains this persuasive data:
80 to 90 percent of murderers had prior police records, in contrast to 15 percent of American adults overall. In a study of domestic murderers, 46 percent of the perpetrators had had a restraining order against them at some time. Family murders are preceded by prior domestic violence more than 90 percent of the time.
Hayes concludes that “Violent crimes are committed by people who lack the skills to modulate anger, express it constructively, and move beyond it.” Sadly, this also describes many of the most virulent opponents of gun control.

If anything could be even more sad than the fact that the mass killing of our children is tacitly endorsed through inaction by our political leaders, it is that it is only one face of the epidemic that is child mortality in the US. This January, Ashish P. Thrakar and colleagues published “Child Mortality In The US and 19 OECD Comparator Nations: A 50-Year Time-Trend Analysis” in the journal Health Affairs. The picture was bleak. The first sentence of their Abstract summarizes their findings: “The United States has poorer child health outcomes than other wealthy nations despite greater per capita spending on health care for children.” Guns are part of it, and the “social determinants of health”, a sanitized way of saying that in the richest country in the world there are millions of children with inadequate food, housing, warmth, safety, healthcare, and educational opportunities, are ultimately the other causes. We may be the richest country in the world, but we are also the most unequal in the developed world, and the increases in the wealth of the top 0.1% does not “trickle down” to those in need.

Indeed, even the outrageous and disproportionate child mortality rates in this country are not the whole story. As I have noted before (Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015; Tom Petty, the opioid epidemic and changing structural inequities in the US, January 23, 2018) the US is the only wealthy country in which mortality rates are rising, a completely shocking finding since, of course, it didn’t used to be true. And this rising mortality is driven by the white non-Hispanic population (although, it must continue to be said, that the absolute mortality rate of minorities, and especially African-Americans, still exceeds that of whites), and more particularly, poor whites.

In a terrific effort to try to explain to the international community what is happening in the US, Steven Woolf recently wrote an editorial for the BMJ, Failing Health of the United States. He notes the causes of the increases in mortality (more than opioids, more than guns, although these are major contributors), provides data, and proposes solutions. “In theory,” he says,
…policy makers would promote education, boost support for children and families, increase wages and economic opportunity for the working class, invest in distressed communities, and strengthen healthcare and behavioral health systems.

Politicians need to address these issues, and they need to be made to do so. By us, the people they are supposed to work for, not the huge money contributors like the NRA. But we can only do this if we stay angry, and stay organized. We cannot heed calls to “not talk about this now” while families are grieving, because it will, based on history, not be very long before it happens again.

It is our job and we must take it on. 

Friday, February 9, 2018

Nursing homes, assisted living, and home care: Can we have reliable quality?

Getting older is unavoidable (until the end); I myself have been doing it all my life. When I was a child and getting older (being a teenager! Or an adult!), it was an entirely positive aspiration. Now, not so much. We know that we will die, and as we grow old, if we are lucky enough to not die young, we know that are going to meet that end sooner rather than later.

As I have grown past “Medicare age”, I have personally experienced many of the issues that I have worked through with patients over the decades, and am also experiencing (vicariously, but closer) the travails of my much-older parent. While not everything that happens with aging is negative (retirement, not going to work every day, is a major positive, provided you can afford it!), the body and the mind can’t do what they once did and often really start to fall apart. Those of us who are lucky enough to avoid dementia, from Alzheimer’s disease or another cause, still find ourselves with memory lapses. And hopefully, we can continue to find ourselves, and our keys, and remember the word or name that we know so well but just is evading us, or the reason we came into this room. A colleague of mine calls this “benign senile forgetfulness”, and I guess it is benign, as long as it doesn’t progress too fast.

Aging is a process of the body falling apart. Different pieces fall apart in different people at different rates, and some folks overall do better for longer than others, but there is an inexorable downward progression. There are things that we can do to help, to slow it, to lessen the risks we face (see, for example, Jane Brody’s article on How to Prevent Falls); among the most important is continued physical activity, as vigorous as we are able to do. I tell people, with a straight face because I am serious, that when I was young I worked out to get fitter and stronger, but now I work out to just fall apart a little more slowly.

As we age we are more likely to acquire disease. These include both the diseases associated with aging (although they can occur younger ages) like Alzheimer’s and arthritis, as well as almost all other diseases that become more common and often more serious: heart disease, most cancers, diabetes, stroke, high blood pressure, influenza, etc. The real question becomes when and even whether to treat them. In youth and well into (and past) middle age we are conditioned to think of illness as curable, or at least significantly treatable. This attitude is enabled by the medical profession, that can do so much more than it used to be able to, and the health care industry, which makes money on it. And we tend to take these views into older age, even when the treatment is worse than the disease, as it often is, or there is no demonstrated benefit, and sometimes definite evidence of harm, both in treatment and even in “preventive” screening (see the CDC and USPSTF recommendations for age-appropriate screening).

Aging and its accompanying diseases and infirmities may require a change in our living situation. Options can include living with family members, or having a health aide (living in or commuting, see below), or a variety of institutional settings ranging from “independent living” (your own place, but some easily accessible help, such as available meals and nurse visits), to “assisted living” (regular meals, more nursing and cleaning help, more protected environment) to full-on nursing home (skilled) care. Given the variety of options, both in terms of “level” of care and in terms of quality and cost of provider, we should be able to depend on licensing, legal standards, and ratings. Unfortunately, we are not always able to do so.

Care Suffers as More Nursing Homes Feed Money Into Corporate Webs”, in the NY Times on January 2, 2018, documents just what the title says. Most nursing homes are owned by for-profit companies, often very large regional or national corporations, and thus there can be cuts in the quality of care (the service ostensibly being rendered) in order to increase profits. Or, looking at it the other way, every dollar spent on actually delivering care is a dollar lost to profit. The insurance industry has a cute term for this, “medical loss ratio”, which is the money lost to the bottom line by paying health insurance claims. In addition, nursing homes contract “out” for many services (food, cleaning, etc.), and management of the homes, and rent for the buildings. The companies that they contract with are often owned by the same people, but through this trick these costs now become fixed expenses, not covered by regulations governing the nursing home itself. VoilĂ ! Instant profit!

Similar problems abound in other levels of care. “U.S. Pays Billions for ‘Assisted Living,’ but What Does It Get?”, NY Times February 3, 2018, documents the low quality of care often provided to people in assisted living for whom Medicaid is paying as much as $30,000 a year (for assisted living, mind you, not even for skilled nursing services). Part of the problem in this case is that, because Medicaid is a joint state-federal program, they operate “…under a patchwork of vague standards and limited supervision by federal and state authorities.” And, again the people being cared for are the ones who suffer.

So there is good reason to be concerned about these institutions. What about home care? At least that is in your own house, right? On January 31, 2018, the Times had two articles about it. One was from Britain, although it is actually describing institutions, “home care” settings that are like small private assisted living facilities. “Britain Was a Pioneer in Outsourcing Services. Now, the Model Is ‘Broken,” discusses serious adverse health outcomes for people in “home care” there. This could be seen as a ‘gotcha’ for those of us who advocate a national health system, which Britain has, but there are some important caveats. One, of course, is that these are not “home care” in the US sense, and a second is that the fault is clearly not with having a national health system, but rather the efforts to privatize aspects of it (“outsourcing”) which has failed because – surprise – these private sector companies make more profit if they provide cheaper, read “worse”, care! The less national, government involvement, the worse the care.

The other important point is to remember the difference between how much money is spent and how it is distributed. The US spends a lot of money, but it is incredibly unequally distributed among the population. Britain distributes it much more equitably, but has (particularly under Tory governments) underfunded it, including the efforts to privatize aspects of it described in this article. Now, if the US distributed its health care funds in a manner similar to the British NHS, it could spend a lot less and the people would get a lot more!

The other article, from the US, is about what we truly understand to be home care, but its focus is not on the quality of care for patients but the difficulties confronted by the home care workers. Titled “For Health Care Workers, the Worst Commutes in New York City,” it specifically addresses the commutes (from poorer neighborhoods where the mostly-minority mostly-female home care workers live to where they work). But these workers are also poorly paid and lack benefits, often including paid time off, and ironic but true, health coverage! They are, of course, employed by for-profit companies. We depend on these people to care for our parents, or us, but like many involved in the doing-actually-important-things-that-make-a-real-difference-in-people’s-lives industries (e.g., teaching, social work, etc.) they are underpaid and undervalued in comparison to those in the let’s-make-a-lot-of-money-for-ourselves-and-the-heck-with-them industries.

Those who advocate a for-profit capitalist market as the solution to all problems, and particularly the privatization of currently government-run activities, claim that the private sector can operate more efficiently and more cost-effectively, and provide better service than a government bureaucracy. This claim usually turns out to be untrue. Such companies, particularly when gifted with government contracts, are better at making profit, especially by keeping down workers’ wages and cutting back services. When we talk about the care of our seniors, our parents, ourselves, the tradeoff between adequate care and profit is not one any of us would want to make; we want the best quality of care, period. So whether this is compromised by inadequate funding, as in the case of British home care, or (almost worse) adequate funding but excessive profit-taking by the private sector, it is unacceptable.

There is an answer. Have the structure of our society reflect the things that most people actually value. Have a well-funded national health system or a well-regulated private one, that ensures quality of care for its clients and living wages for its workers. The elimination of excessive profits (or all profit in a government-run system) would make it not only better, but still cheaper than the way we do it now, where the “care” is the “medical loss” to profit.

Tuesday, January 23, 2018

Tom Petty, the opioid epidemic and changing structural inequities in the US

In October 2017, the rock musician Tom Petty died at the age of 66. Given Mr. Petty’s history of heroin addiction back to at least the 1990s and the frequency with which overdoses seem to cause the death of celebrities, there was some early assumption that it may have caused his. This was confirmed by the coroner, (NY Times, January 19 2018); however, the cause was not heroin but rather prescription opioids (oxycodone plus 3 types of fentanyl), combined with two also-addictive anti-anxiety medicines known as benzodiazepines: “The coroner, Jonathan Lucas, said that Mr. Petty’s system showed traces of the drugs fentanyl, oxycodone, temazepam, alprazolam, citalopram, acetyl fentanyl and despropionyl fentanyl.” (The citalopram is an SSRI anti-depressant). According to a statement from his wife and daughter, he had many ailments including a fractured hip that caused him great pain.

Thus, Mr. Petty becomes another victim of the epidemic of prescription opioid-related deaths. His previous heroin addiction (chronic use of opiates or opioids leads to tolerance, requiring higher and higher doses for relief) and his stature as a rich and famous person (which seems to make it even easier to find doctors who will prescribe such drugs) may have increased his risk, but his death is one instance of a widespread American problem that has been the subject of academic articles, government reports, and opinion pieces from medical providers, patients, and the general range of pundits.

David Blumenthal and Shanoor Servai of the Commonwealth Foundation write in their report “To Combat the Opioid Epidemic, We Must Be Honest About All Its Causes” that “History offers only one other recent example of a large industrialized country where mortality rates rose over an extended period among working-age white adults: Russia in the decades before and after the Soviet Union’s collapse. The economic and social contexts have been eerily similar, and substance abuse has been a dominant factor in both countries: alcohol in Russia, opiates in the United States.” A major study by Princeton economists Anne Case and Angus Deaton in 2015, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century” (which I have previously cited, Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015) posits opioid-related deaths as a major cause of the surprising  increase in mortality rate among white Americans. Blumenthal and Servai note that “Based on weighted estimates, 92 million, or 37.8%, of American adults used prescription opioids the prior year (2014); 11.5 million, or 4.7%, misused them; and 1.9 million, or 0.8%, had a use disorder. The epidemic is spreading so rapidly that it’s likely the numbers are higher now.”

So it’s a very big problem, with many causes, and the solutions are not simple. Doctors play a big role, since they must prescribe the opioids (whether these are taken by the designated patient or illicitly redistributed). While well-known surgeon and author Atul Gawande, in an interview with Sarah Kliff on, says “We started it”, I don’t think that is completely true. Certainly doctors have been vehicles for its perpetration but there are other forces at work. One is the movement that began in the 1990s to adequately address patients’ pain, which was seen as insufficient by many critics. In many institutions pain was labeled the “fifth vital sign”, and staff were instructed to ask about pain relief in every interaction. While this is important, especially for acute short-lived pain (such as post-operative or post-traumatic), the use of opiates for chronic pain skyrocketed. The obvious problem is, as cited above, the more you have taken them the more you need; tolerance to opiate and opioid effects often requires increasing doses. The “high” resulting from these drugs (whether intended or not) increases their potential for abuse.

Long-acting opiates and opioids (such as extended release morphine or oxycodone, methadone, and fentanyl patches) are preferred as they can control pain with less of a “high”, but they still lead to tolerance. While addiction is not an issue for people who are dying of their cancer, it is for people with chronic diseases such as sickle-cell and chronic pain syndromes, most commonly in the US back pain. Opiates and opioids have been shown to be poor choices for long-term treatment of chronic back pain, but taking them is often easier and cheaper for patients than complicated (and often expensive) modalities such as physical therapy, and it relieves the pain more quickly and completely until higher and higher doses are needed. So patients, as well as physicians, are part of the problem, and physicians are working to try to help people, while complicating the problem.

Real villains include those who have originated and perpetuated this crisis only to make money. This includes insurance companies, who often deny more expensive treatments such as extended physical therapy or drugs such as buprenorphine, essentially pushing doctors and patients into the use of opioids. They certainly include the pharmaceutical companies who have developed and heavily marketed these drugs, notably the Sackler family who owned Purdue and made and pushed Oxy-Contin®, as documented in the New Yorker article “The family that built an empire of pain” (October 30, 2017). In brief, they acquired the rights to long-acting morphine, but because this was losing its patent protection (and thus its profitability), they developed a long-acting form of oxycodone, which was patented and thus more profitable. Counting on the negative associations that the public and even physicians associated with morphine, they pushed Oxy-Contin, which was at least as addictive and dangerous, for an ever-expanding list of chronic conditions. Back pain, of course, was the target market, and it soon seemed as almost everyone had an indication for opioids. And we have since been paying the price with their deaths.

The flaws of capitalism that directly drove and continue to drive this epidemic through the pursuit of profit should be clear enough. The structural flaws that have and continue to ruin the lives of so many Americans (not to mention people in the rest of the world) may be less obvious but are no less real. The dramatic redistribution of wealth from the vast majority of us to the already-wealthiest, with the concomitant decrease in the quality of life for so many, proceeds apace. The 1%, maybe even the 5%, are doing great, although the biggest benefit (including from the new GOP tax “reform”) law goes to the 0.1% or less. The richest 1% now owns half the world’s wealth and the 8 richest men have as much as half the world’s population!  Worldwide, it is those in the poorest countries that suffer most. In the US, it remains minorities. While the shocker in the Case and Deaton study was the fact that white mortality is increasing, the fact remains that minorities, especially African-Americans, still have far higher mortality rates.

If we wish to decrease this excess mortality, it certainly will be important to address the opioid crisis, by physicians becoming more reticent to prescribe long-term opioids for chronic conditions, patients to accept alternative treatments, and insurers being willing to pay for those treatments. It will also be important to address other chronic addictions, like alcohol (Blumenthal and Seervai observe that while “11.5 million, or 4.7%, misused them [opioids and opiates]; and 1.9 million, or 0.8%, had a use disorder…By comparison, there are 17.1 million heavy alcohol users among adults over 18.” Legal does not mean safer, whether we are talking alcohol abuse or “legitimized” (by prescription) opioid abuse. It most often reflects the relative power of the industries that financially benefit.

The core problem is in the unfair, unjustifiable, and oppressive structural inequities in our society. These are so deeply seated that we often assume they are inevitable, and that there is no other way. There is. We may not be able to eliminate inequality, but if we are to seriously address the epidemic of unnecessary deaths, we need to do more than treat the symptoms; we must grapple head-on with and change our society’s structure. 

Tuesday, January 2, 2018

The Future of ACA and Health Care for Americans: We need Medicare for ALL!

It’s a new year. 2017 ended with the GOP passing a landmark tax bill that will provide huge long-term windfalls to corporations and the very, very rich, but little and time-limited benefit most folks. “Most”, in this case, being the vast majority. The “99%” probably underestimates it. Hey, how about I give you $10 once and you support my getting $1,000 a year in perpetuity? Well, why not? At least I get my $10. Except, whoops, you’ve raised prices on me by $20 a year.

The Republicans just missed out on their repeal of the Affordable Care Act in 2017, but there is a strong possibility they’ll try again in 2018. The decision will certainly be made on political grounds; maybe they’ll want to do it while they have a one-vote majority in the Senate if they think they might lose it. On the other hand, maybe doing it will increase the likelihood of them losing even more Senate seats. Tough one; you know the American people will stand for a lot of screwing-over, but it may be possible for you to push it too far.

In the meantime, however, the Trumpenik administration has slashed subsidies for people getting coverage on the federal exchanges. The President himself tweeted on December 26, 2017 that the “Tax Cut Bill…essentially Repeals (over time) ObamaCare”. It didn’t, but it did make it much more difficult for many Americans to obtain health insurance, and most of them are in states that voted for Trump and the GOP. As CBS reported on the same day, 80% of the 8.8 million newly covered are in these states. The four states with the highest enrollment, totaling 3.9 million, were Florida, Texas, North Carolina and Georgia. While these are states all went for Trump in 2016, all but Texas are in danger of going Democratic in the future. Florida has long been a swing state (remember the hanging chads of 2000!), NC is probably flippable in a presidential election (although, barring a court ruling overturning it, amazing gerrymandering will protect Republican House seats there), and Georgia is changing quickly. Of the 11 states with the biggest increases in enrollment, 8 voted Republican (Iowa, Kansas, Kentucky, Missouri, Nebraska, North Dakota, South Dakota and Wyoming). So cutting subsidies for buying insurance on the exchanges is a great way to punish your base.

There is even a school of thought that believes the cutbacks in funding for purchase of private insurance, along with the dramatic expansion of Medicaid (in the states that have done so), creates the opposite of GOP intentions, a more publicly-funded health insurance system. This topic is addressed in the NY Times article “Years of Attack Leave Obamacare a More Government-Focused Health Law” by Robert Pear, also on December 26. While only about 10 million have gotten coverage by private insurers through the exchanges, and this will drop as both the individual mandate and subsidies are eliminated, over 75 million people have benefited from Medicaid expansion. The “Medicare for All” movement advocated by Sen. Bernie Sanders is gaining increased momentum in many states (for example, Maine, where it may be pushed over the resistance of the Republican governor), as people increasingly realize that this is their only protection. Eliminating the mandate means healthy people will not buy insurance that they can no longer afford without subsidies, so that the cost of insurance for sick people will become truly unaffordable. If they do not qualify for Medicaid, they will be plumb out of luck, unless Medicare is expanded to cover everyone.

Some advocate for gradual expansion of Medicare, rather than going straight for Medicare for All, by extending it to those over 50 or 55 first. This is most often heard from “mainstream” (“centrist”) Democrats (the Republicans care about the health of the American people not at all), who have been most remarkable for their tentativeness and cautious incrementalism when in power, as opposed to the Republicans’ aggressiveness. And, while expanding Medicare to cover everyone is the simplest and most straightforward route to a single-payer insurance system, it must be an “improved and expanded” Medicare for all, as advocated and detailed by groups such as Physicians for a National Health Program (PNHP). Without this improvement people may legitimately fear an underfunded health system that requires major out-of-pocket expenses, that restricts access to certain procedures and specialties even when medically indicated, and that is more focused on cost-cutting than on health care.

Incremental efforts, such as gradually ratcheting down the age of Medicare eligibility, may seem to be tactically good ideas, but in fact they are silly and likely to cost more both in dollars and in worse health outcomes. Medicare, despite its limitations in funding, has made a phenomenal difference in the health of those eligible since its introduction in 1965. Those who receive Medicare now, the aged, blind and disabled, are the population with the greatest health care needs and costs. However, as physicians we regularly see those just under the age of 65 but with chronic illness suffering serious health outcomes and costs until they become eligible. While lowering the age to, say, 55 would enroll many of those with greatest need, there would always be people with need just below the age cutoff. More important, as the age of eligibility goes down, the marginal cost per covered life also goes down, because younger people are healthier. What makes sense is to simply wrap everyone together, getting both the benefit of an overall healthier younger population paying in and using little care and not excluding individuals of any age who (from chronic or acute illness or accident) do need care.

The day after all these appeared, December 27, a British physician named Rachel Clarke (@doctor_oxford), author of the current [British] Sunday Times bestseller “Your Life in My Hands”, posted a note on Twitter about her father dying of cancer after a long illness. “One major surgery,” she wrote, “countless chemotherapies, & a small army of community and palliative nurses so that he could be at home with us.”  She continued: “The bill? £zero. Grief, pain, emptiness – but not bankruptcy. Thank you, #NHS.”  How many of us could say the same in the US? Some, perhaps many, of us; those with money and good insurance, which is becoming increasingly rare. But MOST of us could not.

The lives of all of us, the health of all of us, and the commitment of society and government to the health of all of us, is what is at issue here. The Republican Party and its leader have demonstrated their clear and persistent opposition to it. And it is all of us, including their voters, who are suffering and will continue to suffer for it.

Wednesday, December 13, 2017

Are resident doctors unhappy? Why?

In a New York Times “Upshot” piece on December 7, 2017, Dhruv Khullar notes that “Being a doctor is hard. It’s harder for women”. I do not doubt it, especially the second part. Dr. Khullar goes through a host of reasons for why it is harder for women, most of them related to sexism (including internalized sexism) such as having children, having the bulk of the responsibility for maintaining a household, being seen as less smart or competent by supervisors and colleagues, and on and on. The idea that “being a doctor is hard” is also one I can agree with. However, Dr. Khullar’s piece focuses mainly on residents, medical school graduates who are in specialty training. He opens it with a parody of Tolstoy’s Anna Karenina: “Happy medical residents are all alike. Every unhappy resident would take a long time to count.”

This is where I take issue, at least a little, with his perspective. Mainly this is because I do not remember being unhappy as a resident several decades ago. Tired, often, but not unhappy. I liked the work I did, as a family medicine resident at Cook County Hospital in the late 1970s, both caring for patients in the hospital on a variety of specialty services and in our hospital and community-based outpatient practices. I liked my colleagues, in family medicine and in other departments, and liked working with them. I learned a lot from them. I don’t recall most of my colleagues being unhappy either, and checked with a few with whom I am still in touch, and they also do not recall being unhappy. One, indeed, said he wasn’t even that tired, as he slept through most noon conferences!

There were not only fewer women residents and medical students, but they were (in my  experience) less likely to be married and have children. A small minority of students in my medical school class were married, but now it is common. I married (another resident) and we had our first child during residency, but when I was a program director, the majority of my residents were married by the time they started (I remember a year when five women started the program with different last names than they had interviewed with).

Yet several studies do tend to support Dr. Khullar’s assertions about residents in general being unhappy, as well as feeling overworked, and I think my experience as a family medicine program director and that of one of my colleagues (and former wife) as an internal medicine program director, support the idea that more recent residents seem unhappier, at least compared to us, then, at that hospital. There could be many reasons for this, including the possibility that memory is inaccurate, and distance dulls the pain, but I don’t think that this is the main one.

Another reason could, theoretically, be that the work was less or easier back then. Indeed, at Cook County Hospital in the late 1970s most residents had every-fourth-night call, a direct result of having a residents’ union in the hospital that negotiated working conditions. Dr. Khullar asserts that “The structure of medical training has changed little since the 1960s, when almost all residents were men with few household duties.” I think that he is wrong about this. Residents who trained in the late ‘60s and early ‘70s, before me and the union, often had every other night call (yes, work all day and all night and the next day, then go home and crash and come back to work). There is a reason that these doctors in training are called “residents” and “interns”; Cook County had a residents’ residence, where many actually lived and all had “call rooms” where we could get, maybe, a couple of hours rest. Although call was every 4th night, there were no other “hours rules”; Cook County had 16 medical services, with 4 taking call every 4th night and taking every 4th admission, and the two interns on each service thus taking every 8th, but this could easily be 10 or more patients per intern per night. And one didn’t get to go home the next day at a certain time even though other services were on call. One specific example was CT scans; Cook County Hospital didn’t have one then, but the private hospital across the street, Rush, did. We could take our patients there, but only at night, when they were finished with their routine scans, and the patients had to be accompanied by the Cook County intern caring for them. Often at midnight, the night after they had been admitted. Residents also did most of the work; attending physicians were not in the hospital at night, and in the day had time only to round on new admissions and those who were very sick. Even having every 4th night call was a big change from every other or 3rd night, but I do not think we had less work than most residents have today.

My point is not to try to disparage the tiredness or unhappiness of more recent residents by citing the “bad old days” when things were worse and we had to walk to school in the snow uphill both ways (although the weather was worse in Chicago then, thanks to global warming, and it was possible in winter to arrive and leave in the dark, and thanks to the system of tunnels under Cook County never see the sun). It is simply to note that workload is not the sole, or main, determinant of whether residents are happy or not. And here I can just speak from my limited experience. Many of us who were residents at Cook County Hospital were there for a reason. From the several Chicago medical schools and those further afield, we came because we were committed to providing the best possible care for people who were poor, underserved, and often ignored. We knew, and daily had reinforced, that our best efforts could not make up for the impact of poverty and discrimination; that despite the fact that the hospital did not charge patients, even for outpatient medications (although they had to wait hours for their prescriptions to be filled) the obstacles to their health were enormous. But we, most of us, cared, and tried to do our best. Our residency was not just a step on the path to a career as a successful physician, but an opportunity to work with and try to help people who had real need. We had a mission, not necessarily in the religious sense (although many who came as residents to Cook County were inspired and motivated by their religious convictions).

And, as a result of this shared mission we were each others’ greatest support, personally as well as medically. Medically, the 4 services with 4 residents, 8 interns, a chief resident, and medical students, shared an “admitting ward”, as so we were all together, to consult, to review x-rays, and help with procedures. But personally, we could reinforce each others’ beliefs, and provide support, succor, and even inspiration. I think that was the biggest part, for me at least.

Certainly, my experience at Cook County may not have been typical for residents of the era (indeed, that is part of why I chose it). Certainly, there were unhappy residents then, and uncommitted residents then, and women residents who were burdened with the care of the household and children. And, as certainly, there are now and have been ever since, happy and committed and inspirational residents. I guess “if you’ve seen one, you’ve seen one”. But I am pretty sure that a commitment to something greater than yourself and your self-interest helps a lot, as does training in a place where many of your colleagues feel the same way. And maybe that’s a lot of what we need as doctors, not just residents.

And as people.

Wednesday, November 15, 2017

Black men being killed by police: A public health epidemic

“Let’s do it to them before they do it to us,” was the line with which Sgt. Stan Jablonski (played by Robert Proskey) dispatched his troops on the old TV show Hill Street Blues. When Sgt. Jablonski replaced Sgt. Phil Esterhaus (on the death of actor Michael Conrad) they had to come up with a replacement for Esterhaus’ “Let’s be careful out there”. Perhaps the show’s writers felt it was ok coming from the shorter, pudgier actor than the 6’6” Conrad, but it has a very different meaning and very different connotation, an “us against them”.

Presumably the “them” was bad guys, not the regular folks that the police were supposed to be there to “protect and serve” but now, 30 years after the show went off the air, we realize how much this was, sadly, prescient. I am not going to recite the names of all the black men – and children – killed by police in recent years, including Tamir Rice, Michael Brown, Freddie Gray, Philando Castile, but it is an epidemic. Yes, more white people have been killed by police than black in both 2016 and 2017 – about twice as many – but the proportions are way off given that just over 12% of the population of the US is black. And what has been even more graphic is the lack of convictions, and frequently even prosecutions, of the perpetrators.

If these deaths were not at the hands of police, but rather had a different cause – an odd virus that struck down black men when being confronted by the police, or a very selective alien attack, we would not hesitate to call it an epidemic and search for the cause. But this issue is political, it is personal, it is an “us” against “them”, raising the issue is seen by many to be attack on the police, who heroically and at great risk to themselves protect us from evil. Certainly, the Governing Council (GC) of the American Public Health Association (APHA), by far the largest public health association in the nation, did not choose to identify the killing of black men by police as a public health epidemic when it voted, 65%-35%, against a resolution so designating it at the recent meeting in Atlanta. The resolution had been introduced a year before, and sent by the GC back to the authors to make changes to the language, which was done. But it was not sufficient.

If it was the language, felt, for example, to be denigrating to police, that was the issue, members of the group could have introduced and passed amendments to correct it. This point was made (after the vote) by APHA immediate past President Camara Jones, MD MPH PhD. But it was not the issue; the GC (and thus, the APHA) did not want to take a stand identifying the killing of black men by police in the United States as a public health epidemic. Speakers against the resolution cited personal but irrelevant concerns like “my brother is a policeman, and he is a good man”, as well as saying “the data is not sufficient to make the case that it is an epidemic”, which is patently false. The vote was portrayed as a scientific decision, but it was clearly a political one, a decision by the overwhelmingly white group to put their fingers in their ears, their hands over their eyes, and shut their mouths rather than standing up and saying “this is a problem”.

Many of these killings have been of people (usually men, but sometimes women or children) who were not involved in committing crimes. They result from the heightened suspicion police hold of black people in general. If you don’t believe that, you’re probably white. Just before the vote, I was at an session at the meeting discussing police violence against black men. Most of the group was minority (predominantly black) and were relatively young public health professionals, students, and junior faculty in schools of public health. A couple of speakers introduced the issue, but then opened the floor. One by one, in random order, unrehearsed, person after person in the group talked about their fears and their experiences; these were not prepared in advance, but slowly came out, one giving rise to another. A government employee noted that she had two young sons, and worried about their safety. Another woman, a public health professional, noted that her flight to Atlanta departed at 5:30am, so she’d left her home in a mostly-white suburb at 3:30am to go to the airport. She was followed by a police car all the way into the city. Another woman, a professor, talked about driving to a neighboring state and being followed by a police car that eventually stopped her for no reason or violation; in the process the officer asked “if you’re a teacher, why aren’t you in school?” The stories went on and on, from the mouths of professional people, most of them, in fact, women. 

Although many people would disagree, often virulently in with this age of Trump giving loud voice to aggrieved white men, being white in America is a privilege. It is a privilege of not thinking that you will be followed by police, or pulled over by them, or subjected to inappropriately probing questions by them. It creates an illusion, obviously held by the majority of the GC of the APHA, that it is mostly criminals, or “probably-criminals”, or people who look like they might be criminals, who are followed by, stopped by, and sometimes killed by police. But that is not the experience of black people in this country, not the black men shot by a police officer who makes up a story about being threated, nor of the middle-class professionals who told their stories at that APHA session. It is not the experience of the young woman who drove me to the Atlanta airport from the conference; in talking she said she had a 3-year old son and I asked if she feared for his safety not just from gangs but from police. In response she said she did, and pointed to a button hanging from her rear-view mirror and said “my uncle was killed by the police 3 years ago”. I don’t know what occurred with her uncle beyond what she told me, but I suspect it is not fate, coincidence, or Kismet that caused my driver to have her own story to tell, but rather the ubiquity of this experience among black people in America.

What about the police? Don’t we have to worry about the safety of the people who risk their lives each day to protect us? What about the fact that there are many (if not enough) minority police officers? To identify the current situation, not only the killings but the very real sense of most black people in this country that they do not have the same rights as whites, that they are, by definition, “suspicious” because of their color, does not require denigration of all police officers. Indeed, the families (especially male family members) of black police officers, and even the officers themselves when off-duty, experience the same indignities (and worse) as other black people.

It does mean that the idea that a police officer’s first loyalty is to other officers rather than to the community that they “protect and serve” must be very narrowly construed. Rather than a “thin blue line” of brothers (always, it seems, brothers, not sisters), it means that we should have tighter standards for police, excluding those who are overtly and viciously violent and racist. It means better training in identifying a situation in which you see through your prejudice and not through reality, and how to de-escalate. It means that when an officer kills a person innocent of a crime, it is not enough for other officers to have not “done it”; they must, if they were unable to prevent it, disclose it and discourage it and, yes, testify against the perpetrator. Police officers who do so are not “traitors”, they are heroes who allow the force to be thought of as we want to think of them.

The fact that even the most respectable and middle-class black people have to fear interactions with police (even when they are the ones who have called them!) is a societal scandal. The enormously disproportionate killing of black men by police is an epidemic, and like all epidemics we must identify it as such, find the cause, and treat it.

Even the APHA should be able to acknowledge that.

Wednesday, November 1, 2017

Making contraception easy and available: we are going in the wrong direction!

It is 2017. It is more than 100 years since Margaret Sanger advocated for contraception, and more than 50 years since the oral contraceptive pill became available. The last two generations of women – and men – have never known a world where there was no effective form of contraception. They probably do not recall when even condoms, although “over the counter” (in that no prescription was required) were stocked “behind the counter” and required requesting them from the pharmacist often with (if you were young) a disapproving glare, and maybe worse, a raft of questions.

The verbal and physical indignations and worse, including even murder committed on unmarried women who got pregnant and were unable, of course, to have access to abortion should be things of the past. They are, horrifically documented in Dan Barry’s New York Times piece “The Lost Children of Tuam”. The film “The Magdalene Sisters” shows the intolerable treatment of girls who may not have even gotten pregnant but were, perhaps, just a little too familiar with boys. Both the Magdalene laundries and the mother-baby home in Tuam were in Ireland, which was perhaps extreme in the poverty, ignorance, and fast ties to the Roman Catholic Church, but the treatment of women in England and the US were also inexcusably harsh. The British drama “Call the Midwife” tells the story of an unmarried teacher who gets pregnant in the early 1960s and is fired from her job (morally unfit to care for children!), tries to self-induce abortion with a coat hanger, and almost dies. Finally, post-hysterectomy so that she will never be able to have children, she is driven out of town. The most sympathetic characters in the show see it as sad, but none indicate it is horrific, immoral, and inhuman. And this was commonplace, even in the 1960s and beyond.

We should not, in 2017, even be discussing the availability of contraception, not to mention whether it works. Amazingly, we are. Teresa  Manning, appointed by President Trump in May to be the director of the Office of Population Affairs, the main family planning arm of the federal government, is not only a former employee of two anti-abortion groups, but has expressed skepticism of the effectiveness of contraception itself! Manning, a lawyer and not a health professional (although this is not an excuse), is completely wrong. The data is in. Contraception dramatically decreases unplanned pregnancy (regardless of marital status). Time recently ran an article accurately describing the science titled “No, birth control doesn’t make you have riskier sex”. That is the truth, but in fact, even if it is was associated with riskier sex for some people, that would be no reason to restrict access to it. The more contraception is available, the lower the rate of bad outcomes of virtually all kinds. It even, of course, reduces the rate of abortion; in fact, the only two things ever to have been shown to significantly reduce the rate of abortion are comprehensive and accurate sex education and easy and cheap availability of contraception. Indeed, the degree to which contraception is effective in decreasing the incidence of unplanned and undesired pregnancy is directly related to the ease of its availability, including financial availability. Unsurprisingly, reducing the cost of and increasing the ease of access to contraception has the greatest impact on teens and on the poor.

So it is amazing that, in what The Atlantic refers to as “one of its boldest moves yet” (I don’t think that they meant it was positive, but “cowardly”, as well as “stupid” and “reactionary” come to mind as better adjectives) has reversed the ACA’s requirements that employers and insurers provide contraception at no cost to women. Politically, it is part of the administration’s efforts to dismantle the ACA piece by piece, since they were unsuccessful in doing it as a whole. Morally, it is an imposition of a minority’s religious values on the rest of us, and is particularly ironic being spearheaded by Donald Trump. It will cause great harm to individual women (and men) and to the society as a whole. Arguments that the cost of contraception is “only” $50 a month may wash with those in the middle class and up, but for poor women and teens, $50 a month is a lot. The most effective methods of contraception, IUDs and implants (collectively referred to as LARC, long-acting reversible contraception) may have a lower amortized cost over the use period but a high upfront cost that is unaffordable, without subsidies, for many women. (The reason, lack of cash on hand, is the same one that leads many poor families, as described by Barbara Ehrenreich in her wonderful and depressing book “Nickel and Dimed”,  to live in expensive weekly motel rentals – the overall cost may be more than an apartment, but the upfront cost, including deposits, rent in advance, etc., is prohibitive for them.) The impact on the teens who will be denied free access is described movingly by a pediatrician in Vox.

The other important impact of such a policy would – and perhaps will -- be on the economy. This is articulately addressed in a column by Bryce Covert in the NY Times, October 29, 2017. The reasons start with individual women, and the cost of purchasing birth control, money which will not be available for them to spend on other goods – with more than 57 million women using contraception, in one year that is $1.3 billion. But the larger impact is societal – women who cannot control their own reproduction, who do not know when and if they will get pregnant – are in a poorer position to contribute to the workforce and to the economy. Again, going back to the history I address at the start of this piece, we know this empirically, not just theoretically:

… a raft of evidence has definitively found that when women gained greater access to the pill in the late 1960s and early ’70s, they were able to delay marriage and childbirth and invest in careers through education, job training and staying in paid work….Legal access to the pill transformed the economy in that era. It increased young women’s labor force participation by 7 percent….about a third of the increase in how many women attained careers in fields like law and business was due to birth control. Women with earlier access to the pill also made 8 percent more than their peers, and the pill was responsible for about a third of the decrease in the gender wage gap by 1990.

And it is still critical. Perhaps Trump himself is just cynically pandering to his base, and probably much of that base depends upon contraception, women directly but men just as much. Opposition to contraception cannot be justified except by the small minority of religious purists (and of course they are welcome to not use it); opposition to making contraception easily and freely available is almost as bad, as it is completely discriminatory. It is still, as Covert describes,

…still playing the economic role that it did in the 1970s. About half of women who use it say they do so to complete education or to get and keep a job. Contraception is still increasing the share of women who get educated and get paid work, particularly prestigious jobs.

Easy and affordable (affordable for all those who need to use it, not just billionaires or even the upper middle class!) is not a “women’s issue”, it is not a “special interest” issue. It is a core need for people. People with the views of Teresa Manning should not be given center stage, and certainly not given authority over contraception. We need to guarantee permanent access to contraception for all, and for accurate sex education. 


Sunday, October 22, 2017

Guns and the Public's Health: what can we do?

 "A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed."

Recognize those words? The Second Amendment to the Constitution of the United States, what all the fuss is about. In addition to the confusing use of commas, apparently more generously applied in the 18th century, we have two key phrases. The final phrase, “shall not be infringed”, is read by the NRA and other “gun rights” zealots (and it is important to remember that only a minority of NRA members, and a smaller minority of gun owners, support this position) to mean essentially “no legislation regulating guns in any way”. That includes assault rifles, semi-automatic and maybe even automatic rifles, armor-piercing (“cop killer”) bullets, and any other weapon or gun modification that creative minds can come up with. Of course, it has been noted that none of these types of weapons were available at the time of the Constitution, when firearms were muzzle-loaded muskets, quite different from current weapons (see graphic).

The NRA take the position that there is qualitatively no difference, as noted by its President, Wayne LaPierre, after the December 2012 massacre at Sandy Hook Elementary School: "Absolutes do exist. We are as ‘absolutist’ as the Founding Fathers and framers of the Constitution. And we’re proud of it!" Others (including me, in case you were wondering) would disagree, and say that clearly at some point the quantitative difference becomes qualitative. This is the only amendment they are absolutist about; the First Amendment says “Congress shall make no law… abridging the freedom of speech…”, but it has long been settled that it is not OK to yell “Fire!” in a crowded theater.

The other obviously important phrase is “A well regulated Militia”. Again, obviously, this has been the source of much discussion, with the NRA taking the position that “Militia” just means “everyone” (kind of a stretch), and (as far as I can tell) “well regulated” means, um, not regulated at all. Is this cherry picking the words one wants? Maybe, but I can’t imagine how it is possible to ignore completely the words “well regulated”. But does it matter? Yes, when we live in a country where
The 36,252 deaths from firearms in the United States in 2015 exceeded the number of deaths from motor vehicle traffic crashes that year (36,161). That same year, the US Centers for Disease Control and Prevention reported that 5 people died from terrorism. Since 1968, more individuals in the United States have died from gun violence than in battle during all the wars the country has fought since its inception.
-Bauchner et al., Death by Gun Violence—A Public Health Crisis, JAMA, October 9, 2017[1]

Those are staggering numbers, and certainly justify the assertion that it is a “public health crisis”.

The authors also note that “60.7% of the gun deaths in 2015 in the United States were suicides, a fact often ignored. That is a majority. A large majority. If it were an election, 60.7% would be considered a landslide. But with guns it is a mudslide of death. I have written before about suicide (e.g, Suicide: What can we say? December 13, 2013, Suicide in doctors and others: remembering and preventing it if we can September 14, 2014, Prevention and the “Trap of Meaning” July 29, 2009) and its impact on myself and my family, with my son’s successful suicide-by-gun at the age of 24. My son, to my knowledge, had never used a gun before his final act. He lived in a state and city with strict gun control laws (some of which, sadly, have been eliminated by the courts). He was nonetheless able to go to another state, buy a carbine (terrific choice! No permit needed, even in those days, like a handgun would require, but short enough to reach the trigger with the barrel in his mouth!), and use it. It would be easier now, in that state and many others.

My son was apparently very committed to this act, and was successful despite some obstacles. But for many, many people it is the availability of guns that make a spur-of-the-moment decision lethal. I have noted before that nearly 95% of suicide attempts by gun are lethal while less than 5% by drug overdose are. My clinical experience is that many suicide survivors do not repeat their attempts (though many do). The successful suicide rate for young adult males in low gun control states is several times higher than in high gun control states. And on and on.

But the epidemic of suicide and murder and mass murders resulting from the easy availability of guns has not changed the legal landscape. After the Las Vegas massacre, there was a small ray of hope that maybe one of the most egregious products the white terrorist Stephen Paddock used, the “bump stocks” that effectively convert semi-automatic to automatic rifles, might be limited; even the NRA voiced some possible support. But never underestimate the cowardice and lack of moral fiber of the Congress; Speaker of the House Paul Ryan has suggested that this be done by regulation rather than legislation. This is absolutely because it will not require any congressperson to actually vote for it and thus be targeted by the zealots in the next election. Hopefully, not literally targeted by guns, but do not forget Gabby Giffords and Steve Scalise!

Dr. Bauchner, who is the editor-in-chief of JAMA, also joined the editors of several of the other most prestigious US medical journals, New England Journal of Medicine, Annals of Internal Medicine, and PLOS Medicine in an editorial that appeared in all their journals (this link is the the NEJM), ‘Firearm-Related Injury and Death — A U.S. Health Care Crisis in Need of Health Care Professionals’.[2] Again, this emphasizes the fact that guns are a public health epidemic in the US, and that there is little likelihood of anything being done at the federal level to stem its carnage. It recognizes that there is a variable response at the state level, with some states going as far as trying to legally prohibit physicians from asking about guns in the home (Florida; since struck down by the courts) while others have had stronger regulations. Many legislatures have also acted to prevent the cities in their states from acting independently to regulate guns in any way. One of the most insane was the state of Arizona suing to prevent the city of Tucson from destroying guns seized from criminals. The legislature mandated that they be sold – thus keeping them on the streets – and the Arizona Supreme Court upheld this, saying state law trumped local ordinances!

Given this situation, the joint editorial suggests that there are many things that physicians can and should do, including (quoted):
·        Educate yourself. Read the background materials and proposals for sensible firearm legislation from health care professional organizations. Make a phone call and write a letter to your local, state, and federal legislators to tell them how you feel about gun control. Now. Don’t wait. And do it again at regular intervals. Attend public meetings with these officials and speak up loudly as a health care professional. Demand answers, commitments, and follow-up. Go to rallies. Join, volunteer for, or donate to organizations fighting for sensible firearm legislation. Ask candidates for public office where they stand and vote for those with stances that mitigate firearm-related injury.
·        Meet with the leaders at your own institutions to discuss how to leverage your organization’s influence with local, state, and federal governments. Don’t let concerns for perceived political consequences get in the way of advocating for the well-being of your patients and the public. Let your community know where your institution stands and what you are doing. Tell the press.
·        Educate yourself about gun safety. Ask your patients if there are guns at home. How are they stored? Are there children or others at risk for harming themselves or others? Direct them to resources to decrease the risk for firearm injury, just as you already do for other health risks. Ask if your patients believe having guns at home makes them safer, despite evidence that they increase the risk for homicide, suicide, and accidents. [this is what the Florida law would have made illegal]
·        Don’t be silent.

The first (JAMA) editorial says:
Guns kill people….the key to reducing firearm deaths in the United States is to understand and reduce exposure to the cause, just like in any epidemic, and in this case that is guns.

The fact is that while physicians have influence and moral authority, so do other health professionals, and, in fact, so do all of us. So the advice must pertain to all of us.

Don’t be silent.

[1] Bauchner H, Rivara FP, Bonow RO, Death by gun violence—a public health crisis, JAMA online Oct 9, 2017, doi:10.100/jama.2017.16446
[2] Taichman DB, Bauchner H, Drazen JM, Laine C, Peipert L, Firearm-Related Injury and Death — A U.S. Health Care Crisis in Need of Health Care Professionals’, October 9, 2017DOI: 10.1056/NEJMe1713355

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