Tuesday, November 24, 2015

Polypharmacy: Over-Medicating Patients

While describing the threats faced by the elderly in his book Being Mortal: Medicine and What Matters in the End, Atul Gawande makes this comment on the probability that a broken hip will occur due to a fall.

“Each year, about 350,000 Americans fall and break a hip.  Of those, 40 percent end up in a nursing home, and 20 percent are never able to walk again.  The three primary risk factors for falling are poor balance, taking more than four prescription medications, and muscle weakness.  Elderly people without these risk factors, have a 12 percent chance of falling in a year.  Those with all three risk factors have almost a 100 percent chance.”

Note the recognition given to taking more than four prescription medications as a risk factor.  Even to be recognized as a risk factor means that taking five or more medications must not be unusual for the elderly.  If combining multiple medicines (polypharmacy) is such a serious risk factor for causing falls, then one would expect it to cause other problems as well.  One has to wonder just how common is it to be medicated at such levels.  The answer will be that it is very common.

Medications are rarely tested in combination with other medications as part of the drug approval process.  Consequently, whenever a patient is prescribed two or more medications at the same time, she is participating in an experiment.  The only way to know if there might be serious risk from such a combination is for the patient to report symptoms and have them entered into a data base.  Adverse effects could be subtle, and might take decades to become apparent.  Even if a known issue is involved with combining two drugs, they may have been prescribed by different doctors who might not be aware that both drugs are being taken.  When five or more drugs are being taken concurrently, the probability of producing adverse effects climbs rapidly.

Ezekiel J. Emanuel provided a relevant observation in his curiously titled article in the New York Times: Are Good Doctors Bad for Your Health?  He presented this seeming contradiction.

“One of the more surprising — and genuinely scary — research papers published recently appeared in JAMA Internal Medicine. It examined 10 years of data involving tens of thousands of hospital admissions. It found that patients with acute, life-threatening cardiac conditions did better when the senior cardiologists were out of town. And this was at the best hospitals in the United States, our academic teaching hospitals.”

“Truly shocking and counterintuitive: Not having the country’s famous senior heart doctors caring for you might increase your chance of surviving a cardiac arrest.”

Emanuel has no clear explanation for this result, but he suggests that heart doctors become famous by doing daring and risky things.  Therefore, it may mean that when the heart doctors most likely to do daring and risky things are not around, the patients are better off.

To support the notion that over intervention by doctors may be a problem, he provides the results of a study of medications prescribed to the elderly.

“This is not the only recent finding that suggests that more care can produce worse health outcomes. A study from Israel of elderly patients with multiple health problems but still living in the community tried discontinuing medicines to see if patients got better. Not unusual for these types of elderly patients, on average, they were taking more than seven medications.”

“In a systematic, data-driven fashion, the researchers discontinued almost five drugs per patient for more than 90 percent of the patients. In only 2 percent of cases did the drugs have to be restarted. No patients had serious side effects and no patients died from stopping the drugs. Instead, almost all of the patients reported improvements in health, not to mention the saving of drug money.”

It is likely that the results in Israel would be duplicated in the United States. 

Information on prescription levels in Medicare patients can be found in The Dartmouth Atlas of Medicare Prescription Drug Use.

“In general, total prescription drug use is high among Medicare beneficiaries enrolled in the Part D program. The average Medicare patient enrolled in Part D filled 49 standardized 30-day prescriptions in 2010; however, the number of prescriptions filled per patient across hospital referral regions varied by a factor of more than 1.6….The average beneficiary in Miami, Florida filled about 63 prescriptions in 2010, while the average beneficiary in Grand Junction, Colorado filled just 39 prescriptions.”

If one assumes that all drugs are taken continuously for chronic conditions, the average is about four medications taken concurrently.  The average number varies by region from a low of about three, to a high of about five.  That fact in itself suggests that the prescription of some medications is arbitrary and probably provides no positive effect.  This method of tracking by prescription levels is also likely to underestimate the actual medications that are being used in combination.

This article provides another perspective: How Many Pills Do Your Elderly Patients Take Each Day?

“….the average elderly patient is taking more than five prescription medications; the average nursing home patient is taking seven medications.”

The article contains a discussion with a physician named Aubrey Knight who is experienced in dealing with the elderly.  He provides a warning about the danger of what he refers to as “the prescribing cascade.”

“With more than 15% of hospitalizations involving elderly patients caused by or related to adverse drugs reactions, and the increased risk of drug-drug interactions or adverse drug reactions associated with polypharmacy, Knight noted it is especially important to be aware of what he called ‘the prescribing cascade’ with elderly patients, wherein the side effects from one prescription medication beget a prescription to counteract them, which leads to more side effects, and still another prescription, and so on and so forth.”

Knight also warns that the elderly do not respond to drugs in the same way as the younger members of the population.

“When treating elderly inpatients, physicians should anticipate a 50% risk of adverse drug reactions (ADR) among patients who are on five or more medications, and weigh the use of high-risk/low-benefit drugs against the increased possibility of ADRs. The care team should also conduct a thorough medication review at admission and discharge to avoid polypharmacy.”

Knight clearly believes that we are too careless when prescribing drugs for the elderly, and, in so doing, causing harm. 

He added this advice to those responsible for the care of the elderly.

“….given what we know about the effects of polypharmacy in the elderly patient, any symptom in an elderly patient should be considered a drug side effect until proved otherwise.”

“ ….heed Osler’s dictum that ‘a medication is a poison with a desirable side effect’ and advised that physicians ‘consider medication as a possible problem, and not just as the solution’ when prescribing medications for elderly patients with multiple chronic conditions”

And we should remember, polypharmacy and “the prescription cascade” are issues for all of us, not just the elderly.

Friday, November 20, 2015

Aging: Dealing with Slowly Falling Apart Yet Finding Happiness

Atul Gawande has produced a must-read book on dealing with our inevitable mortality: Being Mortal: Medicine and What Matters in the End.  Gawande, a practicing surgeon and an excellent author and commenter on medical issues, is appalled by the way we have allowed the act of dying be framed not as a very personal social issue, but as a medical issue.

“You don’t have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help.  The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit.  They are spent in institutions—nursing homes and intensive care units—where regimented, anonymous routines cut us off from all the things that matter to us in life.  Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict upon people and denied them the basic comforts they most need.  Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.”

For those who are in a “fragile” state and unable to care for themselves, there are better options than warehousing them in facilities modeled on penitentiaries. Some patients may wish to experience any pain and discomfort in order to try and squeeze a few more months out of their lives; others might wish to spend their last few months under palliative care in their own homes where they can socialize with their friends and relatives while they settle their affairs.  Too often this latter option is not presented to the terminally ill by the medical community.

Gawande provides numerous examples of how the healthcare industry can provide better service to aged and seriously ill patients, as well as advice for patients who must take the time to seriously consider what they want out of the remaining life they have.

Gawande also provides a description of the aging process that is useful to all of us as we grow older and must deal with increasing decrepitude of ourselves or others.  This aging process will be the subject here.

We are told that there are two main hypotheses that attempt to explain the physical process of aging.  The traditional explanation is based on the notion that the performance of various organs and components of our bodies, and their backups, degrade over time until some critical level of malfunction is reached and the body is no longer viable—with multiple organ failures quickly following.  This is what is known as dying of old age. 

A more recent theory holds that humans are programmed genetically to wind down over a more or less standard time period.  One can make evolutionary arguments why a finite lifetime would be of value to a given species.  This hypothesis is also attractive to some because it provides hope that there is some physical process that controls our life spans and that process might be modified to produce longer lives.  Scientists have been able to demonstrate that longer lifetimes can be produced in some species by introducing genetic changes.

Gawande is a believer in the wearing out hypothesis.  For a programmed lifetime to exist it would have to have been favored via natural selection.  We clearly have the capability to live to near 100 if we are able to avoid early death by disease or injury.  However, all data indicates that our ancestors rarely, if ever, reached such ages.  Consequently, it is not clear how natural selection might have programmed in such a long lifespan.  Most selection is based on the survivability of offspring.  It is difficult to explain how a potential longevity of near 100 years can affect the survivability of offspring when typical longevities might be only 20-30 years.

An even more compelling counter to the genetically programmed hypothesis resides in inheritance data.

“….only 3 percent of how long you’ll live, compared with the average, is explained by your parents longevity; by contrast, up to 90 percent of how tall you are is explained by your parents’ height.  Even genetically identical twins vary widely in life span: the typical gap is more than fifteen years.”

Gawande provides us with a list of the various degradations and breakdowns that occur as we age.  The elderly need to know what has happened to them, and the young need to understand that it will happen to them as well.

Perhaps the first observation is the graying of our hair.

“Hair grows gray….simply because we run out of the pigment cells that give hair its color.  The natural lifecycle of the scalp’s pigment cells is just a few years.  We rely on stem cells under the surface to migrate in and replace them.  Gradually, however, the stem-cell reservoir is used up.  By the age of fifty, as a result, half of the average person’s hairs have gone gray.”

At about the same time, we begin to notice that we are no longer able to read without lens corrections and start surrounding ourselves with brighter light sources.

“The lens is made of crystalline proteins that are tremendously durable, but they change chemically in ways that diminish their elasticity over time—hence the farsightedness that most people develop in their fourth decade.  The process also gradually yellows the lens.  Even without cataracts….the amount of light reaching the retina of a healthy sixty-year-old is one-third that of a twenty-year-old.”

And then splotchy skin begins to appear.

“Inside skin cells, the mechanisms that clear out waste products slowly break down and the residue coalesces into a clot of gooey yellow-brown pigment known as lipofuscin.  These are the age spots we see in skin.  When lipofuscin accumulates in sweat glands, the sweat glands cannot function, which helps explain why we become so susceptible to heat stroke and heat exhaustion in old age.”

Most high-performance athletes will have retired by the age of forty.

“Around age forty, one begins to lose muscle mass and power.  By age eighty, one has lost between a quarter and a half of one’s muscle weight.”

Cherish and care for your teeth—they may not be with you for the entire journey.

“The hardest substance in the human body is the white enamel of the teeth.  With age, it nonetheless wears away, allowing the softer, darker layers underneath to show through.  Meanwhile, the blood supply to the pulp and the roots of the teeth atrophies, and the flow of saliva diminishes; the gums tend to become inflamed and pull away from the teeth exposing the base, making them unstable and elongating their appearance, especially the lower ones.”

Care can help maintain the health of our teeth, but the afflictions of aging such as arthritis and tremors make the scrupulous brushing and flossing difficult.

“In the course of a normal lifetime, the muscles of the jaw lose about 40 percent of their mass and the bones of the mandible lose about 20 percent, becoming porous and weak.  The ability to chew declines, and people shift to softer foods, which are generally higher in fermentable carbohydrates and more likely to cause cavities.  By the age of sixty, people in an industrialized country like the United States have lost, on average, a third of their teeth.  After eighty-five, almost 40 percent have no teeth at all.”

As we lose calcium from the places it is needed, it seems to migrate to places where it is harmful.

“Even as our bones and teeth soften, the rest of our body hardens.  Blood vessels, joints, the muscle and valves of the heart, and even the lungs pick up substantial deposits of calcium and turn stiff.  Under a microscope, the vessels and soft tissues display the same form of calcium that you find in bone.  When you reach inside an elderly patient during surgery, the aorta and other major vessels can feel crunchy under your fingers.  Research has found that loss of bone density may be an even better predictor of death from atherosclerotic disease than cholesterol levels.  As we age, it’s as if the calcium seeps out of our skeletons and into our tissues.”

We can affect the rate of these processes by exercising in an attempt to maintain functionality, and eating a healthy diet, but the processes cannot be stopped.

“Our functional lung capacity decreases.  Our bowels slow down.  Our glands stop functioning.  Even our brains shrink: at the age of thirty, the brain is a three pound organ that barely fits inside the skull; by our seventies, gray-matter loss leaves almost an inch of spare room.  That’s why elderly people….are so much more prone to cerebral bleeding after a blow to the head—the brain actually rattles around inside.  The earliest portions to shrink are generally the frontal lobes, which govern judgment and planning, and the hippocampus, where memory is organized….Processing speeds start decreasing well before age forty….By age eighty-five, working memory and judgment are sufficiently impaired that 40 percent of us have textbook dementia.”

The accumulated changes lead to some accommodations that we must make.  For example, aging causes the shape of the spine to change resulting in your head being tipped forward.  If one attempts to swallow while keeping their head looking straight ahead it is easy to choke on food.  The elderly tend to eat facing downward.

The loss of muscle strength is one of several factors that increase the risk of falling for the elderly.

“Each year, about 350,000 Americans fall and break a hip.  Of those, 40 percent end up in a nursing home, and 20 percent are never able to walk again.  The three primary risk factors for falling are poor balance, taking more than four prescription medications, and muscle weakness.  Elderly people without these risk factors, have a 12 percent chance of falling in a year.  Those with all three risk factors have almost a 100 percent chance.”

People tend to assume that modern medical practices will lead to better, healthier lives for all, including the elderly.  If this were the case, one might expect people to age more gracefully, avoiding some of the inevitable disabilities until a more advanced age.  This presumed trend is referred to as “compression of morbidity.”  Unfortunately, the opposite seems to be the case.  There are data that indicate the disabilities associated with aging are presenting themselves earlier, not later.

Interesting results have been obtained by Eileen M. Crimmins and Hiram Beltran-Sanchez in the paper Mortality and Morbidity Trends: Is There Compression of Morbidity?  Their paper appeared in 2011.  Consider this table from the paper.

These data are based on surveys taken in 1998 and 2006.  Over the span of just eight years people of all age groups are reporting greater incidences of what the authors refer to as mobility functioning loss.  Things like being unable to climb stairs or get up and down without assistance are associated with old age.  People seem to be hitting their senior years in worse shape than they were in the past.  Other data are presented that indicate increased incidences of non-infectious diseases.  We, as a population are becoming less healthy, not healthier.  The authors provide this summary.

“Mortality declines have slowed down in the United States in recent years, especially for women. The prevalence of disease has increased….Mobility functioning has deteriorated. Length of life with disease and mobility functioning loss has increased between 1998 and 2008.”

We are living longer but getting sick, and falling apart, earlier.  This paradoxical result has led some to conclude that we are not living longer; we are just dying more slowly.

Up to this point, we have developed a picture of inexorable physical decline leading to extreme limitations on possible lifestyles.  The elderly have had to shed many of the activities that once were the core of their existence.  They also must face their ever nearing mortality.  One might expect this to become a period of extreme despair.  Surprisingly, the opposite occurs.  Psychologists who study such things claim that satisfaction with life becomes greater as one grows older, provided one manages to emerge from the despair and depression that characterizes middle age.  This finding is discussed in an article in The Economist: Age and happiness: The
U-bend of life.  This chart is provided.

The questions being asked seem to be concerning psychological well-being, or satisfaction with life.  These are not necessarily the same as happiness, but definitely something moving in a positive direction.  If one asks about feelings of depression as a function of age the curve turns upside down with the peak being where the valley had been.  The aged who are terminally ill are probably not being queried about their satisfaction with life, but it seems that those who are well into the falling apart process are dealing with it quite nicely.  This U-bend profile seems to be fundamental to humanity in general.  It is replicated in most countries, although the position of the valley will move around from one society to another.

A number of possible explanations for the U-bend phenomenon exist and are discussed in the article.  For our purposes here, it is important to note that those who are well along in the falling-apart process have managed to maintain a degree of satisfaction with their existence.  They know that they could die at any time, but still persist in having hopes and expectations.  They are people who continue to lead a meaningful existence.  However, their nearness to eventual mortality means that the medical community owes them considerations that are different from those that would be appropriate to younger people.

Gawande argues that a thirty-year-old who acquires a life-threatening illness has the potential for decades more of a healthy life if that illness can be defeated.  In that case, it makes sense to try all options, no matter how painful or uncomfortable they might be to win the battle. 

But a similar illness detected in an eighty-year-old provides a different set of considerations.  There are no decades of health to look forward to.  Instead, trying to defeat the illness may actually lead to a shortening of life, with death coming while hooked up to machines in an intensive care ward and in a state where one is unable to communicate with family or friends.  The patient might prefer to make the best of whatever is left of life and forego any heroic medical adventures. 

Gawande is irate because too many doctors do not understand the importance of the perspective of the elderly patient and encourage the pursuit of maintaining life, whatever the cost.  That is what they are trained to do, but it is also the easiest thing for them to do.  What they are least trained to do, and what they seem to find hardest to do, is have an honest discussion with the patient of what a given treatment might entail and what its potential benefit might be—to the patient. 

Gawande offers his feelings about how medical professionals should approach treatment of the elderly.

“Sometimes we can offer a cure, sometimes only a salve, sometimes not even that.  But whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person’s life.  When we forget that, the suffering we inflict can be barbaric.  When we remember it the good we do can be breathtaking.”

Everyone should read Gawande’s book.  It has relevance to everyone, no matter the age, and it contains much more than was presented here.

Friday, November 13, 2015

Energy: Big Electric versus Big Oil

Most nations of the world take seriously the need to minimize the burning of fossil fuels if an eventual climate disaster is to be avoided.  Alternate sources of power include solar, wind, hydroelectric and geothermal.  These renewable sources produce energy in the form of electric power.  Much of our energy consumption is via electric power and the substitution of renewable sources for fossil fuel sources is straightforward—at least for the consumer.  The area in which the conversion to renewable power sources is most difficult to deal with is in transportation where oil burning vehicles dominate.

The obvious solution is to convert to electric vehicles powered by renewable sources of electricity.  Tesla is the most prominent proponent of this path with a growing array of all-electric automobile options.  Most, if not all, major automotive companies are now producing hybrid or all-electric vehicles.  These vehicles are expensive, mainly because of the cost of the required batteries, but the trend in cost is downward and more affordable models are becoming available.  The biggest unresolved problem for common use of all-electric vehicles is the lack of convenient recharging options.  That may be about to change, and, as usual, California is planning to take the lead.

An article was provided by Bloomberg Businessweek with the intriguing title: Big Electric Shocks Big Oil.  In addition to a slew of aggressive targets for reduction of fossil fuel burning, new legislation specifically aims at improving the infrastructure necessary to assist the acceptance of electric vehicles.

“SB 350 envisions cutting greenhouse gas emissions to 40 percent below 1990 levels by 2030 and 80 percent by 2050. Language in the bill directs regulators to help reach those ambitious goals by making it easier for the state’s 23 million drivers to opt for vehicles that run on electricity instead of gasoline. The law requires the California Public Utilities Commission to solicit proposals from electric companies for ‘multiyear programs and investments to accelerate widespread transportation electrification to reduce dependence on petroleum’.”

Thus far, the impact of renewable energy sources has been negative for the big public utilities.  Rooftop solar is growing rapidly in California and is draining income away.  Providing electricity to charge electric vehicles is a way to increase demand for their product.  Up until now, they have been kept out of the market in an attempt to avoid having a few big players control technology and access.  This recent legislation has changed that and invited the power utilities to jump in—and they have.

“The electric companies see a chance to grab a piece of the $55 billion the state’s drivers spend each year filling up. ‘We really need to have a big push for charging,’ Tony Earley, chief executive officer of PG&E, said in an Oct. 15 appearance at San Francisco’s Commonwealth Club. ‘The charging station ought to be part of our grid infrastructure’.”

“PG&E has proposed installing thousands of charging stations in Northern and Central California over the next three years.”

“….[Southern California Edison] hopes to install 30,000 electric vehicle chargers in office buildings, apartment complexes, and parking lots in the next four years at a cost of $355 million.”

The big utilities are not yet committed to doing everything they can to meet California’s energy goals.  For example, they are trying to discourage the competition that comes from rooftop solar.  They are still wedded to their traditional business model, which must become obsolete.

“Despite the electric companies’ new passion for greener cars, they aren’t cozying up to rooftop solar, which eats into their bottom lines. California, which accounts for half the installations in the U.S., already gets 5 percent of its power from rooftop solar. The state’s utilities ‘are trying to smother that in its crib,’ says Michael Brune, executive director of the Sierra Club. PG&E, SCE, and San Diego Gas & Electric have all petitioned the utilities commission for rules changes that would make solar installation less attractive. Homes and businesses with rooftop solar panels would pay an extra fee to connect to the grid. They’d also pay more to buy power and earn less for selling their excess electricity back to the utilities. That would make converting to solar power two to three times more expensive for the consumer, according to Bernadette Del Chiaro, executive director of the California Solar Energy Industries Association.”

The power companies have two functions: the production of power, and the distribution of power.  As the amount of renewable energy increases and the multiple energy efficiency initiatives take hold, the demand for the power companies’ energy will decrease significantly.  On the other hand, the distribution of energy will become more important and more challenging.

Instead of trying to block progress, the power companies have the opportunity to focus on their distribution function as they develop a new business model.  One of their major functions is providing a reliable source of energy when energy usage changes dramatically within the daily cycle.  Typically, the company will have multiple energy sources that can be brought to bear as demand increases.  That requires bringing in new generation capability to meet peaks in demand.  This adds to the cost of energy delivered when demand is high compared to the cost when demand is low.  They already know how to do this, and they know how to share energy with other producers when power plants go down for maintenance or because of malfunction.

The growth of the renewable component of available power will make the distribution of energy more complicated.  Both wind and solar energy follow daily cycles that are not identical.  Plus, short-term changes in those cycles due to weather variations make for an even more complex situation.  Many cynics have made the claim that it is not possible to have more than about 30% of energy from renewable sources and still provide a stable distribution system.  Others dispute these claims, including Amory Lovins and the Rocky Mountain Institute in Reinventing Fire: Bold Business Solutions for the New Energy Era.  There the claim is made that, in principle, there is no identified limit to the fraction of energy that can come from renewable sources.  In fact, some utilities have already reached over 50% renewable energy on an annual basis.

“Integrating ever higher levels of renewables is being successfully demonstrated in the real world.  In 2009, eight American and three European authorities, writing in the leading electrical engineers’ professional journal, didn’t find a ‘credible and firm technical limit to the amount of wind energy that can be accommodated by electrical grids.’  In fact, not one of more than 200 international studies, nor official studies for the eastern and western US regions, nor the International Energy Agency, has found major cost or technical barriers to reliably integrating up to 30% variable renewable supplies into the grid, and in some studies much more.”

There is a future for power companies in which they embrace renewable energy and take as their responsibility the provision of a newer, smarter grid that that can accommodate the inevitable movement to a greater number of variable power sources, and the situation where every site for energy consumption can also be an energy source.

There is also a future for the power utilities that leads to obsolescence and irrelevance.  Consider this article from Bloomberg: Why the U.S. Power Grid's Days AreNumbered

“There are 3,200 utilities that make up the U.S. electrical grid, the largest machine in the world. These power companies sell $400 billion worth of electricity a year, mostly derived from burning fossil fuels in centralized stations and distributed over 2.7 million miles of power lines. Regulators set rates; utilities get guaranteed returns; investors get sure-thing dividends. It’s a model that hasn’t changed much since Thomas Edison invented the light bulb. And it’s doomed to obsolescence.”

“Crane, 54, a Harvard-educated father of five, drives himself to work every day in his electric Tesla Model S. He gave his college-age son an electric Nissan Leaf. He worries about the impact of warming on the earth his grandchildren will inherit. And he seems to relish his role as utility industry gadfly, framing its future in Cassandra-like terms. As Crane sees it, some utilities will get trapped in an economic death spiral as distributed generation eats into their regulated revenue stream and forces them to raise rates, thereby driving more customers off the grid. Some customers, particularly in the sunny West and high-cost Northeast, already realize that “they don’t need the power industry at all,” Crane says.”

That conclusion may be a bit of a stretch.  It seems likely that homeowners will need to be on some sort of a grid.  But if they are already generating a good deal of the power they need, that grid need not be the one that is currently distributing electricity in the neighborhood.

If the power utilities are smart, they will join the program, not try to torpedo it.

Saturday, November 7, 2015

Education, Income, and increased Mortality in Poorly Educated Whites in the US

In 2012, Sabrina Tavernise produced an alarming article for the New York TimesLife Spans Shrink for Least-Educated Whites in the U.S..  She was reporting on a study of mortality data that indicated that non-Hispanic whites with less education than a high school degree were experiencing a sharp drop in life expectancy.  Such a drop did not occur in the case of Hispanics and blacks without a high school education.  This chart was provided’

There was no good explanation for why this was occurring.  Education and income tend to track.  Consequently, there are a number of possible explanations based on less-healthy lifestyles that might be expected among a very low-income population. The drop in life expectancy was significantly greater for women than for men.  Therein may reside a clue as to what might be going on.

Such a large increase in mortality in a developed country is nearly unheard of.

“The five-year decline for white women rivals the catastrophic seven-year drop for Russian men in the years after the collapse of the Soviet Union, said Michael Marmot, director of the Institute of Health Equity in London.”

“By 2008, life expectancy for black women without a high school diploma had surpassed that of white women of the same education level, the study found.”

After a brief burst of publicity on this topic, it seems to have retired to academic circles with apparently no provable explanation in sight.

In the past few months another analysis of mortality data has emerged and provided new insights.  Anne Case and Angus Deaton have produced the article Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century.  They were particularly interested in health and mortality of those in the 45 to 54 age group.  They provided this chart to make sure we realized that something strange and troubling is going on in the United States.

Note that the curve for (45-54) Hispanics (USH) continues to follow that of other countries while only that of (45-54) non-Hispanic whites (USW) goes soaring into space.

The authors also conclude that education is a critical factor in the level of mortality.  All the rise in mortality comes from the cohort with a high school degree or less.  Those with some college education but no degree have slightly decreased mortality.  For those with a college degree or post-graduate education the mortality rate has continued to drop.  Note that the data presented by Tavernise was based on those without a high school diploma, a much smaller group.

Much of the increase in mortality comes from bad lifestyle choices.  Increases in drug use (poisoning) and alcohol abuse are indicated as major contributors, along with a greater number of suicides.

It is interesting that the data on mortality from diabetes (poor nutrition) and lung cancer (smoking) are not contributors to the rise.

The authors also break out the data on mortality from poisoning, suicides, and liver disease by age group for non-Hispanic whites.

If the factors considered here are the dominant causes of increased mortality, then there is a definite peak in the middle years, with lower increases for younger and older groups.  However, it is significant that all age groups indicate higher mortality from these causes.

The authors provide a brief discussion of possible explanations, but as with Tavernise, they can only speculate about changing lifestyle choices.  It seems that their emphasis on the age factor is perhaps more of a diversion than a fundamental clue.  The educational attainment variable seems to be the dominant effect, as identified in Tavernise’s article.

Education is important because it is associated with income, which in turn is correlated with quality of life (lifestyle choices), family stability, and economic security.  Let’s consider a few more pieces of data that provide additional insight.

This source provides an interesting look at how income (education?) affects longevity.  Consider this chart based on Social Security data.

Beginning in the 1970s, the life expectancies of wealthier 65-year-olds began to diverge from those of lower income people. The fact that lower income people have seen little increase in longevity at age 65 is a good counter argument to those who would claim that the Social Security retirement age should be raised.  One can think of reasons why this mortality divergence might occur, but one has to also explain why this effect suddenly began to occur in the 1970s.

There is an age-related phenomenon that might also provide a clue as to what is at work.  An article in The Economist titled Age and happiness: The U-bend of life provided this interesting chart.

When social scientists poll people on how satisfied they are currently with their lives they derive responses as a function of age that produce a U-shaped curve with a minimum in middle age.  If one equates satisfaction with life with happiness, then the younger are happier and the older are happier.  Scientists conclude that this type curve exists in all but a few societies, but the minimum can vary in age.

“….interest in the U-bend has been growing. Its effect on happiness is significant—about half as much, from the nadir of middle age to the elderly peak, as that of unemployment. It appears all over the world. David Blanchflower, professor of economics at Dartmouth College, and Mr Oswald looked at the figures for 72 countries. The nadir varies among countries—Ukrainians, at the top of the range, are at their most miserable at 62, and Swiss, at the bottom, at 35—but in the great majority of countries people are at their unhappiest in their 40s and early 50s. The global average is 46.”

If one returns to the age-grouped chart of Case and Deaton, a mortality versus age curve would look like the inverse of the U-bend curve just above.  This suggests a possible inverse correlation between mortality and happiness.  If the opposite of happiness and satisfaction is anxiety, then one can hypothesize that the stress related to increased anxiety in middle-age has deleterious health effects and increases mortality.

The article provides this input on the correlation between happiness and health.

“Whatever the causes of the U-bend, it has consequences beyond the emotional. Happiness doesn't just make people happy—it also makes them healthier. John Weinman, professor of psychiatry at King's College London, monitored the stress levels of a group of volunteers and then inflicted small wounds on them. The wounds of the least stressed healed twice as fast as those of the most stressed. At Carnegie Mellon University in Pittsburgh, Sheldon Cohen infected people with cold and flu viruses. He found that happier types were less likely to catch the virus, and showed fewer symptoms of illness when they did. So although old people tend to be less healthy than younger ones, their cheerfulness may help counteract their crumbliness.”

There is also this interesting finding that has some relevance to white versus black and Hispanic issues.

“In America, being black used to be associated with lower levels of happiness—though the most recent figures suggest that being black or Hispanic is nowadays associated with greater happiness.”

Finally, the article makes this assertion related to educational attainment, income, and happiness.

“Education, in other words, seems to make people happy because it makes them richer. And richer people are happier than poor ones—though just how much is a source of argument….”

If we are to make sense of all this data, we must identify a mechanism, or mechanisms, that increase mortality for whites but not blacks or Hispanics, and operates mainly on poorly educated people.  It must also be unique to the United States because it is apparently not operative in any other developed nation.  And yet it is even more complicated than that.  We like to think of the United States as a single country and average data nationwide in order to arrive at conclusions.  This averaging process can hide some rather significant excursions.

This source provides data on life expectancy at the age 50.  It tallies how many years one might be expected to live after reaching age 50 depending on which county one lives in.

The darker colors indicate lower life expectancies.  The amount of variation is enormous.  One could drive a hundred miles and find a location where people live twenty years less than they do in the place just left.

This data suggests that there are multiple factors important in determining mortality rates: climate, culture, ethnicity, race, occupation, environment…..  Good luck in sorting all that out!

The only thing we know for sure is that something is going terribly wrong in our society.

Tuesday, November 3, 2015

Reclaiming Abortion Rights: Calling Out Pro-Choice Politicians

Given the heated rhetoric that is bandied about today on the issue of abortion rights, it is difficult to remember that at the time of the Roe v. Wade decision (1973) it was viewed as a necessary step in resolving an intolerable situation—and had broad support.  This is one of the many insights provided by Katha Pollitt in her book Pro: Reclaiming Abortion Rights.

“Today, the real-life harms Roe was intended to rectify have receded from memory.  Few doctors remember the hospital wards filled with injured and infected women.  The coat-hanger symbol seems as exotic as the rack and thumbscrew, a relic waved by gray-haired ‘radical feminists’.”

Prior to Roe v. Wade, the contention by the factions that today we refer to as “pro-choice” and “pro-life” had been resolved in vastly different ways around the nation.  Abortion was legal in some locations and illegal in others, a situation that could be easily resolved by the wealthy, but left others helpless, depending on where they lived.  The disparity in laws produced economic and racial discrimination.

“The more exceptions there were to the criminalization of abortion, the more glaringly unfair and hypocritical the whole system was seen to be.  By the time Roe came to court, well-off savvy women could flock to New York or several other states where laws had been relaxed and get a safe, legal termination; poor women, trapped in states that banned abortion, bore the brunt of harm from illegal procedures.  There was a racial angle too: Not only did women of color, then as now, have far more abortions than whites in proportion to their numbers, they were much more likely to be injured or die in botched illegal procedures.  According to the Centers for Disease Control and Prevention, from 1972 to 1974, the mortality rate due to illegal abortion for nonwhite women was 12 times that for white women.  The injustice of a patchwork system, in which a simple medical procedure could leave a woman dead or injured based purely on where it took place, was obvious.”

The Supreme Court, the majority of the population, and most religious groups were in favor of relaxing the laws against abortion and decriminalizing it in many situations.

“If you assume the churches were united against abortion, think again: Beginning in 1967, the Clergy Consultation Service founded by the Reverend Howard R. Moody, a Baptist….helped thousands of women across the country find their way to safe illegal abortions.  In the years leading up to Roe, legalization of abortion under at least some circumstances was endorsed by the Union for Reform Judaism, the Southern Baptist Convention, the National Association of Evangelicals, the United Methodist Church, the Presbyterian Church USA, the Episcopal Church, and other mainstream denominations.”

The need to avoid producing unwanted or nonviable children is normal, natural, and inevitable.  It was thus before Roe V. Wade, and remains so today.

“More than a million abortions are performed every year—some 55 million since 1973, when Roe v. Wade became the law of the land.  A few facts: By menopause, 3 in 10 American women will have terminated at least one pregnancy; about half of all US women who have an abortion have already had a prior abortion; excluding miscarriages, 21 percent of pregnancies end in abortion.  Contrary to the popular stereotype of abortion-seeking women as promiscuous teenagers or child-hating professionals, around 6 in 10 women who have abortions are already mothers.  And 7 in 10 are poor or low-income.  Abortion, in other words, is part of the fabric of American life, and yet it is arguably more stigmatized than it was when Roe was decided.”

Today the conversation about abortion has become controlled by a minor, but vocal, component of the population that is determined to place the rights of every pregnant woman below the rights of any zygote, embryo, or fetus they might be carrying.  They are supported by pandering politicians who wish to not lose a single vote by being controversial.  Scoundrels who claim to be libertarians or in favor of small nonintrusive government back legislation demanding the government take control of a woman’s body against her will.

“You would never know that Ayn Rand and Barry Goldwater were pro-choice, and that in 1967, the governor of California, Ronald Reagan, signed what was then the most liberal abortion law in the nation.”

Pollitt provides us with this little tidbit about the family of one of the greatest panderers of all time: Mitt Romney.

“….Mitt Romney’s son Tagg signed a contract with a surrogate mother that gave her the right to abort for health reasons and for him and his wife the right to decide on abortion should the fetus prove ‘physiologically, genetically, or chromosomally abnormal’.”

The pro-life movement has managed to remove the issue of women’s rights from the conversation.  Women who would choose an abortion must be selfish, morally corrupt, or simply ignorant.  What angers Pollitt most is the manner in which politicians who claim to be pro-choice and who claim to be in favor of women’s rights cede the high ground to the pro-lifers by accepting the myth that having an abortion is necessarily a morally troubling issue.

“Nowadays, we take it for granted that having an abortion is a sorrowful, troubling, and even traumatic experience, involving much ambivalence and emotional struggle, even though studies and surveys consistently tell us it usually is not.  Even pro-choicers use negative language: Hillary Clinton called abortion ‘a sad, even tragic choice to many, many women’.”

A recent study by a team of researchers at the University of California, San Francisco supports Pollitt’s claim that having an abortion is not necessarily a troubling experience: Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study.  This effort tracked women who had abortions and monitored their feelings about their decision and their emotional response post-abortion for a period of three years.

“We recruited a cohort of women seeking abortions between 2008-2010 at 30 facilities across the United States, selected based on having the latest gestational age limit within 150 miles. Two groups of women (n=667) were followed prospectively for three years: women having first-trimester procedures and women terminating pregnancies within two weeks under facilities’ gestational age limits at the same facilities.”

The conclusions of the study must have been rather startling even for pro-choice advocates.

“The predicted probability of reporting that abortion was the right decision was over 99% at all time points over three years.”

“Women also experienced reduced emotional intensity over time: the feelings of relief and happiness experienced shortly after the abortion tended to subside, as did negative emotions. Notably, we found no differences in emotional trajectories or decision rightness between women having earlier versus later procedures. Important to women’s reports were social factors surrounding the pregnancy and termination-seeking….Community stigma and lower social support were associated with negative emotions.”

 So, having an abortion seems a quite survivable experience, particularly if a woman is not hounded by pro-lifers.

The pro-life movement is a fraud.  They are against extinguishing life as long as the life form exists within the body of a pregnant woman.   Once it emerges from the woman they don’t give a damn about what happens to it.  Pollitt makes a good case for the ultimate motive being the determination to control women’s sexual behavior as well as women’s social behavior.

“Legal abortion presents the issue of women’s emancipation in particularly stark form.  It takes a woman’s body out of the public realm and puts her, not men and not children, at the center of her own life.”

If men are allowed to walk away from their role as an initiator of life when it is convenient or necessary, then women must have the same right.

If Hillary Clinton wishes to champion women as the first woman president, she must jump in with both feet and speak clearly and loudly.  These are issues for which triangulation is inappropriate.

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