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... and what to do about it.

It is a staple in introductory public health courses to present the leading causes of death as recorded on death certificates -- heart disease, cancer, stroke, etc. -- next to so-called "actual causes of death," which are somebody's analysis of preventable or modifiable factors out in the world, as opposed to inside the person's body, which in the classic analysis are tobacco, overweight and physical inactivity, ethanol, etc. "Microbial agents" are 4th but I have a quarrel with that, which I will defer.  Anyway, you can see it for yourself here.

On the one hand, I do think this is a healthful exercise.  It would be a big step forward if we could spend less resources on treating heart disease and cancer, and instead got people to stop smoking, exercise more, and consume fewer calories. On the other hand, it reflects sloppy thinking, in two ways.  First, you can always go back another step and ask, "Why are people obese?" "Why do people smoke cigarettes?" and perhaps most cogently though of lesser numeric import in today's world (but maybe not tomorrow's), "Why do some people die from 'microbial agents' and not others?" Then your Actual Causes of Death might include, say, advertising, agricultural policy, and television.

But second, and this is the real subject of today's rumination, is it really death that's the problem?  Every one of us is born with an inevitably fatal, absolutely incurable disease which, after we reach adulthood, progressively causes our muscles to weaken, our skin to lose elasticity, our immune systems to decline, our arteries to stiffen, and eventually, if something else doesn't get us first, leads to cardiac or respiratory arrest or fatal pneumonia.  Then the death certificate will say heart disease or influenza or whatever, but we know the real cause of death: birth.  The only way to prevent a person from dying is to prevent the person from being born.

So how should we view this problem?  One way, which appeals to me, is through a justice frame.  Look at this map.  The problem is not that people die, but that many people don't have the chance at a lifespan which gives them the chance to fulfill their potential.  Beyond that, of course, we pay far too much attention to death in the first place. In order to accomplish anything and enjoy life, being alive is a necessary, but not a sufficient condition.  We can extend the lives of people with cancer and heart disease, often at great expense, but I would much prefer to live without them.  And with or without a spiffily functional body, I need the social context and psychological resources to have a fulfilling life.

Medical intervention plays a tiny role in this big picture.  The most powerful determinant of our longevity and our health, however conceived, is our position in society.  For example, here's another open door crashed through:  "Despite increased attention and substantial dollars directed to groups with low socioeconomic status, within race and gender groups, the educational gap in life expectancy is rising, mainly because of rising differentials among the elderly. With the exception of black males, all recent gains in life expectancy at age twenty-five have occurred among better-educated groups, raising educational differentials in life expectancy by 30 percent."  And, again, life expectancy aside, "Among adults over age 25, 5.8% of college graduates,
11% of those with some college, 13.9% of high school graduates, and 25.7% of those with less than a high school education report being in poor or fair health."  The latter factoid is from this memorandum from the Prevention Institute, which reviews all sorts of disparities having to do with race and ethnicity and other social factors as well.

Again, this has little to do with doctors and hospitals and all of those astonishing medical breakthroughs by heroic "top docs" you hear about on TV.  (Or read in the papers, if you do read papers, which is kinda weird nowadays.) By the way, it also has nothing whatsoever to do with influenza.  

This is what we ought to be talking about on Daily Kos and everywhere we can have such conversations.  I hope more people will join me.

Originally posted to therealcervantes on Fri May 08, 2009 at 06:52 AM PDT.

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Comment Preferences

  •  I know, I know (8+ / 0-)

    This isn't about how influenza is about to destroy civilization, so it isn't interesting.  Hopefully somebody will care anyway.

    •  Like sperm. (2+ / 0-)
      Recommended by:
      Justus, bfitzinAR

      The problem is not that people die, but that many people don't have the chance at a lifespan which gives them the chance to fulfill their potential.

      The main problem is how people think about themselves and others. The truth is, just like sperm, we are so many so that some of us "get through". Persons hate that truth so much. It completely smashes any delusions of relevancy, let alone importance.

      Fulfilling human potential is making babies. Past that, human potential is pretty words, grand endeavors, and lots of paint.

      We need to get over ourselves. Your death is required in payment for your life. Personally, I think that is a bargain.

      As if things could get worse without getting better.

      by A Voice on Fri May 08, 2009 at 08:29:49 AM PDT

      [ Parent ]

  •  You very artfully dodged the "blame the victim" (3+ / 0-)
    Recommended by:
    DBunn, Justus, bfitzinAR

    chorus. No matter how you look at it, Europeans are in better health than Americans as much for their lifestyles and demographics as for their public health care.

    I voted with my feet. Good Bye and Good Luck America!!

    by shann on Fri May 08, 2009 at 07:10:06 AM PDT

  •  Wow (4+ / 0-)
    Recommended by:
    DBunn, Justus, bfitzinAR, HenryBurlingame

    Really good.

    Instead of looking at just "cause of death" for leverage to improve health, look at "causes of diminished life"--the why of shortened lives and/or disability. Including things like nutrition, education, environmental toxins, overwork, poverty, parasite loads, social stress, violence, despair.

    And with behaviors, instead of just saying, "They should lose weight, they should stop using alcohol or drugs or cigarettes, they should exercise more, they should eat their vegetables" ask--why do so many people in a given social setting do the same things that can diminish their lives? Don't just stop with the catch-all, "They should have more will power." Or, "I stopped smoking, everybody should be able to do it if they really want to."

    Personal responsibility is real, yet it always takes place in a context. Casinos, for instance, are skilled in creating contexts where many people will gamble more than may be good for them. Can contexts also be created that encourage peeople to act in ways that support health and well-being?

    •  And among the first list I should have added (3+ / 0-)
      Recommended by:
      DBunn, Justus, bfitzinAR

      "health care access"

    •  You must define a "diminished" life. (1+ / 0-)
      Recommended by:

      I would define it as a life of dreamy perfection and sameness removed from the grime and crime of life, sealed in and filtered from virus, dust, and smoke, eliminating all uncertainties, thrice washed to kill the human animal.

      A diminished life would never be hungry or sick so they would never really know the relish of food or the wonder of wellness. A diminished life would be one that defines normal and that accepts the assumptions of its society without question.

      As if things could get worse without getting better.

      by A Voice on Fri May 08, 2009 at 08:44:30 AM PDT

      [ Parent ]

      •  A diminished life (0+ / 0-)

        could be of several kinds, but medically speaking, my list would include e.g. chronic obstructive lung disease, uncontrolled diabetes, stunting due to malnutrition, lead-poisoning-caused brain damage, AIDS, river blindness, MS, loss of limbs, cancer, extreme obseity, chronic pain syndromes...

        You understand, none of these conditions diminish a human being as a valuable person who deserves to live, but they can certainly restrict abilities and enjoyment and/or shorten life.

  •  Several Rotary Clubs along with (1+ / 0-)
    Recommended by:

    The Rotary Foundation are implementing clean water projects in some of the worst areas mapped.

  •  This is how I think the abortion issue (2+ / 0-)
    Recommended by:
    Justus, bfitzinAR

    should be looked at.  Not "why are there so many abortions," but "why do so many women get pregnant when they don't want to have a baby."  I like that you have put death in the same perspective.

    There is a story that goes something like this:  A town along the river has been having an increasing amount of trash wash up along the banks.  Each day a contingent of townfolk go out to the river and pick up trash.  And the next day, there is more trash on the banks.  Day after day this goes on.  Finally, a man shows up and sees what's happening.  He tells the folks to head upriver and find out why there is trash in the river in the first place.  Stop that from happening and your problem is solved.

    So often we look at the effect and try to fix that, but we forget to look at the cause.  

  •  How much of "education as a factor (1+ / 0-)
    Recommended by:

    in life expectancy and better health" is because higher education is a factor of wealth?  Wealth is a moving target - it's not how much you have, it's how much you have compared to others in your society - so it's hard to figure where the wealth/health/knowledge target is.  More social equality is a good thing - it's called having a large middle class - but our society seems to want the old aristocrasy back, complete with 10% or more infant and maternal mortality and seniors starving on the streets.  (I live in the south and that particular belief in the "way things 'spozed to be" is unfortunately strong here.  It goes with the mythology that every white male "should" be a plantation owner and "would" be if the libruls would quit giving all that money and privilege to everybody who isn't a white male.)

  •  Excellent, thanks. Death is okay, (0+ / 0-)

    but life for so many is not so good.  This and all the reasons for it is the elephant in the room.  I put overpopulation as the top concern for the future, and right there with inequality for the present.

    "Neither a borrower nor a lender be"

    by HenryBurlingame on Fri May 08, 2009 at 09:16:50 AM PDT

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