Sex, Drugs, and Public Health

April 2, 2021


Filed under: Uncategorized — cbmosher @ 2:28 am

Retired !

Now what ?

Luckily, many of my patients over the years were in the same predicament cat-bird seat. So I have seen the models.

Model # one involves a couch, a TV, and lots of beer. Initially. Later, it’s lots of vodka. I’ve seen the blood tests on these folks, so – – – no.

Model # two involves cruise ships, tour guides and sunscreen. Also, vodka. But instead of taking pictures of people in foreign lands, I prefer to live with and talk to them. So, again, thanks anyway.

Model # three involves making other people’s lives better. A proven way to feel useful. But – – – Covid. What can you do for others when stuck here?  Well, step one could be De-bulking. Stop acquiring  crap  stuff  things and begin getting rid. Helps the kids with the clean-up after – – – you know.

Step two is get the mail. Chances are fair that, mask on and hand sanitizer in pocket, I’ll be stopped at the Post Office. “Hey, Doc. Can you look at this thing on my forearm?” or “Oh, Doctor. I hate to bother you, but they just diagnosed cancer and I don’t know if I should do Chemo. What do you think?” Actually, after empathizing, the correct answer to most of these situations is “get an appointment with your doctor (or a second opinion).”

Step three uses the miracle of electronic communication. Via e-mail, Zoom and What’sApp phone calls, we’ve been able to continue work with two Foundations. The Mariposa Community Foundation has helped some non-profit agencies weather the Covid –related financial impact. And another Foundation called FAKS (Functionally Active Kids) has kept some children in Guatemala and Honduras walking. Here’s a picture of Mario. 

He was born without a foot. One additional strike for a kid living in a country wracked by chronic poverty, political upheaval and violent crime. FAKS Foundation helped his family obtain a modern prosthetic at a fraction of the cost in the U.S. The result: Mario’s in school, and he’ll be able to support himself without begging. He’s even playing soccer. We’ve been able to stay in contact with Guatemala during Covid, communicating with the local Rotary club.

Step four – turns out, retirement doesn’t erase your career from your dreams or occasional, unsolicited thoughts. If I thought retirement would be Epidemiology – free, well, like some wild animal virus, it tracked me down. Those Post Office consultations have become increasingly centered on the Coronavirus. Both in individuals and in the population. Figuring out answers for a new disease involves knowledge of Medicine, of Physics and of Statistics.

Medicine – are we observing the effects of infection by a virus or of the body’s immune response?

Physics – is the virus transmitted thru the air by droplets or by aerosol?

Statistics – are the deaths we’re seeing “excess” deaths over and above the normal population death rate? Are the control measures decreasing transmission and subsequent infection?

All these aspects – and more – go into the Epidemiology of a disease. Which, by definition, is the study of the behavior of a disease within a population and its control. So, if you were asked to define the epidemiology of the new disease called Covid, how would you approach it?

  1. Count it.  Find out its frequency. For the disease of Covid, the U.S. has the highest case count in the world at over 30 million. You can also by calculate the disease’s Incidence. That is, how many people become new cases over a time period? Or how many become ill? Or die?
  2. Find the pattern. Which groups in the population are most affected by the disease? Most diseases are not distributed uniformly thru a population. Some don’t get infected. Some get infected but not ill. Some get ill and recover completely. Some get ill and remain crippled. Some die from it.
  3. Find the Determinants (AKA Risk). What causes the disease? What influences in the environment or society facilitate it? Protect a group from it? With Covid, the cause is the virus and we quickly learned that close contact, especially indoors, was a major determinant. However, medical conditions and age were also powerful determinants.
  4. Studies. With this unknown disease, we needed information. Fast. Hundreds of studies looked at virus behavior, immune response, clinical syndromes, treatments, prevention measures, vaccines, and the effectiveness of environmental / social preventive measures.
  5. Prevention. All the information generated thru Epi investigations is worth very little if it can’t point to preventive measures. Very quickly with Covid, we implemented what we learned. Face coverings. Distancing. Screening (AKA testing). Vaccination.

The other Public Health epidemic in the news has been with us longer than Covid, but flares into the headlines periodically. So let’s see how Public Health applies epidemiology to Firearm-Related (FAR) deaths.

         1. Frequency: in the U.S., the death rate from this disease is 12.2 per 100,000 per year. That’s more than any other high-income country in the world. The number of FAR deaths in 2020 was the highest in 20 years at 44,000 deaths.

         2. Pattern: the data available (there isn’t as much as we need – see “Studies” below) shows that U.S. FAR deaths include suicides, homicides and accidents. The death rates vary greatly among the states.

3. Determinants: Many people believe that having a gun close by makes you safer. A few studies (too darn few) have been done on this topic. But the clue of differences among states helps. The Rand Corporation spent two years looking at available data and found that (A) a lot more studies are needed on FAR deaths and (B) states with the most permissive policies on gun ownership had higher FAR death rates than states with more restrictive policies. Some studies have shown that households with guns suffered more FAR deaths than those without. There are more guns than people in the U.S. (120 per 100 people). No other country has such a determinant.

         D. Studies: in 1996, congress passed the Dickey Amendment which ordered the CDC to NOT spend any money on studying FAR deaths. This shut down most investigation on the issue, relying on private funding (with the potential of biased studies).

         E. Prevention: a hot topic. In spite of polls from 1990 to now showing a higher percentage of Americans favoring “gun control” than those opposing, very little action on prevention has occurred. Moreover, an Association which represents gun manufacturers is a perennial voice in legislator’s ears.

What does “gun control” mean? Should we outlaw assault weapons except for police and the official U.S. military? Should we apply testing and licensing as we do with the privilege of driving a car or truck (the cause of 38,800 deaths a year)? Should we screen for high risk individuals (those at risk for suicide, for violence, for poor anger control, for situations ripe for accidents)? Like we screen for Heart Disease, Cancer, Covid?

         As with most diseases, more studies will produce more knowledge  which leads to better decisions. If we don’t study a disease, if we don’t apply the proven principles of Public Health, if we don’t act to prevent death-causing diseases, the problem will never go away.

         Next time, it may not be someone else’s child.

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