Public Health, Public Costs, and Public Benefits
The world seems to be heading towards socialized medicine with The United States lagging somewhat behind. We do spend much more on medical care than any other country without even covering all the people. We have also neglected Public Health, which is much more cost effective than curative medicine. Public Health is everything else that medical science does for mankind besides taking care of individuals one at a time, not just providing clean water and waste disposal. First let us do some brainstorming to get our thinking off of dead center, an expression which refers to the fact that a steam engine won’t start without a shove if it is poised with equal probability of running backwards as running forward. Brainstorming is unlikely to start the mechanisms of society in a backwards direction. After the brainstorming there are a couple of paragraphs more acceptable to the public’s present thinking.
When does a human life start? Life as a human starts when an infant makes connection to a competent caregiver—the infant’s only potential to develop into a social creature. Otherwise the infant’s chances would be nil. Romulus and Remus, founders of Rome, were suckled by wolves. Mowgli of Rudyard Kipling’s Jungle Book was also raised by wolves but did not become a human being in operational terms, and probably was as mythical as Rome’s origin. Through the years I have read occasional newspaper stories about teenage mothers abandoning unwanted offspring and facing prosecution for murder. In the nonhuman biological world young animals are routinely abandoned when their existence threatens the long-term (reproductive) success of the parent. Many states now have laws absolving (young) mothers of neglect if they leave their infants at a hospital—no questions asked.
Perhaps we will end up with shelters for stray humans comparable to no-kill animal shelters. Incidentally, some of these animal shelters, when they cannot find owners for all their unclaimed pets, fail to carry out their duty of collecting more strays and leave some of the strays straying as if in revulsion for some of Hitler’s excesses in dealing with unwanted humans. I share some of the revulsion when thinking about the street children of the world’s cities. In Brazil many such children are killed by the police without so much as a coroner’s inquest.
Infanticide is still widely practiced in the modern world almost entirely resulting in the death of females. A few dynasties ago in China an army of 100,000 men with no prospect of finding mates very nearly overthrew the established government. The crime of infanticide is also prevalent in India and is seldom prosecuted. So far all of those convicted have been women. Everyday logic says these convicted women were coerced by males. A 1996 law in India prohibits the sex of the unborn from being determined in government clinics. One result: there are 200 private clinics in Bombay performing this service. The ratio of newborn boys to girls throughout India is significantly enhanced by these activities even in the Christian community. All of this has occurred in regions where sons are obligated to care for aging parents so that elder citizens without sons are doomed to poverty, deprivation and early death. Do we realize that Social Security has become a public health measure and doubly so in Asia? I probably should be gratified to report that a substantial majority of couples in Europe and North America who choose the sex of their offspring, when undergoing in vitro fertilization, choose girls.
When abortion became legal, contraception became much less problematic. When human shelters for unwanted children become well organized and (occasionally) have trouble finding adequate homes for the children, presumably many rights activists will step forward as they do now for the animals—I know several with more dogs and cats than they would otherwise have chosen to own. After all we are animals and as worthy as our pets. A beneficial side effect may be less resistance to needed animal experimentation. Here is an example: knockout mice are created with a specific gene inactivated. It might be a gene of unknown function whose existence is only known by comparison of the complete mouse and human genomes. The biochemical or structural defects resulting in the knockout mice will demonstrate the gene’s function. Ultimately the function of most, if not all expressed genes, will be determined by such methods with great benefit to medicine both human and veterinary, but this will not happen if animal rights activists prevail in all their endeavors. On the positive side these activists have been effective in promoting the humane treatment of animals.
Just a little more brainstorming before we get to something doable in the near future: new information has demonstrated that genes for diabetes (and obesity) have been bred into us because these very same thrifty genes enhance survival after repeated famines. There has been no consistent success in advising the public about avoiding obesity by common sense methods such as eating less and/or getting more exercise. These “thrifty” genes produce their health problems mostly after reproductive age, so it is very unlikely that diabetic tendencies will be bred out of the population any time soon. The only selective pressure I can think of is the small handicap in the success of children lacking healthy grandparents, especially grandmothers.* What can we do to stem the obesity epidemic? For starters: get soft drink machines out of schools; tax motor scooters, electric powered wheel toys, all terrain vehicles, and snowmobiles except those used for rescuing cross country skiers, prohibit golf carts except for disabled golfers (this restriction already exists for golf tournaments), tax junk food enough to pay society’s unnecessary health costs from its over-consumption (obviously not practical)—remember this is brainstorming. Or should we simply prohibit its promotion. We have citizens who get so little exercise that junk food can easily lead to malnutrition. Activity increases total food consumption so that a larger percentage can be junk without compromising intake of essential nutrients. TV and computers are already interfering with getting enough exercise. We need to induce the public to get more exercise even in childhood. Persuasion won’t suffice because most persuasion turns out to be preaching to the converted. Our example in the developed world, if we solve this problem, will be of great benefit to the underdeveloped world because they have even a higher incidence of the thrifty genes than we do. They lack our very long history of settled agriculture and the consequent ability to store food. Public Health has many dimensions.
Here is an idea to promote the use of motorcycle helmets: charge extra for motorcycle license plates that permit the cyclists to ride without helmets. The extra cost could be adjusted to cover unnecessary expense to society, such as nursing home care after the injured person’s assets were exhausted. Years ago I made a “ back of the envelope” calculation and came up with $200 per year per motorcycle. Iowa already has such a program implemented through required long-term care insurance for motorcyclists without helmets. The common feature of these suggestions has been promoting a healthy lifestyle without totally prohibiting its opposite. Obviously many details need working out. A salient omission in my discussion has been disincentives to the use of automobiles on short trips appropriate for walking or bicycling. This needs to be addressed in a fair-minded way.
Finally, here is an item for which my public already has expressed some enthusiasm, so this one might be acceptable to the general public sooner than by most government officials. Create a new category of substances which are not quite legal and not quite illegal. Into this category place tobacco, marijuana, other currently illegal drugs, and probably distilled spirits and gambling. For consistency should all habit forming drugs be placed in the category of neither legal nor illegal? There are reasons, alluded to above, for putting caffeine in this category even though it is harmless. But is it harmless when combined with tasty sweet flavors and promoted to children? I refer to caffeine in soft drinks. I have had teenagers with severe undiagnosed headaches because their parents suddenly ceased to subsidize their caffeine containing pop consumption. A little sleuthing demonstrated that these were caffeine withdrawal headaches.
I hasten to point out that advertising can be educational and beneficial in other ways. Consider advertising for a garage sale: the buyer gets a useful item at a bargain price, the seller learns how to get rid of junk with negative tuition, and the community ends up with less (useful) stuff in the “sanitary” landfill. When the public thoroughly perceives the advantage of our neither legal nor illegal category, what do we take on next after drugs? How about recreational activities which simultaneously degrade the environment and distract us from getting exercise needed for optimum health? We have already mentioned the highest use of snowmobiles as ambulances for rescuing cross-country skiers. Personal watercraft (jet-skis) have no highest use and all terrain vehicles also interfere with health by way of injuries and production of unnecessary greenhouse gases not to mention quasi permanent ruts in virgin (desert) soil. Our new approach must be inserted slowly so the improved health can become apparent and the economy can adjust to less planned obsolescence. For example we are getting along just fine without electric can openers now that we have switched to frozen vegetables.
*Public records in Scandinavia are so complete and reliable that they have been used to prove that there is a slight but statistically significant increased survival in children who have healthy grandmothers.
“Commercial free speech” could no longer be invoked to promote these neither legal nor totally illegal substances and activities. Illegal drugs would have varying restrictions on their availability with the guiding principle of maximum reduction in harm both to health and to law and order with special emphasis on reducing revenues to criminal elements. For years I have been saying that the main reason for not smoking pot is to deprive the underworld of revenue so we can have more honest cops. In other words any possible benefit in pot smoking is insufficient to justify the unintended consequences of civil disobedience. Civil disobedience is only justified if the perpetrators are prepared to go to jail for making their point. Most pot smokers are not that thoughtful about their motives, but we have wasted untold resources and lives by jailing them. Most of them could be perfectly satisfactory citizens or even parents if they weren’t in jail. Luther Terry as Surgeon General in the 1960s said that alcohol and tobacco were both more harmful that marijuana. We doctors knew that he was correct. For evidence, an overdose of marijuana has never caused an acute fatality.
A little further along in our health and economic revolution there is a dogma which must go. I refer to the dogma that the economy must grow continuously in order to maintain prosperity. When the underdeveloped world succeeds in behaving as we do, mankind will quickly “achieve” un-sustainability as a species. Somewhere along the way mankind must also face the fact that overpopulation is the ultimate environmental hazard. The final stage of our health and economic revolution involves adequate amenities for the entire human population. Two related dogmas, also untrue, can be overcome: 1) corporations are private and cannot be interfered with, and 2) boards of directors are legally obligated to maximize returns to stockholders. At the rate our rich are getting richer and our poor poorer, a revolt like the French Revolution is inevitable and it won’t come about with guillotines and its prevention will not be not (entirely) military. Italy, Spain, and Ireland have ceased growing in population by the education of women. This success can be duplicated everywhere regardless of religious and political obstacles.
In summary, we need to do some difficult thinking about how we spend money on health to be sure we get value received. And we need to stop doing some things because “we have always done it that way.” It will be difficult to separate doable brainstorming from pipe dreams. The Public Health perspective is a powerful way to approach many human problems.
John A. Frantz, M.D.
August 2, 2003, revised December 12, 2003.
The more or less equal sex ratio of males to females has a remarkably simple explanation attributed to Ronald Fisher in 1930: Every offspring has one mother and one father. The result is that, on average, males and females will have equal success in passing their genes to the next generation. Fisher’s crucial insight was that a mother producing an excess of the rarer sex, whichever it happened to be at any particular time, would be more successful in passing her genes forward. Thus the rarer sex would become less rare. If the ratio were reversed for a time, the other sex would be the rare one and producing an excess of it would be the most successful strategy temporarily until the present (almost) universal equilibrium near 50/50 was achieved perhaps with a few swings back and forth early on.
Parthenogenesis, where females clone themselves, doubles the reproductive rate compared to sexual reproduction. Some invertebrates do it this way when the going is good but revert to normal sex when conditions deteriorate. This permits reshuffling of genetic traits, producing a great variety of phenotypes, some with the characteristics needed for the species to survive adversity, whether due to climate, disease, or a newly arrived competing species.
Suppose the slippery slope is an otter slide, and you are an otter doing what you oughter.