Saturday, December 15, 2012

The Epidemiology of Senseless Agony

Like millions of other Americans did yesterday, I listened to the news of the tragedy in the Sandy Hook neighborhood of Newtown, Connecticut while my emotions rapidly oscillated between fear, anxiety and outrage. I spent most of the day seeing patients in the hospital and so was only vaguely aware that something terrible had happened. I got into my car in the early evening and soaked in what details were known as I made my way on the hour long commute into Boston where we were having dinner with some friends. I walked into the door, found my child, and held him while I wept.

Surely that scene must have played out in countless homes across the United States yesterday--private moments of utter grief as we contemplate the suffering that must be taking place for the families of those children and teachers in Connecticut. So too are the numerous public expressions of shock and horror that could be found on Facebook or Twitter. Everyone wants to express something of the peculiar emotional state in which we find ourselves after yet another mass killing of people whom we do not know but whose lives very much resemble our own. And so we have, and it is very nearly unbearable to read a Facebook news feed today.

I am no different in wanting to say something to help process my own sorrow, and the words I can summon have already been used by tens of thousands of others: unspeakable and unthinkable and horrific and on and on. But Sandy Hook can also be described in different terms besides moral outrage, and one term in particular leapt to mind because I am a physician and because I treat infectious diseases.

Sandy Hook is part of an ongoing epidemic.

It is an epidemic in every traditional sense of the term: it affects "many persons at the same time, and spreads from person to person in a locality where the disease is not prevalent", as describes it. It is prevalent, and it is widespread. It is, in a very meaningful way, a disease that continues to afflict our country, and will continue to reach new communities unless it is stopped.

For Sandy Hook is, as everyone knows, not an isolated incident, but rather simply the latest in a string of horrors that began its modern phase with the Columbine massacre in 1999 and has included the Virginia Tech massacre in 2007 and this year's repeat performance in Colorado at a movie theater in Aurora. Like, say, HIV, where strange isolated cases cropped up decades before the full-scale epidemic began in the 1980s, almost serving as a warning of things to come, mass shootings also have much earlier precedents, the most famous being the University of Texas shootings in 1966 and, more obscurely, the Bath School incident in 1927 (which was for the most part a bombing rather than a shooting). Since Columbine, however, we've witnessed a steady stream of mass death.

Against the backdrop of these earthquakes of violence are what might be thought of as tremors of shooting--dozens of one- or two-person killing events that would hardly garner a blip on national news coverage today, so desensitized have we become to gun violence that mere individual shootings do not merit our attention or alarm. (The Wikipedia link only deals with school shootings: actual gun violence in the United States currently accounts for over 30,000 deaths per year, which is roughly the same number of people that die of influenza on average in any given year.)

From an epidemiologic perspective, gun violence precisely resembles any number of lethal infectious diseases. And like other infectious diseases, it will not abate simply of its own volition, our expressions of rage and grief notwithstanding. No amount of candlelight vigils or eloquent statements from public officials will put a dent in this problem. We'll see another Sandy Hook, and we'll probably see it again within the next year or two if this behaves like any other uncontrolled epidemic.

So what will make a difference?

I think it's helpful again to look at how we treat infectious epidemics. Over the past several months there has been a very deadly multistate meningitis outbreak; 37 people--almost exactly the number of the Aurora and Sandy Hook casualties combined--have died thus far. And the response of our government has been swift and definitive. The company which was the source of the outbreak was quickly investigated and shut down, as were other pharmacies who were immediately inspected as well. The FDA, CDC and various state health authorities worked in close coordination. And as a consequence of a government that functions to protect its citizens, the outbreak appears to be under control. Should we expect less of our government to address the problem that led to Sandy Hook?

Yet the epidemic of gun violence, which is a far more serious and prevalent problem in the United States, remains "untreated". Indeed, even initiating a discussion about how such a treatment should be administered can cause fierce recriminations. Only a week ago, sports journalist Bob Costas opined in his typically erudite fashion that the Jovan Belcher tragedy might not have happened at all had it not been for Belcher's possession of a gun; the roar of the right wing could be heard immediately. Even the President's statement about Sandy Hook, while unquestionably tactful, was extremely cautious on the subject of gun access. No such caution would have been in evidence had he been speaking about a case of Ebola.

As someone who knows something about how infections and epidemics behave, I'm confident that if we don't change the way we understand an unregulated gun culture, Sandy Hook won't be the last victims this disease will claim.

Tuesday, December 4, 2012

Pure Paul Krugman: Healthcare Costs

"The point is that if you want to control Medicare costs, you can’t do it by kicking a small number of relatively young seniors off the program; to control costs, you have to, you know, control costs...The key is having a health insurance system that can say no — no, we won’t pay premium prices for drugs that are little if any better, we won’t pay for medical procedures that yield little or no benefit."

This from his blog. I'd only add that we also need to figure out a way to say "no" to the needless prolongation of life in ICUs in people who have virtually zero chance of recovery. It accounts for an enormous amount of our expenditures, although I don't have the references on that at my fingertips.