Forest View

The Hidden Big Picture of Preventable Deaths

Photo credit: SUNY Faculty of Forestry

It is entirely possible that I will be smooshed by a tree tomorrow. Highly unlikely, but possible. Don’t worry, I’m not spending all my time dwelling on my doom. After all, it’s equally possible that YOU could be smooshed by a tree tomorrow. In all cases, however, we can make a pretty reasonable estimate that we will not be smooshed by a tree, and plan accordingly. This is the magic of demographics. Homicidal trees are so rare, they don’t have much impact on the average person’s life history. We can worry instead about things which are more likely to matter to us, like serious illness or poor diet.

If only everything that impacts our health was so easy to see. A number of recent research projects have revealed hidden phenomena of massive-scale importance to public health. I find these studies fascinating, because they uncover what hides in plain sight, forehead-slapping stuff that leaves you thinking, “How did I not see it myself?” These projects have the power to surprise us, when we see what’s really worth worrying about.

The Far Side by Gary Larson

We take a lot for granted. For example, most people living today live longer and healthier lives than they would have in the past. If you’re familiar at all with the way medicine used to work — think “leeches” — then this statement is obvious enough to be kind of pointless. Look deeper into it, though, and you can re-format this into a comment on demographic trends: at a worldwide scale, life spans have been increasing, and within every age group, death rates have been falling. Looking down the scale from the whole world to individual countries and even smaller areas, or to social and racial groups of various sizes, the trends hold up across the board.

Except when they don’t. It’s so rare to see death rates going up for a selected group, we might not bother even looking. But two Princeton economists (one of them a Nobel Prize winner) looked anyway, and shocked public health experts by finding an exception. Within the United States, during the last 15 or so years, while virtually all other demographics followed the normal trends (death rates falling, life span rising), middle-aged white men and women were dying more. The reverse trend became even more glaring when education level was given factored in, and in fact those with only a high school education or less appear to be skewing the numbers for the entire group. For white men and women age 45–54 with a greater than high school education, mortality decreased, similar to other categories. But in the same age group, for those with high school or less, mortality increased by 22% from 1999 to 2014. That’s a 22% increase in their chance of dying young.

Case and Deaton, in PNAS, cited by the New York Times, re-cited by me, looked at by you

This requires some serious explaining. In this case, the direct explanation appears to be suicide, drugs, and alcohol. But that only begs the question: what is motivating the increase in these self-destructive behaviors? That’s more complicated, and harder to prove. One thing we can be sure of, though, is that there are steps we can take to try and make this right. Monitoring programs for prescription drugs already exist in 49 out of 50 states, and lives could be saved by implementing such a program in the one state remaining — Missouri. Access to mental health care is an area with much room for improvement nationwide. Devoting greater resources to mental health and substance abuse programs ought to seem more urgent, now that we know the scope of the problem.

Speaking of doing things about things, sometimes it’s hard to determine what those things are. For example, if I have a treatable illness, but I die because I wasn’t properly treated, what killed me: the illness or the lack of proper medical care? The answer can be either or both, depending on the phrasing of the original question. The habit among medical professionals has been to address the direct physical cause of death only. This means that the impact of preventable medical failures has been unknown, but Johns Hopkins has released data suggesting it’s a bigger deal than most people would imagine.

Their work shows that preventable medical errors are the third leading cause of death in the US. Perhaps the first examples to come to mind are surgical accidents, but the category is more broad than that. It also includes incorrect diagnoses, which may result in a lack of proper treatment, or inappropriate treatment that causes unnecessary risks — or both at once. Mistakes involving medications, such as incorrect dosages or even incorrect drugs altogether, are also hugely important. The cumulative effects of these and other simple mistakes are more dangerous than respiratory disease — by a lot.

The Centers for Disease Control disagrees. They are the agency responsible for keeping track of our dying, and in fact the Johns Hopkins study was released partly to pressure the CDC to change the way it records the relevant data. The concern is that the CDC is dramatically under-reporting the impact of preventable medical errors. The authors of the study hope that more accurate reporting will guide our response to the problem. Stricter safety standards for storing and delivering medications would be a good start.

On balance, medical treatment is still better than no medical treatment. So much better, in fact, that differences in access to it cause their own large-scale demographic effects. Breast cancer rates among black women are lower than among white women, but black women have a higher mortality rate from the disease. How does that happen? Unfortunately, it’s exactly what you would think: on average, black women have less access to quality medical services. They are diagnosed later in the progression of the cancer, and they receive less consistent treatment even after the diagnosis.

Black women get breast cancer at about the same rate as white women, but they die from it much more often. Graphs from CDC

This is the clearest example of a fixable systemic problem that I can think of. If we want this fact to go away, we must dedicate more resources to quality medical services for the people that don’t have it. If we don’t provide those resources, the disparity will continue, and more preventable deaths among black women will occur. It’s a one-to-one correlation — fix it or don’t.

These articles may seem on the surface like a lot of doom and gloom, but their potential impact makes them just the opposite. It’s true — and terrible — that a whole section of the population is dying at higher and higher rates. But other sections are not, and that means the causes can be isolated and addressed, and we can be confident that practical solutions are out there. It’s true, and terrible, that preventable medical errors are so prevalent. But that’s what they are: preventable! Given the right practices and resources, medical professionals can catch lethal mistakes before they happen and save lives. It’s true, and terrible, that our system-level neglect of black women leaves them more vulnerable to a treatable disease. It’s also true, though, that if we correct that neglect, we will correct the vulnerability along with it.

There’s a saying about not being able to see the forest from the trees. These are, in a sense, forest studies, rather than tree studies. So now we know — we can see the forest. Solutions are already at hand, waiting for us to implement them. Ignorance is no longer an excuse.