Tag Archives: public health

Oh, Indiana…

I recently read that Indiana’s legislative overlords are taking time out from their attacks on women and trans children, and deigning to address an actual issue–the health of Hoosier citizens.

I haven’t been following those health measures, and to be honest, I lack the background to properly evaluate them in any case, so I thought I’d pose a question to my new research assistant, otherwise known as ChatGPT.

Here’s what I asked:

Please locate Indiana’s relative performance in health related areas, especially drug and alcohol abuse rates, infant mortality, smoking statistics, suicides, life expectancy, and other wellness markers like mental health.

Here’s what I got:

 Sure, here is some information on Indiana’s relative performance in health-related areas:

Drug and alcohol abuse rates: According to data from the National Survey on Drug Use and Health (NSDUH), Indiana has higher than average rates of substance abuse, particularly with regard to prescription pain relievers and synthetic opioids. In 2019, Indiana had the 9th highest rate of drug overdose deaths in the United States, with a rate of 27.5 deaths per 100,000 population.

Infant mortality: Indiana has one of the highest rates of infant mortality in the country, with a rate of 6.8 deaths per 1,000 live births in 2019. This is higher than the national average of 5.6 deaths per 1,000 live births.

Smoking statistics: Indiana has one of the highest rates of smoking in the United States, with an adult smoking rate of 21.1% in 2019. This is higher than the national average of 14.0%.

Suicides: Indiana has an above-average rate of suicide, with a rate of 16.9 deaths per 100,000 population in 2019. This is higher than the national average of 13.9 deaths per 100,000 population.

Life expectancy: Indiana’s life expectancy is slightly lower than the national average, at 76.7 years in 2019 compared to the national average of 77.3 years.

Mental health: Indiana has lower than average rates of mental health care access and high rates of mental illness. According to Mental Health America’s 2021 report, Indiana ranks 45th out of all states and the District of Columbia in terms of overall access to mental health care. Additionally, Indiana has the 5th highest rate of adult mental illness in the United States.

It’s worth noting that these rankings and statistics are subject to change over time and may vary depending on the specific sources and data used.

You might think that–given the sad state of Hoosiers’ health–healthcare might take priority over efforts to stymie DEI investing and destroy the state’s public schools–but of course, this is Indiana….Even a superficial look at General Assembly priorities is enough to demonstrate lawmakers’ utter disregard for public health.

In the wake of Dobbs, Indiana lawmakers couldn’t wait to ban abortion–despite overwhelming evidence that reproductive care–including abortion–is an essential element of women’s healthcare.

Then, of course, there’s the legislature’s ongoing love affair with guns, despite polling showing that a majority of Hoosiers (including a majority of NRA members) support additional regulation.

Perhaps the most direct evidence of our legislature’s lack of concern for the health of their constituents was this session’s mean-spirited denial of appropriate health care to trans children. I went back to ChatGPT for an explanation of the health consequences involved.

Denying appropriate medical care to transgender young people can have serious medical and emotional consequences. Here are some of the potential outcomes:

Delayed or absent puberty: Transgender young people who are denied appropriate medical care may not undergo puberty at the same time as their peers, or may not undergo puberty at all. This can lead to social isolation, low self-esteem, and feelings of dysphoria.

Increased risk of mental health problems: Transgender young people who are denied appropriate medical care may experience depression, anxiety, and other mental health problems as a result of the distress caused by their physical dysphoria.

Increased risk of suicide: Studies have shown that transgender young people who are denied appropriate medical care have a higher risk of suicidal ideation and suicide attempts.

Increased risk of physical health problems: Transgender young people who are denied appropriate medical care may be at increased risk of physical health problems related to their gender dysphoria, such as urinary tract infections or other complications from avoiding the use of restrooms that do not match their gender identity.

Reduced life expectancy: Transgender people who are denied appropriate medical care may have reduced life expectancy due to the physical and mental health problems they experience as a result of their gender dysphoria.

Overall, denying appropriate medical care to transgender young people can have serious and potentially life-threatening consequences. It is important for healthcare providers and society as a whole to recognize and respect the healthcare needs of transgender youth, and to provide them with the necessary medical care and support to live healthy and fulfilling lives.

Our legislative culture warriors don’t care.





Ah, Federalism…

One of this country’s ongoing struggles has been with the concept of federalism. Which rules should be nationally-imposed, and which should be left to those “laboratories of democracy” lionized by former Supreme Court Justice Brandeis?

Students who have been taught the actual history of the United States are aware of the multiple problems the country experienced under the Articles of Confederation; those problems were severe enough to prompt the replacement of the Articles with our current Constitution. In the (many) years since, however, we seem to have forgotten about the very negative consequences of government fragmentation.

Certainly, not all policy needs to be nationally uniform–there are plenty of areas where local control is appropriate. Questions about who is entitled to fundamental rights–and what those rights are–isn’t one of them, as the patchwork of approaches to reproductive freedom that’s emerging is likely to demonstrate. Forcefully.

The application of the Bill of Rights to state and local governments was meant to establish a floor–to ensure that a citizen moving from say, New York to Indiana, would not thereby experience a reduction of her fundamental rights as an American citizen. Justice Alito’s evisceration of the substantive due process clause is–among other incredibly negative things– a step back toward the fragmentation of the Articles of Confederation.

Over the 200+ years of American statehood, the need to rationalize and unify large areas of the law gave rise to the work of the Uniform Law Commission. The Commission drafts and promotes state enactment of uniform laws in areas of state law where uniformity has been recognized to be both desirable and practical. Probably the best-known uniform law is the Uniform Commercial Code– a comprehensive set of laws governing all commercial transactions in the United States. It has national application, but it isn’t a federal law–it was uniformly adopted by each state’s legislature.

As the Commission’s website explains,

Uniformity of law is essential in this area for the interstate transaction of business. Because the UCC has been universally adopted, businesses can enter into contracts with confidence that the terms will be enforced in the same way by the courts of every American jurisdiction. The resulting certainty of business relationships allows businesses to grow and the American economy to thrive. For this reason, the UCC has been called “the backbone of American commerce.”

Obviously, commerce isn’t the only area where uniformity is “desirable and practical.” Federal action in the face of a pandemic would certainly seem to qualify, and before the incompetence and massive ignorance of the Trump administration, the federal government largely directed public health responses to threatened outbreaks.  Last March, Talking Points Memo addressed the disastrous results of Trump’s decision to leave COVID response to the states.

From the very start of the Pandemic in the first weeks of 2020 the Trump administration consistently sought to disclaim responsibility for things that would be genuinely difficult and could have challenging or bad outcomes. Push the tough tasks on to others and if it goes badly blame them. This frequently went to absurd lengths as when the White House insisted that states short on ventilators at the peak of the spring surge should have known to purchase them in advance of the pandemic. Over the course of the year Trump spun up an alternative reality in which the US was somehow still operating under the Articles of Confederation in which individual states were responsible for things that have been viewed as inherently federal responsibilities for decades or centuries.

It is not hyperbole to suggest that a more co-ordinated, federalized response wouldn’t just have saved lives, but in all likelihood would have cut short the period of most vulnerability.

No serious student of governance believes that, in a country as large and diverse as the United States, all decisions should be made at the federal level. The question with which we should be grappling is “which responsibilities are properly federal and which matters are properly left to state or local governments?” (Someone needs to tell Indiana Senator Braun that interracial marriage is not one of those…).

What laws need to be uniform if we are to be the United States of America, rather than a haphazard collection of Red and Blue fiefdoms?

I’m willing to leave zoning decisions up to local municipalities, and a substantial portion of criminal justice measures up to the states. When it comes to fundamental rights, not so much…



Time To Rethink Federalism

I used to begin my classes in Law and Public Policy with what I call the “constitutional architecture,” the structures of U.S. government. As I would tell students, the Founders had divided authority both vertically and horizontally–through Separation of Powers and Federalism.

Most graduate students were familiar with those terms. Undergraduates generally knew that we had three branches of government, although the term “Separation of Powers” was less familiar to them, but very few could define federalism–the division of jurisdiction between the federal government and the states. Both mechanisms were intended to provide “checks and balances”–to limit the power of the central government.

The world we inhabit is very different from the world that confronted the nation’s founders. We still need federalism–but it is past time to review and adjust the current divisions of authority among local, state and federal levels of government.

A number of those divisions are still useful and should be retained. State and federal governments have no reason to assume responsibility for handing out zoning permits or policing domestic violence disputes, to choose a couple of examples, but other current assignments of responsibility no longer make much sense. State-level management of elections, for example, was necessary in the age of snail-mail registration and index cards identifying voters; in the computer age, it’s an invitation to misconduct–an invitation that  state-level lawmakers eagerly accept.

In a number of areas, there are awkward pretenses of state “sovereignty” where contemporary realities mean none really exists. (Think of federal highway dollars that are conditioned on state compliance with federally mandated speed limits. Or the similar “strings” attached to federal funding.) 

At the other end of the spectrum, there are an increasing number of issues, including but certainly not limited to the threats posed by climate change and the pandemic, that must be addressed globally.

Then there are the increasing tensions created by legislators in red states who want to be free of the constraints imposed by the Bill of Rights.

The GOP has never gotten over its original resentment over incorporation–the odd word for the doctrine that nationalized the Bill of Rights. That process was premised on the 14th Amendment principle that fundamental liberties protected by the Bill of Rights should be a “floor”–that a citizen in Alabama should enjoy the same basic rights as a citizen of New York. States are able to enlarge on those rights, but–at least until Donald Trump managed to pack the Supreme Court with rightwing ideologues–they have been forbidden to retract them.

There are multiple reasons to revisit the division of authority between the nation’s state and federal governments. I realize that any effort to do so would be met with alarm–much as we’ve seen with calls to eliminate the filibuster that currently prevents the Senate from actually governing. We humans are creatures of habit: we become accustomed to the world we have grown up with, and assume that the structures of whatever society we inhabit are just “the way it is.” (A great example: the people who argued against same-sex marriage by insisting that marriage “has always been between one man and one woman.” That’s demonstrably false. Even if you ignore biblical history, more than half of the world still recognizes plural marriage. But it was true within the confines of their limited experience.)

A recent guest essay in The New York Times pointed to the undeniably negative effect of our current federalism on public health.

Tennessee and North Carolina are both digging out from catastrophic flooding, while parts of Louisiana were flattened by Hurricane Ida, and most of New Orleans remains without electricity. Ida’s remnants also brought even more rain to areas of the South and beyond that were already dangerously waterlogged.

In the Utter Failure to Understand What “Pro-Life” Really Means tournament, normally a very close battle in the red states, Texas is currently uncontested: Its leaders just made it easier to carry a gun and harder to end an unwanted pregnancy in the same week.

Finally, in the Colossally Botched Medical Emergency competition, it’s neck and neck across the region as Republican governors double down on efforts to block mask and vaccine mandates, along with every other pandemic-mitigation attempt made by people who are not allergic to science.

The author points out that every single one of these disasters is a public health emergency that red state governors have worsened “in every way imaginable.” (A recent NBC poll confirmed that politics has played havoc with public health. It found 91 percent of Biden voters vaccinated opposed to 50 percent of Trump voters.)

 Citizens’ health and safety– and the extent of their civil rights–  should not depend upon their state of residence. 


I don’t post often about America’s insane gun culture, because the lines have been drawn for a very long time, and the combatants’ feet are firmly in cement.

I could share innumerable facts: how many people die by gun each year, the margin by which the thousands domestic gun deaths exceed deaths in war, how guns facilitate suicide…on and on. It wouldn’t matter to the relative minority of gun owners who stockpile weapons and foam at the mouth at any suggestion that we withhold firearms from wife-beaters, crazy people or people on the terrorist watch-list.

Unfortunately, the foaming-mouth folks can rely upon the congressional GOP to ignore any and all facts, and block efforts to fund research into gun violence.

Research does exist, however, and rational people will find it persuasive. The Guardian recently reported on data from an experiment in the Bay Area.

For each new millionaire household the San Francisco Bay Area has produced, there are at least four new people living below the poverty level. San Francisco’s property crime rate has spiked to the highest in the nation. Many people – tech newcomers and longtime residents alike – complain of feeling unsafe.

At the same time, with little fanfare, the Bay Area has seen a dramatic drop in its homicide rate, driven by a considerable decrease in deadly shootings.
Across the region, the overall gun homicide rate has dropped 30% in the past decade, a Guardian investigation of homicide data across more than 100 cities has found.

The study analyzed homicide data across California’s Bay Area from 2007 to 2017. During that time, gun homicide rates fell across all racial groups, but the decrease was largest for black residents.

What was particularly striking about these findings was that the dramatic drop came at the same time as criminal justice reforms in California reduced the number of people in the state’s jails and prisons.

The reduction came as cities like Oakland and Richmond did what a number of scholars have recommended: they changed their approach to the problem, investing tens of millions of dollars in public health approaches to gun violence.

The study considered–and dismissed–the possibility that gentrification was the reason violence subsided.

Three cities that are undergoing intense gentrification saw the biggest drops in gun homicides. But outlying suburbs – the towns where many residents forced out by gentrification have moved – did not see a corresponding increase in violence…

The Bay Area still sees nearly 300 gun homicides each year. But these changes are profound. The majority of America’s gun homicide victims are black, killed in everyday shootings in segregated, economically struggling neighborhoods in cities such as Oakland and Richmond. It’s this everyday toll of violence, not mass shooting casualties, that drives America’s gun homicide rate 25 times higher than those of other wealthy countries.

The article noted that cities that once ranked among the nation’s deadliest have seen enormous decreases, and emphasized that these decreases spanned a decade– they weren’t single-year drops. The declines persisted over the years.

California has the strongest gun laws in the country, and it has enacted more than 30 new gun control laws since 2009 alone. The Guardian credited those constraints, together with the change in approach to violence prevention, for the reduction in gun homicides.

There’s early evidence that local violence prevention strategies – including a refocused, more community-driven “Ceasefire” policing strategy, and intensive support programs that do not involve law enforcement at all – were a “key change” contributing to these huge decreases.

As the article concedes, there are still plenty of problems in the Bay Area. (Police shootings haven’t declined, for example.) But there is a lesson here.

Of course, lessons are lost on people determined not to learn them.

Health and That Chinese “Hoax”

One of the unfortunate aspects of this bizarre Presidential campaign has been the lack of attention to the truly important issues America faces. Not that sexual assault, bigotry and massive ignorance are unimportant, but between disclosures about Trump’s “groping,” his “scorched earth” attacks on pretty much everyone, and his increasingly obvious mental health issues, the Orange One has sucked up all the oxygen in the room, with the result that issues of enormous consequence have received little attention, and even less thoughtful discussion.

Earlier this month, I posted about Trump’s selection of “environmental experts” for his transition team–a group of denialists about the reality of climate change.

We are already experiencing the severe weather that we’ve been warned will accompany our new climate reality; hurricanes that pick up power from warming oceans, flooding in some regions, droughts in others. But it isn’t only weather and agriculture that should concern us.

I often quote my cousin, an eminent cardiologist whose own blog is devoted to providing accurate medical information and debunking what he aptly calls “snake oil.” He recently reminded me that there is a health dimension to climate change that is too often overlooked:

At this time, most thoughtful people acknowledge the reality of humanly generated climate change on our environment, but they often fail to understand the real threat this poses to human health in general.

Now, the American College of Physicians (ACP), one of our most respected medical institutions, has issued a sobering position paper on climate change and it effects on human health, including higher rates of respiratory and heat-related illness, increased prevalence of vector-borne and waterborne diseases, food and water insecurity, and malnutrition. Persons who are elderly, sick, or poor are especially vulnerable to these potential consequences, according to this group. The ACP also states its belief that it’s incumbent on all those in the health industry to play an active role in protecting human health and averting dire environmental outcomes.

This ACP publication emphasizes that climate change presents a “catastrophic risk” to human health over the next hundred years that may wipe out all of the health advances made over the previous 100 years. The average temperature on Earth has increased by almost 1 degree since 1889, and greenhouse gas emissions have increased by almost 50% from 2005 to 2011. It is predicted that by the end of the century, the Earth’s temperature may increase by 5 to 9 degrees Fahrenheit. Ice in the Arctic and Antarctic seas has melted at unprecedented rates and the water levels worldwide have risen by almost 7 inches over the last 100 years. The World Health Organization has predicted that climate change will cause an additional 250,000 deaths per year from 2030 to 2050 due to malnutrition, increased malaria, increased respiratory illness, heat-related illness, food issues due to crop losses, and increases in waterborne infectious diseases and vector-borne illness:

Their current recommendations include the following:

The entire health care community throughout the world must engage in environmentally sustainable practices that reduce carbon emissions.
Support efforts to mitigate and adapt to the effects of climate change.
Educate the public, their colleagues, their community, and lawmakers about the health risks posed by climate change

As guardians of human health, we must assume a more active role in avoiding these disastrous consequences—if not for our own well-being, but for that for our children and all future generations! These efforts could well begin with how we all vote in the coming election!

My concern is not simply with the efforts of fossil fuel companies to stave off changes so that they can continue to profit, or with the fundamentalists (too many of whom are in Congress) who piously insist that God will take care of us.

My concern is that far too many of us arguably normal folks will react just like patients whose doctors tell them to quit smoking or start exercising– patients who know the doctor is right, but who lack the will to follow through.