BLIND SPOTS
Tradition is the DNA of our beliefs. The pull of tradition helps explain the strong emotions that accompany religious beliefs, political leanings, cultural values, and even food preferences.
In public health, one of the great challenges is to promote behavior change. We are all saddled with beliefs that make it hard to change, even in the face of great evidence. Tradition leads to many blind spots.
To reach a conclusion that was not held by my parents once seemed almost disrespectful. But then it became clear to me that they had raised us to think independently. My mother would reinforce this after a discussion on why we had reached a different conclusion, by saying, “You are never too old to learn from your children.”
We all have blind spots. I am surprised at some of the things I believed even ten years ago, and I wonder how I could have been so blind. Likewise is the surprise of learning that large segments of the population can believe something long after it is proven untrue. Consider the evidence for global warming, which seems beyond the grasp of many in Congress, or the studies showing no relationship between vaccines and autism, which many refuse to accept. False beliefs in these two areas have a direct and negative impact on public health. But the mystery is larger.
About half of the US population does not believe in evolution. Darwin was influenced by his religious grandfather, who used selective breeding to improve his domestic animals. This practice requires some understanding of evolution and the belief that it is possible to alter its course and speed. Every microbiologist sees evolution unfolding, sometimes within days. As mentioned earlier, the Westminster Dog Show is a convincing demonstration of evolution, as every breed exhibited has descended, through evolution, from wolves. Most scientists accept evolution as fact and proceed from there.
But half the population nevertheless believes that evolution is not compatible with religious beliefs and is therefore unable to take an open view of the evidence. There are plenty of ways to reconcile evolution with religious beliefs. Blind rejection is not one of them.
Women as Voters
Democracy holds leaders responsible to voters. This accountability is a powerful tool in causing political leaders to improve public health services, such as vaccines, safe water and food, clean air, and a safe environment. It becomes even more valuable if women also have the chance to vote and thereby influence public health decisions of political leaders. Mass delusion is yet another aspect of tradition, and so for almost a century and a half, the American tradition denied women the right to vote. There are still some who would argue that women should not be allowed to vote in this country. But their arguments do not carry the weight that they did 200 years ago. It is difficult for us to understand that once many men actually believed that their wives and mothers did not have the capacity to make an informed and intelligent choice in the voting booth but were able to make an informed and intelligent choice in choosing a husband.
But tradition is so strong that even when we concede the equality of women in voting, we continue our bias in the workplace. And, strangely, the belief that women are inferior continues in some Protestant and Catholic religious orders. To make it more mysterious, 50 percent of these church members, namely, the women, could leave churches that believe that they are not capable of being ministers or priests, but they do not leave. Do they actually believe the idea that they should not have the same rights as men? They do have the vote in the sense that they don’t have to put up with it and yet they stay. Tradition.
Slavery
Throughout history, even in biblical stories, some people accepted the idea that some people should be able to enslave others. It is difficult to find Americans who will espouse that belief today. So how do we explain the lack of common sense that plagued large segments of the US population 160 years ago?
It cannot be explained by intelligence. Thomas Jefferson simply could not bring his intelligence to bear on his personal use of slaves. Likewise, in the 1840s, the president of Emory University led a committee that decided it was ethical for bishops to own slaves. Tradition often blocks rational thought.
Tradition was so strong that people were willing to die in large numbers to defend the irrational idea of slavery. They were willing to put civilians at risk, destroy homes and crops and families so that slavery would continue. They harmed the public’s health. It defies our understanding today.
Tobacco
“And so it goes,” as Kurt Vonnegut would say. While some had early suspicions that tobacco was a hazard to health, it took a surprisingly long time for the degree of that risk to be made clear. The degree of known risk now makes us think that it should have been crystal clear much sooner. But it was not. The early studies on the relationship of tobacco to lung cancer, for example, were weaker than expected because the control groups were often selected from hospitalized persons without lung cancer. Investigators were not aware that tobacco was also responsible for a large proportion of the other hospital admissions, such as heart disease, stroke, and other cancers; therefore, the strength of the relationship between tobacco and lung cancer was diluted by the fact that tobacco was so dangerous that it was also causing many of the problems in the control groups.
Gradually, it became clear that tobacco was toxic across the spectrum of disease problems. In a logical world, rapid action would have been taken to protect people from tobacco exposure to reduce the carnage. But the tobacco problem is made up of two parts—addiction and greed.
The addiction is intense. Solutions require helping those who would like to be freed as well as erecting barriers to make it more difficult for the young to become addicted. But greed stands in the way. The tobacco companies, to ensure their personal profit, came up with increasingly clever ways of getting young people simply to try smoking. Tobacco companies made smoking seem sophisticated; they sponsored concerts. They drew an association between smoking and manly pursuits, as seen in the Marlboro Man, or feminine ideals, as with Virginia Slims. Society looked the other way. Tobacco companies knew that, if they could get young people to smoke a single pack of cigarettes, many would be their slaves for the rest of their shortened lives.
The greed went beyond the tobacco executives and extended to the politicians who received donations from the tobacco companies, representatives of tobacco growers, or both. These same politicians intimidate public health experts who give testimony against tobacco products.
Even when the country was losing more than 1,000 lives a day to tobacco, tradition stifled a logical approach. One of every five funerals was the result of tobacco. In my speeches in the 1970s, I would say, “In other parts of our society, if someone makes their money by killing someone, we call that person a ‘hit man.’ Why don’t we put the same label on tobacco executives, who know exactly how they are making their money?” Tradition is the answer.
In 2014, the problem remained. Smoking rates have decreased, and progress has been made, but how do we account for the fact that 400,000 Americans die each year because of tobacco? Why do public health departments continue to list the causes of death as heart disease, stroke, and cancer rather than saying the cause of death is tobacco? And how do we change a society that values greed over health? Newspapers should have a box score on the front page that keeps the tally on how many people died in that city in the past month because of tobacco. The MMWR could keep a tally on Americans lost so far this year because of tobacco, displayed in a box score on the front page of each issue.
Fifty years after the first Surgeon General’s Report on tobacco, we continue to find the toll even higher than thought. In a hundred years, students will marvel at the collective blind spot involving tobacco, just as we now marvel over the blind spot this country had to slavery and as future generations will marvel at our blind spot to climate change.
For some, viewing contraception as unacceptable is a tradition. It originated as a decision of humans, who then enveloped the idea in a cloak of infallibility. The evidence is that many ignore the idea that contraception is unacceptable, as shown by the low birth rates in traditional Catholic countries, such as Italy and France, and the similar rates of contraceptive use in Catholic versus non-Catholic families in the Americas. But poor families in poor countries have been slower to change their traditions. And meanwhile the population of the world has swollen, as have all of the problems resulting from excess population. The loss of rain forest in Africa, the acceleration of climate change, and the continuing problems of malnutrition, poverty, and the spread of infectious diseases, including Ebola, all result from the inability of many families to make logical decisions on family size and child spacing.
Counterintuitively, high infant death rates are compatible with the population explosion. It does not take much study to realize that the highest population growth rates are found in the countries with the highest infant and childhood death rates, while the lowest population growth rates are in the countries with the lowest infant and childhood death rates. Child health programs lead to improvements in family planning and contraception, which lead, in turn, to fewer infant deaths.
Gun Safety
There are many reasons for violence and the epidemic of gun deaths in the United States. Logical people would want to know as much about the problem as possible in order to offer solutions. But, in 1996, an amendment by Rep. Jay Dickey (R-Arkansas) withdrew funding from the CDC to study gun violence and threatened to withdraw all injury-control funds if the CDC included gun research as part of its mandate to do no harm. The NRA uses scare tactics about the government’s having a long-term plan to take guns away from people. This is sufficient to make many act on the basis of fear rather than logic.
We look back in disbelief at the irrational actions of the past, only to realize that we continue to operate with misguided tradition, rather than with rational understanding of problems and solutions.
There will be a time when we will have to ask whether using the marketplace was a good way to provide medical care in this country.
The facts are that the health indices of the United States—life expectancy, infant mortality, and chronic disease burdens—are not as good as in other industrialized countries. And these, after all, are the reasons for having a health care system. It is in place to reduce premature mortality and unnecessary suffering, not as a way to make money on illness. That should set off alarm bells that something is not working. We spend far more per person on health care than any other country and still cannot match their health outcomes. These facts should lead logical people to conclude that our system is not optimal.
Frequently, the response from politicians is, “We have the best health care system in the world, and we do not want to jeopardize it through socialized medicine.” They are wrong. The United States does not even make it to the top twenty countries in the world when measuring health outcomes. It is an embarrassment to realize that about one-third of our health care expenditures do not go to health outcomes at all. They instead pay for the unneeded superstructure of insurance plans and managers that proliferate when profit, rather than quality and health outcomes, is the bottom line. Most of the twenty-plus countries with better health outcomes have single-payer systems. Our national response is that only the marketplace can improve health care delivery. If that is the case, why don’t we prove it rather than just say it? A single-payer military system still allows for the use of marketplace forces to provide commodities and services. The United States continues to lead in expanding the science base of medicine. But it falls far behind other industrialized countries in improved health outcomes, coverage of the poor, and health equity.
Poverty
The current corollary to slavery is poverty. Poverty is very inconvenient to those in its grip, but it is also a burden to society. It is the single most important determinant of health. It is not just that poor people have poor health. Various studies have shown that the healthiest societies are those with the narrowest income inequality gap. Poverty breeds discontent, and the poor often attempt through crime or social disruption to remedy the disparities. Michael Manley, formerly the prime minister of Jamaica, once said that, “Poverty shared can be endured.” Modern communications have demonstrated to the poor around the world that their condition is not being shared.
Six centuries ago, Emperor Hongzhi of China said that poverty should be seen in the same light as a person drowning or a person in a burning building. He said that in both these situations there is no time to lose, and the person must be rescued immediately.
No social determinant is as significant as poverty in causing poor health. It is not only the very poor who suffer reductions in health. Rather, every step down the income scale leads to an increase in health problems. Poverty, as a health problem, is dose related.
So poverty causes stigma and is a health hazard. But it is also similar to slavery in another regard: the poor actually subsidize the living standard for the rest of us. We get food, clothes, and lodging at a cheaper rate because people in this country and in other countries work at extremely low wages. In effect, we profit directly and indirectly from their poor standard of living in much the same way that plantation owners in the American South profited directly from the work of slaves. The embarrassment of the logic should be enough to lead to action even for those not interested in public health. But tradition salves the conscience of even the religious by repeating, “The poor will always be with us.” That was a description of human foibles, not a law.
Public health workers need to focus on the effects of poverty but also on poverty itself. A living wage, rather than a minimum wage, needs to be established. No industry should be allowed to pay below that level. And the wage should be automatically indexed to inflation.
Fatalism
A close corollary to poverty, but separate in distribution, is fatalism. More common in the poor, but not restricted to them, this is the feeling that one cannot exert control over the future. It adversely affects health because it deters people from taking positive steps to improve health in the future. Fatalism is one of the reasons so many poor people continue to smoke in the face of information that shows the hazards. The poor often do not feel that they can control their future. But empowerment can be learned. The rich and the educated lost their fatalism as they saw what education and money could do to influence their future.
I emphasize to students that we are all a mixture of fatalism and empowerment and that the ratio changes with the day and the subject. It is important to believe that this is a cause-and-effect world, not a fatalistic one.
I am most fatalistic when I enter a taxi or an airplane. I have lost control. I often tell students of my experience in getting a taxi late at night at the Philadelphia airport. I suddenly was aware of the smell of alcohol. To judge the degree of risk, I engaged the driver in conversation. I said to him, “I need to tell you that I am a high-risk passenger.” He asked, “What does that mean?” I told him that I had been involved in five taxi accidents in my lifetime, a true story. His reply was, “Oh that’s nothing. I have been involved in a lot more than that.”