Avoidable Death

Science is supposed to tell us what causes ill health so that we can do something about it. At least that’s one version of what science is supposed to do. Armed with health science, public health institutions can focus on the causes of illness and work to eliminate them. It’s called prevention.

Last week, the CDC—the primary national public health agency in the United States—published a report titled “Avoidable Deaths from Heart Disease, Stroke, and Hypertensive Disease.” The CDC is happy to report that things are looking good.

I’m suspicious of the phrase “avoidable death” as the CDC uses it. “Many heart disease and stroke deaths could be avoided through improvements in lifestyle behaviors, treatment of risk factors, and addressing the social determinants of health.”

So if public health and other institutions can eliminate “unhealthy lifestyle behaviors (e.g., tobacco use, inadequate physical activity, poor diet, and excessive alcohol use)” and treat risk factors such as “uncontrolled hypertension, elevated cholesterol, and obesity” something like a third of heart-related deaths would not occur. The CDC goes on to describe how “additional medical interventions, such as secondary prevention and evidence-based procedures to treat ischemic heart disease and stroke” will also reduce heart deaths.

What the CDC is describing is the medicalization of public health and prevention. This is clear from the way in which the CDC actually counts which deaths are avoidable: it’s simply any death caused by one of four diagnoses.

Even though it mentions “addressing the social determinants of health,” no further mention is made of how social injustice causes avoidable deaths. This is quite surprising given the data the CDC reports.

As I said, about a third of heart-related deaths could be avoided by the CDC’s reckoning—which has primarily to do with increased application of medical potions and procedures. Over the last ten years, the CDC’s version of prevention has gotten better so that the number of avoidable deaths has gone down. The improvement has been a little less than 4%—about 28,000 fewer people died unnecessarily.

But in this same report, the CDC shows that the rate of avoidable heart deaths varies quite dramatically among the 50 states and the District of Columbia. The state with the fewest number of unnecessary heart deaths (that would be Minnesota) has almost three times fewer avoidable deaths than the state with the most avoidable deaths (that would be the District of Columbia).

That’s a 300% difference in the rate of avoidable deaths caused by the state in which you live versus 4% caused by CDC sanctioned medical interventions.

My thinking on this and the missing social determinants of health are this…

Minnesota is one kind of social environment. The District of Columbia is another. If the Minnesota environment were reproduced in DC, it is not unreasonable to expect a significantly greater decrease in unnecessary heart deaths than that caused by lifestyle changes and medical risk factor treatments.

To go further along this path, the CDC report includes a map showing the rate of avoidable heart deaths by county. It’s well-known that the social determinants of health are more pronounced at the local level and so it’s noteworthy that the difference in avoidable heart deaths between the highest and lowest US counties is 10 times—that is, the best county with the fewest avoidable deaths is 1,000% better than the worst.

In other words, where you live and its social environment is far more powerful in reducing (or increasing) your risk of a heart attack than following the medical advice of your doctor or public health agency. This suggests to me that the most effective course of action to reduce your risk of a heart attack or stroke is to move to a place with a better rate of avoidable death.

We don’t need to stop at social causes of heart deaths. Consider not only social environments but physical environments as causes of heart deaths. Earlier this year, researchers at NYU published a paper on the detrimental effects of BPA in causing children to develop heart disease. It goes without saying that if your risk of getting heart disease increases so does your risk of death from heart disease.

The threat posed by BPA captures both social and physical environments. BPA is toxic. It is in products children use or to which children are exposed. It’s there because a company somewhere finds it financially beneficial to use BPA instead of an alternative. It’s also there because the body politic cannot muster the courage to say “No.”

Likewise, exposure to wireless technologies affects the heart. As with BPA, heart deaths are caused by what’s in the physical environment as well as the social environment in which the toxic exposure is caused by the needs of commerce and the failure of political institutions (public health institutions such as the CDC in particular) to act on the heart threat of wireless technologies.

I have trouble with the CDC’s concept of “avoidable death” because it leaves out too many avoidable causes—such as where and how we live and the exposures of that place. The CDC’s concept maintains focus on medical treatment outright or medical treatment by proxy. And most profoundly, I object to the focus on death or lack of it as the measure of health.

I’d much rather see statistics on the causes of avoidable suffering.