In defiance of dire predictions, children haven’t been sent to workhouses and women haven’t been chained to utensils after the GOP gained strength in the House and the Senate. And Vivek Murthy, the unabashed Obamaphile, was finally confirmed Surgeon General.
To be honest, I always thought the controversy surrounding Murthy’s nomination because of his stance on gun control was rather daft. Stopping doctors from pontificating over guns, such as the Docs versus Glocks legislation, is like banning me from trying to convert Pope Francis to Hinduism. The legislation is a parody not just for its own sake but because what it seeks to prevent is parody as well.
Murthy’s first challenge is to raise the position of the Surgeon General from that tokenism of a career UN bureaucrat to something vaguely useful. Which means Murthy must resist the call of banality, the banality of ideology and the ideology of making all of mankind’s imperfections public health problems.
I have the utmost respect for public health. However, public health professionals are at risk of devaluing their work by expanding their dominion and inviting futility. For example, some public health scholars opine that income disparity is public health’s responsibility since disparity signals social injustice, and low income is linked to poor health outcomes. Not only is such a stance moral posturing and laden with ideology, it is prescriptively useless. I cannot imagine Goldman Sachs employing an MD-MPH to ensure that the bonuses doled out are syntonic with Rawl’s distributive justice.
Making health the ultimate good rapidly disintegrates in to absurd logical conclusions. I am much perturbed by the events in the Middle East, as are many others, to the extent that it affects my mental and spiritual peace (yes that is health as well, check the WHO definition if you don’t believe me). Is the Middle East situation a public health problem for the US? If so, should I turn to Vivek Murthy, the Surgeon General of the US, to solve the root cause of this epidemic of anxiety?
Murthy must minimize his pontificating about societal ills that can tangentially be linked to the health of the nation, over which he has no more control than my jumping on the spot. The more he pontificates about these the more he will affirm the cosmetic nature of the Surgeon General.
That is he must make a distinction between problems affecting public health and public health’s responsibilities.
These include but are not limited to income inequality, anthropogenic global warming, Keystone Pipeline, unpleasantness of modern airline travel, gun violence and the second amendment.
Yes, the second amendment. Time to let it go old chap. This is a problem of democracy and a problem for democracy, not a problem that will be solved by the medical profession. To believe otherwise is activism. And your position, sir, should be above the parapet of activism.
It is likely Murthy will be egged on by his supporters including left of center well-meaning millennials. I would urge Murthy to be nonpartisan. The country is deeply divided and perhaps a doctor can do what no politician and very few journalists have achieved – transcend politics and ideology. And a Surgeon General cannot alienate 47 % of the population.
Murthy should achieve the imminently achievable, though. Here is my wish list of initiatives or awareness programs that the Surgeon General can spearhead.
a) Make kids play
Let’s call it Project Locomotion.
Get kids to walk, run, scream, play, anything other than staring at video games and watching TV for countless hours. Let’s have a national “No Video Game Day” where all kids are outside doing what children have historically done, and still do in less affluent societies.
Childhood obesity is a public health problem. It is not a problem of poverty. Locomotion is free. It’s a problem of kids not being physically active enough.
Get your millennial mates, from colleges and universities across the US, to push this initiative at local schools. This will be infinitely more useful than their moral grandstanding about income inequality.
b)Keep kids off Ritalin
Say no to Ritalin. Too many kids are on Ritalin. We are medicalizing the broader coastline of normality. Let me tell you a little secret. Half of my first grade class would have been placed on Ritalin today. At the time they were labelled with that dangerous diagnosis: excitable children. Excitable children! Is that a euphemism for excitable children?
Don’t blame big pharma for the epidemic of ADHD. Big pharma is our servant. It gives us pills for what we can’t handle. If we can’t handle boisterous kids, pharma will happily oblige us with pills.
The number of kids on Ritalin in this country is not only a public health concern but a national shame. Kids need attention. They need to play. But most of all they need self-indulgent, self-absorbed adults to understand that kids will be kids.
c) Reduce Antibiotic Prescriptions
Too many antibiotics are prescribed frivolously. This is because too many doctors are too afraid, and too many patients, usually the half informed with a college degree, conflate prescription with care.
Create a mass awareness campaign about the risks of antibiotic resistance. Make a macabre movie directed by Wes Craven about a flesh-eating bacteria that is resistant to all antibiotics destroying Upper East Side, New York.
Scare people. Scare doctors. Make them feel guilty for antibiotic misuse.
d) Move Americans
Not by your speeches. I mean literally. Get them to walk more.
Remind your fellow citizens what a beautiful country they are fortunate to live in, with the great outdoors, and well-maintained national parks.
If it is the mall they must visit, remind them that even in malls they can walk more, from one end of the mall to the other.
e) Counter the Charlatans
This is the raj of quacks. Half-baked information is accessible at the click of a finger.
From anti-vaccination fear mongers to peddlers of nutritional supplements fight them on Fox Network. Fight them on CNN. Fight them on MSNBC.
Use the gravitas of your title to discredit them.
To maintain your own gravitas resist the urge to comment on every single study that links some toxin found in miniscule quantities to a miniscule increase in the risk of cancer. Don’t cheapen your office by losing sleep over the dangers of anti-bacterial soap or germs on credit cards. Don’t worry. The Perfect Health Squad at the New York Times or Vox will cover these stories.
f) Exit with Dignity
As you know the waste of resources in trying to extend life by 48 hours is preposterous. Create a bottom up campaign urging physicians to apply common sense when treating patients who are obviously in the last throes of their life. Rally the intensivists. Rally the primary care physicians. Tell people what a dismal epitaph it is to die in a CAT scanner with the technologist yelling “take a deep breath in and hold it.”
If anyone accuses you of being a death panelist, refer them to me. Good luck in your job. I understand “Vivek” means wisdom. I hope you will bring a spot of wisdom, a touch of good judgment and an abundance of common sense to the position of Surgeon General and to public health at large.
Categories: Uncategorized
Great advice, Dr. Jha!! (great responses as well).
I don’t know much about Dr. Murthy but understand that he was COMPLETELY chosen as Surgeon General because of his avid activism for Obama, which seems to be his sole qualifying criteria, aside from being a physician.
I am an avid gun owner, and fervent supporter of ALL of the Bill of Rights, not just a couple that happen to fit my own personal ideology. However, I have no problem with Dr. Murthy advocating for GUN SAFETY, as long as he is not espousing “GUN CONTROL,” which is what he (and many others on this site) appear to strongly desire.
I have always thought it was pretty funny to have doctors asking people if they have “guns in the home.” If you asked this where I live, you wouldn’t have time to write down all the responses. Are we supposed to be just wondering about rifles? shotguns? handguns? crossbows? primitive weapons? the dreaded “assault rifles” – you know, the 22 caliber with a banana clip that terrifies so many liberals? Or did you mean “in my house right now” or also in my car, my boat, my ATV, and my grandma’s house? The rest of us in “flyover America” are laughing at you.
As an ER physician, there are times when asking about firearms in the home is totally appropriate, like if someone is possibly suicidal, or has delirium, or other mental illness. But to have government tell every physician to inquire about gun ownership, conduct a “CAGE” profile, query for ebola exposure, counsel about the dangers of smoking (and smokeless tobacco), advise as to the location of rape crisis centers, etc., all just so my patient can get a tetanus shot seems kooky.
To go along with Dr. Jha’s sage advice, here are a few suggestions of mine:
1) Put bad people in prison, and leave them there a long long time.
2) commit a crime with a gun, go to prison for 30 years.
3) don’t let crazy people have guns
4) don’t let convicted felons have guns
5) don’t rely on the cops to protect you from the 4 groups above, because they can’t.
“On a side note, instead of pointing out your commenters admittedly rhetorical ignorance, why not just have the courage to say what you mean sir?”
Courage! A little laughable that this is asserted from someone who remains anonymous to someone who doesn’t!
Everything is written in plain English. I’m 100 % sure you understand. You seem to have picked up the satire on the gun control bit magnificently!
“Either way, I’m not seeing how this is going to move Americans anywhere.”
Indeed. The Tragedy of Ideology.
“So, your proposed agenda items, which I actually quite like, seem to have as tenuous a link to Public Health as gun violence.”
Actually, the link to public health is as strong as gun violence. Not tenuous at all.
When did I say gun violence does not affect public health?
Did you read my piece?
Did you miss this sentence below?
“That is he must make a distinction between problems affecting public health and public health’s responsibilities.”
The difference lies in the effectiveness of public health as an institution in its ability to mitigate the problem.
Not all things that affect the health of a nation are equally amenable to the intervention of public health professionals. Are you in any doubt?
Your post can be surmised as an angst, understandable angst, as a result of a dialectic between hope and disappointment.
Oh, and I subscribe neither to the politics of the left nor the right. Both are remorselessly dull and really a case of six of one and half a dozen of the other.
https://thehealthcareblog.com/blog/2014/03/18/mixing-politics-and-science-is-injurious-to-public-health/
Your recycled anti-gun quips (I don’t own a gun and don’t intend to either) are rather wasted on me!
“The country is deeply divided and perhaps a doctor can do what no politician and very few journalists have achieved – transcend politics and ideology.”
Well, you certainly cannot. Your detached admonishments at the pablum surrounding this issue on the grounds that physicians ought to have free speech did little to center your point of view here.
But I’ll bite.
In 1960 there were something like 4 times as many motor vehicle deaths as deaths from firearms (proportionally to population). While automobile safety improvements have more than halved the death rate from car accidents (even more when considering per million miles driven) the death rate from firearms has risen ever so slightly.
Unless one is deliberately propping up a straw man, it is fatuous to conflate firearms (directly tied to the 2nd and 3rd leading causes of death for Americans ages 15-24 and 25-34) with 4th or 5th degree correlating factors like income and a society that shuns single or gay parents.
On a side note, instead of pointing out your commenters admittedly rhetorical ignorance, why not just have the courage to say what you mean sir?
From here, a place of honest comparison, we can begin to apply some of your much vaulted common sense.
So, are automobile accidents a public health issue? Not directly, no. Clearly we have mostly made improvements in automobile safety through engineering. And yet, I wonder, does the fact that several prior Surgeons General have made recommendations that Americans “buckle up” strike you as a futile devaluation of the office? What about for children and the appropriate use and placement of car seats?
Should the Surgeon General’s office have taken the lead on these issues? I would again say not. But combining efforts with other groups to prevent or mitigate the arrival of patients because of a direct cause (automobile accidents) seems to me quite a reasonable stance.
Continuing on that line, what about accidents in the home? The proper way for infants to be put to bed (on their backs with no padding, not necessarily by a father with a martini and a mother wearing an apron all saying a prayer)? Should these be the primary concern of the Surgeon General? I would say no. Is it appropriate for the office to coordinate and speak out on these items that directly lead to injuries treated by doctors? I would say yes, as has basically every surgeon general going back to C Everett Koop.
This brings us to firearms. Should gun control be a primary concern or policy cornerstone for a Surgeon General? I would, once again, say no. But to pretend that there is no connection between a leading cause of death in the country and the medical profession is absurd on it’s face. Walking through the logic, in fact, more than half of firearms deaths are due to suicide. So there is a direct mental health component related to all of this. Still, no connection in between gun violence and Public Health?
And, if it’s not guns that kill people but people that kill people, I feel compelled to point out that obesity (other than in the maximum extreme) does not kill people. It leads to diabetes or heart disease which then kills people. So, your proposed agenda items, which I actually quite like, seem to have as tenuous a link to Public Health as gun violence.
All that said, really now, are you trying to preach to the choir or shake a self satisfied finger at your left of center readers? Either way, I’m not seeing how this is going to move Americans anywhere.
” I think I’m reading Vik Khanna”
Careful! You are handing Vik’s clairvoyance a victory on a platter! It is I who is trying to give the new SG a fighting chance of utility.
Your skepticism does have some grounding, though. Which is that for a complex social problem such as healthcare with a problem of tragedy of the commons can the SG have any more than a cosmetic role?
Vik doesn’t seem to think so. You seem, implicitly, to agree with him, if your reaction for my shortlisted solvable public health issues is any attestation.
I think the SG has more chances of reducing over treatment by Ritalin in kids than he does of over turning the second amendment.
“Can that broader perspective include efforts I consider futile?”
“a) Make kids play”
“d) Move Americans”
“f) Exit with Dignity”
Futile navel gazing?
Enjoyed your past posts but this one seems totally out your normal perspective. I think I’m reading Vik Khanna
“I get it, but you obviously don’t and simply want to take my “infectious” as literal comparison to discount my intent on the reference because that would require a broader perspective.”
Can that broader perspective include efforts I consider futile?
Your Ebola example was perfect. Because it shows the perfect contrast between risk and impact and risk and navel-gazing.
“I see there’s not point in further “conversation” with someone who doesn’t use their MD education to advance legitimate argument.”
Part of medical education, indeed any decent education, is to know the limits of one’s omniscience, to distinguish between science and ideology, to not mistake moral aggrandizing for impact.
I think a little instruction in constitutional law and political science might be helpful for excitable young physicians.
“I don’t for a moment believe you don’t get it!”
I get it, but you obviously don’t and simply want to take my “infectious” as literal comparison to discount my intent on the reference because that would require a broader perspective .
There is more meaning to the word than just biological, surely you know that, but yet you could not extract the obvious. To water down my comment to “guns are metal, ebola is biological” misses the point entirely for someone who probably uses all kinds of daily non-literal references to make their point.
I see there’s not point in further “conversation” with someone who doesn’t use their MD education to advance legitimate argument.
Nicely handled Dr Jha. I agree with you that several of the commentators here know exactly what you are talking about but are being deliberately obtuse about it to avoid the consequences of their thinking.
Peter, you should tell the Liberians that Ebola is no more infectious than guns!
They could do with some comic relief.
In fact, Peter you can star in the next movie: National Lampoon Vacation to Liberia!
I’d watch it. Although I might burst a few hernias LMAO, which would make it a public health issue!
Peter, Ebola multiplies spontaneously. Guns do not!
Fighting Ebola requires principles of science and medicine.
Controlling guns is a democratic process.
Please do not do sell your intelligence short by laboring to not see the difference! I don’t for a moment believe you don’t get it!
Saurabh, why is “Make kids play” or “Move Americans” not ideology?
Certainly the “right” would want it portrayed that way (especially from Murthy) as an intrusion on the “freedom” of Americans to make their own lifestyle and family decisions.
“Absurd”, you are quite myopic and devoid of the common sense you want others to show.
” public heath have very limited ability to influence it.”
Indeed. Which is my point “achieve the achievable,” which you affirm repeatedly.
“I have no idea what you mean by promoting the “American family”
Oh I think you do! In fact, I am willing to bet my mortgage that you know precisely what I mean! I’m using simple language here. But never mind. Because your next statement is accurate and more important:
“relationship to health outcomes is complex”
Absolutely. And that can be said of many nebulous things public health has adopted in its dominion – social justice, distributive justice, income inequality.
So far, further affirmation of my point: achieve the achievable. Don’t waste time navel gazing.
“Furthermore, that it is ideology ultimately driving the policy”
“but not entirely so.”
Basically, what it boils down to is this. You think there is much objectivity to the menu but I don’t. But I can be persuaded. If you provide me the data that shows that what public health adopts is based on a utilitarian calculus or some other scientific framework.
So let me ask again.
Show me the objective evidence that objectively justifies the relative importance of discussing gun safety over screening for number of hours kids play video games, reading stories to them at night to improve their literacy, screening whether parents (are we still allowed to use this word?) are promoting a balanced diet.
Such data must include whether such a discussion reduces the chances of the health-reducing activity.
Here is a spoiler alert: there is no such data.
Remember, it is you swaggering with objectivity, data and science. I am happy to just use my common sense.
“Guns are more infectious than ebola.”
This is why ideology poisons public health & makes cartoons out of public health professionals.
Alas sir, your ilk will not allow Murthy to rise above a caricature.
Your logic, Peter, is just as absurd as those who peddle fear about death panels.
“Murthy must minimize his pontificating about societal ills that can tangentially be linked to the health of the nation, over which he has no more control than my jumping on the spot.”
“a) Make kids play”
“b)Keep kids off Ritalin”
“c) Reduce Antibiotic Prescriptions”
“d) Move Americans”
“e) Counter the Charlatans”
“f) Exit with Dignity”
Why are any of the above more achievable than gun control? Would your list not require an “activist”?
Is it common sense that the same nuts who say gun control is not a public health issue while they scream that the entire country be immediately put on crisis mode because one person died of ebola?
Guns are more infectious than ebola.
Very well, I will indulge.
I interpreted your original argument to be that the place of these largely non-medical matters within provenance of public health are essentially equivalent, and therefore it is arbitrary which are undertaken and considered worthy of action. Furthermore, that it is ideology ultimately driving the policy,
I argued that this contention is false based on contrasting the issues of child abuse and the crisis in the middle east (which you provided as an index example). Clearly, in one of these, healthcare is vastly more able to intervene and prevent severe harm. I then extrapolated to suggest that the baseline level of risk and ability to effect the outcome are important in determining which matters are more worthy of attention. I suggested income inequality as an example of an issue which does not deserve to be under the purview of public health, because despite having a large impact on health outcomes, those in public heath have very limited ability to influence it.
With this stated, we can evaluate different issues based on the criteria I have argued for. I agree it is in part subjective and “common” sense; but not entirely so.
I have no idea what you mean by promoting the “American family”, but whatever it is, the relationship to health outcomes is complex and heavily influenced by confounders, one of which is certain to be socioeconomic status. What is the ability of public health to influence the (re)establishment of the “American family”? I can’t definitively deem it unworthy, but there is such high uncertainty here. Hopefully you won’t make me repeat this analysis for video games.
This brings us to gun safety, which is the key issue of your article and apparently also of Murthy’s entire existence. I have advocated neither for nor against this as a public health cause, though have deemed it worthy of debate. Gun-related deaths are directly measurable. The cost in terms of years of life lost is high. It is conceivable that those in public health encounter situations in which firearm related danger is high, and thus have the potential intervene to significantly reduce that risk. I am not by any means saying it is a certainty that it would be effective, but these factors distinguish it from something like “promoting the American family”.
As an aside, is not ideological in itself to immediately dismiss any argument (which you perceive might be) in favor of gun control as ideological?
No, you have not answered any of my questions. If you do not wish to, that’s fine. But I will ask again, to highlight your dodging my points.
Why is promoting the American family (which correlates with positive health outcomes) not in the provenance of public health but income inequality is and talking about gun safety is?
Could it be ideology?
Should PCPs talk to parents about dangers of video games? Whether they read stories to their kids? Seeing if they do a good job parenting? Factors associated with positive development of the child.
If not, why not? Why gun safety and not what I mentioned?
Show me the objective evidence that objectively justifies the relative insouciance of public health to the matters I have listed.
Go on. I challenge you.
Of course there is no threshold nor ultimate authority, but on the other hand it cannot be purely subjective (“common sense”). Vivek Murthy might argue that it is common sense to promote stricter gun control. Obviously, many would argue the exact opposite; and there would be no recourse.
I already answered your second and third questions in my original post, so I won’t rehash.
Which is why I asked how many deaths are enough to trigger the concern of public health? 1,10, 100, 502, 1034? Who decides? Is there a threshold? What is that threshold based on?
Since we don’t live in a world where we are forever punching numbers in to utilitarian risk calculators – i.e. we don’t live in a world with perfect information, common sense is our best bet.
The family correlates with positive health. Why is there not a public health campaign promoting the family?
Why should some correlates of good health be the provenance of public health and nor others?
So my original point applies. Use common sense, avoid ideology and achieve the achievable.
Assessing the level of risk and ability to impact equates to the application of common sense, in my opinion, but of course one man’s common sense is another man’s idiocy.
In the case of income inequality, for example, the effect is considerable but the ability to impact is quite small. Where firearm safety falls in this assessment is debatable.
I would recommend using that valuable underutilized commodity – common sense. No common sense can’t be precisely quantified using current management techniques.
My point, and I think you picked it up, is that all societal issues are issues of public health.
Pubic health becomes a huge invitation for ideology and navel gazing. Prime example is making income inequality a public health issue. It’s parody on display.
Ultimately it hurts public health professionals because it makes them more ineffectual than they actually can be.
Should doctors make sure people know about the wilderness before hiking? Why or why not? There are deaths that occur in the wilderness not worthy of their attention? Is there a threshold at which a certain activity becomes important for public health? What is that threshold? Who determines it?
(you see, this is why common sense is so important)
While it is important to distinguish between problems affecting public health and public health’s responsibilities, are you suggesting that all non-medical issues are outside the purview of healthcare and public health? What consequences would result from healthcare forgoing involvement in combating sexual assault or child abuse?
It isn’t obvious to me what ultimately determines the purview of healthcare and public health. It has something to do with level of risk and the ability to impact the outcome. Lumping gun violence with modern airline travel, global warming, and the crisis in the Middle East therefore seems disingenuous. The debate over whether or not the purview includes gun safety needs to at least be had.
Well Vik I didn’t click on any of the links as your “adolescent” readers would have done.
Did you understand anything you read or were you, like any other adolescent or adolescent equivalent, too busy looking at the pictures?
He’ll fumble. Even former SG Carmona says he lacks the maturity for the position. And, we all know how much physicians speak out against one another.
Nice piece Vik. Thanks for the link.
I agree the position can be cosmetic. But it can also generate some real public health dividends. The ball is in Murthy’s court.
Clicked on the opinion link (Daily Caller) you gave us Vik. Great platform for your valued opinion, page is ringed with stories of “Linsay Lohan topless”, “Celebs in open relationships, of course Rush, Sports Illustrated Swimsuit, and the best is kiddy porn masked as “Childhood Crushes”.
You’re in good company Vik.
“Yes, the second amendment. Time to let it go old chap. This is a problem of democracy and a problem for democracy, not a problem that will be solved by the medical profession. To believe otherwise is activism. And your position, sir, should be above the parapet of activism.”
Nicely stated and completely beyond the ken. Murthy has neither the maturity, wisdom, nor the strategic intelligence to heed your advice.
http://dailycaller.com/2014/12/12/vivek-murthy-is-an-activist-dont-confirm-him-for-a-useless-position/