Transcripts For CSPAN3 Stephen 20240704

Good evening, everyone. My name is elijah and id like to welcome you all to the Elliott Bay Book company, where were very happy to have stephen here to give a reading on his most recent book, inequality kills us all. Covid 19 Health Lessons for the world stephen bezruchka, m. D. M. P. H. , is an associate teaching Professor Emeritus in the departments of Health Systems and Population Health and of Global Health at the school of Public Health at the university of washington. Were also joined tonight by cspan booktv, who are recording tonights event. Were going to have a little conversation and start off with stephen, have a little q a from, the audience, and then were all done. Well wrap up our book signing in the back where you can also purchase stephens book from me. So with that lets all give a warm welcome to stephen. Thank you, elijah. I hope you can hear me and thank all for coming and i want to i think this is a complex hearted book. And if i were to read passages from it, it might not be as much fun as just having a amongst us, if thats. So a little more about me, maya. So who am i . In 1969, i got the opportunity to do whats now called a gap year between graduate school and medical school. And i just id been climbing mountains a lot, so i decided to go to nepal. And a friend of mine was working in Family Planning in and he said what, are you distribute condoms in the hills because Family Planning in kathmandu had a big push on condoms. So he gave me boxes and of condoms. And what was i to do with them . I wasnt going to demonstrate how use them, so i blew them up as balloons kids in that entire year spent walking, i only found one person who knew what a condom was for and course these kids played volleyball in this amazing backdrop with these condoms. If i when i blew them up and on the basis of that year i spent there i wrote the first trekking guidebook to the country in 1972. It was published and eventually the mountaineers took american versions. The 11th, the eighth edition was published in 2008 and 11. And im way lame to try to update. So its clearly the last. I then had the good fortune after that year spent in nepal of going back and setting a Community Health project and they remote valley door potton and a weeks walk from the road. So imagine setting up something that far. And i was working on the that i wanted to train local people locally to provide Health Care Services for one another and i when i went to medical school i tried i knew i was this is i wanted to do so i arranged various experiences as a medical student to be able to do that. And one of the things that i did, Plastic Surgery rotation in a county hospital and when i told the Plastic Surgery fellow what i wanted to do, he said, why dont you go out on the on the wards and cut skin grafts with razor blades . So thats what im doing there. Im the right im on your left teaching. Temba the local person to cut a skin graft with a razor blade. It sounds kind of barbaric, but razor blades you can get in most places and you can get a new one instead of prone to sharpen an old dermatol. So after that experience i was i wanted to see what else i could do in nepal. Beside update the trekking guide. And so i managed to set up a remote District Hospital in nepal as a teaching for nepali doctors and so once again i tried to do primitive kinds of of health care and so on the right there is doctor chhetri doing drop ether anesthesia because, you know, all you need is a bottle of ether and a mask, a piece of guys to put over someones face. And it works pretty well. Well, that was and i continued to doing various kinds of image of experiences like that. Nepal mostly working within nepalis, nepali doctors and such. I then got obsessed with what im in to talk to you about about 30 years ago and, and so i began trying talk about the ideas in the book in as many different situations as i could. Democracy, for example, im being by amy, by amy goodman and, a ted talk at uw. So im im trying to look at these factors that produce health in populations and broad ca and to as many different places as i can. So my wife and son and daughter, i are in this picture of a couple of years ago in front of a charging. And thats a bit more about me so i want to sort of go through the book and chapter by and talk about it with you. So the first chapter is called how healthy are we in the United States and the quote there . And americas name for opportunity, the history appears like an effect of Divine Providence on the benefit of the race on behalf of the human race. So about, oh, 25 years ago, i wanted to find a concept that people relate to comparing in countries health outcomes. And so i came up with the term the Health Olympics. You know, we in Olympic Events, we typically win the most medals, the most gold medals. We really clean up in the olympics suppose health were an Olympic Event and the race was how long lived life expect and see so here we are richest most powerful country in World History sort of up to now we spend half of the Worlds Health care bill in this country. How many would give us the gold medal. Okay. One my wife. How many would put us in the top five, 6 to 10, 11 to 15. One, two, three, four, five, six, seven, 21 to 20,. 21 to 25 126 to 31 to anybody put us below 30. Okay, a few hands went up. So this is the latest running. Oh, dear. Can we move the projector over little bit so we can get the United States there. Yeah. And we should make it a little smaller anyway. So here is. So were like, i get my data from the same source. The United Nations hum Development Report and this is read the table one from the u. S. From the report published in september of last year. And it lists all the u. N. Countries, 189 of them and their Life Expectancy. And so do we see here United States. Ive only graphed the top 45 countries, so United States is 44th, meaning 43 countries, u. N. Countries. People have longer lives. Now, were about and a half years below the longest lived country. Whats the longest lived country . Japan. You just want to make. Sure, you can read that anybody vintage any reason why its the longest lived country. Die diet. Okay lets lets ask what percentage of people in america smoke cigarets. Hey anybody smoke . Anybody here think smoking is good for your health out of all the countries on this, which country has . The highest proportion of men smoking. Japan about 45 of japanese men smoke. Now, if i told you thats the reason be healthy smoke cigarets be wise to leave but it does suggest that factors other than personal behaviors diet, exercise and smoking matter more for producing health. Because what percentage which countries this list have the lowest proportion of people smoking . United states and sweden. 15 . So more than three times as many men smoke in japan as here. And and guess what . You know, i spent some time japan they have signs out telling you not to smoke outside youve to smoke inside. Why might that be . I mean, its crazy. It makes sense at all. Well, id better stay down here. Basically, japanese cities are very crowded, and if youre smoking a cigaret and you put it behind you, there might be a little kid there you burn. As i. And thats the reason that you and i have a little touristy signs i show in class. You know, you can smoke inside. And similarly, you are in the narita airport in and they had these smoking rooms where all these japanese are inside puffing away. So personal behaviors doesnt explain this. Now, whenever youre presented with data, this seven and a half year gap between us and japan what does that represent . Is it just a few more years brewing in a nursing home . Whats the significance of that . Well, what is is our leading disease killer cancer cardiovasc, cardiovascular disease. Number two is we cancer. And number three for up to this year at least is covid suppose we eradicated number one. Number two and number three, no deaths from Heart Disease cancer or covid. How many Life Expectancy years would gain by but seven. So if we eradicated our three leading killers, we still wouldnt be healthy each country in the world really close. No you cant and so these numbers Life Expectancy keeps going up. Its been one of the remarque global things over last century. You know, until fairly recently you you lived longer than your grandparents and your parents. We dont know whether thats going to be true in the coming years. But health is kept on improving in the united and in most countries in the world. Covid has sort of thrown into a bit of tailspin by the way if we add this is un countries, taiwan for example is not a u. N. Country. So if we add a bunch more in the World Health Organization or world bank, include we end up being behind 50 to 60 other countries. So i think were did first we die younger than people in so many other countries. And any thoughts on why i havent given you any its not personal behaviors since we spend half of the Worlds Health care bill its probably not that. Stress health, stress, stress. Okay yes, thats chapter seven. Stress is the 21st century tobacco. We dont smoke anymore, but has some of the highest stress ratings in the in the world. And we dont do so well in coping with in my class today it was unhappiness and i pulled the students and everybody agreed happiness is decline in this country were entitled to pursue happiness were not to achieve it. Okay so Life Expectancy. Thank you. Come in. Come in, please. Life expectancy can calculated any year. This is Life Expectancy at birth born. At born today. How many years can you expect live . On average if mortality rates in. Well we can calculate it at 50 years of age how many years do you left to live . If at that and again to and lets look at some trends. So this is a graph of womens life at age 50. How many women in six countries have to live . The american women are the heavy line and and the other countries, japan french, spain, australia and italy and notice in 1952,. 1955 to 2007, notice in 1955, american women, the heavy black line. Were ahead all the other countries and the japanese women were at the bottom and what happened japanese women just raced on ahead and theres longest lived women on the planet. And what happened to american women . Well, they were in the race until. 80 or so. And then we again, health didnt improve as much in the United States and quite a few women here. Any thoughts on why what happened to womens in comparison to these other countries . I think kind of hard hearings. Please shut it up. Its Ronald Reagan, 1980. Okay. And Ronald Reagan said government is the problem. Anything else. What what is expected of american women . Well, career and children and work and please do everything that it yes. We have to have the looks of a supermodel would be a devoted a caring soccer mom you got to have a job and and all that stuff about by the way, if i showed this for men it would be this you know men were a little behind but in the race the entire way. So we men are the same old jerks. Weve always nothing more is expected of. But the expectations on american women. What about the other countries . They dont. They give more support to women in other countries. And that a big difference. Any thoughts . And, you know, does this make sense to you or mixed . You know, most of my students women and they kind of agree they expect asians on american women are huge. Well, how about Life Expectancy in with covid changes. So this a the other rich countries in the United States from. 2019 to 2021. So, you know, we suffered tremendous li from death from covid a million, 100,000 so far more than any other country. And the rates are similarly among the highest in the world. So covid has been kind of a disaster. This country and our Life Expectancy decline, this is dropping. Okay. Thats the thing you got to realize. Not only is it not improving, its going down. Were living shorter lives. And those shorter lives arent healthier. Thats enough. Chapter one. And so all about this depressing stuff and i could i could read you a section about you measure all these things, but i got to keep the time. So how about health care . Surely Health Care Must do something. I put down here is the quote premium. No, thats waiting the hippocratic first do no harm medical care doesnt do as much as we think it does and you know i worked as a doctor for clinically for 35 years and i came to realize its important you want to have medical care, but it doesnt do that much. And this is a graph illustrating that. So this is Life Expectancy and trajectories for expectancy with Health Care Spending on the the horizontal axis. And and there nine other countries you can tell this one is japan and you know they their Life Expectancy the highest and they dont spend a lot of money on health care. And heres the lag or oh you know way we spend enormous amounts of money health care and even in 2015 were not even anywhere close to where japan was when it started. So whats going on here . Well, the next chapter is inequality kills. And they quoted the bottom is the quote is, i believe the virtually all the problems in world come from inequality one kind or another and i came to realize as i was you know i went back to public Health School in 1990 to try to figure out what why it that American Health is not doing so well. And i learned politics and social factors matter most and thats where i glommed onto inequality. This is a march in a Nobel Prize Winning economist and so a very simple graph of inequality, income inequality and problems is is this one you ought to be more complicated than if you want to get a book explains all this very well its called the spirit level. I it as a textbook and in addition to mine why greater equality makes societies stronger and what they did in their very clever way was they took units off the graph and they put indexes of all these factors. Life expectancy, homicides, obesity as infant mortality, school performance, and they graph that for the 23 richest countries between low and high income inequality. And you can see the United States has the worst outcomes pretty well in all those. And the most income inequality. So you remember nothing else. Remember that income inequality. Wealth inequality really matters for pretty well of the problems that we have to face today and pandemic profiteering mean sure, we have an inflation but prices are going up but profits among the corporations are higher than theyve been for a long time. And our inequality is huge. Its not me at any time. If you want to disagree or go on. So whats after . Well, poverty. Know ive been rich and ive been poor and richest. Better. Quite a few people said that mae west, you know a siren from my. Anyway so i so the title of the book is inequality kills all none of us can get away from it. So how am i going to demonstrate that . Well, unfortunately, another graph so this is adult mortal, early dying at age 22, 64 for United States africanamericans and whites and people from six other countries. So what weve done here is take the diamonds are mortality rates for. Africanamericans the brown circles are similar mortality rates for whites and theyre graphed from very poverty to very high poverty. So you can see the slope for the africanamerican line is steeper and at all levels. You its only the richer africanamericans who do reason to be well in terms of dying in adulthood. But look at even the well for years whites this is the so this is the these six lines are these countries mortality rates and heavy the heavy line there is sort of the average. So even healthiest are richest whites dont live much more than the the corresponding people in the other countries that are poor. Its kind of hard hard to sort of realize. But, you know, the critical thing to to recognize is that none of us can really escape the effects, even if we make a lot of money. Another way of looking at that is that the oldest old person mean if we were so healthy at some point the oldest old person would be in this country. Theyre never in this country. Theyre almost always in in japan. Yes. So poverty kills to early life last a lifetime. T. S. Eliot wrote in the beginning my end. And thats something dont think about much in Public Health unfortunately. So the evidence is huge. Namely, the conditions that you faced in early life really matter for your health throughout the lifespan. And so theres a life cycle. You know, you start in diapers you go to disneyland, rock and roll masturbation and sex marriage, career, and then youre on the downslope calng ask to be retirement seafood buffet or my back drill i now confuse andm going to be back in diapers its this period before you go to disney where roughly half of your health as an adult is program so a healthier society is condition that time in some very important ways so this is another way of looking at as you go from the to the resurrection the first thousand days after conception are in half of your health as an is programed and a student of mine gave. An intimate talk at town hall in seattle on this subject. And this is the graphic she displayed. For the first thousand days by the youre blowing out two candles on your birthday. Thats about a thousand days. You know, half of your health is already. And so in the class on thursday, my students are going to talk about their early life issues and ill talk about mine. And thats worth some discussions. Okay, so early life last a lifetime, by the way, my students came up with that phrase. Early life flashed a lifetime. I learned from my students, they pay the tuition, they pay me. But i learn from them. Shouldnt be that. So chapter six is about health inequities, unfair differences in health outcomes. And i love this quote. Equality is getting huge equity is getting huge. That. So how can i display that . Well, lets look at the map of the United States Life Expectancy in 2019 where the red is the laws like by counting the red is the lowest life and the dark blue is the highest. Theres somebody wanted describe what they see. Where is all the lower Life Expectancy in the middle of the country. So with all the high Life Expectancy know so its interesting. Oops lets go back to no. Here we go. So whats this . Right. Thats the reddest reservation. You know, if theres pine ridge indian reservation, look, a Oglala Lakota county and men there live about 46 years. They they live very short lives and not too far away is here the longest Life Expectancy. So within the United States, poorer counties, counties with the poor life situations have shorter lives. And whats these are rich and colorado Summit County and others where aspen and and the rich people live. And then the key thing is the Mississippi Valley and appalachia and southeast in general. So this is and were looking at 64 to 90 some odd years. So were looking at all at almost 30 year difference in Life Expectancy within this country, this is 2019. The graph is from our institute for Health Metrics evaluation and my students to the website and get all these graphs i want you to see what happened . What do you think . If i showed you the same map for 2014 what would you expect to see. Well where youll wonder where blue went. You see, are the good is somehow disappearing and the poor health is somehow increasing. I mean, this is reality. I wish it werent true, but its what, you know, its what we to change in this country if were going to make make changes. Chapter seven stresses the killer and that, as i said, stress is the 21st century tobacco. My quote there is, if you want to increase your chances of, avoiding stress related diseases, make sure you dont inadvertently allow yourself to be born poor. Robert sapolsky a neurosis scientist at stanford. So we are chasing the almighty dollar off cliff and and its very stressful. Its killing us. And so in that chapter i die, i talk about all the biology behind the issues that weve been talking about. Well well, chapter eight, our Health Depends political choices. And thats what most people in the United States do not realize. They think its health care and personal and our language just doesnt really help us there. You know, we for Health Access help get Health Insurer health when its health care. So we think its health care that produces health when it doesnt. And politics impacting health, you got to be you got to be nuts. So Jeffrey Rhodes said the primary, a british epidemiologist said the primary determinants of disease are mainly economic and social and therefore its remedies must also economic and social medicine and politics cannot and should not be kept apart. So im going to illustrate this go to the hawaiians are our longest lived state or healthier state and they produced report a few years ago. And this is the graphic on page two. Sorry the one is its it depicts the Production Health as the department of health in hawaii sees it. And down here look at downstream effects and then we go further and further to see what really matters. So downstream are all the chronic diseases that youre suffering from or you will suffer from as you get older and on the shore by the traditional risk factors, their behavior, you know, smoking, obese and that sort of stuff. And they put on the other side of the river health care. So hawaii, for some reason seem sees health care as far downstream. So whats whats next . Well, these are what are called the social determinants of health, namely races from education, income, wealth, environment. Really important is where the water is is just pouring whats above that, what are the root causes of health . Well socioeconomic conditions . And then above that, economic, political context and, governance. So something about our healthy states Health Department realizes politics is really the important. So what are we going to do . Well, we cannot solve our problems. The same thinking we when we created them. So what how are we going to unpack political context and governance . My wife is signaling me to go faster and lecture quicker. So this is a graph of Life Expectancy tnds for the 50 states over that 40 year period. 1958 to 2017, and states that had conservative political policies. Their Life Expectancy began to flatline, and states that had liberal state policies saw much more improvements. So we see this at the state level, namely, political policies matter for Health Improvements and. Heres a whole list of the kind of political policies that im not going to go into, but in this paper, id be glad provide to anybody who wants it is described in the book. Its reason to buy the book. So what are you going to do . Well, i like this idea we got to care for one another namely weve got to care for us in early life, there are only two countries in the world where a working woman whos pregnant doesnt have a nash, doesnt get paid time off after she has her baby. One is, of course, the United States. We cant afford it and the other is papua new guinea. Half of a big island of australia, only two countries in the world. Imagine that going north to canada you get a year at 60 pay the employer tops it off so you dont have to go far to see that. So we got to care for early life. We to share namely lets decrease our extreme and reparations are what we owe the people enslave and the indigenous people. We we kill at random at every. So when we are we going to do well knowing not enough willing is not enough. We must do and. Now im going to read the law last part of the book of that chapter. Its appalling and. The poem is called the low road, and maybe you can read it with. What can they do to you . Whatever they want, they can set you up, they can bust you, they can break your fingers, they can burn your brain with electricity, blur you with drugs till. You cant walk, cant remember. They can take your child all your lover. They can do anything. You cant stop from doing. How do you stop them alone . You can fight. You can refuse you can take revenge can. But theyoll over you two people together can keep each other sane, can give each other support conviction, love massage, hope, sex three people or a delegation a commite, a wedge with four you can play bridge and start an organization with six you can rent a whole eat pie whip for dinner with no seconds and hold a funding fundraising party. It doesnt make. A demonstration of 100 kill a whole a thousand that solidarity and your own newsletter 10,000 power and your own paper a hundred thousand your own media 10 million your own country. It starts it goes on one at a time. It starts when care to act. It starts when you do it again. After they said no it starts when you say we and know who you mean each a you mean one more. So im presenting a whole bunch of ideas that probably most of you hadnt heard of before, and i bet almost everybody in this room absolutely believes something was really true. And they had to give up that belief. Can you remember that . Can you remember a time when you something was absolutely so and you had to abandon that belief . Thats right. We got over it. So maybe you can maybe you can get over this as well. So you for listening. Im happy to have any other discussions. Were sort of on time. So ill be brave. You want people to act . Are there any organized nations in the area that people can get involved in or some support or get information from . So can is the board, as i am of washington physicians for social responsibility and thank you for for tip. So we have an economic inEquity Health task force. So we have three or the physicians for social responsibility is an organization thats actually been involved in winning two Nobel Peace Prize is the international group, the physicians for the prevention of nuclear war. The one physicians for social response ability has a variety of chapters in different cities and states and we have one in Washington State and theres an anti nuclear arm of that, a Global Warming arm of that, the economic and Equity Health task force, and are task force was meeting tonight. Unfortunately i couldnt but its the name physicians is in the but most of the members are not and its a very Good Organization to get involved with. I lay a lot of ways in which you can join organizations or present these ideas in various ways in the last chapter which dont think youll find in most is very, very specific in my courses for example the students have to plan an event in a place invite people there and present these ideas to them and theyre graded on how many people they to get out now during the covid era, they couldnt have a face to face meetings, so they used social media. And whereas if you got ten people out or so, that was a good turnout. But with instagram or these others, they get a thousand and so social is a tremendous way to get the idea up. And there are many, many others. So, you know, like marge pierces poem, we have to join organizations. And unfortunately, Public Health the health really produced organizations to try and make us healthy again. That reminds me. So we want to make america healthy again. You know, we were one of the healthiest countries back in the 1950s. And we can make it there again. Peter, you are so you can ask me all the time years ago, im but it was the last. You listed in five print all these things we can do but your opinions which of those are these committees and things going to attack and get the most payoff from i mean. Well if a political solution what should be the of which which is the big payoff. Well think we need to make known that we that were dead first remember in 1957 the russians launched a satellite into space sputnik and it beep to signal to earth and we we were totally caught off guard and so what did we do . Well, we launched a program to land a human on the moon by the of the next decade. So we, in a sense, need a sputnik event to come to recognize the ideas im presenting and set a goal to. Well beating japan be hard unless we nuked them but you know there are countries do set goals australia which close to the number of number one and Health Olympics the countries a goal in 2008 to beat japan. And i think the question what specific policies could we do in this country just two or three specific policy things that would really improve things. I think that was lets back to in 1950, the highest marginal rate was 91 . If you made 1,000,000, made an extra dollar, 0. 91, went to the government what did the government do with that money . Well, they spent it on a variety of social program. So we need to have tax rates and use that that money to fund various programs, early life use it. Yeah. So im at the school of Public Health and im often writing about how were debt. First, this critical with Maternal Mortality and our decreasing Life Expectancy precovid and im sort of told that well things arent that bad and its its not that serious and perhaps im fudging the numbers a little bit. I get a lot of pushback from faculty there. And so we. What can you say about how what the school that you know your perceptions on the school of public and the importance of of of changing kind of the central ethos there and sort of younger folks studying this kind of stuff. So we have a of faculty in the school. Can i turn the question over to amy or to james. Older student . I was trying to tell you and ive no one i know we want to say that, you know, ive got knowledge that i need. Be honest. Theres a certain resistance to sonia sitting over there. She so we have an online program. And when donna was the assistant chair. She made my course mandatory and then when leadership changed, they dropped course. So to be honest, there is a real resistance in almost every of Public Health in the country to confront our poor Health Status. How important is it to try and change that. How can we change that. Well, because i feel the same way. No. Yeah, i its going to be difficult. So what im proposing to school of Public Health is that we have a series of conferences on our declining Health Status and invite major speakers on this from around the world. Actually to talk about this. And have the school. You know, we have our popular Asian Health Initiative and its mostly just funding Small Research projects that dont address question covid. You know, theres. Basically some events like sputnik was a was something that really launched this country and a certain direction our invasions of afghanistan and iraq that killed millions that could have been a oh a way of leaping into these ideas the American Health association it should be rallying around this. And we the first week in april as american Public Health week. But the rest of the day the american Public Health association and can do is their slogan nation in one generation and paraded that out in the in the in the Global Health week and then they put it back in safe. So i dont know. Amy do you have any thoughts. On what we should do . Yeah, i well, i totally agree. The tax and spend it on bush we do in the public Health School. Oh well leadership. Leadership, yes, its always leadership okay. James. Well, also with the public school, i mean, i think what we need to discuss isnt just sharing information, it is an understanding of the political interests of work and of the school. And those are whether its pharmaceutical interests in the school of medicine, Insurance Industry and understanding how our field of Public Health is influenced by this big, often private actor. But i theological activists who are quite committed to maintaining it doesnt matter what data we tell them and to expose those those of influences in our field and push back on it. So i think important of we do to make sense. Yeah in other thoughts glenn so get over here she works for she was a a student of mine a century ago and and she has this program just health action, which tries to educate people. And when i talk inequality, she makes the point that the poorer people she works with or think of inequality. They recognize all of their rather than the gap between. The rich and the poor. I dont know. Can can you shed some on on your work with your with just health action. Well i just want to say really what they dont recognize the concept of income inequality. You know, its its really about poverty more than income inequality. Um, but i have spent the past. I dont know if you guys have heard about the flooding. South park. I was then just literally came up with two weeks of flood response there. And its been exhausting. And its all about the system. You know the, political system and how messed up it is. The people are have been. Well, i have to say the Public Health seattle king county didnt show until today ten seema didnt show up until may nine. So its been exhausting in asking where everyone is and how come they didnt show up. And this is a community that has a 13 year difference in Life Expectancy compared to the parts of seattle and the system. There was no Emergency Management system set up to respond to the flooding and so yeah, back to policies where the pilot wheres the policy to deal with these inequalities. I dont know so now that im depressed to hell are you thats it. Please, id be happy to go to the back and sign some books if you want or james, you, you had a comment. This you quoted amartya sen who is i think a hero to many people here inequality and he has a famous i dont know how state but he basically said when you have a robust you dont have hunger and you wrote a lot of famines and hunger and he said its a barometer. How much democracy has how much hunger you and i guess kind of speak to what youre saying. I mean isnt the solution is its participation in the political process and planning for democracy because thats going to lead to big changes and we need to make im making an obvious statement. I just thought the marchs wisdom perhaps to this day. Thank you, james. I dont know what say. Okay, thank you all for coming. Happy to sign books and talk about anything good evening, ladies and gentlemen my name is jim byron. Im president and ceo of the Richard Nixon foundation. Its my pleasure to welcome you to nixon library. Thank you for being. 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