Map of life expectancy at birth from Global Education Project.

Friday, May 08, 2009

The actual cause of death . . .

. . . and what to do about it.

It is a staple in introductory public health courses to present the leading causes of death as recorded on death certificates -- heart disease, cancer, stroke, etc. -- next to so-called "actual causes of death," which are somebody's analysis of preventable or modifiable factors out in the world, as opposed to inside the person's body, which in the classic analysis are tobacco, overweight and physical inactivity, ethanol, etc. "Microbial agents" are 4th but I have a quarrel with that, which I will defer. Anyway, you can see it for yourself here.

On the one hand, I do think this is a healthful exercise. It would be a big step forward if we could spend less resources on treating heart disease and cancer, and instead got people to stop smoking, exercise more, and consume fewer calories. On the other hand, it reflects sloppy thinking, in two ways. First, you can always go back another step and ask, "Why are people obese?" "Why do people smoke cigarettes?" and perhaps most cogently though of lesser numeric import in today's world (but maybe not tomorrow's), "Why do some people die from 'microbial agents' and not others?" Then your Actual Causes of Death might include, say, advertising, agricultural policy, and television.

But second, and this is the real subject of today's rumination, is it really death that's the problem? Every one of us is born with an inevitably fatal, absolutely incurable disease which, after we reach adulthood, progressively causes our muscles to weaken, our skin to lose elasticity, our immune systems to decline, our arteries to stiffen, and eventually, if something else doesn't get us first, leads to cardiac or respiratory arrest or fatal pneumonia. Then the death certificate will say heart disease or influenza or whatever, but we know the real cause of death: birth. The only way to prevent a person from dying is to prevent the person from being born.

So how should we view this problem? One way, which appeals to me, is through a justice frame. Look at the map above. The problem is not that people die, but that many people don't have the chance at a lifespan which gives them the chance to fulfill their potential. Beyond that, of course, we pay far too much attention to death in the first place. In order to accomplish anything and enjoy life, being alive is a necessary, but not a sufficient condition. We can extend the lives of people with cancer and heart disease, often at great expense, but I would much prefer to live without them. And with or without a spiffily functional body, I need the social context and psychological resources to have a fulfilling life.

Medical intervention plays a tiny role in this big picture. The most powerful determinant of our longevity and our health, however conceived, is our position in society. For example, here's another open door crashed through: "Despite increased attention and substantial dollars directed to groups with low socioeconomic status, within race and gender groups, the educational gap in life expectancy is rising, mainly because of rising differentials among the elderly. With the exception of black males, all recent gains in life expectancy at age twenty-five have occurred among better-educated groups, raising educational differentials in life expectancy by 30 percent." And, again, life expectancy aside, "Among adults over age 25, 5.8% of college graduates,
11% of those with some college, 13.9% of high school graduates, and 25.7% of those with less than a high school education report being in poor or fair health." The latter factoid is from this memorandum from the Prevention Institute, which reviews all sorts of disparities having to do with race and ethnicity and other social factors as well.

Again, this has little to do with doctors and hospitals and all of those astonishing medical breakthroughs by heroic "top docs" you hear about on TV. (Or read in the papers, if you do read papers, which is kinda weird nowadays.) By the way, it also has nothing whatsoever to do with influenza.

This is what we ought to be talking about on Daily Kos and everywhere we can have such conversations. I hope more people will join me.


Anonymous said...

I have always advocated (without any success) the simple measure of not considering cause of death of ppl older than some rubric (average age of death for ex. - that could be discussed..) Ppl will die, and what they die of in the end should be an interesting topic for specialised types - but these stats should not be used to direct public health policy in any way. Or at least, not ‘as is’, careful reflexion needed.

In the west, we seem to consider that life is extendable for ever, if only we could prevent 85 year-olds dying of what they die of (cancer, heart, some infectious diseases, general malfunction, chronic conditions, etc.) we would be better off! This skews public health get the drift...


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Incredible! I these days it's difficult to determine what's the real cause of death because we can get heart disease, cancer and other diseases related to, the problem is I think the way we're living.m10m

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