The weather outside is frightful! But the fire is so delightful! Since we’ve no place to go … Abdul’s about to nerd out on all of your health & medicine questions. Here we go, here we go, here we go.

TRANSCRIPT

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Dr. Abdul El-Sayed, narrating: Happy holidays, everyone. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. The holidays are upon us. Chances are you’re getting ready for time away from the usual grind. Spending it instead with friends or family. But the holidays are also a time to reflect, to think a bit about the year that’s past and the year that lies ahead. So today, I wanted to step back and reflect on 2022. It kicked off with the pandemic’s worst surge as Omicron and its many nefarious cousins set records in daily cases, hospitalizations and deaths accounting for more COVID deaths than all the variants that came before it. As we emerged from Omicron in the spring, everyone was over it. We saw governments, big and small, rush to take down COVID precautions like masks and vaccine mandates. And yet we continue to watch as hundreds of people die of COVID every single day. But COVID wasn’t the only major story in health and health care this year. In June, there was this: 

[clip of unspecified news reporters] In a sweeping ruling that overturned a half a century of precedents, five justices ended the right of American women to choose abortion under the Constitution, rocking the foundations of more than five decades of legal precedent in our country. Demonstrators, both for and against the court’s decision were quick to react. Here in Washington. 

Dr. Abdul El-Sayed, narrating: For the first time in nearly half a century, the Supreme Court turned its back on millions of people and revoked the constitutional right to a safe and legal abortion. Within months, 14 states moved to ban abortion, many without exceptions for rape or incest. The move dramatically decimated the landscape for reproductive health in this country. And then there was this: 

[clip of unspecified news reporters] As the COVID 19 pandemic rages on, growing concerns about monkeypox, the US declaring a public health emergency over the monkeypox outbreak across the country. New York City declaring a public health emergency. Officials are calling it the epicenter of the monkeypox outbreak in this country. 

Dr. Abdul El-Sayed, narrating: Monkeypox officially renamed Mpox surged among men who have sex with men across the United States in the summer, exploiting a tattered public health system and a basic failure to update our stockpile of vaccines. And yet, in a testament to the LGBTQ communities, organization and engagement, spread has since slowed to a trickle. But that wasn’t the only rare virus to spread unexpectedly this year. 

[clip of unspecified news reporters] Someone in New York has contracted the first case of polio in the United States in nearly a decade. Polio can be a life threatening, a disabling disease. The virus caused thousands of cases of paralysis in the 1940s and ’50s. Local, state and federal health experts are on high alert. 

Dr. Abdul El-Sayed, narrating: That’s right. Polio, you know, a disease that we almost eradicated from the world a few decades ago. It began to spread. Why? Because of vaccine mis and disinformation. Much of the mis and disinformation around vaccines in the wake of COVID has had a spillover effect on the rates of other types of vaccinations, including polio. But it wasn’t all bad news. 

[clip of unspecified news reporters] The Senate working through the weekend as Democrats look to pass their sweeping climate tax and health care package, the landmark $740 billion economic package, I am confident the Inflation Reduction Act will endure as one of the defining legislative feats of the 21st century. 

Dr. Abdul El-Sayed, narrating: For the first time in American history, the US federal government can negotiate prescription drug prices with manufacturers. But that’s not all. Unlike in years past, when the New Year hits, farmers are going to have to think twice about raising the prices on their prescription drugs. Or they’ll have to pay the federal government if they raise their prices higher than inflation. Throughout the year, we’ve tried to stay right there with you to cover it all and so much more from myopia to wellness to mental health to organ donation. And we’ll be right here for you in 2023. Today, I wanted to let you take the reins, to ask your questions. Your questions. My answers, starting now. So I’ve invited our associate producer Emma Illic-Frank to be your voice. She’ll be asking your questions submitted on Instagram and Twitter and on email. So Emma, take it away. What did we get? 

Emma Illic-Frank: Thanks, Abdul. So our first question is from Maha Ayoub 2021? who asks, what are some of the ways to deal with the opioid addiction that are not conventional? Also, some cities put some Narcan vending machines. How effective is that? 

Dr. Abdul El-Sayed: That’s a really good question from Maha. I um want to just step back and I want to remind folks that the single biggest issue that we are dealing with in public health and health care before the pandemic of COVID 19 was the pandemic of opioid overdose. And it continues in the background. In fact, um so much of the evidence suggests that, in fact, because of the pandemic, because of the mental health challenges that have come with it, because so many people have been disconnected from their networks. In fact, uh opioid misuse and overdose has increased over the past several years. And um when we look at the declining life expectancy, it wasn’t just COVID. We’d seen a decline in life expectancy uh in years before COVID, and that was largely attributable uh to a constellation of what we call diseases of despair, um from suicide to opioid overdose. And so this really is uh an ongoing, low burning pandemic, and we have to treat it as such. And you sort of think about breaking down the challenge of opioid overdose, that there are three really big ways to think about it. The first is you want to prevent uh folks who are addicted from dying of an overdose in the first place. And that’s where Narcan and Narcan vending machines can be so helpful. Narcan is a drug that uh biologically opposes the action of opioids. The way that opioids kill someone is that they actually stop your brain from sending the signal to keep you breathing. Uh, If you think about it, if you just sat there, um you wouldn’t have to think about taking every breath. That’s something that uh your basic the basic part of your brain will do on its own. Um and uh that part of your brain, um when when opioids are on board, uh in effect it gets turned off. And what Narcan does is it reverses uh the effect of opioids and keeps you breathing. Um. And so once you sort of turn on that midbrain function of starting to breathe again, you can save a life um from someone who’s who’s who’s overdosed. And so putting Narcan anywhere and everywhere and training people on how to use it is critical. And so uh it’s not just vending machines where people can get access to free Narcan. Of course, it’s not just like a normal vending machine. You have to put your credit card in to get the Narcan. Instead, you can just pick it up. Um uh. But also making sure that all first responders um have access to Narcan and making sure that folks are trained on how to use Narcan. Um. And in effect, making it ubiquitous, I think is really important. The other important part of this, though, is making sure that there are spaces where people can use in an observed manner. You know, the challenge is that um in a world where we criminalize drug use, uh people will hide their drug use. And if they hide, um that’s what creates the risk of potentially overdosing in a situation where no one sees you and potentially dying. And so um one of the things that we have to think about is how do we create spaces where people can use safely? And I know um that folks out there uh might be thinking, well, you know, aren’t you empowering people to use drugs? Well, um what you’re doing is empowering them not to die uh because of the disease of addiction. Toward that end, the other part of this is is stabilizing, um folks, with addiction. And the the overwhelming strategy to do that um that has incredible evidence behind it uh is what we call medication assisted therapy. What that means is, rather than leaving people to get opioids oftentimes off the street, that can be laced with uh fentanyl and all kinds of other uh chemicals. What you do is you offer them a less potent um opioid, something like methadone or buprenorphine. And what these um medications do is, in effect, um they quell the withdrawal symptoms that people will have if they stop using opioids um and protect them from the street versions of the drugs. Because the natural course of this is that, um you know, somebody might get a a script for an opioid um and then they develop an addiction. And um when they can no longer get the script, either they turn to drug seeking behaviors that themselves can be really dangerous, um or they go to the street. And um that’s when you start having a situation where people are getting all kinds of different potencies um with very little oversight. And so in this case, what you’re doing uh is you’re giving someone a consistent access to prevent their withdrawal uh and to go about living their lives. Now again. Right. A lot of folks who might take a um a very puritanical approach to this would say, well, you’re literally giving people drugs like, well, you are, but you’re allowing them um to get access to the means of preventing their withdrawal so they can live their lives without having to worry about where they’re going to get their next um their next dose uh or whether or not the dose that they’re getting is laced with something that could, you know, eventually kill them or make their addiction worse. The third piece of this, of course, is preventing addiction in the first place. And, um you know, the story of the opioid uh epidemic has been told in a number of different places. To that end, I really recommend the book Dopesick. The author does a fantastic job walking through exactly what happened, but a lot of it had to do with, hey, our forgetting um that uh opioids consistently throughout history have caused the same fundamental issues um and frankly, pharmaceutical company greed uh in rewiring the way that doctors were taught to think about pain. I remember being in medical school uh in uh the late aughts and being taught that I should think about pain as a vital sign uh and that we had to aggressively treat pain. All of this a ploy um to get us to write more scripts for opioids. And um the challenge here, right, is it’s not just about um limiting the amount of opioid that we write scripts for. It’s it’s about trying to identify opportunities to use opioids where they ought to be used. And that that is not in writing a long term script for somebody who has short term acute pain, um but for folks who have serious pain, they need these medications, but they need these medications in circumstances where they’re being very directly observed um and that the risk for opioid addiction is is being considered. Um. And so it’s about rethinking the way that we use these medications so that we’re limiting uh the number of people who fall into an addiction in the first place. So it’s preventing the overdose deaths. It’s managing the disease of addiction, uh and it is um preventing addiction where we can. The last thing I want to say is that we need to, as a society, rethink the way that we think about drug use. Um. So often this is seen as, you know, when we think about drug use, it’s easy to think about Nancy Reagan and the just say no campaign um as if it’s some sort of choice. And instead, um we need to destigmatize drug use, recognize that addiction is a disease like any other disease, um and treat it as such. Um. We would not we would not blame people for having diabetes or getting cancer. Uh. But we blame people for addiction all the time. Um. And I think that that stigma it it stops us from doing the basic things that we can do uh in our society to protect folks. 

Emma Illic-Frank: So we got a lot of questions about mental health. And so I’m going to bundle a couple of them into one. Roxanne Taylor asks, What are your thoughts on New York forcibly taking homeless people off the streets? Crystal Deal asks, What are we doing about our crumbling mental health system? How are we protecting community mental health from privatization and corporate greed? And Maria asks, What is the path to universal, well coordinated quality mental health care and physical, of course, for all? 

Dr. Abdul El-Sayed: Yeah, I really appreciate the question because I think um in some respects it goes hand-in-glove with the previous question about about opioids. This pandemic, I think, has highlighted the the fundamental failure to provide people mental health services. But it’s also highlighted maybe why mental health is becoming such an acute challenge in our society. I think even before the pandemic started, we as a society had started to lose the ties that fortify us, our relationships to other people. And what we were given instead was the online facsimile of relationships. And it turns out, you know, even when you when you talk to someone on Zoom, it’s not the same kind of joy as when you talk to them in real life. There’s something hard wired into our brains to want and crave um direct human contact and interaction, even if you’re not touching another person, just just making eye contact. Think about that. We call it eye contact um is is a profound human need. And I think the pandemic accentuated that, given that we we lost access to one another to fight this pandemic. But all of that has reminded us that uh we are facing a series of mental health crises in our country, um and we’ve been underequipped for a while uh to be able to deal with it. So just uh some history. Um. In the ’60s, ’70s and ’80s, uh there was a recognition that the way that we’d been handling mental health and mental illness by warehousing people into large state in effect penitentiaries, um but, quote, “hospitals” uh was failing, it was inhuman um and it was degrading. Uh. And the kinds of circumstances in those spaces was just appalling. So the idea was, you know, can we with the advent of new uh treatment modalities, can we move people out of psychiatric hospitals and out into communities where they can continue to live and learn and work and play out in the community with the assistance of far better treatment. The problem, though, is this aligned with a moment of pretty deep austerity and a rethinking of the U.S. social contract where um we decommissioned these hospitals but never actually invested in the outpatient mental health institutions that we needed to be able to support people. And what happened was, instead of warehousing people in state psychiatric hospitals, we warehouse people in jails. That’s that’s largely what we did. And um the consequences of that have been uh utterly shameful. I think we’re finally in a moment now where we’re starting to recognize uh that we have a profound need for mental health care and um and we’re actually putting pen to paper on it. Uh. If you think back to um the bipartisan gun reform bill, it was less of a gun reform bill than it was a mental health infrastructure bill. Um. It did some some important things on on guns, don’t get me wrong on that. Uh. But what it really did was it made the single biggest investment in outpatient mental health infrastructure in American history uh by establishing and scaling a system of comprehensive community behavioral health clinics. And so you’re going to see from this law uh the um establishment of a number of these community mental health institutions. And that’s really a great thing. Um. It means that a lot of people who otherwise might not have had care can get care. Um. The other thing that the pandemic did is it um it forced us to recognize that a lot of mental health care can be provided online, and it really ought to be. And so we’re still waiting for um permanent uh legal infrastructure to protect um tela-mental health. But but I think that things are moving in that direction. So that’s good news. Um. And yet, at the same time, the challenges with acute mental illness, uh we continue to watch play out in community after community. Um. The fact that we respond to people with mental health crises, with people with guns is an abomination. And too often it ends with people losing their lives simply because uh they have a disease that we have failed to treat as a society. Um. And then the other part of that is um that homelessness uh is um an increasingly huge challenge, largely because we have not invested in building homes. But the interaction between homelessness and and mental illness should be pretty clear. Right. One of the things that unfortunately um serious mental illness can do um is that it disrupts the ability to sustain the basic infrastructure of one’s life. And uh when you do that, it means that, you know, being able to go to your job consistently to earn a paycheck, consistently, to pay your rent consistently, um that starts to go away. And so the tip of the iceberg, unfortunately, on our homelessness crisis um tends to be people uh with serious mental illness. And and and it’s been that way for a while. But it’s particularly bad now because the bigger the iceberg gets the the bigger the tip gets. And, um you know, we watched as uh in in New York, Mayor Adams announced that they were just going to clear people off the streets. Well, you know, the way you solve homelessness is not just to take homeless people off the streets. That’s not actually a solution to the problem uh that caters more to the whims of, you know, upper middle income or upper income people who don’t want to see homeless people because they don’t want to be reminded of the inequality and the shameful level of inequality of the society in which they live. Um. But part of the problem here is that, you know, so much of the real estate in um in communities where there is more homelessness tends to be a commodity that’s speculated on by the richest people, not in that community or, frankly, abroad. Um. And so you end up having these homes that are unoccupied um and uh thousands of people who are forced to live on the streets. And so if you really want to do something about homelessness, you got to do something about uh about housing supply. And if you want to do something about housing supply, you’ve got to do something about the fact um that in communities like New York City, uh we’ve allowed the rich and the powerful to control real estate in a way um that uh that artificially limits the amount of actual housing that we have. So, you know, if we’re serious about this, we got to we got to take that problem on uh take it on seriously, rather than trying to, in effect, sweep the problem under the rug and pretend like New York doesn’t have a housing crisis or San Francisco doesn’t have a housing crisis. And what we’re starting to see is a politics that wants to end around um the problem. They don’t want to actually take the problem of housing access seriously. And instead, uh what they’d rather do is just, again, sweep homelessness under the rug and pretend like it’s a non-issue so that they can continue to cater um to people who uh don’t want to have to be reminded uh of the consequences of a challenge that they’re unwilling to be a part of helping to solve. 

Emma Illic-Frank: So our next question is from At My Hayes hashtag It’s time for Medicare for All. 

Dr. Abdul El-Sayed: Yes, it is. 

Emma Illic-Frank: [laughing] What’s it going to take for Americans to take to the streets, literally or metaphorically? For hashtag Medicare for all? 

Dr. Abdul El-Sayed: Oh, I’m so, I’m a start on the um the downside. And then I’ll move to the [?] upside, the mid-level side. Um. The downside is this, I would have thought that a pandemic in which millions of people lost their health insurance in a matter of a month would have demonstrated the fundamental failure of a system that that requires you to have a job to have basic access to health care, because, well, in the time when you needed your health care the most, i.e., a pandemic of a deadly disease, that’s when people lost it. By definition, our employer sponsored uh health care system is insecure and it’s also exceedingly costly. So this gets me to the mid-level point, right? While I am saddened that that, frankly, health care has has like declined as a political issue, it was the most important political issue in 2020. Then we had a pandemic. Then somehow it faded from the political map. Um. I think that the trend in the cost of health care is going to continue to force this issue onto people’s minds. What do I mean by that? In the past, when we used to talk about the challenge of health care, the implicit issue was how do you provide quote “coverage” to the poorest Americans? That that really was the the main issue. And that was because for people um who are, you know, middle class, middle income. They generally had pretty good health insurance. And then the industry, both the health insurance industry and then the hospital industry and the pharmaceutical industry, all of them, their greed started to show. And so the costs started to skyrocket. And what happened is that insurance companies used um the outcomes of this experiment called the Rand experiment, which showed that uh people who are forced to pay some sort of co-pay uh tend to use less health care, although they also don’t know what health care is useful. Meaning you could argue that the less health care that they use is wasteful, but you could also there’s also been really good evidence to demonstrate that people forego really important points of health care like they are less likely to get breast cancer diagnosed, for example. And what the insurance industry did is they interpreted this in the best light for them and said that we need to start charging people at the point of care. And that’s when in the nineties and the 2000s, you started to see health insurers charge things like deductibles and co-pays, um which massively increased out-of-pocket costs. Deductibles have skyrocketed over the past several years, and the average deductible now is nearly $4,000. Um. I talked about this last week when when we interviewed Ellen Haun, the actor who uh made a whole movie to get her insurance. Uh. But if you do the math, the median income for a family of four is about 75 to $80,000. The median deductible for a family of four is nearly $4,000. That means you’re forgoing a paycheck just to get the health care you already thought you paid for. Not only that, though, it’s also the fact that premiums are skyrocketing and they’re skyrocketing both for employers and for employees. And so I just think that as people recognize that their insurance is getting more and more precarious because they’re taking on more and more of the financial risk of getting sick, which is what insurance is supposed to protect you from. I think people are just getting more and more pissed off about it. The hard part, though, is that most people who don’t have to use their insurance ie. they’re generally healthy, don’t know how bad it is. Um. But as the costs continue to rise and yes, they are continuing to rise um and it’s not even that they’re rising linearly, it’s that they’re rising exponentially. Um. I think more folks are starting to realize that insurance is a basic racket, and once that happens, right, it forces this question that all of us face back onto the political scene. And so I wish right that, you know, in the context of the pandemic, people would have recognized just how much of a failure our system is. Um. I think that the the long term consequences of the slow and steady uh parasitic greed of the uh industry is what’s going to ultimately force this into the issue that that changes things. The other thing I’ll tell you is that, you know, um the people who tend to vote tend to be people who who for most of their lives uh took advantage of a health insurance system that was actually pretty robust. Right. If you’re over 65, you gotta think about it. For most of your life, insurance wasn’t so expensive and now you’re on Medicare. So, uh you know, the government actually does pay for your health care. Um. And if those are the folks who continue to to make up the majority of voters, it’s unlikely um that we’re going to kind of see the political power or at least the translation of this problem into the political power that we need um to to actually change the system. So uh all of that is to say that all of us who realize that the vise is getting tighter and tighter, um that we have to translate our frustration with the system into political power. Um. And I think that’s, you know, as that as that continues to happen, as the vise turns and turns, um you’re going to see more and more people who make this their top issue and their top priority. It’s no wonder young people are more likely to support Medicare for All than anyone else, because we’re the folks who look forward and say this is fundamentally unsustainable and I don’t want to be in a situation where I’m raising my family and I can’t pay for their health care. 

Emma Illic-Frank: Our next question is from Yamans, who asks, How will private equity change medicine? 

Dr. Abdul El-Sayed: Woo. Not for the better. Um. So just to set some context for this. Uh. Private equity firms are companies that uh invest in other private companies, meaning not um publicly traded corporations, the privately held companies. And what they’ll do is they’ll invest in them, and then they will do one of the following. They’ll either grow them and then sell them uh and make money that way. Or what they’ll do is try and buy a bunch of them and then sell them as a bouquet um and make money on the fact that they’ve like what they call rolled them up. Uh. And the idea is that the whole is greater than the sum of the parts, or what they’ll do is fundamentally gut them uh for parts and um and try and sell those parts uh for more than the whole. Right. But that’s what private equity is. All of this sits on the background of consolidation in the health care system. So, you know, if you’re listening, I want you to think about the hospital near where you grew up, the hospital you would have gone to if you broke your arm when you were a kid. Ask yourself if that hospital has the same name now as it did when you were young. And chances are it doesn’t. Chances are now. It is part of a system that is a demonstration of consolidation at work. You have hospitals that are leveraging their scale and scope to buy up other hospitals. And um what that means is that you have fewer and fewer hospital providers that are now arrayed in networks, um and those networks then have substantially more power. And we all know from basic economics that if you have a monopoly or an oligopoly, um it allows you to set price. And that’s what um these these uh consolidated hospitals are doing and have done. Now, um what happens is that while hospitals are busy buying up hospitals, um they aren’t always focused on physician practices. And what private equity is doing is buying up physician practices. And usually they’re rolling them up, setting them up then to sell uh to these larger hospital systems. All of that means that for patients we have fewer choices at the point of care and that those uh providers, be they um practices or large hospitals, are better able to set prices in ways that contribute to the increasing cost of health care. And then what it also means, though, is that for physicians or uh or health care providers, when you have fewer options, those companies exert what’s called a monopsony. They are um one of a fewer number of buyers of your labor. And when you have monopsony power, it’s like uh doing exactly the same thing uh to providers as uh you’re doing to patients. So while you can squeeze patients and make them pay a higher price, you can squeeze providers and offer them a lower price for their labor. And what that means then uh for providers, be they nurses or hospital staff or doctors, is that they end up making substantially less money than they used to. Uh. Interesting statistic in 2018 um the average physician no longer worked for a physician owned practice. Remember, doctors back in the day used to put up a shingle and say, I’m a doctor, come see me. Uh. And then over time, you’d build your practice, you’d hire more doctors. Um. And so doctors used to work for doctors. No longer is that the case. Most doctors now work for large corporations, and in part that is because of the power of private equity. Now, um one of the things that those consolidated practice systems will do once they’re owned by private equity firms is that while they may offer uh physicians a higher salary at the front end, on the back end, physicians used to make a lot more because they own the practice. Right. So they would they would benefit not just from the salary that they collected for seeing patients, but because they owned a business and no longer are physicians business owners. And so in large part, they’re getting squeezed out. The other last point of this is that it’s just harder to work in a consolidated environment, because well um you’re not your own boss uh and the person who is your boss doesn’t know what you do every day, they just see you as someone who, in effect, works a line that um produces health care. Uh. And um and so doctors are getting squeezed. To my mind, I think the single most important thing to address, the impact of private equity consolidation and frankly, uh Medicare for all, is that doctors start to form unions. And one of the most unfortunate things about the kind of selection process into who becomes a doctor is that uh we tend to be people who are really good at following rules. Um. And unionizing implies being willing to buck rules. Uh. And if you have gotten where you are because you know you’re the best at getting an A in your orgo class and did the best studying for the MCAT and the best at memorizing PowerPoint slides and the best at taking your boards. Um. You tend to believe that the folks who employ you have your best interests at heart. And I hate to say it, but private equity firms, consolidated hospitals. They exploit that at every turn. Uh. And so doctors need to unionize and recognize that, um you know, we are not special snowflakes. Uh. We are a form of labor like other forms of labor. And unless and until we are willing um to step up and advocate not just on our behalf, but on behalf of everyone else who works in hospitals and clinics, and most importantly, on behalf of our patients, we’re going to continue to see greed running and moving our health care system in ways that hurt us and more importantly, hurt our patients. We’ll be back with more after this break. 

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Dr. Abdul El-Sayed: And we’re back with more of our holiday mailbag. 

Emma Illic-Frank: Well, it’s been quite a year. Our listener, Lindsay, asks, is public health worse off now than we were at the start of 2022? How prepared are we to face the next public health threat? 

Dr. Abdul El-Sayed: I’m going to interpret that question in a couple of ways. Are we worse off right now? Yeah, absolutely. Will we be worse off for having gone through the pandemic? That has yet to be seen and is a function of what we do moving forward. To substantiate my first point. I just want you to think about Mpox. This is the public health 101 of outbreaks. Unlike COVID, which is airborne, uh which is exceedingly contagious and um for which we did not have a treatment or a vaccine, Mpox is a disease we’ve seen before. It has such a long incubation period that somebody can literally get exposed, get a vaccine, and that vaccine can prevent them from getting the actual disease. And it requires people to have really, really close contact. Not only that, though, because it’s not airborne. We knew the community that it was affecting first. So this should have been easy to stop and look at the end of the day. We got our stuff together and we stopped it. But there are a lot of people out there who had unnecessary infections of Mpox um that should have and could have been prevented. And the fact that our public health system could not do that from the jump is uh a serious issue and one that we should be really, really concerned about. Because let’s be clear, um there are many possible permutations of viruses that could do what COVID could do. And if one of those were to hit us right now, um I think we would be in a really dire strait. As you all know, um I work in municipal public health. The number of vacancies uh in health departments across the country is profound. We’re talking about, you know, tens of percents um and large part that’s burnout. But it’s also just the morale of having to do more work and do it understaffed and know that you have so much more to do that you’re not even getting to because you’re just trying to take on the pandemic. You can imagine what that does to a team of people whose commitment is to the public health. Now, the choice that we have moving forward um is twofold. Number one, it’s um what we do around investing in our public health workforce. Uh. We need to be better staffed. Um. We need our workers to be better paid. Um. We need to invest in the means of their success. And we’ve been behind the eight ball. I mean, this was an issue that we were staring at before COVID even happened. And I think what COVID did is it just exploited all of those holes. Uh. The other part of it is what we do as a society, what what we choose to uh engage with and the conversations that we choose to have um and how we choose to get behind public health and the science that backs it. Um. You know, just this week you have Ron DeSantis pursuing this public health McCarthyism uh in trying to impanel a grand jury um to go after everyone involved with the vaccine rollout. There’s going to be nothing there. But, you know, the best single way is, as Joseph McCarthy demonstrated, um to vilify something uh is to go through a witch hunt process where the frame of the conversation is entirely about how this thing is evil, wrong, bad, um and we can’t countenance that. We have to decide that where people are vilifying public health and public health leaders and public health agencies, that we’re going to step up and defend public health. Because I’ll tell you what, even if we don’t defend public health. Public health has been working in the background to defend us. And I think um we owe these folks so much more than we’ve given them. Uh. And that responsibility, I think, in the very least, uh has to lie with with with defending them. You all know, I wouldn’t host this podcast, wouldn’t do the work that I do uh in my day job if I didn’t believe in public health. But what I wish folks understood is that, you know, when we’re doing our best work, by definition, you don’t hear about us. It’s because the uh virus that could have been a pandemic, the the traffic stop that could have led to several accidents. They just don’t. And um and we go about our days thinking that um somehow we’re just super lucky or bad things don’t happen to us. Um. But I spent a lot of my childhood in Egypt where um folks routinely drink dirty water and routinely breathe air that leaves your nose the inside of your nose black, um where children routinely die before the age of one, uh where there is no semblance of any sort of traffic enforcement. And so people die in car accidents all the time, like my younger cousin did in his early twenties. And I see the consequences in the contrast in the life that I get to lead, that my uh daughter gets to lead, um that my cousins and their kids don’t. And I just wish more people saw that. And it’s really frustrating um that they don’t. 

Emma Illic-Frank: Mmm. Enchanted wants to know what’s a public health fact you wish people knew, mine is how zip code is a great predictor of life expectancy. 

Dr. Abdul El-Sayed: Yeah, that’s a really um important one Enchanted, I appreciate the question. The one I wish people understood is what life expectancy means. Like, I hear very educated people cite these statistics about what it was like to live back in the day, and they were like, well, life expectancy was 30 and the assumption is everybody just dropped dead at 30. Like that’s just not how it works. [laughter] Like life expectancy is an average. It is um. It is um a recognition of the average age that people will die. So you can imagine if 50% of everybody born died at one and 50% of everybody born died at 100, the life expectancy would be about 50.5. Right? Doesn’t mean that everybody is dying at 50.5. It means that literally half of everybody’s living to 100 and half of everybody’s dying as a baby. So I just kind of wish that people understood that there was a distribution that we were talking about when it comes to life expectancy um and stop citing life expectancy statistics as if everybody just dies at the life expectancy. That’s just not how it was. And like, it just kind of makes us, most people who are around 30 don’t I mean, that’s not to say that people who are 30 don’t die. That’s just to say that this is not a usual time to die. Right. Like what is killing you at 30? Obviously, you know living in a society where, you know, people are dying in uh in childbirth or people who are dying in war. Yes, there are going to be younger people who die, but it’s like not like your whole society dies at 30. Like just it’s just not a thing. Stop saying it. And please, let’s just remember, you’re talking about a distribution of death statistics. And as I say that I realize why nobody wants to think about it, but like. But please do. Please. 

Dr. Abdul El-Sayed: Um. Our next question, um talking about kids comes from Nicole Duffy, who wants to know, what can I do to minimize the sickness my kid comes home from daycare with? We’ve been knocked out time and time again this fall and it sucks. 

Dr. Abdul El-Sayed: Nicole, you and me both. I am the father. Proud father of a five year old. Who insists upon infecting me with her dirt and grime every time she comes home from preschool. I love her dearly. But I’m very upset about this. Um. Look, the hard part with younger children, particularly toddlers, is, you know, you can put them in a mask. It just doesn’t usually stay on their face. Um. They tend to have other ideas and uh trying to sit down with them and walk through statistics about their risk of being infected with um a high prevalence infectious disease is somewhat futile, um and so that’s not really a great option. One of the things that um I really wish we talked more about. And that more institutions invested in was basic air purification. Um. You know, the [?] on at public health is about changing the context in which people are uh are are are existing and living. Um. So that that context prevents uh illness. And, you know, I hate to say it, so much of our public health response has been about what you or I can do individually to protect ourselves. And, you know, part of that is just because we are a deeply individualistic society, and that’s how we think about the world. But we sometimes forget about the things that we can do around um ourselves that protect us. And we know from evidence that air purification works and investing in high quality air purification um in particular at the HVAC level, at the building level. But but also just um air purification units that you can put uh in a daycare that that really helps. And um it doesn’t just help with COVID. It’s not just a COVID response, but it’s all of uh these um fall and winter infectious diseases that we’re getting hit particularly hard with right now. And so I that is one thing that I think really can be helpful. Um. So maybe sitting down with um the administrators at the daycare and saying, hey, you know, can we install some air purification units um that might reduce the burden of uh infectious diseases, particularly in a moment like this, where we know RSV is running rampant um and that is landing a lot of children in hospitals. 

Emma Illic-Frank: In the same vein of family care. Another question from Maria, what about adequate paid sick leave, family paid leave following the welcoming of a child? How do we catch up with the world? 

Dr. Abdul El-Sayed: Maria, I um am with you, and I’m thinking about this, particularly in the context uh where I don’t think I’ve announced this yet, but uh Sarah and I are expecting a second child in January and um she’s going to have three months of maternity leave. Uh I just started a new job, and so I’m doing my best to scrape um out as much as I can. But that’s just not a question that people have to think a lot about because, believe it or not, three months is really generous. Um. But, you know, the last time Sarah was pregnant and delivered, thankfully she’s now healthy, but there were some complications there uh and um she actually had to petition her uh house officers union um doctors organizing, uh but she had a petition her House Officer Union to get more time off because, you know, for the first couple of weeks there, she she just really couldn’t walk. Um. And I just think about the fact that we make it so hard to do one of the most important natural things that humans do, which is procreate. Um. And of course, the burden of this falls um way disproportionately uh on on women and um the consequences that has for families, the knock on consequences it has on uh the ability to um, you know, to afford a home, uh particularly as you think about, you know, young people uh these days. Right. They like to tell us that um the reason that folks uh who are millennials or folks in Gen Z can’t afford housing is because we’ve spent so much on lattes and avocado toast, which, you know, I’ll be honest, like, if if boomers had more avocado toast, I think they’d just be happier. But it’s neither here nor there. It’s largely because housing is super expensive. And um we live in a society where we are constantly paying down debt uh for doing basic things like going to college. And so, um you know, when you add on the cost of then having to think about whether or not you can sustain childcare and a job at the same time um when you decide to have kids, it’s no wonder that fewer people uh in in their twenties and thirties are uh remotely considering having kids. And so this is a society wide question that we have to think through. And obviously, um what what what we think of as choices are a function of the consequences of those choices. And when the consequences uh get substantially harder, um when you think on the other side of having a child, uh it’s we are we are stacking the deck, um particularly against women, but frankly, against against all of us. And the last point I just want to make about this, and I think we fail to consider the generational consequences of the choices that we make. You know, when you think about Social Security, when you think about Medicare and their sustainability, uh we damn well better figure out how to start having more kids. And when you make it really, really hard for young people to have kids. Uh. Well, what you’re basically saying is our ability to sustain um the kinds of um programs that provide for our seniors uh is substantially lower. And and so we’re all kind of connected here as much as we don’t really want to believe that we are. Um. And so, you know, if you’re a senior right now, uh it is in your best interest um to uh invest in and politically support uh things like paid family leave and universal childcare. Um. That facilitate us having more children so that, you know, we can keep our society moving um and we’re just not doing that. So uh I worry a lot about that. And I’ve seen up close and personal what the consequences uh too often are um for uh for women in particular, but families in general. 

Emma Illic-Frank: So often when things go wrong, ERs are on the front lines. Bella wants to know, and she’s an ER RN, is health care ever going to get better? The ER is a dumping ground for everything. This feels unsustainable. 

Dr. Abdul El-Sayed: Bless you, Bella. I really appreciate um what you do every day. And I’m really grateful that you do it. And you’re absolutely right uh that the ER is a dumping ground. And what people don’t appreciate is that our failure to offer universal health coverage in this country doesn’t mean that people don’t get the health care that they absolutely need. It means that they don’t get it when it’s the most efficient, it’s the most effective, it’s the best for them. So what happens is, if you can’t walk into a primary care clinic to care for your diabetes, for example, and you can’t afford your insulin, what will happen is you’re going to get extremely sick because you’re trying to ration what little insulin that you have, which means you’re a lot sicker than you should have been because um because you are are now going without the treatment that you need and where you end up winding up is in the emergency room. And so you end up getting emergency care when it’s extremely expensive. It’s extremely inefficient. And you’re way sicker than you ever should have been. And so we as a society end up paying more to provide worse care because we’re unwilling to invest in providing basic primary care to everyone. And um and folks like Bella have to bear the consequences. Um. You know, I. I decided not to practice medicine because of an experience in an emergency room. Uh. In large part, um you know, because A.) Our Health care system does everything it can to gatekeep against low income people. But, B.), because um of the burnout that people in emergency rooms tend to experience. Uh. I had a patient who uh when I was in medical school, I was helping to take care of um who had fallen and hit her head. Um. She had been drinking in the morning um and uh lived with alcoholism. Um. She was indigent. Uh. She was unhoused at the time, and um she had a huge welt on her head. And when I asked the emergency room physician what the CT showed, uh he he said that they didn’t do one because they thought she’d be a social admit. Now, to explain why, you need a CT if you fall, you hit your head. Um. You know, if you have insurance, you’re going to get a CT scan to rule out a brain bleed, which can be a medical emergency. And because she’d been drinking, um he didn’t want to uh admit her. And he knew that the longer she spent in the emergency room, the higher the probability that she would start to withdrawl and from from alcohol. And so they basically didn’t do a real history and physical exam, didn’t get her the CT that she needed because she’d fallen and hit her head. You could clearly see the welt. And they were trying to, you know, basically figure out how fast they could get the sign off uh and get her back out on the street. And when um I talked to my attending physician, we ultimately ended up uh admitting her. But the fact that our emergency room um between the hospital level incentives not to admit patients like this because they can’t pay. And the fact that the physician who decided not to do a CT was on you know the end of a overnight shift, just really wanted to go home and couldn’t be bothered. Right. You see how this system fails to care for the people who need it most and burns out the people uh who are asked to fill in the gap. Um. And it’s just it is a travesty uh and it is a consequence of the fact that our system does not humanize people, and instead uh it’s built specifically to monetize them when they’re the sickest. And um I think all of us should be uh outraged about it, um but also not forget that you know we live in a society. And what happens to uh the poorest, most indigent, most marginalized of us um could happen to us. And I wish we all understood that a little bit better. 

Emma Illic-Frank: On a related note, Melissa Miller asks, What is the impact of eviction on a person’s health? 

Dr. Abdul El-Sayed: Hi, Melissa. Um. I assume this is the Melissa Miller uh that I worked with at the Detroit Health Department, who asked a fantastic question. I’m sorry that you have to ask the question because well too many people get evicted every single day in this country, if you’re at home right now or you just recently left your home, why don’t you think about all of the features of that space you call home that are uh foundational to your own stability. Um. That bed that you sleep on, right? The food that sits in your refrigerator, just the toothbrush and toothpaste that you store in your medicine cabinet um that you use to clean your teeth before you go to bed and after you wake up. Uh your clothes and where you hang them, your medications and where you store them. Homes uh are such a foundation for our lives that when we lose them, um it is really, really difficult to reorganize. And, um you know, you think about people with chronic ailments, be they physical or mental. And I think the division between those two things is fundamentally arbitrary, but um your ability to to take your medicine on schedule, your ability uh to see a um a medical provider at a regular [?]. All of that is founded on you having an ordered life. And when you lose that foundation of your own order, the consequences tend to spiral out. Not only that, though, just the insecurity of knowing you may be at risk of eviction is itself such a profound stressor um that it has huge impacts on your mental health and your physical health. Again, arbitrary. Um. We know that when you’re in in chronic stress uh levels of the hormone, cortisol uh abound and we know that when you’re exposed chronically to high cortisol levels, uh this impacts on everything from uh the health of your heart to um the health of your bones to, um of course, your mental health. So all of these things uh compound on each other. So it’s not just the eviction um that is so disordering and such a stressor, but it’s also just the risk of being evicted and the chronic stress of having to make rent every single month. Um. And so you know when we talk about housing being a human, right. Right, it is it is the right to live an ordered life without the stress of knowing that you may lose that order uh at any given period. And there’s so much that we as a society need to do around making sure that we have adequate shelter for everybody in our society. Um. And a lot of that has to do with rethinking the way uh that we build and pay for um our shelter. 

Emma Illic-Frank: Our listener Alissa um wrote to us saying, really would appreciate some discourse on the rampant fatphobia on the left with progressives. It’s become one of my biggest pet peeves and it causes real, actual harm. 

Dr. Abdul El-Sayed: Yeah, I really appreciate the point. And um the more we understand about uh overweight and obesity, the more we understand that they are environmental uh and not individual. And that is so in contrast to the extremely individualistic approach that we take to everything. As we talked about with respect to our approach to the pandemic. But in particular, when it comes to um, you know, food and exercise, the uh assumption that someone who is overweight uh or obese does not have self-control, cannot uh exercise consistently, does not uh eat well or makes bad food choices, is such a simplification of the circumstances in which people are making those food choices now I want you think about this, obesity has tripled since the seventies. That’s not because people have changed. Our genetics haven’t changed, our behaviors haven’t changed. It’s that in the seventies we started to subsidize corn, and then we started to put corn everywhere. And it started to lead to extremely cheap, extremely plentiful uh food that was designed specifically um to increase our consumption of that food. And um then you couple that with inequality uh in the fact that, um you know, you can buy for the same price a Big Mac as you could buy two bags of spinach. And you start to think about who gets access to a store to buy that spinach and who doesn’t. Um. You know, where uh can you buy a can of soda versus where can you buy green leafy vegetables? Uh. You think about the ways that um we market uh or we allow corporations to market these goods. And you start to appreciate that so much of this is environmental uh and not individual. And what Fatphobia does is it blames individuals for what is ultimately a function of context um and resources. And uh when you put it that way, you start to appreciate um just how wrong it is and uh and frankly, just how hurtful um and counterproductive it is. You know, you look at what the impact of weight stigma is, is that it tends to uh lead to poor mental health. And poor mental health then tends to lead to weight gain and so on and so forth. And um so, you know, there’s this and you see it with doctors all the time. Uh. They think that they can you know, they can shame someone into uh no longer being overweight or obese. And um all that does is actually make the problem worse. And so I think in the same way that we talked about mental health stigma, um I really appreciate uh the asker for bringing up weight stigma um and the impacts that that has on too many people in our country and um the fact that we should not be advancing it um and we need to be calling it out. So I really appreciate the question for doing that. 

Emma Illic-Frank: Question from Emma Illic-Frank, 96, what’s in your skincare routine? 

Dr. Abdul El-Sayed: All right. Well um, okay. Uh. You know, I feel like uh with our conversation with James, I feel like I shouldn’t have a skincare routine. 

Emma Illic-Frank: Yeah. [laugh] Exactly. 

Dr. Abdul El-Sayed: But let’s be clear. Like I’m an aging Egyptian-American man, um so uh in the morning, I wash my face, and um if it’s the summer, then I will uh usually use a a tinted sunscreen. Um. The the usual sunscreen tends to go on kind of chalky, and it’s just not great. Um. I will regularly try and put more sunscreen on at lunch. Um. There is a history of skin cancer in my family, so I try and take that seriously. If it’s in the winter in Michigan, like the sun doesn’t come up until 9:30, it barely stays up until like five. Um. So I have a stay on face mask that I use. It’s just like a really thick moisturizer um and actually it’s kind of great. Um. I like the way it feels on my face and it keeps me moisturized. And then in the evening I will wash my face again. So if I work out, I’ll wash my face after that and do exactly what I, I would have done in the morning. Um. And then in the evening I’ll wash my face and I will apply some retinol uh and um some some basic moisturizer. And that’s that. Um uh. But I will say that as I’ve gotten older, you know what it was actually uh Sarah was reading about J-Lo, who still looks like she’s 25, despite the fact that she’s like, take those numbers and reverse it. And the one thing that she swore by was was sunscreen. And then I like. I like went down the rabbit hole. 

Emma Illic-Frank: Mm hmm. 

Dr. Abdul El-Sayed: Um. But but but now I think I have a routine that I kind of like. And um, you know, we’ll see if it likes me. Like, when I’m when I’m a bit older. That’s that’s when we’ll know if it actually– 

Emma Illic-Frank: –Sure. 

Dr. Abdul El-Sayed: Works. 

Emma Illic-Frank: Sure. [laugh] So, no, like magic lasers? No like?

Dr. Abdul El-Sayed: No, I mean, I try and, like, you know, I try and so the nerd in me um is tries to be very evidence driven. And the two things that have really good evidence behind them are sunscreen certainly, and retinol. Um. Those are the two sort of very evidence driven uh skin care must haves. I think washing your face is important and like I tend to have really oily skin, so I just don’t like not having my face washed. So that’s why I, I think some would say I wash my face too much, but, you know. 

Emma Illic-Frank: Yeah. James Hamblin, if you’re listening, we’re sorry. 

Dr. Abdul El-Sayed: Sorry man. 

Emma Illic-Frank: [laugh] Last question. What’s the one public health problem we should invest more money, time, and person power in? 

Dr. Abdul El-Sayed: Air pollution. Um. I think we tend to confuse climate change and air pollution and they’re not the same thing, right? Climate change is what happens when uh we burn carbon into the atmosphere. Um that then uh creates a greenhouse effect uh by which the heat from the sun um is held into the atmosphere, which raises the the temperature of the earth, uh which melts polar ice caps. It interferes with all sorts of um seen and unseen features of um the world around us, causing everything from hurricanes to uh to to forest fires to a receding coastline. That’s climate change. Air pollution is just the very basic fact that when you burn stuff into the air, um you’re releasing toxic chemicals into the air. And the ones that you know we tend to overlook aren’t even chemicals at all. They’re just tiny little particles called particulate matter. And where uh we call it particulate matter, which is an unnecessarily jargony name for stuff in the air, and there are two sizes that we tend to measure. One is um PM10, which is less than ten microns, and then we, we measure PM 2.5. And the evidence is starting to come out about the attributable mortality of just particulate matter is um it really is astounding, um even just, you know, cooking with gas, gas stoves, um there is a demonstrable increased risk uh of lung disease. And the thing about it is that over time, when you get bad lung disease, it tends to lead to heart disease. And the reason why is, if you think about your heart, it’s a two way pump. It pumps um consistently, you know, oxygenated blood into your body, into your musculature, uh to your brain, and then it pumps deoxygenated blood after it’s gone to your body and the oxygen’s been used, it pumps it into your lungs. And the interesting thing is, you would think that there’s more resistance on your body side, but it’s actually more resistance on your lung side uh because you’re trying to pass blood through an increasingly small network of arteries and arterials um so that you can get as much surface area uh exposed to that blood in your lungs so that you get more oxygen from your lungs into your blood to oxygenated blood. So um when your lungs get injured because of persistent exposure to things like particulate matter. What happens is it starts to get fibrosed, so that the ability to pass the blood is limited. And now your heart is consistently beating against more and more resistance, which then leads to heart disease. So one of the ways that air pollution kills is through the single biggest killer in the world, which is heart disease. Um. And we’re only now starting to really appreciate just how profound the impact is. Um. So I really wish as a society, we recognized that while we’re trying to take on climate change, we also have to realize that um it’s also really important uh to tackle that instrumental feature, which is the fact that every time we burn fossil fuels, uh we’re burning that air before it ever gets up into the atmosphere uh through the lungs of children and seniors. And um that that takes thousands of lives in communities across this country and across the world every single year. That should be a really big focus, and I really wish we paid more attention to it. [music break] First of all, Emma, thank you so much for joining us today. I really, really appreciate you being uh the interlocutor for the episode today. Thank you. 

Emma Illic-Frank: Thank you for having me. It’s nice to be on this side of the microphone. 

Dr. Abdul El-Sayed: Isn’t it fun? That’s it for today. On your way out. Don’t forget to rate and review. It goes a long way. Also, if you love the show and want to rep us, I hope you’ll drop by the Crooked store for some America Dissected merch. We’ve got our logo mugs and t-shirts. Our science always wins sweatshirts and dad caps make fantastic gifts. [music break]

Dr. Abdul El-Sayed, narrating: America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illic-Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz and Ines Maza. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, Sandy Girard, Michael Martinez, and me, Dr. Abdul El-Sayed. Your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It is not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests and do not necessarily represent the view and opinion of Wayne County, Michigan, or its Department of Health, Human and Veterans Services. 

Emma Illic-Frank: I just have to say I had avocado toast this morning and I don’t own a house. Is that correlation? Is that causation? Who’s to say? 

Dr. Abdul El-Sayed: I mean, I think we should talk to more boomers about it, right? I’m just saying, they don’t eat avocado toast and like they own a lot of houses. 

Emma Illic-Frank: And they do own houses. Yeah. Hmm.

Dr. Abdul El-Sayed: [laugh] There may be an intervening variable in there, which is age, [laughter] um but uh but there may not be. Um. Here’s the thing. Don’t eat any avocado toast for a year. Take all the money you would have spent on AVO toast. Save it up. And if it’s not enough to make a down payment on a house, [laughter] then then we know our answer here. [laughing]