Saturday, August 01, 2009

Ten Leading Causes

Some years ago, I heard then Governor Lamm (of Colorado) give a speech about health policy. He was one of those people who said things that were seen as being outrageous--people would get very angry at what he said. For example, he said--old people have a duty to die. He was widely misunderstood for that statement. More on this statement later.

Among the things he said in the speech I heard was a statement that really struck me at the time, and that has stayed with me. He said--there will ALWAYS be 10 leading causes of death.

Health policy people (which I was at the time) love to look at statistical analyses and compute things such as life expectancy, leading causes of death, and so on. A cheery lot! Health policy people look at the epidemiology of health issues--what is happening, why is it happening, what are the causes. Knowing these things helps you design interventions.

When Governor Lamm said--there will always be 10 leading causes of death--a virtual light bulb went on over my head. Of course! Throughout all of history, people have died--and if you had the statistics, you could compute what caused those deaths.

Over time, the reasons, of course, have shifted. For example, in 1900 the leading causes of death (according the CDC) were:

1. pneumonia & influenza
2. tuberculosis
3. diabetes
4. diseases of the heart
5. intracranial lesions (stroke)
6. nephritis
7. accidents (excluding motor-vehicle)
8. cancer
9. senility
10. diphtheria
The average life expectancy was 49.2 years.

In the year 2006, the list shows evidence of medical advances, as communicable diseases such as diphtheria are largely controlled by immunizations, chronic diseases such as diabetes are understood, and antibiotics help with lethal effects of bacterial infections.

1. heart disease
2. cancer
3. stroke
4. chronic respiratory diseases
5. accidents
6. diabetes
7. Alzheimer's disease
8. influenza and pneumonia
9. nephritis
10. septicemia

And the average life expectancy has risen to 78.1 years.

It is striking that many of the same causes are there; the positions have switched around. The other big change is that the top diseases are those that usually take a life time to accumulate and end up causing death.

If we would go further down the list, you would find that suicide is the 11th leading cause, and homicide the 15th.

The placement of these two causes of death--entirely preventable--brings me to what it is that health policy people really want to focus on. Death, of course, is not preventable. I am reminded of the scriptural saying: it is appointed unto man once to die. Death is a condition of life.

What is preventable is UNTIMELY death. If you listen to health policy talk long enough, you might hear the term that sounds like "yipple." Don't go running to the dictionary--it is an acronym: YPLL=years of productive life lost. So it is not death that should be challenged, but untimely death. We should put our greatest effort in reducing those deaths that are preventable.

My--you must be thinking along about now--what is it with KGMom? Yes, the subject of death has been on my mind. The death of our church sexton reminds me of the unpredictability of death. But I can't think of a better way to die. Jim lived a long, productive joy-filled life. He spent the last days of his life with his family, enjoying a vacation. There was no painful lingering--he was here one moment, and then gone.

I promised a comment or two on Governor Lamm's outrageous statement that old people have a duty to die. He was not advocating involuntary euthanasia. He was simply arguing for the best use of scarce health resources. Since death is certain, he reasoned, public money should not be spent on ever more costly health resources to treat the diseases that are the eventual causes of death in people of extremely advanced years. I suspect, he might have thought it poor use of health resources to perform heart surgery on Dr. Michael DeBakey at age 97. DeBakey had turned down having surgery, but when he became "unresponsive" a surgical team performed surgery anyway. He took 8 months to recuperate, at a cost of $1 million. He was eventually "returned to good health" and lived two more years.

Why Dr. DeBakey? Well, he pioneered open heart surgery. No doubt his colleaguess felt they couldn't let him die of heart disease. But his case really raises difficult questions.

As we continue to debate health care coverage in the U.S., it is instructive to remember--people die. People have to die. It is a condition of life. We should place our emphasis on preventing untimely deaths, not place our emphasis on prolonging lives beyond a reasonable life span.


Jayne said...

Amen, amen, amen Donna. It's not that I at all advocate just letting people die, but....

For example, we had a 90 year old, demented, bed bound, nursing home patient who had developed a pressure wound on the top of her foot from a boot. Yes, it was deep, and yes, by the time it fully declared, there was exposed bone, but the chances are that she'd had bone infection for months. But, because we have gotten in such a titter about practicing "defensive medicine" our MD called in the infectious disease people, ordered a PICC line (long term IV for antibiotics) and they put her on SIX WEEKS of two very high powered antibiotics IV. I was just standing there with my mouth agape at the excessive waste of it all. Uh, she's 90, and she does not walk, and she does not know what day it is. Chances are old age would take her before a bone infection in a foot she no longer walks on. There just has to be a line drawn some where. A conservative round of oral antibiotics with good local wound care would probably have been just fine. Stepping of my soapbox now. Can you tell you hit a nerve? :c)

Anvilcloud said...

We're always nattering about health care up here too. I think it's something that could always be improved, but we do tend to live to a ripe old age (relatively speaking) compared to the past.

Ginnie said...

I love the idea of tackling smoking and obesity as preventative measures. It would assure a much better life expectancy for millions of people. I am 76 and can't, for the life of me, see any reason to prolong life if it means being put on life preserving machines or in a state of senility. There are worse things than dying and we seem so frightened, as a society, to be able to face this.

Anonymous said...

I know I'm a long way from a timely death but I will have a living will (or whatever the required documentation is called at the time) to ensure that I am not kept alive beyond my time. I can't think of a worse legasy to leave my family. As a matter of fact, I ought to look into what I've got in place now. I don't want to be hooked up to machines and kept alive for years that way. I'd much rather see that money spent on helping those who can be helped! Just because we can do soemthing doesn't mean we should! Go KGMom!

Climenheise said...

Scott Peck has an excellent book, "Denial of the Soul", in which he notes a basic problem in the way that North Americans talk about death and dying. We focus exclusively on the physical (hence our preoccupation with the 10 leading causes of death) and ignore the place of the soul in the process. We all die; a basic question is how we die -- not the physical cause, but the journey of the soul in the process.

Tossing Pebbles in the Stream said...

Dying with dignity is an acceptable outcome of an illness. A lot of doctors see death as a failure of the medical system and themselves.

I once had an elderly parishioner who was injured in a car accident. When the doctor came out to say to me and her daughter she had died he said an interesting thing, "We did everything reasonable for a person her age." The daughter did not question this but I, who was very intested in death and dying at the time, picked up on it. He was saying that they practiced a form of passive euthanasia in her case. I assume if she had been 16 they would have intervened in a more heroic way.