A COVID-19 Story From a Place That Can’t Afford to Get It

When I look at COVID-19 maps, which I’m doing at least several times a day, I usually start by clicking on my own state (Nevada) and sort of move outward from there, hitting other states, sometimes checking Mexico and Canada, and then going to hotspot countries like China, Iran, Italy, and Spain. My focus, both in checking maps and reading articles, has definitely been on the U.S. and other wealthy countries, a group that includes most of those hardest hit. And I have to admit, my geographic focus in life has been mostly on those countries too, crisis or no crisis.

But lately, because I’ve been looking into the geography of health and disease, I’ve been pulled out of my comfortable box more often. And one of those times was about a month ago, when I talked with two doctors in Honolulu, Neal Palafox and Seiji Yamada, to hear what they had to say about the health problems of Marshall Islanders. The Republic of the Marshall Islands is a poor country in the Western Pacific that has been battered by a perfect storm of woe—it’s probably best known as the place where the U.S. did an ungodly number of nuclear tests, irradiating many Marshallese in the process, and, more recently, for the prospect that the whole country may simply disappear under rising seas, an erasure by way of climate change. And, related to these disruptions, it is also a hotspot for type 2 diabetes and suicide, among other things.

Those two doctors, Palafox and Yamada, had a lot to tell me, much more than I can cram into a blog post. Yamada, in his demeanor and his knowledge of government machinations, reminded me a bit of the whistleblower Ed Snowden (and I mean that as a compliment!). His view of  the U.S.’s actions in the Marshall Islands was damning, to say the least. For instance, he said that the U.S. military presence there has created what amounts to “an American apartheid,” with the Marshallese in the place of blacks in South Africa.

At some point, I’ll have to write more about what Yamada said. But here I want to recount a story that Neal Palafox told me about the nine years he spent working in the Marshall Islands in the 1980s and 1990s. I think it’s kind of a funny story, but it also has implications for the COVID-19 pandemic.

Palafox went to the Marshall Islands on a National Health Service Corps scholarship, and he said that his original goal in going there was to become the best clinician he could be in the area of family medicine. However, soon after he arrived, he was asked to add a new and unexpected role—to run the mental health program. His response was that he didn’t know much about that field. But then he was shown the mental health facilities, and found that the patients with the worst problems—the ones who had gotten “really psychotic and out of hand”—were being held in a jail. “I went there,” he said, “and I go ‘aaagh!’” And so, feeling like there was no option, he took on the job.

Next, Palafox was asked to take over the hemodialysis unit. He said he wasn’t a nephrologist, but they told him nobody was in charge of the unit, the supplies would sometimes run out, and they needed a physician to head the operation. So he took on that job too.

After that, he was asked if he could visit some of the more remote islands to do screenings for tuberculosis and leprosy, infectious diseases he knew little about, and he went and did it. Then he took on a monumental task, becoming the director of a nation-wide public health program, another area he had hardly any training in.

And, finally, he was asked to run a new program to help people who had been made sick from the nuclear testing. Palafox described what happened then, basically the same thing that had happened all the other times: “I said, ‘I don’t know anything about [it], what do I know about taking care of this stuff?’ [But] They said, ‘Well who’s going to do it?’ So I said ‘aaghh!’” And then, of course, he became head of the program.

So, in addition to practicing as a family physician, he did infectious disease screenings, and became the head of a mental health program, a hemodialysis unit, a national public health program, and a national program for people affected by nuclear fallout, despite the fact that he had hardly any prior experience in any of those fields other than the first one.

This story says something about Neal Palafox, and I guess that’s part of the reason I’m telling it. But, more to the point I want to make about COVID-19, it says a lot about the state of health care in the Marshall Islands. What Palafox did is beyond admirable, but it also underlines the glaring holes in the system. No doctor should have to wear that many hats, and, in countries like the U.S. or Italy or Japan, no one does.

And this brings me back to the COVID-19 map. Lately, after checking the numbers for Nevada and the rest of the U.S., I’ve been scrolling over to the Western Pacific, to the Marshall Islands. So far, the country is happily invisible—the islands themselves are too small to show up on the map, and there have been no confirmed cases to light up the area. And this is very good news, because, if COVID-19 were to take hold there, the bare-bones health care system would be almost immediately overwhelmed. It would be especially bad, because so many Marshallese have diabetes and other diseases that would make them more susceptible to becoming extremely sick or dying from the virus. And then the economic fallout would come, in a place without much in the way of government safety nets.

Fortunately, the leadership of the Marshall Islands, realizing how catastrophic COVID-19 could be, quickly closed off the country to international travelers. So, perhaps it will escape the disease or, at least, hold it off until a vaccine or some effective treatment is available.

The bigger problem, though, is that many poor countries are like the Marshall Islands in terms of health care (not to mention lack of economic safety nets). And the coronavirus has already reached most of those places. Another wave of the pandemic is coming, and it could be bigger than the one we’re now experiencing.

It’s yet another reason to do our part with social distancing and hygiene to keep this thing under control in places like the United States. We should be doing it not just so our own health care systems don’t get overwhelmed and our own economies don’t collapse, but also to ensure that when other places need help, as they almost surely will, we have the ability to give it.

We need to keep to our own little spots, for the sake of the whole world.

 

(Photo of Jaluit Atoll Lagoon, Marshall Islands, by Keith Polya via Wikimedia Commons.)

Health, Race, and Inequality—Tying Up Some Loose Ends

Sometimes, after writing an article or a blog post, I end up with a lot of loose ends—thoughts and feelings about the writing, or the topic, or the people encountered—that rattle around in my head, as if to say, “Please let us out!” But, mostly, they never do get out, except in little snippets of conversation. What is a blog for, though, if not to say things that otherwise would never be said?

So: I just wrote an article for the Reno News & Review (the local alt-weekly) on race, wealth, and health in Washoe County, and, for various reasons, the loose ends really got out of hand this time. And I think some of those wayward threads might be worth mentioning, because they add some unexpected twists and a bit more depth to the story.

The gist of the article is that health in Washoe County is strongly tied to race and wealth, as it is for the U.S. as a whole, and that the differences are mostly caused by how people live—what they eat, how much exercise they get, how stressed they are—and are not, for instance, connected to genetic differences among groups. Right off the bat, I can say that I completely left out two relevant, huge topics—exposure to industrial toxins and access to healthcare. And the toxins thing I’m going to leave untouched, except to say that it probably is not nearly as important as living habits. Healthcare, though, I’ll get back to.

I began the story with the example of the high rate of diabetes among the Paiute (Numu) on the Pyramid Lake Indian Reservation. Actually, the original plan was to write a story entirely about health issues on the reservation, but at some point I became uncomfortable with that idea. I came to feel that a gloomy picture entirely focused on the reservation Paiute would give an inaccurately bleak image of that place and people. I did end up painting a dark picture of diabetes on the reservation (although I noted in passing that the situation appears to be improving), but at least I ended up spreading the pain around to other groups.

Even with the change in focus, I still felt very uneasy writing this story. Part of me feels that it’s worthwhile—in fact, critical—to let people know about the difficulties faced by various racial and ethnic groups. Where would we be if nobody ever did that? But another part of me wonders if some issues are best dealt with by members of those particular groups. I know that, as a Japanese-American, while I am usually grateful for whites who bend over backwards to publicize racism against “my” people (World War II internment camps are often the focus), at times I can feel annoyed, spoken down to, by those same well-intentioned folks. Maybe it’s irrational to feel that way, but there it is.

Adding to my discomfort in writing this story was my monumental ignorance of Native American experience. That came home to me at various times, but maybe especially when talking with Stacey Montooth, the Community Information Officer for the Reno-Sparks Indian Colony. Montooth, who is a member of the Walker River Paiute, was extremely outgoing and helpful, getting me in touch with people and giving me a tour of the colony’s health center, and in those ways was what you’d expect of a PR person. But she began our interview by giving a whirlwind history of Native American-European interactions, including plans by Europeans to completely wipe out Native Americans, the attempt to erase Indian culture by forcing kids into Indian boarding schools, and the fact that reservation Indians are even now constrained by not being able to own the land their houses are built on. Talking with her, I was thinking, “Wow, for a PR person, she’s pretty radical.” And then it occurred to me that probably almost all Native Americans, by the usual standards, are pretty radical.

Stacey Montooth, by a pine nut symbol, representing the Paiute tribe, at the Reno-Sparks Tribal Health Center

(Another thought on radicalism: Check out the Pyramid Lake tribal newspaper. It makes The Washington Post look like a mouthpiece for Donald Trump.)

Montooth had a lot of illuminating things to say. For instance, she mentioned that the doctors that serve Native Americans are often connected to the military, and wear military uniforms, and that those uniforms promote mistrust. In that context, she said, “You’d be hard pressed to find any Native American who trusts the federal government. If you just looked at our history, it’s pretty clear why…”

And, talking about education, she said that her family had moved from the Yerington Reservation to Fallon, so that she and her sister could go to a better school. (Fallon, I should point out, is a town about an hour east of Reno, and is not really known for having great schools.) More positively, she also mentioned that she hears about kids from the high school at Pyramid Lake, which is run by the tribe, going to places like Stanford and Harvard.

These things were not on my radar, and that lack of knowledge, and lack of understanding made me wonder about my right to speak of Native American problems, even in a very limited way. Well I went ahead, I wrote the story, but I still feel a little weird about it.

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Stacey Montooth introduced me to Stacy Briscoe, the Diabetes Program Manager at the Reno-Sparks Tribal Health Center. Briscoe is white, is trained as a diabetes educator, and said that, when she was looking for a job, she was especially interested in finding a position to work with Native Americans, because she knew about the seriousness of the diabetes problem in those communities. Talking with her, I felt very much like the pie-in-the-sky writer, wondering how we might rid the world of diabetes, while she is actually making things happen, educating people about living healthily, running all sorts of programs to make it easier for them to exercise more and eat better. It was inspiring to talk with her. Like Jeff Davis and Rita Romo at the Pyramid Lake Tribal Health Clinic, Briscoe struck me as dedicated and compassionate, dealing with the concrete, doing what can be done.

Stacy Briscoe at the Reno-Sparks Tribal Health Center

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Another person I talked with was Joseph Grzymski, a scientist at the Desert Research Institute (DRI) who is the head of the Healthy Nevada Project, a collaboration between DRI and Renown Health that has the aim of gathering a large amount of data on socioeconomic variables, genetic make-up, and other factors that might be tied to health outcomes. Going into the interview, I knew that the Healthy Nevada Project involved getting genomic sequences from thousands of Nevadans, and I was thinking that Grzymski might try to convince me that genetics held the key to solving society’s health problems. But, in fact, he didn’t do that at all. Instead, he stated very clearly that he does not believe that the big health differences among racial or other groups are based on genetic differences. In that context, he said, “It would be nonsense to say that genetics explains, you know, deep-seated issues…the past history of the United States and how we’ve dealt with certain things.” (My thoughts exactly!)

He went on to say that the main, immediate benefit of collecting the genetic data will be to identify people who have relatively rare genetic alleles that make a person especially susceptible to certain diseases. (The BRCA alleles that put one at extreme risk of developing breast and ovarian cancers are a good example, made famous by Angelina Jolie.)

Grzymski also said that health outcomes are not primarily about the quality of healthcare, but instead are “teed up very early on with behavior, patterns of understanding…and of course a lot of that is driven by socioeconomic status.” And he continued, “Traumatic things that happen to children have massive impact on health outcomes in adulthood…much more so than whether or not you saw a good pediatrician.”

His words lead me to the biggest loose end of the story, which is the significance of the healthcare system. Like a lot of people, I am completely behind universal healthcare; it seems criminal that this country does not have it. But Grzymski’s thoughts about quality healthcare, which are backed up by a lot of research, imply that if, by some miracle, good healthcare for all suddenly became a reality, the profound disparities in health among racial and other groups would not disappear. Those disparities are tied to inequalities that run far deeper than access to doctors, medicine, and other aspects of healthcare.

I was mulling those thoughts as I wrote the ending to the RN&R story. And those thoughts are part of why I said what I did about the change required to close the health gap, about the need for a seismic shift in society.

What a poor county in Texas might tell us about living longer

[This is an article I wrote for The Huffington Post for June 6, 2017.]

My wife has been going to the gym a lot lately, a gym with lots of older folk, people in their 70s and 80s. She says that, along with super-fit older women in her classes, there are some who are barely moving, carrying the tiniest weights and lifting them the tiniest amount, performing a kind of symbolic exercise. But they are obviously having a good time. They’re chatty in class, and chatty in the locker room. It’s social time at the fitness center in Reno.

Exercise is obviously helpful for living a long life, but I wonder if these women have hit upon something just as important. In his book The Blue Zones, about small regions where people often live past 100, Dan Buettner says that one of the common traits of people in these longevity hotspots—from Sardinia to Okinawa—is that they have strong and persistent social networks. They stay connected to family and friends even into extreme old age.

The gym in Reno might not be the greatest example of a social support group, but, quite possibly, it’s a lot better than nothing.

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I was thinking about those old women the other day, while poring over a map of the United States. This map, which has been all over the internet, comes from a study headed by a public health researcher named Laura Dwyer-Lindgren, and shows life expectancy by county for the whole country. Counties with long life expectancy are in blue, and the best of the best are in the deepest shade, so the longevity Blue Zones are easy to pick out.

Life expectancy for the United States, by county, for those born in 2014 (both sexes combined). The lowest values are in dark red, the highest in dark blue. Map from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington.

I love a good map, and this one is a thing of informative beauty. It’s a window onto the character of the nation, onto racial inequalities and cultural diversity, onto immigration and assimilation, onto the vigor or decrepitude of regional economies, in short, onto endless social, political, and economic complexities. But some quick insight into the links between culture, wealth, and longevity can be had through a small part of this mapping project, namely, a list of the ten counties with highest life expectancy.

So here’s that Top Ten, a set of American Blue Zones:

The top ten United States counties for life expectancy, from a study by Dwyer-Lindgren and colleagues. Income rank is the per capita rank among 3,143 counties from the American Community Survey, 2009-2013. Ethnic makeup is from the 2010 U.S. Census. The Aleutian Islands combine data for the Aleutians East Borough and the Aleutians West Census Area. The income rank for the Aleutians is the average for those two areas.

One thing that’s immediately apparent is that most of these counties are wealthy and white (meaning non-hispanic white). That’s not surprising; wealth usually means relatively good health care, and, more importantly, it probably often means being well-informed about healthy living habits, along with the means to easily make those habits a reality. To put it simply, wealth usually equals health, and most wealthy people in this country are white.

There’s a lot more to ponder here as well. Why all those Colorado counties? And why the remote Aleutian Islands? But what I want to focus on is the most obvious outlier on the list. That would be Presidio County, in West Texas, along the Mexican border. Presidio County is more than 80% Hispanic, and it’s not just poor, it’s really poor, ranking in the bottom 5% of all U.S. counties.

The flip side of “wealth equals health” is that poor Americans tend to be unhealthy and short-lived. So, one wonders, is there something peculiar about the way people live in Presidio County that opposes that tendency? It certainly doesn’t look like it: despite some Bohemian-style gentrification of Marfa, the county seat, Presidio County is pretty much as bad as you’d expect it to be when it comes to standard indicators of healthy lifestyles. For instance, people there are far more likely to be obese and far less likely to exercise regularly than the average American. And, too, measures of health care in Presidio County are toward the low end, as you’d expect for a poor county.

In other words, by its obvious measurables, Presidio County ought to be much closer to the bottom of the lifespan list than the top. Yet there it is at number 9, in the top third of the top 1 percent.

So what’s the story?

Well, the story at this point is incomplete, but it almost certainly has to do with something called “the Hispanic Paradox.” It turns out that, in the U.S., Hispanics as a group are poor, yet they’re relatively healthy and long-lived. In fact, for the country as a whole, the life expectancy for Hispanics is about 2.6 years longer than for non-hispanic whites.

Getting back to the map, notice that almost all of the counties along the Mexican border are in those good, blue shades, in spite of the fact that nearly all of them are poor. It’s a 2,000-mile-long incarnation of the Hispanic Paradox, stretching from the Pacific to the Gulf of Mexico. Presidio County does stand out as a Blue Zone even within that collection of border counties, but it no longer looks so extreme. It’s just a moderate outlier within a larger anomaly.

Researchers don’t all agree on what explains the Hispanic Paradox, but a likely key factor is what many of us would identify as the key to life in general: it’s about connections to other people. Hispanics tend to have strong ties to family and community, and are more religious than Americans as a whole; that’s probably intuitive to anyone familiar with Hispanic communities, but it’s also been confirmed by scientists who put numbers on such things. And there is now evidence from many studies that those sorts of ties—positive social networks, to put it a bit simplistically—translate to better mental and physical health.

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The idea that strong social ties can help explain Buettner’s Blue Zones and the Hispanic Paradox is food for thought. It brings to mind all our striving for some kind of recurring connection, from monthly book clubs to Sunday family dinners, from meditation groups to stitch ‘n bitch clubs to middle-aged men meeting up to play soccer or basketball. More specifically, the fact that, for most of us, those endeavors tend to be short-lived makes me wonder how a society might offer ways to sustain such connections in the face of a modern world that doesn’t value them enough.

These thoughts bring me back to the old women in the gym, the women who don’t exercise much, but chat a lot. The gym is part of a hospital, and it’s a place where the old, flabby, and weak don’t really stand out. You can go there and not feel self-conscious lifting very light weights, or displaying your startling lack of flexibility, or doing almost nothing at all. In short, it’s a comfort zone.

Is it possible to translate that comfort to other situations, to promote those social activities that tend to fall by the wayside? The message from Presidio County is that doing so might have a substantial influence on our health and longevity. And, in any case, whether those connections make us live longer or not, they’ll probably make us happier for whatever time we do have.