to be the first gelfond lecturer here u w tonight i plan to cover a great deal of material and i would appreciate it if you don't believe a word i say instead try to discredit everything consider nonsense however if you want to have healthy children and healthy grandchildren there may be some useful concepts resulting from my remarks so the title might talk was health and health care what's the difference and asking this question i'll also inquire as to how healthy we are for living in the richest most powerful country in the world that spends more money on health care than all the rest of the world combined well can we learn about producing health from slovenia country that used to be a part of yugoslavia what's the commonest sexually transmitted infection by only what is the medicine we need most in the united states i'm going to spare you and not engage in powerpoint malpractise but i'll be power pointless since the most effective presentations in through all throughout history have been done without visuals except one in the judeo christian tradition which was said to use two stone tablets i'll ask you that you use your imagination to visualize the facts of present tonight a begin by presenting my trajectory and how i came to ask these questions so i began practicing medicine in  three in a very different climate from that present today my clinical experience has been in three countries canada nepal and the united states and it's from that vantage point that i speak i went to medical school after a brief career in mathematics because i wanted to do something unquestionably useful to society i had come to see mathematics is a game played according to a set of rules with meaningless marks on paper i wanted to play a different game one  impacting human lives for the good so after completing my training i went to work in a community health project situated in a himalayan value a weeks walk from the road in nepal that may be hard to imagine walking to a walking a week to get to work so i lived there was truly on my own as the next doctor was four days walk away much of the time i was the only white guy or outsider there and that experience required self teaching and cooperation with the mountain community as i improvised equipment and treatments for neglected illness and trauma i wanted to help them polly doctors do more with less so after i returned from my initial work in nepal i became an emergency physician here to support my my further work in the poll as an e r doc i could take months or years off of work to go to nepal and then return and get another  you might consider that career for the flexibility it provides the next thing i had the remarkable opportunity to set up a remote district hospital as a teaching hospital for an apology doctors that i supervise our care may have been makeshift but we were determined to do good for our patients and i taught by example my nepali doctor trainees cut skin grafts with razor blades and did emergency surgery in the middle of the night with flashlights my clinical motto was hone during this period namely don't just do something stand there and that is unless it is really clear that doing something is better than doing nothing so i came to see that medical care could that of many other nations this is really disturbing to me as i knew we had state of the art medicine and we were wealthy beyond belief in one hundred seventy six when i returned from the paul after that first job a week's walk down the road i came across a book titled medical nemesis the explorer pre a sion of health written by eve on ilitch who became a critically thinking hero of mine elites are good medical care didn't do that much to produce he that book was a catalyst for developing reasoning skills and led me to question important beliefs that i had not critically evaluated in one thousand nine hundred one the first studies of medical harm were published as a series of three articles in the new england journal of medicine that medical care could be a leading cause of death was very unsettling to me as it could cast my work as an executioner rather than a healer so i became very confused and lost almost thirty years ago as a child i had two rather ambitious goals especially for someone who was the son of working class immigrant parents my father repaired shoes my mom worked as my mother and and as a housewife and we lived above the shoe store a few repairs stores but i was interested in what we call stem today science technology engineering and mathematics so the goals i set for myself in early adolescence were to harness fusion the thermonuclear process going on in the sun or cure cancer so what was the impact of the work i was doing well i was now doing instead of curing cancer i got cancer my cancer was caused by a state of the art treatment for acne back in the one nine hundred fifty s namely radiate does it today we call such changes in thinking medical reversals we thought they were back then but then came to recognize they harm instead of help similar some of what we do in medicine today we thought was not useful when i went to medical school an example is giving aspirin to someone having a heart attack and which is now routinely done before you get to the emergency department so what was i go when you're uncertain you return to school to see if you can clear up confusion so i went to johns hopkins school of hygiene and public health founded in one thousand nine hundred sixteen as the first such school in the world in my application statement i said i wanted to figure out what produced health in a population and why health outcomes in the united states were not stellar there i learned that social and political factors influenced health the most and medical care as i already knew didn't play that big a role as to why health was declining in the united states relative to other nations the professors were silent no one was funding that kind of research and that remains true to this day we only compare ourselves to ourselves and not to other nations american exceptionalism remains rampant throughout this country and if you know you're the best you don't have to prove it so amazing accomplishments have been done in this country which might lead us to believe we're the best at everything except when it comes to our health we where we are less healthy than thirty five to sixty other countries political and economic factors are the most important drivers of our health so we need population medicine and population doctors to provide this it won't get accomplished in the clinic or the hospital but in the political arena as we people exercise our right to life by which i mean a long life not the short life we have in this country today so accomplishments in the united states are astounding during our history have flown the first airplane produced the first atomic bomb and dropped two of them on japan produced the first hydrogen bomb we invented the transistor which produced integrated circuits that menu tries to electronics and led to the modern computer which we also developed we met humans on the moon we grew silicon valley to be the innovative hub of the world we sequenced the human genome as to our testimony of our ability we won the most nobel prizes almost three times as many as any as the next country that's pretty impressive so america's great but not when it comes to our health as an emergency doctor the easiest diagnosis for me to make was that someone was dead that's hard to fake an e r so i take the easiest way out and consider whether you're alive or dead is the measure of health we're all alive in this room and i hope no one dies before i'm finished tonight and i hope you don't shoot the messenger either so measures of health as mortality rates are easy to come by all you need to know is when someone is born and when they die all of you know your birth dates and your report that all the time most of you don't know your date of death but others will in the e r i have to fill out a death certificate and write the date on it all rich countries collect this information as do many poor ones and there are good estimates available in countries that don't collect such vital statistics so birth and death records are some of the most accurate data we have what can be what can we learn from those well let's begin with the early life if we take child mortality or under five mortalities it is called the proportion of children dying in the first five years how does the united states to do in comparison to other nations there are many sources for this information for example the united nations the world health organization or our institute for health metrics and evaluation a part of our global health department here at u w so take world health organization data for two thousand and fifteen for child mortality it puts our rank at forty fourth meaning that forty three nations have lower child mortality rates than the united states this includes all the other rich nations and some poorer ones is such as poland the roof's cuba and greece suppose we take one of the countries with a very low child mortality rate say slovenia where our first lady was born and asked how many children would be alive today if we had slovenia's child mortality rate this represents something achievable in the united states for every ten thousand births sixty five children die in the first year of life in slovenia only twenty six children die during that period then look up the number of births in the united states in two thousand and fifteen and multiplied by thirty nine the difference in deaths per ten thousand between the united states and slovenia the answer is fifteen thousand five hundred thirteen deaths that is the number of children that died every day in this country in two thousand and fifteen that needn't since lavinia shows what's attainable that works out to over forty two children dying daily needless that far exceeds the children dying in our worst school shooting tragedy our president sent tomahawk missiles to syria after seeing pictures of children suffering from the serin gas attack there the trial death toll from that those missile attacks was less than forty two dying every day here that need is our president killing forty two children a day in what i call structural violence and what is the difference between structural violence and the usual behavior of violence well the tomahawk missile strikes are an example of behavior of violence donald trump gave the order to fire the missiles were launched and their destruction was obvious on the video news coverage behavioral violence is characterized by inaction the equivalent of pulling the trigger causes visible injuries and deaths and then there's the lingering smoking gun that's behavioral one to be clear our president is not responsible for the excess deaths in two thousand and fifteen here that happened on someone else's watch we won't know the toll for two thousand and seventeen until we until later when we get the data but i think you have the idea since you've all survived childhood consider the probability of a fifteen year old girl dying before reaching age sixty that's called adult mortality none of us want people to die in our in their their prime of life so i mentioned slovenia the first lady's birth country a fifteen year old girl there has an almost forty percent greater chance of surviving to age sixty than an american girl forty percent even a fifteen year old girl in sri lanka has a better chance of living to age sixty than an american girl same for a fifteen year old tunis even boy these are killer facts that can't be denied but almost nobody knows about this carnage here the causes are economic inequality consider structural violence the violence of  quality to be like a colorless odorless invisible gas that is worse than sarah it kills us from the usual conditions we die from heart disease cancer homicides are long and kidney disease and we're totally unaware of its existence this could be the perfect crime but it is not because even the rich and powerful fall victim to this gas of inequality that is of no group in this country that  abate it's affected studies demonstrate that the rich and powerful die younger than their counterparts in other rich nations so any quality kills them too so structural violence by its very nature is almost invisible in contrast to the behavior of the variety the action that causes it relates to the economic and political structure of a society in deciding who gets what power relations are at the core of the actions that cause truck drove violence structural violence is taught in school when you take the pledge of allegiance where you state there is liberty and justice for all with a quarter of the world's prisoners how did in the us the clearly isn't liberty or justice for all not with our being dead first you are taught that the united states is the examplar to the world because of its democracy founding fathers and moral authority so our political system decides who gets what share of the pie and we slice up the biggest pie in the world one way to describe this pie is to look at the wealth of the eight richest people in the world the wealth is equal to that of the bottom three and a half billion people on the planet eight individuals have more than three and a half billion people who are those eight well six are americans and to live a stone's throw from here bill gates the richest person on earth is over there jeff bezos is over of amazon is over there doing these eight people work much harder than the three and a half billion people and so deserve their wealth if not then there's not liberty nor justice for all so that inequity exists because of policies and process is put in place by corporations and governments these institutions create poverty and poverty kills are used to think people were poor because they didn't work hard enough i've come to see that people are poor because of the conditions we create to make them poor like mortality poverty can be measured in comparisons across countries mate if we take measures of child poverty in rich nations we have the most almost a quarter of u s families live in poverty the highest of all rich nations so in my quest to understand what produces health and society i came to see that relative poverty or economic inequality was the driver of worse health outcomes we have the world's highest paid people in the united states these are hedge fund managers and in two thousand and nine one of them made four billion dollars one way to visualize how much money that is would be to take a stack of brand new hundred dollar bills and stack them up and see how high they are well it would reach two hundred feet below the summit of mount rainier that's how much one person made in a year and that were so to about four hundred thousand dollars an hour nice work if you can get it and in this country we believe you can get it if you try that's a lie so i don't measure income inequality in the world well to gauge income inequality among nations if you go to our central intelligence agencies world rankings web site and click on the distribution of family income gene decks you discover that slovenia has the lowest inequality the hundred forty four nations listed there you come to the united states with our genia forty five so in a sense we're twice as unequal by this measure as slovenia and pay the price with shorter lives remember the forty two children dying needlessly every day and our adult mortality being almost twice that of slovenia so in my career as a doctor i've learned that any quality is the worst killer in society the effects of inequality and poverty begin before you're bor even before your conceit as an example consider children who have had heart transplants children in poor parent households are much more likely to reject their transplanted heart than those in rich households  because these children get worse care or they've already begun to smoke or other explanations we might consider the first studies done in boston children's hospital surprised the investigator so they did a multicenter study that showed the same thing poverty kills why do we have so much child poverty or any other kind of poverty in the ninety's in the united states didn't we fight a war on poverty in the one nine hundred sixty s you know we decided to fight a war on the poor let me explain it has a lot to do with power and democracy so fasten your seat belts of the be some turbulence in flight from this country's beginnings the rich and powerful knew they were a small number and so they needed to control people in order to maintain their power the declaration of independence said all men are created equal they didn't mean that but used code words so that men meant all white men they didn't enfranchise slaves who were not here but the founding fathers did not enfranchise women either remember there were no founding mothers men were in complete control and they made it difficult by making election day not a holiday but  work day and the recent elections in france that are held on a sunday and in most countries and most of my chrissy's voting day is a holiday so more people can vote we needed a political system that disguise the real power base take our most recent presidential elections here one party has always been the party of big business they don't hide that they said they believe in very little government president reagan said that government was the problem we needed to do away with big government forget that reagan raised the size of the government and ran up a huge debt what matters is what he said and that is what people believe to be true the other party supposedly caters to the needs of small businesses and workers or at least they say that now let's dissect the last election in this country what happened and why a little history says about nine hundred seventy the wages of workers have not increased and inflation adjusted dollars employers said we needed to pay the c e o s more so the workers were not going to have salary increases we the workers did not protest and accepted that situation how did we cope since we now have much more stuff and one could argue that our standard of living has increased a great deal as we have i get it's in fantastic media entertainment as well as designer meatballs we coped in several ways first women entered the workforce and employers and so families could make ends meet and employers like that because they could pay women less and reap greater profits that only went so far as we still needed more income to buy the products that were being heavily advertised to us it became easy to not spend money but to use plastic and we ran up huge credit card debts then the economic bubble will allowed many people to buy homes even though they had no money they pretended to live the american dream social spending was cut drastically president clinton ended welfare as we know it you had to survive on your own as government wouldn't help you when reagan entered ended low cost housing subsidies and curtailed mental health care services suddenly the home most renard face we have the most homeless pre capitalist of any country and this serves our society too so we have the highest poverty rates of rich countries and the most homelessness as professor sir michael marmot a social epidemiologist in england wrote in about us poverty in his book the health gap quote this must be the level of child poverty you want otherwise you would do something about it and sort of how does having so much poverty and homelessness service in the united states remember that the rich and powerful own number only a few if the rest of us organized ourselves to take on the rich and powerful there would be no contest we would win handily but we the people fear the government contrast this with friends where the government feels th fears the people in the one nine hundred sixty s when i came of age we had the highest public involvement in democracy both in the united states and in western europe voting rates here were the highest they've ever been out of the rich and powerful feel about the situation did they welcome it is it showed that democracy was working well the right wing has never been in favor participatory democracy but i would argue neither is the left the liberal trilateral if the heated protests of the one nine hundred sixty s continued it would lead to an excess of democracy and excess democracy that was not acceptable and so they called for moderation in democracy that was the legs that these liberals used so how was this moderation accomplished well big business corporations were explicit in telling us our roles were to be workers and consumers and this has to be taught in schools they spoke of the difficult sell drug to be done namely getting us to accept our roles so the rich would have more and we would blame ourselves for not working it out so we accepted that the rich would become richer and we would have less it was the perfect crime we slash taxes on the rich and on rich corporations we gave them huge subsidies that came out of our pockets the for's billionaire list was created in one nine hundred eighty seven to document the stratospheric rise of well remember everyone has it it's not will it's only wealth of a few have it so income and other economic inequality has increased tremendously whether republicans or democrats or in the government it increases more in republican in administrations but it rises no matter who's in charge meanwhile every government policy is touted as being really good for the poor so fast forward to the present eight years under bush the second resulted in the huge financial bubble bursting rather than send the bankers to jail as we did in the savings and loan scandal and in one nine hundred eighty s we gave the money o lot of our pockets so they could pay themselves large bonuses the banks were too big to fail and too big to jail and the banks toure's had committed the perfect crime then the democrats came in with the first african american elected president how did he help the poor well he could have prosecuted the banks toure's but he didn't instead poverty increased and we had large numbers of people as homes because of foreclosures as well as record numbers of homeless people what a paradox with inequality at a all time high last november eighth there were two choices more of the same or something that on the face of it sounded different when there's great inequality how do you behave well consider were george bernard shaw the british playwright wrote in one nine hundred twenty seven quote the woman from the brick box maintains her social position by being offensive to the immense number of people she considers her inferiors reserving her civility for the very few who are clinging to her own little ledge on the social precipice for inequality of income takes the broad safe to socialism and capitalism written in one published in one nine hundred twenty seven so with a big gap between the rich and the poor you're glad to have the poor to put down you even want to kick them further below and who are the poor today well certainly african americans and immigrants from mexico and others who are stealing our drugs along come somebody who says he wants to make america great again as i pointed out already great when it comes to wealth the creation technological advances and nobel prizes what on will meant was make america white again our countries complection was changing we have to get mexico to build a wall we have to deport muslims women are getting too uppity remember is locker room talk so if you're a white working male here comes this guy that says what you hear in the locker room if you're lucky enough to have a gym membership and if you don't you still think that way so he's selected president notice i said selected since two million more people voted for the other candidate promising more of the same this would be impossible in france where the election has to be the president has to be elected by the majority of the people so there's a runoff election that's taking place there in three days so if the situation continues with the recently announced tax cuts for the rich we will certainly see further rise of income inequality if trump carries through with having stuff made in america get again and if the us corporations have to export products rather than import them they'll be more drugs for americans but there will certainly not be higher wages remember republicans believe the market should dictate wages and without labor unions will be no pressure to raise incomes since americans will be making more stuff in the usa prices for goods will rise considerably since up to now what we buy has been made in china where they don't pay people much so we won't have the money to buy the stuff we're used to if we drive up american exports to other countries they won't be able to compete with chinese exports since our goods will be more expensive china meanwhile might have even greater problems because they won't be exporting their goods to the u s that will leave hundreds of millions of chinese workers without were that could be the breeding ground for another revolution there so inequality is having its toxic effect in most places on the globe one example was last year when people in the united kingdom voted to leave the european union and then the us election surprised the world what will happen in france this sunday could be another harbinger of the injuries wrought by economic inequality people are responding by voting for someone who wants to limit immigration and other signs of toxicity in french so such choices won't work in this global pandemic of economic inequality well you're not dead yet and i hope no one has died so far escaped childhood mortality in the killers facts i presented won't matter to you until you're their victim that is why it's so difficult to get people in this country to make comparisons with other nations on their h the other key point in understanding health is that earthly life lasts a lifetime namely the conditions from the time of conception to the first thousand days or certainly before we go to school matter more for mark for our health as adults than anything that happens after that period so as we go from the erection to the resurrection study show that conditions that begin when we're conceived and then by the time we are two to five years old to determine much of our health as adults you began life in your maternal grandmother's womb since that's where the ovum that your father sperm fertilized was main so what is the most common sexy transmitted infection in the world know not herpes not clemente a not a peavy everyone in this room is infected life is the most common sexually transmitted infection we're all here because of a sexual ac are only five for cycles of cell division to produce you sitting here so a cell division is an extremely sensitive period if you wanted to impact it would you pick forty two cycles over nine months or a further five over twenty years well birth weight is a good measure of fetal development along with whether you were born it term or not and this helps us understand why african americans have poor h no matter how well educated their mothers are the chances of being born with a low birth weight are higher than for any other so called race in this country and low birth weight has been transmitted intergenerational  no matter how much prenatal care these women get they continue to have the highest rates of low birth weight and resulting health inequities it's not fair for never illusionary perspective we're here for one purpose to reproduce and not become extinct like the dodo the compromises we make in early life as we live in a womb with a view and see the outside world a stressful program of us to modify our physiology to reproduce and pay the price later with all the chronic diseases we suffer from first thousand days matter most for our health healthier nations support that period we do not one major problem is we c health with health care we say we access health we pay for health we get health care insure health when we do nothing of the kind we access health care we pay for health care we insure health care until we make that distinction we will never understand health health care is a huge industry in the united states as i said we spend more than all the other nations combined on health care in two thousand and fourteen this is three point two trillion dollars that's a little over three with twelve zeros after a sixth of our total economy and this industry employs one people in mind here so what is the relation to ship between health and health care well what medical care really does is what can be called rescue medicine the groundwork has been laid for better or worse health in early life you get your chronic illness diagnosed and then take rescue medicines to limit the fat the bad effects of high blood pressure or cornering artery disease or lung disease or diabetes were many cancers we're talking about most of the chronic illnesses that will do us in medicine surgery and various procedures will only ease the wear and tear on the body until we're pushing up daisies recall i said medical care is one of the leading causes of death something that became evident with the first  study done by harvard university and published in one nine hundred ninety one since then there have been more than a score of such studies all with similar results if you get admitted to a hospital in this country your chances of dying from medical care in the hospital are about one or nine hundred such studies get reported in for example a two thousand and fifteen u s news and world report on the best hospitals in the united states last year  study by surgeons at johns hopkins university said that medical error was the third leading cause of death in this country not happy news so when the quarter is over and you're flying home but if you knew that the airplane had a one percent chance of crashing before arriving at the destination i bet you'd be taking the covered wagon but we consume medical care with reckless abandon i'm not saying you shouldn't seek medical care if necessary but be careful it might kill you then too it might perform its rescue purpose so since this talk is being sponsored by a medical fraternity pi delta epsilon i have to be careful about trashing the work i did over most of my life and the mission of the fraternity to do good by providing medical care i'm not saying you should become a doctor or a ph or a nurse or a pharmacist or undertake similar careers in the healthcare industry you just need to be aware of the limitations of health care so consider a room with a sink on one side there's a faucet there in the sink is overflowing with water two people in white coats one a man and a woman are mopping up the water but they can't keep up with the what needs to be done well clearly turn off the faucet but that's not the job of those mopping up the water medicine doesn't consider what needs to be done to produce health this wasn't taught at stanford junior university medical school in the early one nine hundred seventy s when i was there and it still isn't taught in medical schools today i was just talking to a student who took my course a few years ago and she confirms that it's not the drop of doctors to produce healthy populations it's just to treat illness and injury diagnosing and treating illness an injury is what medical care is all about so whose job is it to turn off the faucet well in the united states is not the role of public health public health tells you as an individual what to do to be healthy eat right exercise get your immunizations wear a condom and don't smoke that is what is taught in our public health school here at u w one of the highest ranked in the country turning off that foster requires a population health approach and no government agency see in this country is set up to do that that we're did first the need to do something about it is not taught so i'm a lone wolf howling about this in my courses but otherwise there's deadly silence so you w s created this population health initiative but their mission is very broad and our poor health status is the richest most powerful country in world history is not considered no one wants to do that so put some pressure on president coach a who started this initiative to get with the program and make america healthy again to say let's make america healthy again is meaningless unless i point out that in the nurdin than in the early one nine hundred fifty s we were one of the healthiest nations by any measure while i health has improved since then other countries have enjoyed more of this miracle and their health improved faster than ours so how are we going to get back to the relative health status we enjoyed in the one nine hundred fifty s well in a hierarchical or very unequal society everyone feels more stress stress is the twenty first century tobacco as the gap between the rich and the poor gets ever larger there's more air rage such as the recent united airlines incident air rage increases when there's first class seating in the airplane it increases when passengers have to enter through the first class cabin these incidents increase air rage not only in coach class but also in first class then there's road rage which is increasing as more and more people carry assault weapons and rifles in their automobiles we live in a pressure cooker and have among the highest reported stress levels of all countries despite our labor saving life and  technologies and not facing the terror are present in other countries where we attack with drones one way to see how stress is impacting our health in the united states is to compare health during adulthood in the forty five to fifty four year range people in that age bracket in other rich nations are seeing declines in mortality over the period one thousand nine hundred to two thousand and fourteen one group is seeing an increase whites in the united states their dying of stress with the researchers call deaths of despair namely those from alcohol excess drug poisonings and suicides so this points out how stresses impacted working age whites here and why they are likely to have voted for the new president so how did change the society in which the circumstances of your birth largely determine your health as i said inequality kills and it kills in early life so we have to pay attention to the first few years of our lives healthier societies privilege that period not by preaching family values but providing time off to parent and by lessening stress during pregnancy so how to start this country becoming healthier the institute of medicine of two thousand and thirteen report titled u s health an international perspective shorter lives poorer health said first tell the people were did first then look at healthier countries to see what they're doing that could be of use here so we need to start this this discussion to make america healthy again are we going to do that well let's slovenia what is slovenia doing that we are not that produces better health to begin with as i said they have the least income inequality of all nations on the cia world rankings website so they have much less of the inequality gas there they have universal health care insurance the entire population is sure isn't sure but that's only a very smart small part of the process of producing health at the societal level believes parents should be provided time and resources to parent so paid maternity leave leave ass last one hundred five days after delivery and twenty eight days during pregnancy and the amount you get paid is the average pay in the preceding year the father gets ninety days of similarly paid the after parental leave expires one of the parents can have an additional two hundred sixty days of paid leave to care for a child at the average pay for the preceding year in addition the parents are given a trial the lowance from the government perhaps you go on the allowance from your parents growing up this is similar only it is paid to the parents by the government to help raise the child the allowance is based on the average income the previous year i could go on to describe the childbirth grant childcare allowances and any other benefits that everyone in the country gets but you get the picture people in slovenia believe that having healthy children that grew into healthy adults is important they get what they pay for namea better health and lower death rate than we do so venia has pre k schools tha begin at age three all education in slovenia is free including all higher education in universities there are many higher education courses taught in english and americans go to sleep in year for university and they don't pay  just like those born in slovenia the slovenian government lists all these benefits for living there on their web page and at the top is the leading phrase welfare state their welfare means very well what they get for this is lower mortality at all ages than we do in the united states it's not a very wealthy nation there are no billionaires there we have almost a third of the world's total and having these billionaires doesn't by itself so let's copy so beany is population health policy since we know they were so to begin we need a national policy of granting generous paid parental leave it for pay only one of two nations in the world without a paid maternity leave policy and this should include a month during pregnancy create a national paid preschool and daycare program that begins at age three let's decrease the gap between the rich and the poor by going back to the policies we had when we were one of the healthiest nations so increase taxes on the rich and then spend that on social programs as slovenia does bring robin hood back to take from the rich and give to the poor to fantastic medicine with no side effects those richer will also be healthier by being less rich let's have a single payer universal health care system that spends half of what it spends today the profit out of health care and move to having salaried doctors who will make less to big challenge you're sitting there saying i can't do that i want to help my patients well as a single person you can't do much remember the proverb if you want to go fast go alone if you want to go far go together we have a far distance to go so how are we going to tackle this together how are we going to turn off the overflowing together i said that the invisible gas of economic inequality kills since we're not aware of this gas we don't put on gas masks gas mask have been around since the plagues of europe when doctors put them on to work with patients today there are a symbol of horror movies or scare tactics used by protesters or a part of street art we can use this symbol today i suppose all of us in this room left and got some army surplus gas masks to wear to more you draw attention so people might turn away from you others might ask you why you're wearing the gas mask this is your chance to tell them about the odorless colorless invisible highly toxic gas inequality that's killing us and we're unaware of it so gas mask can be used to foment political change in this country to make america healthy again it's not as simple as putting on a gas mask to deal with the global pandemic of inequality as these gas mask won't protect you from it but there are only a symbol that will allow you to draw attention to the gas which we must do if we are to curtail the production of  if you give me a fish you fed me for a day if you teach me to fish you fed me until the rivers polluted or the shoreline seas for development so you can no longer fish but if you teach media organized if you teach me to organize then whatever the issue i can work together with my peers and we'll fashion our own solutions we don't teach organizing in schools we should be doing that in kindergarten and on to graduate school we should teach critical thinking as well in texas a proposal was made to teach critical thinking in public schools but it was squashed as legislators said it would conflict with family values so now that i've taken you to the brink of despair what are we going to do well we need deep organizing if mama isn't happy then nobody is happy and it probably doesn't surprise you to learn that our happiness has been slowly declining in the last few decades as our power as citizens has been eroded and the decline in happiness has been greatest in women clearly mama ain't happy in the usa today even the first lady doesn't look very happy maybe she thinks she should have stayed  slovenia but we're all here now corporate media are on thin ice too and afraid of falling through numbers of fox news debacle many of them are criticizing our leader and this represents a gold opportunity to affect change to take advantage of this critical period in the us history we need to go public and dawn are symbolic mask to draw attention to the highly toxic structural inequality developer speaking points you slovenia as an example of a country that has better health than we do there's plenty to discuss with others both friends family and strangers we need to fight truth decay and then organized or not good first we must work together put on your gas mask because we must organize or die th speaking today when the house you know congress passed a bill the new health care bill the bill will take three hundred billion dollars in taxes and give it back to those who earn over two hundred fifty thousand dollars a year i would like you to address this bill and your topic of inequality if you could you know words want to be by that is that there seems to be a disconnect between our politicians on the one hand most of whom in congress are gerrymandered to either be democrat or republican and on the other hand the call for equality for health it seems likely that as a result of the bill today to believe passes many americans will die as a result thank you so i'm not sure i agree with you that many americans will die as a result life expectancy declined in the united states from two thousand and fourteen to two thousand and fifteen first time in decades why might that happen if medical care is a leading cause of death it could be because more people access to health care now i don't what i mean that's really outrageous for me to say that but you know i mentioned my cancer as a result of radiation and i'm alive today because i have shunned a lot of medical treatment yes in two thousand and thirteen i had a recurrence or required a lot of chemotherapy and that probably made a difference but i've tried to avoid medical care and the trouble is  we think of medical care as the solution for so many things that it has no business messing i do lady come in the year one morning at three on a saturday morning saying she wasn't happy she wanted to be admitted you know that's that's not the role of  you know we shouldn't be trying to deal with those problems there are symptoms of something else that's happening in society i mean the big you know the disgrace really first of all every other rich country has universal health care that most people want a single payer universal healthcare program surveys of shown this since the one nine hundred seventy s but it's not remember what our previous president said that's off the table so even though the public wants it where not considering we won't consider it until we go back and suppose we had a million person march on the mall in d c or suppose we did a lot of demonstrating on may day i was surprised i'm eighty here a little demonstration there was i canceled my quiz takes place on mayday because i thought nobody even the classroom we're not organizing and we're not working together and yes everybody should have medical care yes the new legislation will decimate that and yes it will give more to the rich and i'm even hearing that people think you know people say that some people say that if we had there was of elections today he'd get even more  very confusing i mean he has a little very low approval ratings people are very concerned about everything as they should be and the passage of this bill should be a huge public but i don't know if it we'll that's not a direct answer to your question the quality is going to increase the studies coming out on monday showing that at the us county level things are a disaster in terms of mortality  i think it's going to get better on till we decrease inequality i don't think you want to say however that less health insurance will mean healthier people in america no more health care insurance member we conflate health and health care i think everybody should have access to health care without paying at the point of of delivery you know i worked in canada where that was the situation  and people just expect that that's when the right it's only in this country that people somehow think that you know they have to go bankrupt to access health care that's crazy i mean people come from other countries and they can't believe the system here but just as michael marmot said you must be happy with the level of poverty you're you do something about it similarly we seem to be happy with the richest situation this country or at least we're not protesting down so this is a slightly different topic but those are if you could talk about medical futility if you think that has a significant contribution to to the inequality really have really low percentage is of working out and people still wanting to do that because they want to try every single option but it's not really recommended by doctors an by recognizing respond twenty percent of the entire health care budget on administration that's an exercise in futility other countries spend one percent maybe there's the number one futility  people seem to think that the latest greatest treatment is the best even though it hasn't been very well evaluated why is all this happening well basically it's a very profitable industry and we get the media to hype all sorts of things that people think that there are miracles happening out there when there are if we had an education program beginning in kindergarten in grade one two that medical care was limited in what it could do if we had social spending you know we don't if you some people say you add the medical care costs in the social cost together to get  an indicator of what produces health in society we don't spend very much on social factors and so we don't have very good health so we need to teach people that economic status and any quality and attention in this country they're actually using that phrase integrative medicine and i just got the most recent magazine consumer reports it's not advertising consumer magazine and they're talking about treatments for back pain and they're basically saying shut all this stuff and the experts they quote are practicing integrative medicine do yoga do exercise go to see the chiropractor i mean all sorts of stuff that would have been h while back so we need to recognize that you know there isn't a pill for every ill or a procedure for every pain and you know we can say we're very we're in a tremendous amount of pain in this country and i think it's more psychic pain it's called chronic pain and consume the most opioids per person of any country and we're not even an industrial country where there are workplace accidents or things that might cause a very screwed up i don't know so medical futility yes i agree it can only happen through well do what oregon did oregon said we're not going to spend money on medicaid money on stuff that doesn't work we're going to concentrate it on a few things that were and that was governor kitzhaber is planned remnants of that are still there i mean we could at a state level or over hopefully at the national level make policies that would limit what we provide in terms of medical care and help people understand that it's not you can't can't treat things with you know it's rescue medicine only