What causes heart disease – Part 63
by Malcolm Kendrick
To keep this simple, and stripping terminology down things down to basics, the concept I am trying to capture, and the word that I am going to use, here to describe the factor that can affect entire populations is ‘psychosocial stress’. By which I mean an environment where there is breakdown of community and support structures, often poverty, with physical threats and suchlike. A place where you would not really want to walk down the road unaccompanied.
This can be a zip code in the US, known as postcode in the UK. It can be a bigger physical area than that, such as a county, a town, or whole community – which could be split across different parts of a country. Such as native Americans living in areas that are called reservations.
On the largest scale it is fully possible for many countries to suffer from major psychosocial stress at the same time. […] Wherever you look, you can see that populations that have been exposed to significant social dislocation, and major psychosocial stressors, have extremely high rate of coronary heart disease/cardiovascular disease.
Britain and America are in the midst of a barely reported public health crisis. They are experiencing not merely a slowdown in life expectancy, which in many other rich countries is continuing to lengthen, but the start of an alarming increase in death rates across all our populations, men and women alike. We are needlessly allowing our people to die early.
In Britain, life expectancy, which increased steadily for a century, slowed dramatically between 2010 and 2016. The rate of increase dropped by 90% for women and 76% for men, to 82.8 years and 79.1 years respectively. Now, death rates among older people have so much increased over the last two years – with expectations that this will continue – that two major insurance companies, Aviva and Legal and General, are releasing hundreds of millions of pounds they had been holding as reserves to pay annuities to pay to shareholders instead. Society, once again, affecting the citadels of high finance.
Trends in the US are more serious and foretell what is likely to happen in Britain without an urgent change in course. Death rates of people in midlife(between 25 and 64) are increasing across the racial and ethnic divide. It has long been known that the mortality rates of midlife American black and Hispanic people have been worse than the non-Hispanic white population, but last week the British Medical Journal published an important study re-examining the trends for all racial groups between 1999 and 2016 .
The malaises that have plagued the black population are extending to the non-Hispanic, midlife white population. As the report states: “All cause mortality increased… among non-Hispanic whites.” Why? “Drug overdoses were the leading cause of increased mortality in midlife, but mortality also increased for alcohol-related conditions, suicides and organ diseases involving multiple body systems” (notably liver, heart diseases and cancers).
US doctors coined a phrase for this condition: “shit-life syndrome”. Poor working-age Americans of all races are locked in a cycle of poverty and neglect, amid wider affluence. They are ill educated and ill trained. The jobs available are drudge work paying the minimum wage, with minimal or no job security. They are trapped in poor neighbourhoods where the prospect of owning a home is a distant dream. There is little social housing, scant income support and contingent access to healthcare. Finding meaning in life is close to impossible; the struggle to survive commands all intellectual and emotional resources. Yet turn on the TV or visit a middle-class shopping mall and a very different and unattainable world presents itself. Knowing that you are valueless, you resort to drugs, antidepressants and booze. You eat junk food and watch your ill-treated body balloon. It is not just poverty, but growing relative poverty in an era of rising inequality, with all its psychological side-effects, that is the killer.
Will Hutton has an article in the Guardian in which he argues that the recent decline in the growth of life expectancy in the UK (and its decline in some parts) is down to what he describes as ‘shit-life syndrome’. This is the state where life is reduced to an exercise in mere survival as a result of the economic and social oppression lined up against those suffering the condition. And, as he points out, those suffering are not just those on the economic and social margins of society. In the UK, as in the US, the syndrome is spreading.
The reasons for this can be debated. I engaged in such argument in my book The Courageous State. In that book I argued that we live in a world where those with power do now, when they identify a problem, run as far as they might from it and say the market will find a solution. The market won’t do that. It is designed not to do so. Those suffering shit-life syndrome have, by default, little impact on the market. That’s one of the reasons why they are suffering the syndrome in the first place. That is why so much of current politics has turned a blind eye to this issue.
And they get away with it. That’s because the world of make belief advertising which drives the myths that underpin the media, and in turn out politics, simply pretends such a syndrome does not exist whilst at the same time perpetually reinforcing the sense of dissatisfaction that is at its core.
With Brexit, It’s the Geography, Stupid
by Dawn Foster
One of the major irritations of public discourse after the United Kingdom’s Brexit vote has been the complete poverty of analysis on the reasons behind different demographics’ voting preferences. Endless time, energy, and media attention has been afforded to squabbling over the spending of each campaign for and against continued European Union membership — and now more on the role social media played in influencing the vote — mirroring the arguments in the United States that those who voted to Leave were, like Trump voters, unduly influenced by shady political actors, with little transparency behind political ads and social media tactics.
It’s a handy distraction from the root causes in the UK: widening inequality, but also an increasingly entrenched economic system that is geographically specific, meaning your place of birth and rearing has far more influence over how limited your life is than anything within your control: work, education and life choices.
Across Britain, territorial injustice is growing: for decades, London has boomed in comparison to the rest of the country, with more and more wealth being sucked towards the southeast and other regions being starved of resources, jobs and infrastructure as a result. A lack of secure and well-remunerated work doesn’t just determine whether you can get by each month without relying on social security to make ends meet, but also all aspects of your health, and the health of your children. A recent report by researchers at Cambridge University examined the disproportionate effect of central government cuts on local authorities and services: inner city areas with high rates of poverty, and former industrial areas were hardest hit. Mia Gray, one of the authors of the Cambridge report said: “Ever since vast sums of public money were used to bail out the banks a decade ago, the British people have been told that there is no other choice but austerity imposed at a fierce and relentless rate. We are now seeing austerity policies turn into a downward spiral of disinvestment in certain people and places. This could affect the life chances of entire generations born in the wrong part of the country.”
Life expectancy is perhaps the starkest example. In many other rich countries, life expectancy continues to grow. In the United Kingdom it is not only stalling, but in certain regions falling. The gap between the north and south of England reveals the starkest gap in deaths among young people: in 2015, 29.3 percent more 25-34-year-olds died in the north of England than the south. For those aged 35-44, the number of deaths in the north was 50 percent higher than the south.
In areas left behind economically, such as the ex-mining towns in the Welsh valleys, the post-industrial north of England, and former seaside holiday destinations that have been abandoned as people plump for cheap European breaks, doctors informally describe the myriad tangle of health, social and economic problems besieging people as “Shit Life Syndrome”. The term, brought to public attention by the Financial Times, sounds flippant, but it attempts to tease out the cumulative impact of strict and diminished life chances, poor health worsened by economic circumstances, and the effects of low paid work and unemployment on mental health, and lifestyle issues such as smoking, heavy drinking, and lack of exercise, factors worsened by a lack of agency in the lives of people in the most deprived areas. Similar to “deaths of despair” in the United States, Shit Life Syndrome leads to stark upticks in avoidable deaths due to suicide, accidents, and overdoses: several former classmates who remained in the depressed Welsh city I grew up in have taken their own lives, overdosed, or died as a result of accidents caused by alcohol or drugs. Their lives prior to death were predictably unhappy, but the opportunity to turn things around simply didn’t exist. To move away, you need money and therefore a job. The only vacancies that appear pay minimum wage, and usually you’re turned away without interview.
Simply put, it’s a waste of lives on an industrial scale, but few people notice or care. One of the effects of austerity is the death of public spaces people can gather without being forced to spend money. Youth clubs no longer exist, and public health officials blame their demise on the rise in teenagers becoming involved in gangs and drug dealing in inner cities. Libraries are closing at a rate of knots, despite the government requiring all benefits claims to be submitted via computers. More and more public spaces and playgrounds are being sold off to land-hungry developers, forcing more and more people to shoulder their misery alone, depriving them of spaces and opportunities to meet people and socialise. Shame is key in perpetuating the sense that poverty is deserved, but isolation and loneliness help exacerbate the self-hatred that stops you fighting back against your circumstances.
“Shit-Life Syndrome” (Oxycontin Blues)
by Curtis Price
In narrowing drug use to a legal or public health problem, as many genuinely concerned about the legal and social consequences of addiction will argue, I believe a larger politics and political critique gets lost (This myopia is not confined to drug issues. From what I’ve seen, much of the “social justice” perspective in the professional care industry is deeply conservative; what gets argued for amounts to little more than increased funding for their own services and endless expansion of non-profits). Drug use, broadly speaking, doesn’t take place in a vacuum. It is a thermometer for social misery and the more social misery, the greater the use. In other words, it’s not just a matter of the properties of the drug or the psychological states of the individual user, but also of the social context in which such actions play out.
If we accept this as a yardstick, then it’s no accident then that the loss of the 1984-1985 U.K. Miners’ Strike, with the follow-on closure of the pits and destruction of pit communities’ tight-knit ways of life, triggered widespread heroin use (2). What followed the defeat of the Miners’ Strike only telescoped into a few years the same social processes that in much of the U.S. were drawn out, more prolonged, insidious, and harder to detect. Until, that is, the mortality rates – that canary in the epidemiological coalmine -sharply rose to everyone’s shock.
US doctors have coined a phrase for the underlying condition of which drug use and alcoholism is just part: “shit-life syndrome.” As Will Hutton in the Guardian describes it,
“Poor working-age Americans of all races are locked in a cycle of poverty and neglect, amid wider affluence. They are ill educated and ill trained. The jobs available are drudge work paying the minimum wage, with minimal or no job security. They are trapped in poor neighborhoods where the prospect of owning a home is a distant dream. There is little social housing, scant income support and contingent access to healthcare. Finding meaning in life is close to impossible; the struggle to survive commands all intellectual and emotional resources. Yet turn on the TV or visit a middle-class shopping mall and a very different and unattainable world presents itself. Knowing that you are valueless, you resort to drugs, antidepressants and booze. You eat junk food and watch your ill-treated body balloon. It is not just poverty, but growing relative poverty in an era of rising inequality, with all its psychological side-effects, that is the killer”(3).
This accurately sums up “shit-life syndrome.” So, by all means, end locking up non-violent drug offenders and increase drug treatment options. But as worthwhile as these steps may be, they will do nothing to alter “shit-life syndrome.” “Shit-life syndrome” is just one more expression of the never-ending cruelty of capitalism, an underlying cruelty inherent in the way the system operates, that can’t be reformed out, and won’t disappear until new ways of living and social organization come into place.
The Human Kind, A Doctor’s Stories From The Heart Of Medicine
It’s not like this for all kinds of illness, of course. Illness, by and large, is as solid and real as the chair I’m sitting on: and nothing I say or believe about it will change its nature. That’s what people mean when they describe an illness as ‘real’. You can see it and touch it, and if you can’t do that, then at least you can measure it. You can weigh a tumour; you can see on the screen the ragged outline of the plaque of atheroma in your coronary artery which is occluded and crushing the life out of you, and you would be mad to question the legitimacy of this condition that prompts the wiry cardiologist to feed the catheter down the long forks and bends of your clogged arterial tree in order to feed an expanding metal stent into the blocked artery and save you.
No one questions the reality and medical legitimacy of those things in the world that can be seen, felt, weighed, touched. That creates a deep bias in the patient; it creates a profound preference among us, the healers.
But a person is interactive . Minds can’t exist independently of other minds: that’s the nature of our kind. The names we have for things in the world and the way that we choose to talk about them affect how we experience them. Our minds are made of language, and grammar, intentions, emotions, perceptions and memory. We can only experience the world through the agency of our minds, and how our minds interact with others. Science is a great tool for talking about the external world: the world that is indifferent to what we think. Science doesn’t begin to touch the other, inner, social stuff. And that’s a challenge in medicine. You need other tools for that.
‘Shit-life syndrome,’ offers Becky, whose skin is so pale it looks translucent, who wears white blouses with little ruffs buttoned to the top and her blonde hair in plaits, whose voice is vicarage English and in whose mouth shit life sounds anomalous. Medicine can have this coarsening effect. ‘Shit-life syndrome provides the raw material. We doctors do all the rest.’
‘That’s all I ever seem to see in GP. People whose lives are non-specifically crap. Women single parenting too many children, doing three jobs which they hate, with kids on Ritalin, heads wrecked by smartphone and tablet parenting. Women who hate their bodies and have a new diagnosis of diabetes because they’re too fat. No wonder they want a better diagnosis! What am I meant to do?’
I like to keep this tutorial upbeat. I don’t like it to become a moan-fest, which is pointless and damaging. Yet, I don’t want to censor.
‘… Sometimes I feel like a big stone, dropped into a river of pain. I create a few eddies around me, the odd wave or ripple, but the torrent just goes on…’
‘… I see it different. It’s worse! I think half the time we actually cause the problems. Or at least we create our own little side channels in the torrent. Build dams. Deep pools of misery of our own creation!’
That’s Nadja. She’s my trainee. And I recognise something familiar in what she is saying – the echo of something that I have said to her. It’s flattering, and depressing.
‘For example, take the issuing of sick notes. They’re the worst. We have all of these people who say they’re depressed, or addicted, or stressed, who stay awake all night because they can’t sleep for worry, and sleep all day so they can’t work, and they say they’re depressed or anxious, or have backache or work-related stress, and we drug them up and sign them off, but what they’re really suffering from are the symptoms of chronic unemployment and the misery of poverty, which are the worst illnesses that there are! And every time I sign one of these sick notes, I feel another little flake chipped off my integrity. You’re asking about vectors for social illness? Sick notes! It’s like we’re … shitting in the river, and worrying about the cholera!’
Strong words. I need to speak to Nadja about her intemperate opinions…
‘At least, that’s what he keeps saying,’ says Nadja, nodding at me.
Nadja’s father was a Croatian doctor, who fled the war there. Brought up as she was, at her father’s knee, on his stories of war and torture, of driving his motorbike between Kiseljac and Sarajevo and all the villages in between with his medical bag perched on the back to do his house calls, she can never quite believe the sorts of things that pass for ‘suffering’ here. It doesn’t make Nadja a more compassionate doctor. She sips her coffee, with a smile.
Aly, the one training to be an anaesthetist-traumatologist, says, ‘We shouldn’t do it. Simple as that. It’s just not medicine. We should confine ourselves to the physical, and send the rest to a social worker, or a counsellor or a priest. No more sick notes, no more doing the dirty work of governments. If society has a problem with unemployment, that’s society’s problem, not mine. No more convincing people that they’re sick. No more prescriptions for crap drugs that don’t work. If you can’t see it or measure it, it isn’t real. We’re encouraging all this pseudo-illness with our sick notes and our crap drugs. What’s our first duty? Do no harm! End of.’
She’ll be a great trauma doctor, no doubt about it.
* * *
From Bad to Worse: Trends Across Generations
Rate And Duration of Despair
Trauma, Embodied and Extended
Facing Shared Trauma and Seeking Hope
Society: Precarious or Persistent?
Union Membership, Free Labor, and the Legacy of Slavery
The Desperate Acting Desperately
Social Disorder, Mental Disorder
Social Conditions of an Individual’s Condition
Society and Dysfunction
It’s All Your Fault, You Fat Loser!
To Grow Up Fast
Individualism and Isolation
To Put the Rat Back in the Rat Park
Rationalizing the Rat Race, Imagining the Rat Park
The Unimagined: Capitalism and Crappiness
Stress Is Real, As Are The Symptoms
On Conflict and Stupidity
Connecting the Dots of Violence
Inequality in the Anthropocene