Value based payment in SNFs

A Margolis Center for Health Policy project funded by the Robert Wood Johnson Foundation this week put out a policy brief on value based payments in skilled nursing facilities. It started as a look only at impact of COVID19 on SNFs but was broadened a bit to include movement toward VBP in nursing homes more broadly.

Thank You

The Department of Health Policy and Management, in the UNC Gillings School of Public Health honored me last week with their Distinguished Alumni Award. Both my undergraduate BS and Ph.D. are from this Department and I owe them a great deal. Thank you to Morris Weinberger, the Chair, and the rest of the Faculty of the Department of Health Policy and Management for this wonderful Award. I am deeply honored and wanted to say a few thank you publicly and offer a reflection on my primary intellectual regret from the nine years spent learning at Alma Mater.

Thank You.

  • Thank you to UNC Chapel Hill. Carolina changed my life and I would be nothing professionally without the training I received from the faculty and so many passionate graduate students. I moved into Winston Dorm in August, 1986 as an uninitiated kid, just bouncing through life and having a good time, and left as a scholar committed to research and education. I was introduced to the life of the mind at Carolina and was shaped as a scholar and person there. I am forever grateful.
  • Thank you to the UNC School of Public Health for teaching me a simple definition of Public Health—“you protect the individual best by  protecting the whole.” While this principle works most deterministically in infectious diseases, I believe there is something called the common good, and I encourage everyone to keep searching for it even when it is difficult. Public Health is the appropriate way to think about most profound societal problems such as Racism, wealth inequality and sectarianism because these are systemic problems and not individual failures alone.
  • Thank you to the Sheps Center for Health Services Research, for both pre doctoral and post doctoral training. I now direct the Social Science Research Institute at Duke University and try to catalyze funded research across Duke. This perspective has taught me what a gem UNC has in the Cecil G. Sheps Center for Health Services Research. Great credit is due to Gordon DeFriese. They have managed to create and nurture an intellectual legacy built upon some state support, soft money, hustle and a passion for trying to make the world and the lives of the disadvantaged a bit better.
  • Thank you to Tom Ricketts. He was a part of all 9 of my years at UNC. He taught me introduction to Health Policy in 1987 when an undergrad, and it was the first inkling that I would study health in some manner. He mentored me in undergrad, hired me as a research assistant one summer when I was doing the MPA program at UNC and needed a job, and later became my dissertation chair after I refocused on health policy for my Ph.D. Tom Ricketts exemplifies great mentorship—he treated me as a colleague before it was warranted, but did so in a way that protected me from horrible mistakes.

As I reflect on my time at Carolina, and the 35 Augusts I have lived since I moved into Winston Dorm, I have only one intellectual regret–I did not take a course in United States history at UNC because I placed out of it via my score on the AP US History Exam.

However, in the last decade or so, I have come to understand that my education in both United States as well as North Carolina history was incomplete and purposefully false. Just one example. Charles B. Aycock is the most famous person from my hometown of Goldsboro, NC. We learned growing up that he was “the education Governor” a title that is perhaps deserved because he brought about compulsory education for Whites and Blacks, though segregated, and certainly not equally funded. However, he was also an unreconstructed White Supremacist to the end of his life in 1913 who clung to a philosophy that bordered on a personal theology that Blacks were inferior to Whites.

No word of this was taught to students growing up in Goldsboro.

We need to trust young people with a more full and truthful telling of our history. Middle School and High School students can handle ambiguity. They know people are not always as good as their best moment, nor always as bad as their worst. Our State needs to trust our young people with a full look at our past as we wrestle with what it means for the future, and the various bills in the North Carolina General Assembly seeking to write curriculum policy via bumper sticker slogan is an embarrassment to our great State. Finally, I would like to suggest that all undergrads at UNC should be required to take a course in North Carolina or United States history, regardless of their score on the AP US History Exam.

Structural Racism–the ways in which White is the default ideal in numerous life domains–is the biggest public health challenge of our time, and part of the solution is an honest reckoning with our history, and learning how to talk about difficult topics, especially when we disagree. I suspect if we trust our adolescents and teens and give them just a bit of guidance, they will do a better job at this than have their parents and grandparents.

Godspeed.

Don Taylor

Chinese laundry’s in the American South

The murders of 8 people in Atlanta last week, 6 women of Asian descent (4 of whom were Korean-American), appear to have been the result of a multi-faceted, murderous toxic stew in the gunman. Misogyny. Xenophobia. Racism. Objectification of Asian women as sexually available. And guilt-driven Christianity that viewed other human beings as a temptation–rendering human beings as only existing in relation to this killer’s mind–may have been the tipping point that led to these pre-meditated murders.

The pain expressed by Duke students and faculty colleagues who identify as Asian or Asian-American has been palpable, heart breaking and long-coming. This event seems to be a breaking point of sorts, and I realize the many common tropes related to the “model minority” have been accepted by me, especially in the context of a world class University, causing me to not take as seriously as I should have, the Racism, Bigotry and “Othering” that some of my students and colleagues have experienced.

The Duke Office of Faculty Advancement hosted an event yesterday in which four of my Faculty colleagues provided their insights on Asian and Asian-American culture informed by their scholarly pursuits, shared personal reflections and discussing what things they believe need to change at Duke. One thing that came through clearly to me was the sense that “Asian” and “Asian American” and “Asian descent” are overbroad terms, that depending on definitions could include one third to one half of the people alive today. These terms mostly have meaning in the way that people identify individuals who look different from them, labelling folks as “Asian” based on a casual glance. This is not a term of choice, but a term of the reality of simplistic Racial categories applied to people from myriad backgrounds in the United States.

The reason that I commonly use the phrase “White Supremacy” instead of “Structural Racism” even though they could be thought of as synonyms is the degree to which the application of much of the hate and discrimination in our world is applied to individuals based on nothing more than a cursory glance. Our brains are amazing devices that process billions of instructions per second, and shortcuts or heuristics are necessary or we would not even be able to get out of bed in the morning. A glance of how someone looks categorizes them in many ways, often leading to harm for those who are not viewed as White.

A key takeaway from yesterday’s event was the necessity of humanizing people by learning and telling their stories for their own value and worth. We can overcome biases if we work at it, and understanding people as people, and not as members of a group falling under an umbrella term like “Asian” is a start.

That leads me back to the title of my post. In my hometown of Goldsboro, N.C., there was a laundry started in 1910 by a man who had immigrated from China. He was known as Sam Lee, but it turns out that there was a Sam Lee laundry in most every State in the United States by the early 20th Century and that was probably not his name, though he cannot be found in the 1910-1930 Census.

As noted in a prior post, Sam Lee was a common name for a Chinese laundry.  A small sample of Sam Lee Laundries is shown in the photograph below.  You could find one in virtually every state, but the Chinese men who operated them were not necessarily named “Sam Lee.”

I did not know this history from my small town, Eastern North Carolina home, until I did a bit of research. The blog Chinese Laundry is excellent, written by John Jung, whose family opened a laundry in Macon, Georgia in 1885. This blog uses the device of the Chinese Laundry to tell some of the story of the United States, one small town and city at a time, one person and family at a time. In doing so, he brings to life some of the immigrants who helped to make the United States what it is today.

The Awokening–about to break or getting started?

Razib Khan is one of the people I follow on twitter who makes me think–that is why I follow him. His recent tweet below harkens a question folks have been asking me lately–has “woke” culture gotten out of control on campus and where does it stop?

https://twitter.com/razibkhan?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor

Let me provide a practical definition of how I understand “wokeness” in the best sense of the word, with respect to myself. Only within the past few years did I come to understand my identity as being White. I would always have checked “White” on a demographic survey, but I viewed being White as a fact, and thought of my perception of most everything as being the obvious default. Anyone compared to my views was bringing an identity–I was just bringing me. My daughter tells me stumbling through life without this realization was also related to being a White man.

The best of wokeness is being open to new information that you may have missed altogether in the past. Understanding how people of different identities have experienced the world is not a toxic thing, it is just a part of seeking to be a more practical Bayesian in a diverse society, meaning striving to be someone who is not fully convinced of everything and is willing to consider new evidence, and to be persuadable. If you never change your mind, that is a bad sign.

Of course some folks go to far, and illiberalism is antithetical to the life of the mind that is the best of the University community, regardless of the ideology of the imposer. The biggest blind spot in the pushback about “wokeness” on campus and the broad discussion of safe spaces is as follows.

1. Students live on campus at a place like Duke. The first Amendment principle of “freedom to assemble” includes sometimes not wanting to be subjected to unfettered speech. I go home at night.

2. Much of the worst speech, has a disproportionate impact on historically marginalized groups, and someone who is fearful for their safety, or who does not feel as if they belong, has little chance to engage in full dialogue. It is very difficult to walk the line of making a college campus a place where all who are willing to defend their words can speak up, while ensuring that all have a chance to join the fray.

My two cents.

A new hobby

I struggle with anxiety, commonly triggered by what I call “role clutter”–the need to juggle between the various roles that people play. Husband, father, son, brother, professor, mentor, director, neighbor, etc. As 2020 came to an end, I read that taking up some type of artistic outlet was a helpful practice, so I started drawing/sketching and a bit of painting with watercolor. This has been immensely relaxing and rewarding. I am going to share some pieces from time to time.

Unobserved Counterfactual. Our world today would be quite different if General Order #15, issued by General Sherman in January, 1865 had been followed through on. Forty Acres and a Mule was a military order, but did not last past the Fall of 1865 when President Andrew Johnson had it rescinded. I drew this while basking in the beauty of one of the Sea Islands that was covered by this order. Pencil and charcoal.
Notorious RBG. Faces are hard to draw well. I drew this one for my daughter Morgan, for whom RBG is a role model, and an icon. Rest well. Pencil.
Potential. Books may have some inherent, or intrinsic value, but only because someone can pick it up and engage their mind. The engagement can result in good or bad. Pencil.

Tower Bridge. I enjoy drawing landscapes and the like and this is my attempt at this landmark. Pencil and charcoal.
Blanche’s Rooster. One of my beloved possessions is a sketch of a Rooster, drawn by my Great Grandmother Blanche in 1913. This is my attempt to draw that, with a bit of color added. Pencil.
Rooster. This was drawn by my Great Grandmother Blanche Sugg, in 1913. My Rooster above is my attempt to sketch her sketch. Pencil.

How do you know what you know?

Peder Zane has a piece in the WSJ based on an interview with James B. Duke Professor Emeritus of Psychology, Neuroscience and Biology, James Staddon, criticizing Duke University’s “Anti-Racism” efforts, couched as defense of Science. The essence of the interview is that Professor Staddon is a scientist, and that many Duke faculty are not, especially those in the Social Sciences, because they do not follow the semantic reductionism of Randomized Control Trials (RCT)s or adhere to the internal validity conventions of animal-based model research.

“weak science competes with activist political tendencies around fraught issues of race, class and gender.”

This leads to the conclusion of a University that has lost its way and no longer seeks truth alone, but is instead a tool of political indoctrination.

The span and scope of the material covered in the piece is centuries long, and the disciplines involved touch nearly every corner of Duke, yet Professor Staddon and Mr. Zane seem fully sure of their conclusions. However, I would like to grant Professor Staddon the benefit of the doubt and assume he is interested in answers to the questions he posed about Duke and Race in the WSJ piece. It is in the spirit of answering a colleague that I offer this post.

“What are these ‘systems of racism and inequality?’ How have they affected Duke and how is Duke involved in them?”

From 1931-1964, Duke University included Racial Covenants (see the pdf download below) in the deeds of 300 homesites in the Duke Forest neighborhood that it sold to faculty and staff that remain today, even though legally unenforceable for decades. These covenants state that people who were not White could not stay overnight in the house unless they were servants. I once owned one of those homes, built in 1959, and asked about it at closing in 2006, and my lawyer said it was unenforceable but difficult to change given how the covenants had been written. Thus, Duke: (1) imposed Racial segregation in robust form to make Durham palatable for White faculty; (2) did not fully tell this story in a transparent manner; people (like me) knew about it for a long time; (3) these covenants helped define the residential segregation patterns seen in Durham today that influence things like school assignment, and public services, including policing; (4) residents of Durham, especially those who are Black, understand that at the heart of Racial covenants is an idea–some people are worth more than others, and the persistence of this idea is how “systems of racism and inequality” still affect Duke.

One more example. Duke hospital and the University’s physician practice plan had segregated floors and clinics from the 1930s until the early 1960s. They were replaced by the nomenclature of “private v. public” even before segregated medical care became illegal, and with the advent of Medicare and Medicaid in 1966, huge inflows of money began as health insurance coverage surged, helping make Duke University what it is today. The full story of how this shift in language nevertheless lead to continued segregation (when in doubt, Black patients were “Public”, White patients were “Private”) is just now in the process of being fully told, in part due to the fact that Board of Trustees records are confidential for 50 years. There is a straight line from this history—deeply known through experience and mostly untold—to the current reticence at receiving the COVID19 vaccine by some Duke employees and Durham residents who understandably doubt that Duke has their best interests at heart. This affects us all as we seek herd immunity.

These are just two “systems of racism and inequality” that Duke University built to segregate both housing and health care based on Race, and those systems influence our world today, at Duke, in Durham and in the lives of all the students we have taught and trained over the years. Naming and addressing these realities and blind spots is key if we as a University claim to have, or aspire to a more equitable culture of scientific excellence (the bold is my goal for Duke, and I understand the broad efforts to address Structural or Systemic Racism at Duke to be part of making that goal a reality).

How do systems of racism and inequality affect health? Broadening the discussion beyond simply answering Professor Staddon’s questions with the two examples offered above, the vision of the life of the mind described in Mr. Zane’s piece is too narrow to address many of the most important problems of our day. While animal model experimentation is a crucial part of the cannon of knowledge produced by a Research University, this approach alone cannot ask, nor answer all the important questions. A far more difficult and nuanced approach is called for to understand cause and effect in areas that cannot be studied in reductionist fashion via placebo and randomization, or measured only at the cellular level. This does make it difficult to find agreement about “how do you know what you know?” an important question raised in Mr. Zane’s piece by Professor Staddon. Let me try and explain what I mean.

The 2009 Nobel Prize in Physiology and Medicine was awarded for advances in understanding Telomeres, caps on DNA strands that provide protection during chromosome replication, and whose length provides a measure of cellular aging. An emerging body of research suggests that cellular aging is more rapid for Blacks as compared to Whites, even after controlling for other factors that influence Telomere length, such as poverty, obesity, smoking and exercise. More work is needed to calibrate the practical impact on life span and to so determine what proportion of a Black/White mortality gap could be explained by differential cellular aging. Science builds upon on Science. The 1983 Nobel Prize in Physiology and Medicine was awarded to Barbara McClintock, for her discovery in the 1930s of “mobile genetic elements” identified first in maize and then fruit flies. This forgotten finding became a building block for the 2009 Nobel Prize that shows the progression of findings from plant, to animal model, to human discovery and finally to the potential to intervene in the lives of human beings–the march of Science.

However, others were working as well, motivated not by an intrinsic interest in human biology, but instead by an explicit focus on explaining why Black/White mortality differences were so large and persistent. A finding that cellular aging is more rapid for Blacks versus Whites net of other factors, is consistent with an interpretation that Racism causes negative health impacts, providing a link between structural factors such as those noted above and individual health, most likely via the bodies stress response as measured by allostatic load. My Duke colleague, Susan B. King Distinguished Professor Emeritus of Public Policy Sherman James first proposed John Henryism, a hypothesis to explain this Black/White mortality gap nearly 40 years ago, based on the idea that striving against the headwinds of being Black lead to individual harm, with numerous mechanisms hypothesized as potential causal links (see pdfs linked at the end). Professor Arline Geronimus followed with the Weathering Hypothesis in the early 1990s to explain Race by Gender mortality differentials, and this work has been tested using allostatic load and cellular aging techniques in addition to being applied to other outcomes (pdfs at the end). The 2009 Nobel Prize in Medicine provided a means of using biological evidence in the form of Telemores, to study the impact of structural Racism on individual health. The march of Science.

The use of Telomeres to document differential aging by Race remains an emerging field that is limited by the samples available for study (selection bias is always an important factor when interpreting research, whether a RCT or not, and there are tradeoffs between internal and external validity). More research, as always, is needed and understanding Black/White mortality differences affects us all, because our assumptions about the causes influence what we think about one another and therefore how we respond, individually or as a society via public policy. Life expectancy at birth is 4.6 years less for Black males as compared to White males; and 1.8 years shorter given survival to age 65 (red underline males; yellow highlight females–table is in this post).

The best that the modern Research University can offer is an amalgam of scholars doing what they do in the manner that they do it, and disputes both within and across disciplines are legion. It is difficult to synthesize scholarship across disciplines, time and methods. Maize, mice, humans, telomeres, bench to bedside translation, history, public policy, business, art, literature and ethnography. This is who we are collectively as a modern research University, and just as Barbara McClintock’s discovery gained dust for decades until she won the Nobel Prize in 1983, human knowledge progresses in a non-linear fashion, and you never know when a unique insight will provide the missing piece of the puzzle.

Answering whether Racism or “living while Black” is an independent predictor of health, or simply a proxy for other factors cannot be investigated in an experimental manner. We cannot go back and randomize some to live under Structural Racism and others to not, or to run 1,000 experiments of “Reconstruction” and identify how different courses of history over the past 150 years might change the distribution of illness and longevity by Race that we see today. The 1862 Homestead Act, in force and revised numerous times until its repeal in 1972 distributed 10 percent of the land in the United States to individuals. Had this program not had a Century long history of discriminatory practices against freed Slaves and Blacks, we would undoubtedly observe a different wealth distribution and life expectancy spread by Race. Counterfactual thinking is hard, and requires painstaking effort to piece together what different disciplines have to say.  

How Do You Know What You Know? Zane’s piece describes Professor Staddon as simply wanting to ask “how do you know what you know?” and having no interest in politics. I agree that this question is central to the life of the mind and the University, but the Harold Lasswell definition of politics still rings true from graduate school–“Who gets What, When and How?” Nothing is apolitical, including, or perhaps especially, assuming that only those things that can be studied via experimental or reductionist evidence are knowable, or worth knowing. Interestingly, a book that I wrote with Frank Sloan and others (The Price of Smoking MIT Press, 2004) apparently played a role in Professor Staddon’s “tipping point” to concluding the University has been given over to political correctness , based on the quote in Mr. Zane’s piece of him mis-interpreting one of our book’s findings:

Still, he says, “my personal tipping point” regarding the uses and misuse of science occurred some two decades later, “when I found out that despite massive publicity to the contrary, smoking has no public cost.”

This is not what we found. This post from 2011 explains what I mean—cigarette taxes did on average cover the external costs of smoking, but did not cover quasi-external ones, and we explicitly assigned a dollar value of $0 to the intangible cost of life years lost. We did this because the range of estimates in the literature differed by orders of magnitude, thus allowing readers to use the per pack estimate they believed to best represent the intangible costs of smoking mortality that we left aside in order to painstakingly highlight the economic costs and their distribution. Many have made a similar assumption about the book, and there is much nuance of interpretation, and very little of this work is based on experimentation. However, our work was obsessed with identifying the best possible counterfactual given that experimentation is uncommon or impossible in the study of Smoking outside of pharmaceutical work and social-psychology based perceptions of risk, and our concept of the non-smoking smoker, estimated via Smoking Life Tables, and the identification of “quasi-external” costs, or those imposed by smokers on their families are the most important theoretical and methodological innovations of the book. If such research is not Science then most of what impacts human beings today cannot be studied by Science.

I think our book is great, and you should buy 20 copies. However, if the distributional analyses of one book (no matter how good!) on the most heavily studied topic of the past 80 years (the impact of Cigarette Smoking on humans) could send Professor Staddon over the top to his conclusion that Universities have given into political correctness and lost our way, then to paraphrase the Eagles, that had to be where he already knew how to go.

PDFs of selected relevant works mentioned above, but not readily available via hyperlink are below

White Supremacy v. Structural Racism

Working on an NIH Institutional grant to develop a culture that is more conducive to the thriving of faculty who are from under-represented backgrounds. The task at hand is to create an equitable culture of scientific excellence.

The FOA from NIH focuses on Race, and the writing team has been discussing whether to use the term White Supremacy or Structural Racism. I think that White Supremacy is the most directly correct term, because a great deal of the Structural or Systemic harm operates visually–the billions of calculations my brain makes when I see someone in a space. This is how “may I help you?” operates when it is experienced and sometimes meant as a worried “Why are you here? Am I in danger? Are you going to steal my stuff?”

We are going with the phrase Structural Racism, which I consider broadly to be a less specific synonym of how Race in the United States helps those who can pass as White, and harms those who cannot, but this is NIH, a slowly moving organization. And them having this initiative at least acknowledges that identifying the impacts of Structural Racism on Universities has not yet lead to true culture change. May a new day dawn at Duke.

Teaching history in North Carolina

The North Carolina Board of Education is discussing how to teach U.S. and North Carolina history in public schools and some Republican members of the Board are saying proposed changes are “anti American” and wrongly teaching students that the U.S. is “racist” and “anti capitalist.”

Lorda mercy.

Why don’t we elevate and teach some of the stories that I did not learn in 4th and 8th grade units in North Carolina history, and in two units of U.S. history in high school. Get the kids talking about why (1) this did not used to be taught; (2) why we are doing it now; and (3) let them discuss what they think this means for the World we are leaving them.

Several topical suggestions that can provide students with a sense of discovery and get them talking about Race, based on engaging some of our history that has been avoided.

  1. Ask Students to read and then rewrite Article 1, Section 2, Clause 3 of the U.S. Constitution in modern language. What was being said here? Is that section still in force?
  2. In 1871, Governor William Holden of North Carolina became the first Governor in U.S. history impeached and removed from office. Why was he removed?
  3. In 1898 the local government in Wilmington, N.C. was deposed and run out of town and a bunch of folks got murdered. I never heard of this event until I was 30, even though I grew up in Goldsboro, about 75 miles from Wilmington. Why did this event take place? Why did I not learn of this until I was 30?
  4. Today in the U.S. Capitol building, the two statues representing N.C. are Governors Zebulon Vance and Charles B. Aycock (from Goldsboro!). They have been there since the 1920s (Aycock is being replaced by the Rev. Billy Graham later this year). Why were they the two N.C. statues for nearly a Century? In 2011, the North Carolina Democratic Party changed the name of their annual fundraiser away from the Vance-Aycock dinner, so named in 1960. Why did the Democratic Party add and then remove their names when they did?
  5. There has been lots of discussion of removing Confederate monuments and memorials. Let’s talk about when they were put up and where. In the first wave from the 1860s-1880s they were mostly in military cemeteries (purple bars), while in the twentieth Century they were mostly put up in public places like town squares and college campuses (orange bars). Why the change? [the below is one slide in this link on the “Silent Sam” monument that used to be on the UNC Chapel Hill campus].

I promise the students will do a better job talking about what this history means for our World today and their World tomorrow, than their parents or grand parents will.

Confederate monuments in North Carolina, by year of erection. Purple is in cemetery, Orange is in public place like a town square, or a campus.

Should Race be used in vaccination guidelines?

The draft report of the CDC’s Advisory Committee on Immunization Practices (ACIP) on November 23, 2020 suggested the use of Race in prioritizing the allocation of limiting COVID19 vaccination as a means of promoting justice and reducing health inequities. This move was controversial and the final ACIP recommendation released on January 1, 2021 removed the explicit use of Race, and emphasized the use of age once health care workers were vaccinated, before moving into further specific risk groups that prioritized congregant living and occupational exposure. Is there any scientific and epidemiological evidence that Race should be used to prioritize the limited supply of COVID19 vaccines? In short, yes.

The United States has had more direct discussion of the role of Race in American life this year than in the rest of my life combined, focused on COVID19, the BLM movement, the spate of Confederate monument removals, and the differential treatment of White protesters who attacked the U.S. Capitol on January 6, 2021. However, the idea of using Race to help allocate limited vaccine supply caused an immediate, and guttural pushback. Why?

CDC data shows that Race is a predictor of increased risk of COVID19 cases, hospitalizations and deaths.

The CDC describes Race as a proxy for poorer outcomes, and Black, American Indian and Latino/a persons all have substantially elevated COVID19 mortality as compared to Whites:

Race and ethnicity are risk markers for other underlying conditions that affect health including socioeconomic status, access to health care, and exposure to the virus related to occupation, e.g., frontline, essential, and critical infrastructure workers.

Measures of Biological Aging and Distribution by Race

Telomeres are caps on on DNA strands whose length provides a measure of cellular aging, and an emerging body of research suggests that cellular aging is more rapid for Blacks as compared to Whites, even after controlling for other factors that influence Telomere length, such as poverty, obesity, smoking and exercise. This remains an emerging field that is limited by the samples available for study, so more work is needed. Life expectancy at birth is 4.6 years less for Black males as compared to White males at birth; and 1.8 years shorter given survival to age 65 (red underline males; yellow highlight females). It is longer for Hispanic males and females, a complex phenomenon know as the Hispanic/Latino paradox.

The discovery of Telomere length differences by Race support the Weathering hypothesis explanation originally put forth by Arline Geronimus in 1992 to explain shorter Black life expectancy, that posited that the cumulative social stress and Racism experienced by Blacks in the United States leads to accelerated aging. Subsequent work has identified Allostatic Load, a cumulative measure of stress processes that is linked to the processing of Cortisol that floods the body during fight or flight situations, as a likely pathway through which Blacks experience accelerated cellular aging as compared to Whites as measured by Telomere length. More recent research has confirmed the independent effect of Racism and “living while Black” on Telomere length and allostatic load. There is a plausible biological pathway linking Racism to shorter life expectancy, particularly remaining life expectancy given attainment of age 65.

Age is by far the largest predictor of COVID19 mortality, in the U.S. (data through December 20, 2020), and a far stronger predictor than is Race (The relative risk for Race is 2.6-2.8–see figure 1, while age 65-74 has 90 times the mortality compared to age 18-29–figure 2). However, given the evidence of differential cellular aging identified among Blacks as compared to Whites, Race may well be a reasonable age-modifying variable that would allow us to better target those at most risk of death from COVID19. For example, the top priority group after front line care workers is persons age 75+ a standard that could be modified to be age 73 for persons who are Black, for example, using life expectancy at age 65 results shown above. This would easily be implemented via electronic medical record notification and a different age cut in mass inoculation events. A similar adjustment could be made for American Indians, as well as for Hispanic/Latino individuals though for the latter the excess mortality due to COVID19 is in the opposite direction of the Hispanic/Latino paradox and may be more related to occupational exposure than cellular aging and Weathering, making that subgroup finding all the more striking.

The United States was fully unprepared to have a conversation about the use of Race as a modifying variable for distributing a highly sought after commodity, in part because White people tend to lay the blame for worse mortality outcomes for Blacks as solely being the responsibility of people who are Black. We tend to exempt ourselves from any responsibility for the systems we live in that benefit us and harm others. We have strong scientific evidence that Racism and the social stress of living while Black in our society causes cellular level harm that plays a role in poorer outcomes experienced by Blacks, including reduced lifespan. There are scientific advances that are needed to better understand and operationalize the use of allostatic load and telomere length for public health interventions, but the most important task may well be that White people learn to talk about how Race impacts our world today in a less defensive, and more informed posture. It will be hard, but we will only get better with practice.

Re-norming our Government

On January 20, 2021, the day that Donald Trump leaves and Joe Biden moves into the White House, there are two principles that I believe are most important for the next four years: accountability for the assault on our democratic norms, not only for President Trump, but for enablers in the Republican Party and beyond, while seeking to reimpose and reinforce these same, fragile norms.

Unfortunately, the rhetorical phrase “but that is not as bad as what President Trump did” now covers anything short of a successful, violent overthrown of the Constitutional system of transferring power. What we saw on January 6, 2021, was four years in the making, and it could have gone differently. The system did not work, we got lucky. We need to heal, and the first step toward that is confession by elected Republican enablers telling their supporters the truth, that the election was not only a fair one, but the most parsed and adjudicated election in U.S. history. It seems to me these Republican enablers also owe their constituents an apology for misleading them.

Democrats and Progressives cannot control what Republicans will do, but we can control what we do.

We need some old school boring civics the next four years. On immigration, the House should see if it can pass a bill, and the Senate do the same. Pass a rule in the House that allows floor amendments, let the Senators make their case and then vote. Then lets have an old school conference committee see if they can bang out a deal that can pass both Houses of Congress and be signed by President Biden. The Congress needs to be reinvigorated as the Article 1 branch of government that it is, and we have to get away from omnibus legislation linked to debt limit increases for money we already spent getting jammed into must-pass legislation at 11pm, the night before we default. I know immigration is hard, as is COVID19 relief, health care, voting rights and elections, etc. If members of Congress cannot lean into hard work, then they should resign.

I am not suggesting a head in the sand Jedi mind trick approach that pretends that the last four years did not take place, I am saying that we need to hold people accountable while reinforcing our democratic system of government so that we make something worse less likely in the future. Our peaceful transfer of power string has been broken, about two and a half Century’s into our history, and we should now know that nothing inevitably continues. It will take work.