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Proc (Bayl Univ Med Cent). 2017 April; 30(2): 246–252.
PMCID: PMC5349846

Facts and ideas from anywhere

SLEEP DEPRAVATION

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William C. Roberts, MD.

Arianna Huffington has produced a terrific book entitled The Sleep Revolution: Transforming Your Life, One Night at a Time (1). Her approach includes discussions of important recent scientific discoveries on sleep and many human stories and experiences. Sleep is one of Ms. Huffington's passions. She dedicated this book to “the millions of people around the world who are sick and tired of being sick and tired and longing for a good night's sleep.” The rest of this piece comes from her book.

The medical consequences of sleep deprivation have only recently been recognized. In the 1970s there were only three centers in the USA devoted to sleep disorders; by the 1990s that number had increased to >300, and today, there are >2500 accredited sleep centers. The delusion persists that we can do our jobs just as well on 4 or 5 or 6 hours of sleep as we can on 7 or 8. It is a delusion that affects not only our personal health but our productivity and decision-making. She writes, “The surrendering to sleep every night is the ultimate letting-go.” More than 40% of American adults get less than the recommended minimum 7 hours of sleep per night. Huffington continues, “We are only now beginning to come out of a phase that started with the Industrial Revolution in which sleep became just another obstacle to work. The veneration of sleep as a unique portal to the sacred was sacrificed to the idea of progress and productivity.”

Sleep deprivation has become an epidemic. Both our daytime hours and our nighttime hours are under assault as never before. As the number of things we need to cram into our day has increased, the value of our awake time has skyrocketed. Scientists are resoundingly confirming what our ancestors knew instinctively: that our sleep is not empty time; sleep is a time of intense neurologic activity—a rich time of renewal, memory consolidation, brain and neurochemical cleansing, and cognitive maintenance.

Our sleep time is as valuable a commodity as the time we are awake. In fact, getting the right amount of sleep enhances every minute we spend with our eyes open. And it is a collective delusion that sleep is simply time lost. Sleep deprivation is glamorized and celebrated: “You snooze, you lose.” The distractions and temptations of a 24/7 wired world have imperiled our sleep as never before. Most of us are paying a high price for cheating sleep. Sleep is just as important as good nutrition, physical activity, and wearing a seatbelt. Sleep deprivation is our most underrated health habit.

The crisis is global. The unquestioning belief that work should always have the top claim on our time has been a costly one, and it has gotten worse as technology has allowed a growing number of us to carry our work with us in our pockets and purses in the form of our phones. Being perpetually wired is now considered a prerequisite for success. In the last 50 years, our sleep on work nights has dropped from 8.5 to just under 7.0 hours per night. Thirty percent of employed Americans now report getting 6 hours of sleep or less per night, and nearly 70% describe their sleep as insufficient. Getting less than 7 hours of sleep per 24 hours is one of the biggest factors in job burnout.

The lower the socioeconomic position, the poorer the subjective sleep quality, the greater the sleepiness and sleep complaints. Where we live also affects our sleep. There appears to be a direct association between neighborhood quality and sleep.

The annual cost of sleep deprivation to the US economy was estimated recently to be $63 billion in the form of absenteeism and presenteeism (when employees are present at work physically but not really mentally focused). A tired worker accomplishes less than a nontired worker. Our loss of sleep, despite the extra hours we put in at work, adds up to more than 11 days of lost productivity per year per worker, or nearly $2300. Besides lost productivity, sleep deprivation leads to driving and workplace accidents.

Women need more sleep than men. Poor sleep is strongly associated with high levels of psychological distress and greater feelings of hostility, depression, and anger. Women who work outside the home work more at home than most male mates.

Good sleep lengthens lifespan. Death rates from all causes go up 15% when we sleep 5 hours or less per night, and sleep deprivation makes us dangerously less healthy. About 60% of men who suffer a heart attack also have a sleep disorder. Adults who have trouble falling asleep are involved in a third more fatal car accidents than those who do not have trouble. And those with symptoms of insomnia are nearly three times more likely to die from a fatal injury. Sleep deprivation also makes us more susceptible to garden-variety illnesses, like the common cold.

Sleep deprivation has a major impact on our ability to regulate our weight. In a Mayo Clinic study, sleep-restricted subjects gained more weight than their well-rested counterparts over the course of the week, consuming an average of 560 extra calories a day. People who get 6 hours of sleep a night are nearly 25% more likely to be overweight than those who get more than that. Getting <4 hours of sleep per night increases the likelihood of being overweight by nearly 75%. In other words, cutting back on sleep is a fantastic way to gain weight.

And sleep deprivation plays havoc with our skin. In a Swedish study, untrained participants were asked to look at sleep-deprived and well-rested people. Participants judged those in the sleep-deprived group as “less healthy, more tired, and less attractive.” The skin was analyzed and photographed after they slept for 8 hours and then again after sleeping 6 hours for 5 nights in a row. Fine lines and wrinkles increased by 45%, blemishes went up by nearly 15%, and redness increased by nearly 10%. In other words, we wear our lack of sleep on our faces.

Good sleep is also a key to mental health. Sleep affects our mental health every bit as profoundly as it does our physical health. Sleep deprivation has a strong connection with practically every mental health disorder, especially depression and anxiety. One study showed that sleep-deprived people were 7 times more likely to experience feelings of helplessness and 5 times more likely to feel lonely than controls. Sleep deprivation takes a toll on our mental abilities. Our cognitive performance is reduced greatly, memory capacity is reduced, and social competence is reduced. In just 2 weeks of getting 6 hours of sleep per night, the performance drop-off is the same as going 24 hours without sleep. For those getting just 4 hours, the impairment is equivalent to going 48 hours without sleep. The side effects of not getting enough sleep include having difficulty concentrating, losing interest in hobbies and leisure activities, falling asleep at inappropriate times throughout the day, losing our temper or behaving inappropriately with children or partners, and behaving inappropriately at work.

In terms of driving while drowsy, one study found that after being awake from 17 to 19 hours, we can experience levels of cognitive impairment equal to having a blood alcohol level of 0.5% (just under the legal limit in many US states). And, if we are awake just a few hours more, we are up to the equivalent of 0.1%—legally drunk. There is of course a roadside test for drunk driving; there is no equivalent test for sleep-deprived driving. Awareness of the impact of sleep deprivation on driving is important. Nearly 60% of train operators, 50% of pilots, 44% of truck drivers, and 29% of bus and taxi drivers admit that they never or rarely get a good night's sleep on work nights.

So why do we tolerate, much less venerate and applaud, sleep deprivation? In much of our culture, especially in the workplace, going without sleep is considered a badge of honor. Yet since the effects of sleepiness are largely the same as those of being drunk, when we get behind the wheel of a car without enough sleep, we are engaging in behavior that is dangerous to both ourselves and others. Sleepiness-related motor vehicle crashes have a fatality rate and injury severity level similar to those of alcohol-related crashes. Drowsy drivers are involved in 330,000 accidents each year, 6400 of which result in death.

Sleep experts have a name for the phenomenon of nodding off: “microsleep.” Microsleep occurs when we unknowingly fall asleep from a few seconds to a minute or so. It is a terrifying phenomenon when one is behind the wheel of a car. Imagine commuting home from work driving down the highway at 60 miles per hour. At that speed, the car is traveling 88 feet per second. If your eyes close for only 4 seconds, your car has traveled roughly the length of a football field before you jerk awake, and the consequences, of course, can be deadly. And nowhere is this truer than in the trucking industry. There are now an estimated 2 million truckers on our highways, and accidents involving trucks and buses are responsible for 4000 deaths and >100,000 injuries in the US each year. More than 60% of the drowsy drivers involved in fatal crashes were driving trucks, and nearly half of all truckers have said in a survey that they had fallen asleep behind the wheel in the previous year. Several states are considering measures that would make driving while sleep deprived a criminal offense.

Airlines have stricter standards, with rules mandating specific rest periods for commercial pilots between flights and dictating how many hours they are allowed to fly in a given period of time. One pilot of a Boeing 747 said in the PBS documentary Sleep Alert, “It is not unusual for me to fall asleep in the cockpit, wake up 20 minutes later and find the other two crew members totally asleep.” Luggage screeners deteriorate rapidly when they are sleep deprived. Air traffic controllers averaged only 5.8 hours sleep per night, which dropped to 3.25 hours per night when they worked overnight shifts. Of the controllers who made safety errors on the job, 56% attributed the mistake to fatigue. Train accidents from sleep deprivation also occur.

Of course, physicians and nurses commonly are sleep deprived. Sleep-deprived health care workers show less empathy, among other consequences. Sleep-deprived adolescents (those getting <7 hours of sleep per night) were at a higher rate of failing and had higher dropout rates than those sleeping >7 hours nightly. Politicians, soldiers, and law enforcement officers are burdened considerably with sleep deprivation.

I found the book to be superb. Every page is loaded. And she advises how to sleep better. She has never taken a sleeping pill.

BELLEVUE

David Oshinsky, who previously authored Polio: An American Story, has produced a terrific book entitled Bellevue: Three Centuries of Medicine and Mayhem at America's Most Storied Hospital (2). The information that follows comes entirely from his 2016 book.

Bellevue started as a small infirmary built in the 1660s for soldiers overcome with “bad smells and filth,” and it was replaced in 1736 by a two-story almshouse that served 19 paupers, included a prison, and had a room for the sick and insane. By 1795, the almshouse had become home to 800 people. Bellevue Hospital opened on its present site—30th Street and the East River—in 1816 and contained an almshouse, orphanage, lunatic asylum, prison, and infirmary.

The hospital then and still today serves what a 1900 city official said were the “dregs of society”—a dumping ground for poor patients who could not pay and for those who were dying. Through every major epidemic, Bellevue has provided free care to the medically indigent. From the yellow fever outbreak at the end of the 19th century to the AIDS epidemic of the 1980s, when Bellevue treated more AIDS patients than any other hospital in America, the hospital “has borne witness to every imaginable public health scare, every economic swing and population surge, every medical breakthrough and controversy.” During the great influenza epidemic of 1918–1919, no one was turned away, “forcing the patient overflow to sleep on doors ripped from hinges and piles of damp, fetid straw.”

“What set Bellevue apart, even in the worst of times,” Oshinsky writes, “was its powerful connection to New York City's top medical schools.” By the mid-19th century, Columbia College of Physicians and Surgeons and the Medical College of New York (later New York University [NYU]) sent their students to Bellevue. The city's “elite physicians for whom the lure of interesting patients outweighed the fear of deadly miasmas and physician blight” were applying for visiting positions. Soon after it opened in 1898, Cornell Medical School joined Columbia and NYU in sending its medical students to Bellevue. The training the young physicians received in the early 1960s may have been the best any physician could receive, largely for two reasons: the dedication of many faculty members and the fact that the hospital was “a virtual war zone.” Because the patient population came largely from New York City's foreign-born residents and its underclass—immigrants, derelicts, alcoholics, addicts, the homeless, the mad, and the discards and dying sent from other hospitals—students became familiar with a wide range of illnesses few other medical students would ever see elsewhere.

The students and young houseofficers worked under abysmal conditions. More than 100 tuberculosis patients were often stacked in corridors awaiting beds. Operations were routinely canceled during heat waves because there was no air-conditioning. Stray cats roamed the doctors' basement dining rooms to ease the invasion from the hospital's maze of rat-infested underground tunnels.

By the time of the Civil War (1861–1865), Bellevue “had become both our nation's largest hospital and its most important medical training ground.” Medical training could be summed up in a single word: immigration. Early waves of immigrants were mostly Irish and Germans; after them came Italians and Jews; and then Hispanics, Haitians, Africans, South Asians, and Chinese. Most of Bellevue's patients—the poor, the mad, and the despised—have been those who had nowhere else to go. In its >280 years of existence, Bellevue has never turned away a patient! Just as Irish immigrants were considered dangerous foreigners inflicting a typhus epidemic on New York in the mid-19th century, so Jewish immigrants were later thought to have a “tailor's disease” that was causing an epidemic of tuberculosis. In recent times, gays, blacks, Hispanics, drug addicts, and homeless people have been vilified as carriers of AIDS. No matter which ethnic group is alleged to spread disease in New York, Bellevue has not only persisted in providing medical care for generations of the city's residents, but has served as a model of how a public hospital can survive and give excellent care. Bellevue handles nearly 670,000 nonemergency clinic visits and nearly 116,000 emergency visits each year. Approximately 80% of those it serves are either uninsured or poor enough to be covered by Medicaid.

More than 3 million of New York City's 8.5 million residents are foreign-born, many of whom are undocumented. As many as 800 languages are spoken in New York, making it the most linguistically diverse city in the world, and at Bellevue >100 languages are translated. Among them are Mandarin, Cantonese, Polish, Bengali, French, Spanish, and Haitian Creole. As Oshinsky writes, “Doctors and patients communicate on dual telephones through an interpreter trained in the nuances of regional dialects. The directional signs that guide visitors through the hospital are multilingual—the destinations now include a Muslim prayer room and a clinic for the survivors of political torture.”

During its 300-year history, Bellevue Hospital has always been short of funds. Somehow Bellevue has always survived, probably because of the quality of its medical care, the fact that it provides unique services to the city (e.g., the medical examiner's office and forensic labs), and its ongoing relation to NYU Medical School, an affiliation that has served both well for over 100 years. It is unlikely that Bellevue will go away. NYU's physicians, medical students, residents, and attendees train and work at Bellevue. And Bellevue pays NYU an annual sum for these services. Bellevue's increasing lack of funds remains a major concern for the city presently.

There was never a time when Bellevue appeared to be even remotely trouble free. Yet, while caring for millions of patients other hospitals turned away and often on the verge of being closed down by the city, it was also among the nation's leaders in medical research and innovation. Bellevue, for example, was the first American hospital to establish a maternity ward (1799), a nursing school (1873), a children's clinic (1874), an emergency department (1876), a psychiatric ward (1879), an ambulance corps (1869), a pathology laboratory (1884), and a medical photography department. It produced lasting innovations in amputations, anesthesia, antisepsis, and the treatment of tuberculosis, heart disease, and AIDS. Throughout its history, its physicians constantly demanded that the city provide decent conditions for their patients and humane conditions for the city's poor and underserved citizens.

Bellevue's faculty and graduates read like a “Who's Who” of modern American medicine: Hermann Biggs, a pioneer in the prevention of tuberculosis; Walter Reed and William Gorgas, who tamed the ravages of yellow fever; William Hallock Park, who brought the lifesaving diphtheria antitoxin to the US; Joseph Goldberger, who discovered the cause of pellagra; Thomas Francis, whose influenza research revolutionized the study of virus strains; André Cournand and Dickinson Richards, who introduced cardiac catheterization as a clinical tool; and Albert Sabin and Jonas Salk, who developed the two successful polio vaccines still in use today. Two of the most influential figures—William Welch, the father of modern pathology in the USA, and William Halsted, the era's most innovative surgeon—bonded as interns at Bellevue in the bitter struggle to bring antiseptic methods to the profession.

By the early 1900s, Bellevue seemed less a city hospital than a hospital city, with 2000 beds, a nursing school, the city morgue, a massive psychiatric pavilion, a special prison ward, top-flight laboratories, a maintenance force of 4000, and a medical staff provided by the three best medical colleges in New York. A major facelift came in 1973 with the addition of a 25-story patient tower. The impact on New York City was dramatic.

Bellevue today remains a buttress against unforeseen crises that periodically arise. Its resilience was displayed in the heroic patient evacuation during Superstorm Sandy, the largest storm ever recorded in the Atlantic Ocean, with a diameter approaching 1000 miles. It hit New York City full on October 29, 2012, when the hospital became flooded and its elevators went out of service. The staff began carrying patients down the stairwells led by medical students and residents holding flashlights. Houseofficers were dispatched with oxygen tanks to the beds of every ventilated patient. Intravenous infusions were converted to subcutaneous injections, and prescriptions filled by flashlight were taken by medical student runners to various floors. The National Guard arrived, and together with physicians, nurses, medical students, technicians, and secretaries they passed 5-gallon jugs of gasoline hand-to-hand until the jugs reached the backup generators on the 13th floor. If the jugs stopped moving and the generators died, so would patients. No patients died. The bucket brigade staved off disaster, and all 700 patients were saved, including surgical patients, alcoholics, drug addicts, hundreds of psychiatric patients, and 61 criminal patients locked up on the 19th floor. Superstorm Sandy closed the hospital for the only time in its history. Bellevue reopened a few months later. The patients it currently serves are every bit as poor and needy as the patients who preceded them in centuries past. Those with viable options almost always wind up going somewhere else. That is what makes Bellevue so comforting and so disquieting. It stands for all its troubles as a vital safety net—a place of last resort.

GUNS IN THE USA

Individuals in the USA own far more guns than populations of any other country in the world (3, 4). In the USA there are 114 guns per 100 citizens. The US gun-ownership level in 1968, 48 years ago, was 56 per 100 people, or half of what it is today. The estimated number of civilian-owned guns per 100 people in other countries is as follows: Serbia, 76; Yemen, 55; Switzerland, 46; Cyprus, 36; Saudi Arabia, 35; Iraq, 34; Uruguay, 32; Sweden, 32; Norway, 31; France, 31; Canada, 31; and Australia, 22. There are >33,000 gun deaths annually in the US, according to averages from 2014 to 2016. Terrorism and mass shootings grab the headlines but make up a small percentage of US gun deaths, numbering 45 in 2016. Other deaths, by comparison, include armed toddlers, 21; lightning strikes, 31; and lawnmowers, 69. Since the mass shooting at Sandy Hook Elementary, an American child under age 12 has died by intentional or accidental gunfire every other day. More than half of all homicide victims are young men and two-thirds are black. Among blacks, 82% of fatalities are homicide and 18% are suicide, and among whites, 23% are homicide and 77% are suicide. Gun manufacturing is big business in the USA. The 2015 revenue from manufacturing guns and ammunition was $15 billion; that's more than the 2015 combined government funds for medical research.

Gun deaths in Australia have dropped dramatically since 1996 when its buyback program began (5). Since the massacre that year in Australia, where 35 people were killed and 23 wounded by a semiautomatic rifle used by a 28-year-old man on the island of Tasmania, off the southern coast of Australia, the country's criminal justice system quickly held Martin Bryant responsible, and he is serving a life sentence. Just-elected Prime Minister John Howard, a conservative, led the charge for a bipartisan deal with state and local governments to enact far-reaching gun laws. A conservative-led government action contradicts those who maintain that the gun problem is unconquerable, that smart laws cannot make a difference. Australia put its national firearms agreement into action within 2 months of Bryant's rampage. The law prohibits automatic and semiautomatic assault rifles and pump action weapons; it also requires residents who already owned high-powered long guns to sell them back to the government. More than 650,000 firearms were handed in, at a cost of $350 million funded by a temporary federal tax. The law also made buying other guns more difficult. People now must pass a safety test, show good moral character, and wait at least 28 days to make their purchase. And they must qualify under carefully defined “genuine needs” to own a gun. Private sales are prohibited, and all weapons must be individually registered to their owners.

In the two decades prior to the reform, Australia saw 13 fatal mass shootings, defined as those with five or more victims. In the two subsequent decades, not another mass killing has occurred! The law also appeared to accelerate a reduction in firearm-related homicides and suicides without prompting a rise of alternative means of death. Thus, an intervention designed to stop mass shootings also has limited other gun-related deaths. The daunting size of America's gun violence does not have to paralyze us. Large-scale change is possible.

GUN-RELATED VERSUS MOTOR VEHICLE DEATHS IN THE USA

For the first time in decades, the annual number of gun-related deaths in the US is expected to surpass the annual number of automobile fatalities (6). In 2013, the most recent year for which data is available, motor vehicles killed 33,804 people and firearms killed 33,636, according to the US Centers for Disease Control and Prevention. Firearm deaths and injuries pose a major public health problem.

TEXAS PRISON POPULATION

In 1985, it was 37,488 and in 2016 it was 146,843 (7). The annual budget of the Texas Department of Criminal Justice is $3.4 billion, and for the entire US it is roughly $80 billion. The USA, with 5% of the global population, leads the world in people locked in prisons. Presently, the US imprisons approximately one-fourth of all the world's prisoners. Black and Latino men make up >60% of the prison population, including two-thirds of those locked up in Texas' 109 facilities. One problem is the 1994 Omnibus Crime Bill that gave birth to the federal three-strike rule that mandated life sentences for criminals convicted of a felony after two prior convictions, including drug crimes. Although these numbers are high, Texas is beginning to see a drop in the number of prisoners, thanks both to a budget pinch and to a shift in philosophy.

TEXAS EXECUTIONS DECLINING

Texas executions and death sentences are occurring at the lowest rate in decades (8). Only three people in the state were sentenced to death in 2016, and seven others were executed. The numbers are still higher than in most other states, but represent a sharp decrease for Texas. There are now 242 inmates on death row in Texas—the fewest since 1987. Death sentences in 2016 are at their lowest level in 30 years and executions at their lowest level in 20 years.

ALCOHOL DRINKING IN WOMEN

According to a recent analysis by two writers of The Washington Post, women in the USA are now drinking far more alcohol and far more frequently than their mothers and grandmothers, and alcohol consumption is killing them in record numbers (9). White women are particularly likely to drink dangerously, with more than a quarter drinking multiple times a week, and the share of their binge drinking is up 40% since 1999. In 2013, more than 1 million women of all races wound up in emergency rooms as a result of heavy alcohol consumption, with women in middle age most likely to suffer severe intoxication. This behavior has contributed to a startling increase in early mortality. The rate of alcohol-related deaths for white women aged 35 to 54 in 2015 was 8% of deaths in this age group, twice that in 1999.

Some of this increase has been attributed to advertisements in social media—Facebook, Twitter, and Instagram—focusing on the most eager consumers. Jokes about becoming inebriated are common. One Twitter ad featured a bottle the size of a refrigerator tilted toward a woman's lips. Its contents: Fireball Cinnamon Whiskey. Women also are frequently shown drinking alcohol to cope with daily stress. In one image that appeared on a company website, two white women wearing prim, narrow-brimmed hats, button earrings, and wash-and-set hair confer side-by-side. “How much do you spend on a bottle of wine?” one asks. The other answers, “I would guess about half an hour….” At the bottom is the name of the wine: “Mommy's Time Out.”

Drinking alcohol can be especially hazardous for women. Women, of course, tend to have smaller bodies than men and differences in physiology that make blood-alcohol levels climb faster and stay elevated longer than in men. Some studies have found that women have lower levels of the stomach enzymes needed to process the toxins in alcoholic beverages. As a result, according to the Centers for Disease Control and Prevention, women are more prone to suffer brain atrophy, heart disease, and liver damage. Even if a woman stops drinking, liver disease may continue to progress in ways it does not do in men. There is no gender equity when it comes to the effects of alcohol on men vs. women. Women are more susceptible to the unwanted biologic effects of alcohol when they consume the same amount of alcohol and at the same frequency, even when there is an adjustment for weight.

DRY EYES AND CELLPHONES

According to an article by Ann Lukits (10), pediatric dry-eye disease can negatively affect vision and school performance and is believed by many specialists to be underdiagnosed. Staring at smartphones, computers, and other screens has been linked to reduced blinking, which can lead to faster evaporation of the tear film and increase the risk of dry-eye disease. Smartphones also have a short watching distance due to their small screens that can tire the eyes. Researchers in South Korea conducted eye exams on 916 children aged 7 to 12 years: 60 (7%) of the total met the criteria for dry-eye disease based on various assessments including tear-breakup time, a test that measures the stability of tear film. Of those 60 children, 58 (97%) reported on questionnaires that they used smartphones an average of 3.2 hours a day. In contrast, of the 856 children without dry-eye symptoms, the control group, 55% used smartphones 37 minutes a day. The latter group also spent more time outside—an average of 2.3 hours a day compared with 1.5 hours by the dry-eye group. The prevalence of dry-eye disease was higher among students in urban than in rural schools.

US ABORTION RATES

The rate of abortions in the US has fallen to its lowest level since the 1973 Roe vs. Wade Supreme Court decision (11). In 2014, there were 14.6 abortions per every 1000 women aged 15 through 44 in the US, down 50% from a peak of 29.3 abortions per 1000 in the early 1980s. The number of abortions fell to 926,200 a year for the first time since 1975. The number of abortions in the US reached a peak of 1.6 million in 1990. The decline in numbers of abortions is likely the result of reduced unintended pregnancies due to the increased availability of affordable, long-lasting contraceptives, such as IUDs.

MANDATORY IUDS IN CHINA

Thirty years ago, China began demanding that women be fitted with an intrauterine device after they had one child and sterilized after they had two (12). From 1980 to 2014, 324 million Chinese women were fitted with IUDs. Now these IUDs can be removed free of charge at government expense. While IUDs in other countries often can be removed with a tug on their strings in a physician's office, surgery is usually needed in China because most devices were designed or altered to be more difficult to extract. Now, with fewer young people to support larger numbers of retirees, President Xi Jinping relegated the one-child policy to the Communist Party's scrap heap of discarded dogma—pivoting from punishing couples for having a second child to encouraging reproduction.

HOTTEST YEAR

The average temperature in 2016 was the hottest recorded since 1880, when records started being kept (13). In 2015, the temperature was the hottest up to that point, and in 2014, the hottest up to that point. According to the National Oceanic and Atmospheric Administration, the average surface temperature in 2016 was 0.07°F warmer than 2015 and featured eight successive months (January through August) that were individually the warmest since the agency's recording began. That the earth is heating up is a point long beyond serious scientific dispute, and one becoming more evident each year. Temperatures are rising toward levels that many experts believe will pose profound threats to both the natural world and to human civilization. In 2015 and 2016, the planetary warming was intensified by the weather pattern known as El Niño, in which the Pacific Ocean released a huge burst of energy and water vapor into the atmosphere. The biggest factor in setting the records, however, is the increasing levels of carbon dioxide and other greenhouse gases. The heat extremes were especially pervasive in the Arctic where temperatures in the fall ran 20° to 30°F above normal. Sea ice in that region has been in precipitous decline for years. Arctic communities are already wrestling with enormous problems, such as rapid coastal erosion, caused by the changing climate.

Since 1880, the planet has now warmed about 1.1°C or 2°F. That is very significant because the global community has been striving to limit overall warming to considerably below a 2°C rise, and even, if possible, to hold it to a 1.5°C increase. That is now only about 0.4° away.

The warming in 2016, of course, was not limited to the Arctic. Off the coast of Northeastern Australia, the Great Barrier Reef experienced its worst coral bleaching on record. Extremely high temperatures were seen in India—where the city of Phalodi recorded temperatures of 124°F in May—and Iran, where temperatures of 127°F were recorded in Delhoran on July 22.

El Niño has now ended, and climate scientists almost universally expect 2017 to be cooler than the year before. But the scale of the heat burst has been startling to many experts, and some of them fear that an accelerated era of global warming could be at hand over the next few years. Even at current temperatures, billions of tons of land ice are melting or sliding into the ocean. The sea is also absorbing most of the heat trapped by human emissions. These factors are causing the ocean to rise at what appears to be an accelerating pace, and coastal communities in the US are now spending billions of dollars to fight increased tidal flooding.

SLOWING US POPULATION GROWTH

The US population in 2016 grew at its lowest rate since the Great Depression, and the population of the State of New York shrank for the first time in a decade (14). An uptick in deaths, a slowdown in births, and a slight drop in immigration all damped US population growth for the year ending July 2016. The 0.7% increase, to 323 million, was the smallest on record since 1936–1937. Americans continue to leave the North for Western states, with Utah, Nevada, Idaho, and several others in the region topping the country in percentage growth. Besides New York, Pennsylvania and Illinois also shrunk, with Illinois losing more people than any other state. About 593,000 people left the Northeast and Midwest to move to the South and West in 2016, slightly more than during the prior 1-year period.

SELF-DRIVING CARS

The race to get humans to give up the wheel is picking up speed (15). Self-driving cars have rapidly moved from science fiction to actual fact and will start hitting the road within 5 years. After 7 years and >2 million miles of road testing, Google's self-driving car project, “Waymo,” which uses sensors and processors to drive a car without human input, will be sold commercially for a variety of uses by the end of 2017. Plenty of carmakers are getting ready to build their own driverless cars: Tesla Motors, BMW, Ford Motor Company, and Volvo Cars have all promised to have fully autonomous cars on the road within 5 years. The technology is expected to transform transportation as mobility becomes a service one orders from an app, rather than an expensive machine bought and mostly stored in a parking space. The use of self-driving cars could drastically reduce urban congestion and dramatically reduce or even eliminate the 1.25 million road deaths a year globally. Human error is the cause of 94% of roadway fatalities, and robot drivers never get drunk, sleepy, or distracted. These autonomous vehicles are presently being tested on the streets in Pittsburgh, Boston, and Singapore.

IF TEXAS WERE A COUNTRY

Only nine countries and one US state (California) have a larger gross domestic product than Texas (16). The 2015 gross domestic product in trillions is as follows: USA, 17.9; China, 11.0; Japan, 4.1; Germany, 3.4; United Kingdom, 2.8; California, 2.5; France, 2.4; India, 2.1; Italy, 1.8; Brazil, 1.8; and Texas, 1.6. Public education is underfunded in Texas. Among the US states in 2015, it ranked 43rd. It is also behind in health care availability. No state had more to gain from Obamacare, and Texas lawmakers fought it at every turn. They rejected Medicaid expansion, even though the feds covered over 90% of the costs. Access to health care for over 1 million low-income residents of Texas apparently is lacking.

MONEY AND AGING

Spending tends to decline as we age (17). Spending tends to peak in our early 50s and then it declines until it levels out in our mid 80s. With the exception of medical spending, our costs decline across the board: shelter, food, cars, clothing, and entertainment—all of it. The decline is not due to running out of money to spend. It is due to changes in what is important to us and to changes in our physical capacities. André Gild may have said it best: “Our judgments about things vary according to the time left us to live—that we think is left us to live.”

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William Clifford Roberts, MD
February 3, 2017

References

1. Huffington A. The Sleep Revolution: Transforming Your Life, One Night at a Time. New York: Harmony Books, 2016; p. 392.
2. Oshinsky D. Bellevue: Three Centuries of Medicine and Mayhem at America's Most Storied Hospital. New York: Doubleday, 2016; p. 387.
3. Editorial. Grave statistics: Guns in America. Dallas Morning News, November 20. 2016.
4. Editorial. Australia shows large-scale change is possible. Dallas Morning News, November 20. 2016.
5. Editorial. Let's treat gun violence as public health issue it is. Dallas Morning News, November 20. 2016.
6. Unknown. Unlocking safer guns. Scientific American, October. 2015.
7. Ragland J. High inmate count shows need to reform. Dallas Morning News, September 17. 2016
8. Ketterer S. Death penalty on the decline. Dallas Morning News, December 16. 2016
9. Kindy K, Deating D. Women drinking more. and it's killing them. Washington Post/The Dallas Morning News, December 24. 2016
10. Lukits A. What smartphones do to children's eyes. Wall Street Journal, January 6. 2017
11. Washington Post. Associated Press. Report: US abortion rate falls. Dallas Morning News, January 18. 2017
12. Unknown. Offer to remove once-mandatory IUDs draws ire. New York Times/Dallas Morning News, January 8. 2017.
13. Unknown. 2016 hottest year on record. New York Times/Washington Post/Dallas Morning News, January 19. 2017.
14. Adamy J, Overberg P. Population growth stalls. Wall Street Journal, December 21. 2016
15. Naughton K. Self-driving cars are just down the road. Bloomberg News/Dallas Morning News, December 18. 2016
16. Schnurman M, Hogue M. The other side of the ‘Texas miracle.’ Dallas Morning News, November 28. 2016
17. Editorial. The older we get. the less money we spend. Dallas Morning News, January 5. 2017

Articles from Proceedings (Baylor University. Medical Center) are provided here courtesy of Baylor Health Care System