Lessons In Political Violence

 

I got tired of waiting for the American free press to provide an analysis of political violence in the country.  It is a huge omission in day-to-day discussions of the coarsening of American politics.  I was prompted to think about it as I was out driving around today listening to stories of election officials being threatened and manipulated as the federal election approaches, some to the point that they will no longer do the work that they have been doing for years. In a long-standing democracy why is this not front-page news?  Where is the analysis of the problem?  Who has an interest in suppressing the vote and why are they continuing to do this?  At the same time, I heard about a poll today saying that most Americans will not trust the election results – even though they are the most secure at any time in history and there is no evidence of suspicious activity.

Elections are not the only places where political violence is acted out in the US.  Abortion clinics – even during the days of Roe were places where women were harassed and doctors were shot and killed. Schools, teachers, librarians, and school board members are targets for similar politics with threats, work exhaustion, and ultimately moral injury when they are shouted down and threatened for doing the work that they are trained and licensed to do.  Public health officials are attacked for providing the best possible public health advice just because some politicians don’t like it or need to cover their own incompetence.  Since when is it acceptable for politicians to be inciting this level of violence against competent citizens with high levels of competence – who are just doing their jobs?   

Before proceeding I will define what I mean about violence.  The same people who incite it frequently minimize it after the fact using the rhetorical sleight of hand: “It is free speech and I can say whatever I want to say.”  Without invoking the famous Supreme Court quote – let me provide a little detail about definitions.  First, violence or aggression does not require physical act.  Aggression has components that occur on a strictly verbal level and aggression toward property or inanimate objects as well as self (2).  If you have ever witnessed any of those forms of aggression, you know why it is important.  It has a direct impact on you that can be long-lasting. Threats alone can significantly affect your sense of physical and mental well-being. Many states have terroristic threat statutes that can result in legal action before any physical contact occurs (see Minnesota statute below). Threats alone are a signal that physical aggression may occur and in many states it can result in visits from the police, orders for protection, and in the case of mental illness – involuntary holds and civil commitment. Interestingly, the political violence I described typically results in the victims trying to protect themselves.

What does interpersonal violence look like?  On a verbal basis it can be angry shouting like we have seen many times in televised school board meetings.  That can include name calling, personal insults, and profanities.  As the verbal aggression increases the insults gets worse to the point of threatening physical violence. That is evident in routinely televised road and customer rage incidents.  Whether it culminates in physical violence or not is not the point. For years the police tended to ignore verbal aggression and operated on the basis that the only type of aggression that counts is physical aggression.  Over the past 20 years there has been a more enlightened approach since verbal aggression is harmful and predicts physical aggression.  That has been associated with domestic violence and terroristic threat statutes.  In the main areas I have discussed the violence has increased to the point that the Department of Justice is aware of it and successfully prosecutes cases (3,4,5).

Social media has become another source of aggression and interpersonal violence. The popular press documents an explosion of hate speech on X (formerly known as Twitter) while the new owner Elon Musk denies it and claims to have reinstated both right wing and left wing posters as a "centrist".  In the meantime academics debate the definition of hate speech (6) but were still able to find 91 papers written about it on Twitter alone.  Violence and hate speech are probably best analyzed on a case by case basis and in my estimation there is no better example than the last two chapters of Anthony Fauci's book On Call (7).  In it, Fauci clearly describes how providing the best possible public health advice to the White House angered President Trump and the non-experts he hired to manage the pandemic. Fauci was politically scapegoated, derided by other Republicans and MAGA, terrorized at work and home, and ultimately threatened with incarceration for providing historically outstanding public health service to the American people.  MAGA politicians are still threatening to incarcerate him even though he is retired.  I encounter people to this day who "hate" Dr. Fauci - not based on any semblance of reality but the gross misinformation provided to them by MAGA.  That entire sequence of events flowed from Trump's anger that the scientific facts (masking, herd immunity, immunization) did not fit with what he wanted to tell the public.  This is exactly how political violence occurs.  

From a political standpoint, this violence and aggression is often rationalized as “free speech” and it is not.  Violence is often rationalized as the absence of physical contact.  That really minimizes the impact of significant unprovoked threats that can include threats to bodily integrity.   The current elimination of gun laws makes some of these situations even more dangerous.  To cite one example, there was an armed protest in front of a director of public health’s home and in this case the police did nothing.  How would anyone feel about have a group armed with assault rifles outside of your home saying there will be no violence “for now” because you are doing your legal job.

What I find missing from most of these discussions is the overall cause.  I do not think there is any doubt that it originates with one party or more specifically movement and their aggressive rhetoric essentially because they have no useful policy. That is as obvious as the continued denials of the 2020 Presidential election results and the high percentages of people polled within that party (88%) that have doubts about the current election.  We have seen the effects of their propaganda, repeated lies, and political violence on these systems and it is completely unnecessary.  It also causes significant degradation of these systems when long time competent professionals leave because of the threats and harassment.  

Political violence in the US is quite literally the elephant in the room.  And it is time to start talking about it that way. Where is the press with this analysis?

 George Dawson, MD, DFAPA

Supplementary 1:

I decided to include the current Minnesota terroristic threat statute as an example. Note that physical violence is not necessary.  I am no attorney but carrying assault rifle and saying that you are not going to commit violence "yet" would seem to be an indirect threat of violence.  

Supplementary 2:  My wife and I voted at City Hall today.  It was technically an "in-person absentee" ballot.  The process was identical to the one 4 years ago.  We provided several levels of ID including - Driver's License number, address, phone numbers, email address, and Social Security Number. The election official was separated from us in a separate room and all discussion occurred through a heavy glass window with a portal.  We presented an identification form.  When that information was confirmed the election official printed a label with verification that was affixed to the top of our ballots. We were advised to complete the ballot - seal it inside 2 envelopes using tape provided at the voting stations and then return it to her.  When we returned the ballot she personally signed each ballot with her name and address.  There was no public access to a ballot box or voting machine and the entire process was airtight.  I did notice that Robert F. Kennedy, Jr. is still on the Minnesota ballot along with several other third party candidates.

Supplementary 3:  Former President Trump's ad in 1989 directed at the Central Park 5 is another good example of political rhetoric obscuring the facts.   In this ad he discusses hating the suspects and wanting them executed.  They were subsequently exonerated based on DNA evidence and won a $41 M lawsuit against the city of New York for malicious prosecution.  

https://www.documentcloud.org/documents/6131533-trumpdeathpenaltyad05011989

Supplementary 4:  Updated graphic to include a number of false attacks on the Biden Harris administration and their handling of hurricane emergencies.   Many were ultimately refuted by Republicans including Republican Governors.  First responders and aid workers were described as demoralized.  This occurs two weeks after Elon Musk commented that  "no one is even trying to assassinate Biden/Kamala"  Musk subsequently said he was joking and removed the comment from Twitter but said he would not retract it.  The White House condemned it for condoning political violence.  In an age where you can not joke about bombs or terrorists on airplanes "jokes" about assassination should obviously be out of bounds.  I have seen people interrogated by the Secret Service for similar comments.   

  

Addendum:  There are so many of these incidents of violence out there I decided not to try to reference them all.  They can easily be found by Google searching the main heading like "election worker violence" and secondary elements.  You will get a lot of references and very little attribution to the political cause other than "divisiveness".   That word in itself should be telling because it is one of the main strategies of one party. 

References:

1:  Meghna Chakrabarti.  On Point.  "Elections officials endure protests, death threats. Here are their stories."  https://www.npr.org/podcasts/510053/on-point

This is the radio program I heard this afternoon.

2:  Yudofsky SC, Silver JM, Jackson W, Endicott J, Williams D. The Overt Aggression Scale for the objective rating of verbal and physical aggression. Am J Psychiatry. 1986 Jan;143(1):35-9

3:  USDOJ Election Threats Task Force:  https://www.justice.gov/voting/election-threats

4:  USDOJ.  Justice Department Addresses Violent Threats Against School Officials and Teachers

https://www.justice.gov/opa/pr/justice-department-addresses-violent-threats-against-school-officials-and-teachers

5:  Fraser MR. Harassment of Health Officials: A Significant Threat to the Public's Health. Am J Public Health. 2022 May;112(5):728-730. doi: 10.2105/AJPH.2022.306797

6:  Mansur Z, Omar N, Tiun S. Twitter hate speech detection: A systematic review of methods, taxonomy analysis, challenges, and opportunities. IEEE Access. 2023 Jan 25;11:16226-49.

7:  Fauci A.  On Call: A Doctor's Journey in Public Service.  New York, New York: Viking, 2024: 374-455.

If It Was 1968 – I could get a New Car for $2400….

 

Odd statement for a psychiatric blog?  I decided to address my favorite economic fallacy of election season and that is the effect of the President.  It came up as recently as four days ago in the Presidential debate.  During that debate – Trump claimed that he created the “greatest economy” and made the following statement:

“When I had it, I had tariffs and yet I had no inflation. Look, we've had a terrible economy because inflation has --which is really known as a country buster. It breaks up countries. We have inflation like very few people have ever seen before. Probably the worst in our nation's history. We were at 21%. But that's being generous because many things are 50, 60, 70, and 80% higher than they were just a few years ago.”

It was not clear to me if his statement abut 21% was supposed to be under his administration or Biden-Harris, especially when he makes the claim that “I had no inflation.”  That brings me to economic fallacy #1 in the Presidential race:

1:  Inflation is a fact of life in the American economy and there has never been a recent President with “no inflation”:

You don’t have to believe me. The evidence is abundant starting with retirement savings.  All the retirement advice you get gives you strategies on how to keep pace with inflation over the next 30 years.  There will be additional advice on how to keep up with inflation during your retirement years.  There is no advice that you can forget about inflation because it does not exist at times.  The title of this post refers to an ad for the Ford Mustang in 1964 that ran constantly on television with the title “$2,368 F.O.B Detroit.”  The starting price for a Ford Mustang today is $30,920. 

You don’t have to rely on those kinds of memories.  There is actual economic data tabulated.  The only problem is that it is not typically tabulated by Presidential term.  You must add that yourself.  I used the Bureau of Labor Statistics purchasing power calculator that uses a broad index of consumer goods to look at the last 7 administrations:

President	Years	Inflation
Biden	2021-2024	20%
Trump	2017-2021	12%
Obama	2009-2017	15%
Bush	2001-2009	22%
Clinton	1993-2001	24%
Bush	1989-1993	12%
Reagan	1981-1989	42%

 Inspecting those numbers – most people can come up with explanations for the variability.  Explanations of policies under any President responsible for the numbers is doubtful.  Reagan and his “trickle down” economic policies were a mainstay of Republican rhetoric for decades and he has the worst inflation rate.  The most likely difference between the Trump and the Biden figures was decreased demand and unemployment under Trump creating less demand and pricing pressure and then increased employment, financial incentives, and pent-up demand as the pandemic improved under Biden.

The rhetoric of the economy often leads people to come up with lists of commonly purchased items and how those prices have been affected.  First off – price inflation is expected irrespective of who is in the White House, but I encourage anyone to not take these lists at face value and do an easy recheck.  Here is one I did not too long ago after somebody posted their list of inflated items on Facebook.

Note that the GOP version in the first two columns does not match the prices I got off a Walmart web site on May 7, 2024.  The GOP version shows uniform increases in all prices between 2020 and 2024 and that is not the case.  Half of the items are less than they were in 2020 (see sparklines in last column).  Anyone can do this exercise when they see these postings about price increases of common items over time.  Secondly, there are factors that affect these prices that no President or country could conceivably control.  A good example is coffee.  Brazil and Vietnam are the largest producers and their production is currently affected by drought and climate change. Despite the current decreased production coffee prices are not as high as they were in 1976-1977 when over 70% of Brazilian coffee was affected by a frost and coffee prices doubled to $4.19/pound or $19/pound corrected to 2022 dollars. 

Do these lists really prove anything in terms of the candidates?  Not really because once again inflation is expected.  The political rhetoric is such that the GOP is portraying the current inflation as catastrophic.  Certainly, the higher end of the range that Trump describes has not happened.  A much more reliable index of inflation is available from the Federal Reserve.

The only relatively flat spot on that curve was at the peak of the COVID pandemic with decreased demand for goods and services. As demand increased the CPI increases and the Biden administration took over at that point.  The commonly quoted inflation numbers are consumer prices defined as: “Inflation as measured by the consumer price index reflects the annual percentage change in the cost to the average consumer of acquiring a basket of goods and services that may be fixed or changed at specified intervals, such as yearly. The Laspeyres formula is generally used “

2:  The most direct and sustained effects on inflation are initiated by the non-partisan Federal Reserve Bank:

The Federal Reserve Bank has been independent of political influence since 1951.   Between 1935 and 1951  “monetary policy would basically be dictated by Congress and the White House…”.  Even after that period, the Fed has come under pressure from the executive branch.  The Fed actions are a potent driver of the economy and check on inflation as evidenced by the following graphic on interest rate adjustments.  These interest rate adjustments are done based on macroeconomic rather than political considerations and many administrations have disagreed with them because they did not seem politically expedient.  Note the differences in interest rates over the past 2 administrations.  It is also generally agreed that the US economy has recovered post pandemic better than other high-income countries. Should an administration take credit for that or the Fed?

3:  Academic comparisons of the impact of Presidents on the economy show little effect.

The best-known study of the issue was done by Blinder and Watson (3).  They conclude that by all measures the economy does much better under Democrats in Congress and the White House.  It is not even close.  But they did not leave it there and went on to see if there was any clear explanation for this phenomenon at the policy level or based on the make-up of administrations and there was not.  They take it a step further and look at whether the economy was just poised for rapid growth at the time Democrats were elected and that was also not an explanation.  They consider various luck factors that are shocks to consumer expectations and find that makes up part of the difference.  In the end they find no complete explanations but suggest more favorable international conditions and consumer optimism may have something to do with it.  In short, the economy does better under Democrats but there is no clear explanation why that is.  Why then is it a top priority for the election?  The answer is that it is purely emotional appeal rhetoric with no basis in reality. 

Conclusion:

If you are really basing your vote for the President on the economy – find a different issue.  There is very little to no evidence that the President has much of an effect.  If you do your own research - there is a ton of information on this that is as accessible as doing a simple Google search on: “Does the President have any effect on the economy?”   There are papers, podcasts, blogs, interviews, radio programs, and more academic papers that say the same thing – probably not much if any of an effect. When I hear that polls suggest that most Americans think one party or another can manage the economy better – what is that based on?  A candidate saying that during his term he had the “best economy ever.”?  There is absolutely no evidence for a statement like that.

So “its not the economy stupid.”  Move on to another issue.  If you vote based on that issue – you are voting on unsubstantiated rhetoric,

 

George Dawson, MD, DFAPA

 

References:

1:  Overview: The History of the Federal Reserve.  September 13,2021:  https://www.federalreservehistory.org/essays/federal-reserve-history

2:  de Soyres, Francois, Joaquin Garcia-Cabo Herrero, Nils Goernemann, Sharon Jeon, Grace Lofstrom, and Dylan Moore (2024). "Why is the US GDP recovering faster than other advanced economies?," FEDS Notes. Washington: Board of Governors of the Federal Reserve System, May 17, 2024, https://doi.org/10.17016/2380-7172.3495

3:  Blinder AS, Watson AW.  Presidents and the US Economy: An econometric exploration.  National Bureau of Economic Research. Working Paper 20324, July 2014.  http://www.nber.org/papers/w20324

4:  Bilen C, El Chami D, Mereu V, Trabucco A, Marras S, Spano D. A Systematic Review on the Impacts of Climate Change on Coffee Agrosystems. Plants (Basel). 2022 Dec 25;12(1):102. doi: 10.3390/plants12010102. 

 

We Live in Different Realities….

 

 

“We don’t have to like the reality that we live in, but it is the reality we live in.”  JD Vance comment on Apalachee High School shooting in Georgia that left 4 dead and 9 injured.

 

The school year began with a school shooting and all the associated irrationality of mass shooting in the US.  One of the most irrational comments is posted above and was made by the MAGA party vice presidential candidate.  When I say irrational – I mean that what Vance refers to as “the reality we live in” was in fact created by his party, its judges, gun extremists (who are undoubtedly all from his party), and the gun lobby in Congress.  They have created a parallel universe where there are minimal to no gun regulations, people can openly carry weapons, people are encouraged to use firearms, the country is saturated with guns, and the expectation that there will be no problems.  If there are problems it is always due to somebody else – as further elaborated by Vance:

“I don’t like that this is a fact of life.  But if you’re—if you are a psycho, you want to make headlines, you realize that our schools are soft targets. And we have got to bolster security at our schools… We’ve got to bolster security so if a psycho wants to walk through the front door and kill a bunch of children, they’re not able to.”

As far as I can tell nobody has confronted his statement about bolstering security in schools.  We just witnessed former President Trump’s near miss as he was protected by a full contingent of secret Service Agents and snipers. Even that impractical level of protection at every school in the country is no assurance that children will be safe.  In the case of this incident, an armed security officer at the school engaged the shooter in about 120 seconds and forced him to surrender. By that time, he had already shot 7 people.  His other theory is that the increasing numbers of mass shootings are due to increasing numbers of "psychos".  That term really has no meaning other than a pejorative one.  If he is referring to mental illnesses there is no evidence that mental illnesses are causal in mass shootings.  He leaves out the most likely causes of gun extremism and a mass shooter culture as well as easy availability of guns.

The other argument that seems to be gaining traction is blame the parents. As I predicted this is being sold as a solution to the problem rather than going directly at the culture of gun extremism. I heard several television commentators saying this was a “wake up call” to parents who allow their children to have access to guns.  I really doubt that it is.  The analysis will always be complicated by how the parents are portrayed in the media, but even without the parents in the picture we still have very easy gun access and a cultural basis for mass shootings that nobody ever addresses.  Having been a kid, I can’t think of a teenager who could not defeat their parents access prevention security measures – whether it was reading material, phone access, or weapons.

Many of the same commentators are also blaming smartphones. The context seems to be that parents are not able to deny their children access to smartphones anymore than they can deny their access to guns.  They cite as an example recent legislation that bans smartphones in schools.  Apparently it is much easier for politicians to limit smartphone access than it is to limit gun access.  Smartphones are not nearly as dangerous.

The blame the parent argument may have some application, especially in states where the gun laws specify that parents are responsible for their child’s use of a firearm. In many cases those laws are currently complicated by the fact that a child may possess a gun in certain circumstances – even if they are not eligible to purchase one. The smartphone argument is a weak one.  Banning smartphones in educational venues and where specific decorum is required – but smartphones clearly have nothing to do with mass shooting.  Not being able to say “No” to your kid doesn’t either. Gun extremists and the mass shooter culture has everything to do with it and it requires serious action.  It is time to get back to reality and acknowledge what we already know from American history.   Gun regulations save lives and lots of them.

I will cite what is known by most people in my generation and a frequent reference to the Old West that I have used before.  In the 1960s, 1970s and the years before – there was no mass shooting problem in the US and certainly no problem with children being shot in schools. Many middle school students took the National Rifle association Hunter Safety course.  In that course safe use of firearms was emphasized including treating every gun like it is loaded and never pointing a gun at anyone.  The middle schoolers in these courses were about the same age as the most recent shooter.  They had no access to high-capacity semiautomatic weapons or handguns.  The basic idea was – learn how to safely handle guns and use them for hunting and target shooting. There was no discussion of needing them for personal protection or needing to always carry them. There were no politicians promoting gun extremism.

There is evidence that the period of gun safety extended back to when frontier towns noticed that armed citizens were problematic and law enforcement started to insist on voluntary disarmament when people rode into town.  I have posted the Tombstone Arizona statute from 1881. There is also an article in the Smithsonian (1) that outlines some of the highlights of early gun control law including the association of the Gunfight at the OK Corral with Tombstone’s gun law.  Strict gun control laws existed in several other towns and the 1881 law in Tombstone is much stricter than the laws that exist today.  Today you can carry a gun without a license or permit in Tombstone. There was a contrast between frontier towns that had disarm laws and those that did not – with the latter having a higher gun homicide rate.  

A political gun extremist movement has endangered the lives of every American and made schools an unsafe place. We are well past the time to get rid of these extremists and their gun violence rhetoric.  The reality that most Americans want to get back to is to be able to walk down the street or go to school and not have to worry about getting shot.  That knowledge goes back to the Old West and it kept us in that reality right up until the 1970s.  The only strong message that needs to be sent here is that gun extremist politicians and excuse makers need to be voted out.  Even then there will be a lag time because of the gun extremist judges they have appointed.

Apart from gun extremism as a bizarre populist issue on its own – it also reinforces autocratic ideology.  The autocrat playbook reinforces political violence as a good idea.  That includes all the autocrats of the 20^th and 21^st century who typically target the “elites” in their population and encourage political violence against them.  The practical way it plays out today is self appointed militias showing up to intimidate elected officials,  self appointed law enforcement showing up to intimidate protestors, and verbal threats that the more heavily armed will prevail in any controversial elections.  

Never doubt that there is a gun extremist agenda in the United States.  I have pointed out the features in many posts on this blog. The gun extremist agenda is currently indistinguishable from the MAGA agenda.  It is more than a little ironic that the mass shooters it creates are labelled “monsters” and “psychos” by members of this political movement.  That is the reality that JD Vance is talking about and it will continue as long as these authoritarian politicians are elected and maintain that reality.    

 

George Dawson, MD, DFAPA

References:

 1:  Jancer M.  Gun control is as old as the Old West.  The Smithsonian Magazine.  https://www.smithsonianmag.com/history/gun-control-old-west-180968013/

 

 Graphics Credit:  Click directly on the photo - it is linked to Wikimedia Commons and all of the information about this phot and the CC license.  

It’s Not The Heat – It’s The Wet Bulb Global Temperature (WBGT)!

Despite the current election cycle and massive denial of climate change by the MAGA party – the average temperature of the Earth is getting much higher. The ten warmest years on record are the last 10 years (see graph above).  That is corresponding with the expected melting of glacial ice, increasing sea surface temperatures, and higher sea levels. It is equally obvious that the necessary measures to reduce carbon dioxide in the atmosphere are not being taken.  We can therefore expect future generations to experience the burden of excessive heat, unstable weather patterns, flooding, crop shortages, and all of the economic and international instability that will occur.  I don’t think it is a stretch to see this as potentially catastrophic to civilization.

Of all those weather related phenomena – extreme heat and humidity are the number one cause of death.  Mortality due to heat stroke is increasing every year. This was the first year that I heard frequent stories about hikers perishing from the heat.  The CDC estimates that about 1200 people a year die from extreme heat and they have a web page dedicated to providing resources about this public health threat. The EPA has a site that looks at heat related deaths over the past 20 years and although they are higher – they discuss the issue of variable reporting, largely due to inconsistent criteria about what is called a heat related death.  There is a good chance that heat related deaths are underreported and attributed to other causes.

Modern reviews of heat stroke and heat related illnesses (1-3) suggest that there are two conditions that are clear emergencies and varieties of heat stroke – classic heat stroke and exertional heat stroke. Classic heat stroke develops in people exposed to heat who may be predisposed because of chronic illness, medications, and an environment that is excessively hot.  These patients are typically elderly.  Exertional heat stroke occurs when heat is generated by muscle exertion in hot weather and that leads to excessive body temperature. In both cases emergency cooling is a critical treatment along with fluid volume replacement if that is an issue.  Heat stroke is a multisystem inflammatory disease that leads to a combination of autonomic, cardiovascular, and metabolic responses that can lead to organ failure and death.  Mortality is high - 80% in classic heat stroke and 33% in exertional heat stroke (3) if there is no immediate treatment.  The issue of immediate treatment is problematic because heat stroke can cause compromised mental status including loss of consciousness – further exposing the person to prolonged heat exposure.  Preexisting cognitive compromise complicates both recognition of heat related illness and getting timely care.      

The issue of heat, humidity, and heat dissipation from the human body is an exercise in physical chemistry.  Evaporative cooling is one of the ways that mammals cool their bodies to maintain a stable body temperature.  In humans the other way is skin surface vasodilatation and heat transfer from blood.  Every time water changes phase (solid -> liquid -> gas) there is an energy requirement that is termed enthalpy in physical chemistry. The enthalpy or heat of transition from liquid to gas is 40.67 kJ/mol.  That means that we can calculate the amount of water necessary to maintain cooling at an amount of energy production. The relevant variables include how much energy the person is expending, ambient air temperature, and the relative humidity since the last two affect the amount of water that can transition to the gaseous phase.

All these variables can be considered form a meteorological viewpoint using the concepts of heat index and wet bulb global temperature. On this prototype site you can chose either value, click on your location on the map (it scrolls), and get the heat index or WBGT.  As an example, two days ago the temperature at my location went firmly into the danger zone as indicated by this tracing that I downloaded at the time. Suggested activity levels and precautions are available on the site for the WBGT values on the curve over the course of the day.  Another way to look at WBGT is that it is the temperature where evaporative cooling starts to fail and that is the measure of danger.

WBGT was recently assessed looking at wet-bulb temperature adaptability thresholds in health young research subjects (4).  Under experimental conditions they looked at subjects under moderate metabolic load and determined the critical wet-bulb temp beyond which the heat stress could no longer be compensated for.  The researchers looked at the proposed critical wet bulb temp of 35ºC (95 Fº)(threshold wet bulb temp) and discovered that it could be considerably lower and that it was unlikely that a single critical temperature for all conditions could be found.

Irrespective of the reporting issue, public health officials are concerned about ambient temperatures and the heat island effect of concrete in large cities where emitting energy can raise the ambient temperature up to 7 degrees hotter than the surrounding area.  They have identified high risk populations including the elderly, people with inadequate housing, and people with no air conditioning. That last category can rapidly expand whenever weather conditions effect power transmission and cut electrical power to large populations.  We just experienced those conditions in Minnesota shortly after a burst of peak temperature and humidity conditions.

Many people with chronic mental illnesses are in the high-risk category.  Compromised judgment whether due to effects on cognition or more focal problems with judgment and problem solving can lead to potentially fatal situations at either end of the temperature spectrum. During the recent heat emergency, I witnessed several people wearing excessive clothing and at the same time expending a lot of calories.  They were in a weather zone where the National Weather Service (NWS) suggested minimal activity. Chronic mental illness also creates the risk of no housing or inadequate housing. In extreme heat – the lack of air conditioning can create an emergency situation for many people.  

At the policy level (5) there have been some approaches to try to assure the safety of people that might experience exertional health stroke.  They are in the form of mandated breaks, access to water, and access to air conditioning.  They are far from universal and in some cases there has been political opposition based primarily on anti-science (climate change, human physiology) ideology and ignorance. It is a reckless approach to humanity but consistent with gun extremism views held by the same groups. 

At the individual level, psychiatrists need to be aware of their patients’ living conditions and their theoretical susceptibility to heat related illnesses.  That requires an integrated view of their current health status, medications, cognitive status, functional capacity, physical activity level, and specific access to air conditioning. Assertive Community Treatment (ACT) teams will have an advantage is knowing first hand what the living conditions are. In the past I have worked out a plan for people to go to an air-conditioned shopping mall depending on the weather conditions. Some people will find this difficult and could benefit from a visit and prompts from a case manager. A call list of people who may be at risk could be useful for case management teams.  As more municipal areas develop cooling shelters – a more formal referral process might be possible.

In the short term, a focus on the medical and social aspects of patient care will be necessary to mitigate the potential lethal risks of heat related illness. It is a necessary role for all physicians as the climate disaster unfolds.

 

George Dawson, MD, DFAPA

 

1:  Savioli G, Zanza C, Longhitano Y, Nardone A, Varesi A, Ceresa IF, Manetti AC, Volonnino G, Maiese A, La Russa R. Heat-Related Illness in Emergency and Critical Care: Recommendations for Recognition and Management with Medico-Legal Considerations. Biomedicines. 2022 Oct 12;10(10):2542. doi: 10.3390/biomedicines10102542. PMID: 36289804; PMCID: PMC9599879.

2:  Epstein Y, Yanovich R. Heatstroke. N Engl J Med. 2019 Jun 20;380(25):2449-2459. doi: 10.1056/NEJMra1810762. PMID: 31216400.

3:  Sorensen C, Hess J. Treatment and Prevention of Heat-Related Illness. N Engl J Med. 2022 Oct 13;387(15):1404-1413. doi: 10.1056/NEJMcp2210623. Epub 2022 Sep 28. PMID: 36170473.

4:  Vecellio DJ, Wolf ST, Cottle RM, Kenney WL. Evaluating the 35°C wet-bulb temperature adaptability threshold for young, healthy subjects (PSU HEAT Project). J Appl Physiol (1985). 2022 Feb 1;132(2):340-345. doi: 10.1152/japplphysiol.00738.2021. Epub 2021 Dec 16. PMID: 34913738; PMCID: PMC8799385.

5:  Burton A.  Energy justice for all: keeping disadvantaged populations cool in a heating world.  Federation of American Scientists: https://fas.org/publication/energy-justice-keeping-cool/

6:  Knochel JP. Heat stroke and related heat stress disorders. Dis Mon. 1989 May;35(5):301-77. PMID: 2653754.

This was the first comprehensive review I read on the topic.  I was a subscriber to Disease-a-Month and the Medical Clinics of North America early in my career - based on recommendations from an Internal Medicine resident who I worked with.  This remains an excellent review of the topic.  

Graphics Credit:

National weather Service (weather.gov) for all except for the North Carolina High School Athletics Association as noted.