How long will you live? That depends on your zip code | Celine Gounder

Where you live in America predicts not just how long you’ll live but also how you’ll die. The “Black Lung mountains” run along the border of West Virginia and Kentucky. They are the epicenter of the so-called “hillbilly heroin” epidemic. In the lower Mississippi there’s “Cancer Alley” and heart attack valley. Violent deaths lead the list in the Far West, Alaska and Native American reservations. When it comes to health, one thing is clear: the US is not one nation. It is many.

In an analysis of 80 million deaths in the United States between 1980 and 2014, a study published on Tuesday finds dramatic differences not only in life expectancy, but also in cause of death from county to county. “We’re not narrowing the gap. The gap is widening,” said Christopher J L Murray, one of the authors of the study.

Their analysis shows that our health differs by geography as well as race, socioeconomic status and political culture. One particular hotspot has emerged: the border between Kentucky and West Virginia. The region is plagued by not only mental illness and substance abuse – which have received much attention in the media – but also chronic lung disease, cancer, cardiovascular disease, diabetes, motor vehicle accidents and common infections like diarrhea and pneumonia.

In Appalachia, many of the largest coal deposits have been exhausted. To access the smaller deposits, miners have to blast through a lot more rock, not just coal. All that blasting releases more dust and more toxic dust into the air. The result has been that between 2000 and 2012, there was a nine-fold increase in the most severe form of Black Lung.

As jobs have evaporated, diseases of poverty are exploding along the Kentucky-West Virginia border. Deaths from common infections have gone up in and along the Kentucky-West Virginia border as well as in the lower Mississippi Valley. Deaths from cardiovascular disease and diabetes are also up.

If environmental protections are further weakened and the Affordable Care Act is dismantled – and with it Medicaid expansion in Kentucky and West Virginia – the health of the region may well sink further.

The lower Mississippi is another death hotspot, most notably the Arkansas-Mississippi border and Louisiana’s “Cancer Alley,” but also extending towards Missouri, Oklahoma and Alabama. Like Appalachia, the Deep South is anti-union and anti-regulation; just swap coal mining for the oil, gas and petrochemical industries, and many of the same factors are at play. As in Appalachia, environmental contamination is driving higher rates of cancer and lung disease.

More than elsewhere in the country, social class in the Deep South is taken as evidence for what one deserves in life—also known as the just-world hypothesis—so it’s no surprise that support for social safety nets, including the Affordable Care Act and Medicaid, are weakest here. Arkansas is the only state in the Deep South to have expanded Medicaid. Along with the southwest and Alaska, the Deep South has the highest proportions of uninsured – this causes diseases of poverty to flourish.

While poor white and black Americans both have worse health in the Deep South than in most other parts of the country, black people also continue to suffer from racial discrimination and segregation. In earlier research, Murray showed that poor black Americans in the Deep South and in cities with high homicide rates have the highest mortality rates in the country.

Race creates a geography of its own – especially when you factor in residential segregation. According to David R Williams, a social science researcher at Harvard University “For many Americans, your zip code is a stronger predictor of how long and how well you will live than your genetic code.”

Research on the geography of health will help local health departments focus on the most urgent health problems and will arm citizens with the data they need to advocate for better health in their communities. But it’s important to remember that the geography of health is intertwined with the local political culture and local economy.

Not only do diseases vary county to county (and on an even more micro level), but solutions that may have worked to curb disease in one region—environmental and occupational regulations, for example—may not be palatable elsewhere without fundamental changes in the local culture and how people make a living.

In this age of inequality, none of the symptoms of our malaise can be ignored without consequence. It is up to us all to find out why some Americans are so much worse off than their compatriots – and close the gap fast.

How long will you live? That depends on your zip code | Celine Gounder

Doctors would all support Obamacare if they saw the vast inequality that I do | Celine Gounder

When Americans head to the polls in November, they’ll be deciding the fate of the Affordable Care Act, what Barack Obama has called “the most important healthcare legislation enacted in the United States since the creation of Medicare and Medicaid in 1965”. Over the past decade, healthcare providers have observed the rollout of Obamacare and its net-positive impact on their patients and their practice of medicine.

But how will they vote? Data reported by the New York Times last week suggests that different kinds of doctors tend to have very different political views. My experiences lead me to believe that this empathy gap can be traced to the mix of patients that clinicians care for. The more doctors get out of their privilege bubble, the more likely they are to support keeping, and strengthening, the ACA.

All doctors bear witness to the lives of others. But whom we meet depends in part on what insurance we accept. Medical specialists including cardiologists and orthopedic surgeons and are less likely to take patients on Medicaid than are primary care doctors, pediatricians and infectious-disease docs.

Poverty, discrimination and other social factors also increase the risk of certain diseases such as HIV, hepatitis, childhood asthma, obesity, high blood pressure and depression. So certain medical specialists, like me, see a higher proportion of patients from backgrounds vastly different from our own. Call it empathy boot camp.

One of my patients has been to the hospital six times in as many months because her asthma flares up every time she smokes crack cocaine. She lives with her elderly mother and can’t move, and it’s hard for her to quit when most of her neighbors smoke crack too. Another of my patients had PCP, a severe pneumonia related to HIV/Aids, which required treatment with multiple medications. She left the hospital against our advice because she doesn’t feel comfortable asking family, friends or neighbors to look after her kids.

I have another patient who bounces around from hospital to hospital looking for safety from her abusive partner. Another patient with advanced Aids refused to go to a nursing home where he would have gotten help taking his dozens of medications, three square meals a day, substance abuse treatment services and physical therapy. He was afraid of losing the apartment he shared with his HIV-uninfected girlfriend, leaving her homeless. He died. This is just a sample of patients I saw in one month.

My patients have shown me it’s nearly impossible to get someone healthy when they don’t have stable housing. I’ve learned that if my goal is to help people get better, I’ve got to be pragmatic. I’ve realized that most people with an opioid addiction will never be opioid-free. But with medication-assisted treatment (using substances like methadone, buprenorphine and naloxone), they can become functioning members of society, return to work and resume their roles as caregivers of children or ageing parents.

I’ve even come to believe in safe injection sites, where people can use heroin and cocaine under the supervision of healthcare workers. Not only are they less likely to overdose, but they’re also channelled into testing and treatment. I used to think it was unfair for transgender women to want their breast implants covered by insurance when equally flat-chested cisgender women have to pay for their own cosmetic surgery. But then I saw the harm that comes from injecting industrial grade silicone.

As doctors, we have the privilege of crossing social divides when most others don’t. With that comes a responsibility to our patients and our country that goes beyond our vote. We know all too well what’s at stake.

Doctors would all support Obamacare if they saw the vast inequality that I do | Celine Gounder

Dr Oz"s missed opportunity: scolding Trump for all his bad habits | Celine Gounder

On the The Dr Oz Show Thursday, Donald Trump spent only a fraction of the hour discussing his health, on his own terms. There’s still a lot that he – and, for that matter, Hillary Clinton – still haven’t told us, but a superficial, televised chat did little to change that.

Dr Mehmet Oz started off his interview by asking Trump how he stayed healthy. Oz didn’t delve much into the candidate’s diet, though Trump has bragged that he loves fast food. With a body mass index of 29.5, Trump is overweight – practically obese.

As for exercise, Trump says he golfs, but hasn’t much lately, and poked fun at President Barack Obama’s time on the green. “He could play on the PGA tour,” Trump said.

During a commercial break, Dr Oz explained that lack of sleep has been linked to weight gain, heart disease and some cancers. He went on to say that sleep helps regulate your immune system and strengthens your memories. But when Trump told Oz he doesn’t need much sleep, Oz didn’t delve into it.

An occupational hazard of running for president is all the handshaking, which exposes candidates to innumerable viruses and bacteria at a time when they’re exhausted. Trump, a self-professed germaphobe, no doubt carries his own stash of alcohol-based hand sanitizer on the road, as Obama does on the advice of his predecessor, but Oz didn’t inquire about that either.

Dr Oz then moved on to the “Review of Systems,” a long checklist of symptoms that’s usually part of the form you fill out in your doctor’s waiting room. It’s a tool doctors use to jog patients’ memories and elicit additional symptoms of concern. It was cursory, at best.

Trump’s blood pressure and labs were all in the normal range, though his blood glucose, if fasting, was concerning for prediabetes. This would have been a great opportunity for Oz to educate his audience about the links between obesity, diabetes, heart attack, stroke, kidney and liver disease and various other medical conditions. Absent from Dr Harold Bornstein’s report on Trump’s health was a complete blood count and kidney function tests, labs most doctors would order before checking liver and thyroid function tests or a testosterone level. Absent signs or symptoms of disease, it’s unclear that Trump needed some of the tests he’s had, such as the EKG, chest x-ray and echocardiogram.

As for Clinton, her blood pressure was even lower than Trump’s and both have cholesterol levels in the normal range. Clinton’s calcium score – the higher the number, the higher the risk of heart attack – was zero in contrast to Trump’s 98. In other words, her risk of a heart attack is very low while he’s at moderate risk. Clinton has had a normal breast cancer screening, but there’s no mention of her having colonoscopies. Trump’s doctor reports he last had a normal colonoscopy in 2013.

Still, neither candidate has released anything close to their complete medical records. Releasing a letter or two from one’s personal doctor, as Trump had prior to his Dr Oz appearance, doesn’t come close to releasing complete medical records. Nowhere in Bornstein’s letter about Trump’s health did he mention anything about the bone spurs that supposedly sidelined him during the Vietnam Conflict. Trump, who described sex in the 1980s as his own “personal Vietnam,” must have taken tests for sexually transmitted diseases over the years. Trump reports having been hospitalized once for an appendectomy at age 11, but we haven’t seen those records.

As for Hillary Clinton – who wasn’t involved in the Dr Oz broadcast but whose health status became part of the news cycle when she was diagnosed with pneumonia – where are the records of her healthy child visits and childhood vaccinations? Of the prenatal care, including STD tests, she received when pregnant with Chelsea? In recent years, Clinton has suffered from falls, which could all be due to exhaustion or dehydration, but could also be a sign of an abnormal heart rhythm or other heart condition. And we don’t know why she takes coumadin, a blood thinner.

And does the public need full access to a candidate’s medical records to determine if candidate is healthy enough to serve as Commander in Chief? Or is this just to satisfy our own prurient interests?

What is relevant is whether either candidate has a chronic or life-threatening medical condition that would prevent them from doing their job or would lead to their untimely death while still in office.

We all get the occasional cough or cold. Sick with intestinal flu, Former President George HW Bush famously vomited and collapsed at a state dinner given in his honor at the home of Japanese Prime Minister. It was embarrassing, but he recovered. What I want to know is what Trump’s going to do to avoid developing full-blown diabetes or having a heart attack, and how Clinton’s going to take better care of herself so she doesn’t drive herself to the point of exhaustion.

The conspiracy theories about Clinton’s health are really a demand for transparency, but neither Trump nor Clinton is offering anything close to that. Both candidates have long relationships with their personal physicians. Doctors want to help their patients and may be biased, whether consciously or not, in reporting on their health when so much is at stake.

The best way to give voters the answers they need isn’t a data dump of thousands of pages of medical records. Even then, those records may not be complete and still need to be interpreted in the context of an up-to-date interview and physical exam. Early in the campaign, candidates should submit to examination by objective third party physicians – whether they be former Surgeon Generals or the attending physician for Congress – so that they are all held to the same standards.

We need a system that respects patient privacy, even when those patients are our presidential candidates, while answering voters’ reasonable questions about a candidate’s ability to serve.

Dr Oz"s missed opportunity: scolding Trump for all his bad habits | Celine Gounder

Think Zika just affects Brazil? It"s here in the US now | Celine Gounder

On Friday the Florida State Department of Health reported four cases of Zika, and on Monday, another ten. All were likely contracted locally from mosquitoes in Wynwood, a north Miami neighborhood. The CDC is advising pregnant women not to travel to the area. Meanwhile, hundreds of women have tested positive for Zika virus in Puerto Rico. At least 2% of blood donors in Puerto Rico have recently been infected with Zika: another ominous sign the infection is spreading rapidly.

Given the geographic distribution of the Zika-transmitting Aedes aegypti mosquitoes in the US, we fully expected to see Zika cases in Florida, Texas and elsewhere along the Gulf Coast and in the Caribbean. What we didn’t expect was that Congress would be so slow to fund emergency efforts to control the spread of Zika.

Congress just went on vacation without approving emergency funds to fight the disease. They won’t reconvene until after Labor Day. In February, President Obama requested $ 1.9bn from Congress, and the Administration has continued to press Congress for funds since then. But according to US House Speaker Paul Ryan, “There is plenty of money in the pipeline right now, money that is not going to Ebola, that was already in the pipeline, that can go immediately to Zika.”

Republicans haven’t wanted to allocate new emergency funds, wanting hold to caps under the routine appropriations process.

The Ebola epidemic should have taught us the importance of strengthening disease surveillance and health systems at home and in those parts of the world where new disease threats are most likely to emerge. I suspect Republicans have been quick to push for reallocating Ebola monies to the Zika fight because they think it’s foreign aid. But, by analogy, is it foreign aid to gather intelligence or train foreign troops in the Middle East? Or are we doing that to protect ourselves?

Strategically supporting disease surveillance and health systems in Africa and elsewhere is very much about protecting our national security. But that takes time and money.

Related: Florida issues warning after cluster of new Zika cases in Miami neighborhood

Meanwhile, the Zika funding bill currently before Congress includes provisions to cut funding for Planned Parenthood. Democrats argue that Planned Parenthood provides important obstetric and gynecological services, especially to poor women. These services include birth control, and when necessary, abortions – all services that women will need to prevent having Zika-affected microcephalic babies.

American views on abortion shifted in part due to another infectious disease: a rubella outbreak in the 1960s resulting in over 20,000 babies being born with microcephaly and other birth defects. Abortion was no longer just a sign of moral failure. It became a white, middle class issue, in much the same way that opioid abuse has today. But regardless of where you stand on abortion or Planned Parenthood, I’d argue that we need new funding to fight Zika.

Our system for financing public health emergencies is broken. If we were under attack by Russia or North Korea, you can bet that Congress would immediately approve emergency funding to fight back and defend our shores. We have federal disaster relief funds on hand should an earthquake or hurricane or flood hit. But when a public health threat strikes, we’re caught off guard with our pants down.

We can’t keep playing this shell game: defunding long-term, strategically important public health programs to respond to emergencies. Siphoning off funds from other public health programs – such as the national strategic stockpile of vaccines and other emergency supplies to combat epidemics – to fight Zika doesn’t make sense either. Moreover, local public health departments – our frontline defense against disease outbreaks –have suffered huge funding cuts and lost one-fifth their manpower since the 2008 recession.

We know that the combined forces of globalization, climate change, population growth, urbanization and poverty will lead to more frequent disease outbreaks. It’s our “new normal.” And we can be certain that members of Congress will try to leverage any crisis to their party’s advantage. But politics must not get in the way of our ability to protect the American people. We must insist on stable, permanent funding for public health emergencies because we know there are many more to come.

It’s time to acknowledge that sometimes being a world leader means doing what’s best for our people – even when that means doing good for the rest of the world too.

Related: Democrats demand Congress end its vacation to approve Zika funding

Think Zika just affects Brazil? It"s here in the US now | Celine Gounder