October 3, 2017




JULY 20, 2016



My reading of an outstanding “biography of cancer” titled The Emperor of all Maladies by Siddhartha Mukherjee has led me to conclude that we should re-frame and attack the issue of the enormous number of gun -caused deaths in our nation as an issue of PUBLIC HEALTH. 
One thing guns, cancer, tobacco and automobiles have in common is their association with high rates of mortality, actual and potential.  And with their association with morbidity, automobiles, guns and tobacco have, to different degrees and at different points in time, raised the question of how “causal” the relationship is.
The struggle, or more precisely the “fight” (for industry did fight every step of the way) against the ever more evident and deadly linkage between cigarette smoking and cancer was brutal. 
Cigarette smoking skyrocketed during the first half of the 20th century.  In 1870, the per capita consumption of cigarettes in America was less than one cigarette per year.  By 1953, the average adult American was smoking ten cigarettes every day.  (Sadly, as we went into the 1960s, I was smoking at four times that level!)  Not surprisingly, in this same period—the 1950s—a meteoric increase in lung cancer was being observed in the U.K. and the United States.  But was it being caused by the increase in cigarette smoking?  At first, that notion was greeted with more than skepticism. It was disbelief.  One evidence of this: medical journals were routinely carrying cigarette advertisements.  At the annual conferences of the American Medical Association in the early 1950s, cigarettes were distributed free of charge to doctors who lined up outside the tobacco booths.  When I joined Procter & Gamble in 1963, there was an ashtray placed in front of every member of the Executive Committee, with no thought it was carrying a danger (though by then research was amply available to demonstrate that).  Almost everyone smoked, many nonstop. 
Ironically but profoundly, and this has great significance to the issue we face on the causal relationship of the availability of guns to increased morbidity,  it was the “rapid, viral ascendency of tobacco that made its medical hazards virtually invisible.”  

Mukherjee points out that our intuitive appreciation of statistical correlations “performs best at the margins.”  When rare events are superposed against rare events, the association between them can be striking.  That had been seen in drawing a link between scrotal cancer and chimney sweeping in the U.K. Both the profession and the disease were uncommon enough that the juxtaposition of the two stood out starkly like a lunar eclipse; two unusual occurrences in precise overlap.
However, as cigarette consumption escalated into a national addiction, and the documented incidence of cancer also sky rocketed,  it became harder to discern an association  of smoking with cancer. 
Similarly, with the penetration of guns today growing at a rate which like cigarettes in the past can only be described as an “addiction”—over 300 million in homes in the United States, twice the level of 1968—and, sadly, with deaths involving guns also becoming more prevalent day to day, it becomes harder to make direct associations.
In time (measured in decades)  and with great difficulty, the causal relationship of cancer and smoking, was irrefutably established.  It happened thanks to the perseverance and courage of scientists and academics.  Prospective trials were carried out, ironically  first among doctors, matching those who smoked and those who didn’t and then documenting the prevalence of lung cancer over many years. The results were unarguable. 

Even then, getting clear warnings on packages and banning televison advertising was resisted by the industry-- and by legislators committed to the industry, just as is the case today with guns.   It took decades to bring regulations which recognized and grew from the knowledge that cigarette smoking is a “public health issue” of the highest magnitude. And it came through the Public Health Administration, not Congress which was beholden to special interests just as  is the influence of the NRA on legislators today.  

I do not believe it would be possible to create the kind of irrefutable " prospective" research to establish the causal relationship of guns and various forms of death that would match the research which eventually documented the causal relationship of cigarette smoking and cancer.  

But there is powerful "retrospective" and "associative" evidence to show the correlation between gun penetration and deaths caused by fire arms. The facts are staggering. Based on 2010 research reported in the Journal of American Medicine, deaths caused by fire arms are (per 100,000):

U.S. 10.2
Canada 2.3
France 2.8
Germany 1.1
UK 0.2

Gun penetration per 100 people:

U.S. 112.6
Germany 30
UK 6.6
Russia  8.9

The death which a gun can cause in a domestic dispute or mass public shooting of the kind we have just witnessed in Las Vegas makes it altogether more lethal than other weapons  because it can cause instant death and as we have tragically witnessed scores of times, multiple deaths before anyone can intervene. 

While the term seems too pristine, this represents a  "public health" issue of enormous magnitude. 

Today, no one who can read can mistake the danger that they are embarked on in smoking.  This is not being done with the usage of guns.

So what about automobiles?  How do they come into the picture?

On a per capita basis, automobiles used to place far higher in the ranking of the causes of death (and injuries) in this country than they do today.  In this case, it was easy to establish the causal relationship.  There was no mistaking that, when a car crashed and there were no seatbelts, and the passengers flew through the windshield and died, that the cause of death was irrevocably related to the car accident.  And in time, for this and other reasons, sharp regulations have been brought to driving a car.   You need to have a license and you have to have that license renewed regularly.   You have to pass a driver’s test to show that you know what you’re doing when you drive the car.  Surely we should insist on nothing less than that when one buys a gun.  We don’t insist on that today.  There is no logical explanation for that.
Many will raise the familiar argument that guns don’t cause death, killers do. It is their choice.  

Of course, that could have been said about tobacco—and  indeed it was, literally, vehemently, repeatedly.  

It wasn’t the tobacco that caused cancer, it was the smoker.  And it could be said about automobiles, too.  It wasn’t the car; it was the driver or the weather or the road.  

Yes, but…we have identified a causal relationship of such importance that we ought to be certain that proper steps are being taken to regulate its use so that not only harm to the “owner” but harm to others who are not the owner can be constrained.  That is certainly the case with guns.  Sometimes, it is the harm to the “owner” in the case of accidentally shooting oneself and suicides

  But much more when it comes to "public health" I am addressing the danger to people who don’t “own” the gun.  

To not require a license and training on how to use a gun, especially one capable of firing multiple rounds quickly,  is absolutely irresponsible. 
Which brings me to my last point where the relationship of tobacco and cancer, and of automobiles and guns, has something to teach.  It come under the heading of prevention.  It was decades before the medical community was prepared to really address the issue of “prevention” when it comes to cancer.  There were those who favored surgery; others, oncology; many, both. It was only later that  “prevention” to reduce the risk of cancer --in terms of diet and living habits--was addressed,  especially in the focus on not smoking.  This has had a major effect in reducing lung cancer. 
“Prevention” has played a big role in the reduction of deaths through automobile accidents too.  The requirement for seatbelts, speed limits and other safety devices, have all come into play, under the mantra of “public health”.
We have failed to think deeply enough, or taken action, on what can be done to prevent needless deaths from widespread gun ownership--just as we have done on smoking and driving a car. There are common sense actions that can be taken such as registration for all guns, positive owner identification like we have on cell phones, etc. 
There will be many, including the NRA, that retreat to the familiar citation of the “rights” conferred by the 2nd Amendment.  This argument should carry no weight when it comes to making intelligent modifications on the requirement for gun ownership dictated by learnings from history.  The authors of the 2nd Amendment did not contemplate that it would confer the right to have semi-automatic and automatic military-style weapons in the hands of millions of people; weapons capable of killing dozens and dozens of people in a matter of seconds as just happened in Las Vegas.

 Just as with automobiles, or now with tobacco, I cannot believe the authors of this Amendment would object to there being strict rules dictated by the well documented knowledge of the risks these guns pose to public health and life.

I believe the great majority of the American people would agree that guns should require registration before they are purchased and training before they are used to be as sure as possible that they were going into responsible hands that are capable of responsible use.   
I hope this provides actionable perspective on what it took to understand, document and control the causal impact of cigarette smoking on cancer and the impact of automobiles on highway deaths in a way that provides insight on what we should do to diminish  the horrible loss of life from the broad and inadequately regulated penetration of guns in this country today.

 Put simply, this is a "public health" issue of enormous importance. It covers the rights--including the right to life--of the public, of all people, not only the gun owner. 

It demands action now. 


August 20, 2017

The frantic, rather impulsive even if understandable rapid removal of statues in public places memorializing symbols of slavery and  leaders of the Confederacy raises important questions in my mind.

I suspect much will be written on this in the coming months by people, including historians, better equipped to provide perspective on this than I am. But I would offer these very preliminary thoughts.

1. Anything that "celebrates" or appears to celebrate or condone racial, ethnic or religious prejudice or violence or the division of our Union such as the swastika or Confederate flag or KKK outfits should never be commemorated as something to be emulated in a public space.

2. We should use history--the good and the bad with all its complexity--to learn for the future and not obliterate it or pretend it did not happen.

We should recognize that some leaders like Robert E. Lee had some noble characteristics that led them to support what they felt they owed service to (in Lee's case, Virginia) even though in hindsight that decision--as well as his view on racial equality-- was wrong.

Rather than tearing down statues, we should surround them with contextual historical information which elucidates what is to be learned from them, with all its complexity. Alternatively, these statues should be placed in a museum, again surrounded by information as described above.

One way or the other, the historical learning from our history, both in conveying the best and worst of it, and the values that drove leaders to do what they did, should not be lost. We need more of this history, not less.

Deciding what to do with these statues and the interpretation which should surround them should be decided locally and time should be given to do this properly by giving a wide group of people the chance to speak so the decision will not be seen as arbitrary and will be as informed as possible.

3. I believe we may need a national museum which we may not have today which would tell our nation's history in an honest, comprehensive way, exposing what we are most and least proud of and revealing the complexity and mixture of motivations which have guided leaders, for good and for ill.
Undoubtedly,  the content of that museum would be controversial. So be it.

The Civil War Museum in Richmond (which I have never seen) could be a good place to tell much of this history from the founding of the Nation through Reconstruction and beyond.

The National Underground Railroad Freedom Center in Cincinnati also has the Mission and much of the content necessary (film, exhibits) to contribute to telling this story honestly and in  a way pointing to the future.

4. Whatever, we do,  we must  continue to share and learn from the "reality(its)" of history even as we acknowledge that the definition and interpretation of those realities will be complex and likely evolve over time. There are  themes which I hope would emerge founded on the prefatory principles of our Declaration of Independence ("all men are created equal") and the call of all religions to treat others as we would want to be treated ourselves.


 I posted this originally on October 10th, 2016. About a month before the election.

I hoped my deep concerns then about Donal Trump's character would be modified by his actions.

They have not.

This cannot continue.

A message to Donald Trump and myself and all of us:
"Watch your thoughts; they become your words.
Watch your words; they become your actions.
Watch your actions; they become habits.
Watch your habits; they become character.
Watch your character; it becomes your destiny."
Frank Outlaw


June 26, 2017


This remains an ill-conceived, cruel piece of legislation. 

It should be rejected. 

The reduction in coverage (20MM plus) makes it inconceivable that we would put this in place.

It fails to deal with the cost issues that have to be addressed at the root cause level (e.g. cost of drugs; multiple profit centers picking up $$; lack of consumer visibility into true costs, etc. ). It fails to study other health care systems which are affording close to universal health care at a cost  40%  BELOW ours. 

The process followed to do this, after 7 years of seeing the flaws of Obamacare, is tragic.

There are two premises which will ultimately have to be and will be accepted:

1. Everyone should have health insurance. Everyone. We don't allow people to opt in or out of Social Security. Or having automobile insurance. It is an issue of the national interest, not just the individual. 

2. Providing quality health care is a Right, just like education is and safety is. For everyone and it is the government's responsibility to provide it. Like Social Security. For the National Interest. 


June 9, 2017

If I put my Procter & Gamble hat on and assess this challenging subject, there are two things that we aren’t doing which P&G would be doing:
1.     We would examine what the outcomes are today in the United States compared to other countries which we know are achieving lower costs, broader coverage and strong health outcomes.  
It is striking and hopefully instructive to look around the world and see so many developing countries, including Canada to our north, providing close to universal coverage, with costs much lower than our own (10% vs. 17% of GDP), and health outcomes, in terms of duration and quality of life, equal or better than our own.
Within our own country, I would benchmark Massachusetts, which I understand is providing 97% coverage.  I don’t know what the costs are, but I would be looking at that and any other states which can be benchmarks for learning.
2.     I would break down with great specificity what the differences are in cost between the United States and those countries (Canada, Europe, Japan, etc.) which have significantly lower costs.  What explains the difference? I am sure a big part but by no means all are higher drug costs. There are also the profits being made by companies in the distribution chain. 
The type of benchmark comparisons I’ve referred to above would yield important learning. We are failing to do the obvious. 


May 13, 2017

I am re-posting my blog of 3/7/17 which called out President Trump for the disrespectful, and demeaning actions and remarks he was making about our public servants in the FBI, CIA, etc.

He has done it again.

Quite apart from the rightness of the decision (with which I disagree), the manner in which he fired Comey was unforgivable and denigrating.  It reflected disrespect on him and the entire Bureau.
This is a man who dedicated his life to our country.

No personal contact. No heads-up. Decision reaching Comey by the media while he is addressing this organization.

I have never seen an uglier, more thoughtless dismissal of a top leader in any organization.

Then Trump adds to that by alleging that Comey was not supported by his own people, a charge flatly denied by the #2 person at the FBI and numerous agents.

Have you no shame, Mr. President.

Sessions shares in this shame.


I have been living with a growing and deepening concern.

President Trump  should be ashamed of himself for the disrespect he is showing to the women and men dedicating their lives to public service in the:

-State Department
-Environmental Protection Agency
-and more.

It is all too easy to paint an organization with a broad brush, serving it up as an impersonal entity, leveling attacks on it for a mistake of  the past (e.g. weapons of mass destruction in Iraq) and fail to recognize that it is made up of thousand of individuals, imperfect as we all are, but almost without exception dedicated to the welfare of our nation and working tirelessly and in some cases at significant personal risk to achieve it.

These men and women deserve our respect and that of the President.

For Trump to tweet the accusation that former President Obama engaged in tapping his phone without even consulting with one of his own team on the likelihood of this being true, is the height of disrespect and irresponsibility.

Can you imagine what it would be like as a new recruit to the CIA or FBI today? How you would feel about your career being one that was properly honored and recognized? How you would feel in coming to work, perhaps even risking your life,  with the President of the United States saying what he is?

This has to stop. The newly installed leaders of these organizations have to lead and not allow the President or anyone else destroy the morale and moral fibre of the men and women of these professional organizations.


May 11, 2017

Have we ever seen  a tornado of swirling news like this?

The President of the United States contradicting himself and leading his surrogates to do the same.

The President continuing to make unsubstantiated claims such as Obama having wiretapped him without any evidence whatsoever.

The President firing the FBI director in the most disrespectful way imaginable disrupting the investigation of Russia's ties to the election-- justifying the action because, as the President said, Comey was a "showboat" and was not supported by the members of the FBI--both assertions categorically denied by the Acting Director the FBI.

It is all too easy to get caught up in it minute to minute, to the point of having it overwhelm our daily lives and lose focus on what we can and must do to make a difference.

We cannot be complacent. The policy issues are too large. Even larger are the issues of the character and values we live by. We cannot accept lying as the new norm and pass it off as akin to a vaudeville act we have to put up with. Common decency has to be upheld.

Increasingly I say to myself:

Pursue truth at all costs.


Speak out and act on what I believe are the most important issues which I can try to influence such as health care, early childhood development; overcoming poverty; and tax reform which drives economic growth and achieves greater fairness across incomes.