Improving America's Health: Personal and Public Solutions

Thomas C. Ricketts, Ph.D., M.P.H.
Professor of Health Policy and Administration and Social Medicine
School of Public Health
University of North Carolina at Chapel Hill 

Since 1900, Americans have been used to seeing measures of their nation’s health steadily improve.  Unfortunately, as documented in America’s Health Rankings™, the last few years have seen a slowdown, even stagnation, in this improvement.  This stagnation is accompanied by unfavorable comparisons between measures of health in the United States and those for other countries.  

This trend is worrisome and a concern.  The membership of the Scientific Advisory Committee, which supports the United Health Foundation on the scientific content of the Rankings reviewed these trends and felt the need to issue a call for more emphasis on action.  This commentary reports on how the Scientific Advisory Committee has been challenged by the sponsors of America’s Health Rankings to bring us, as a nation, to an agenda for action.

As a Committee, we call for an increasing level of awareness and an increasing level of activity to overcome the stagnation reflected in the data.  We feel a sense of urgency to respond to this development given the implications of the worsening of health status in years to come.  As public health experts, we are encouraged by a growing body of evidence-based guidance that, if fully utilized in personal and population health decisions, can result in health status improvements that have characterized our modern history.  These strategies and policies must be implemented more broadly.

The United Health Foundation, the American Public Health Association and Partnership for Prevention, who sponsor this report, asked the Scientific Advisory Committee to develop an empirically-based framework for informing a national conversation for improving the health status of the country.  The sponsors also requested that this framework be informed by an analysis of the factors that are generally accepted to have accounted for health status improvement from 1900-WWII and the WWII until the present.

This discussion represents an initial formulation for that analytic framework, which will be developed and matured over the coming year.  The Committee recognizes that the framework must guide us beyond simply understanding what the determinants of health might be; it must go further and tell us how we can change those determinants to make things better.  The Committee was also asked to look at what interventions will be most significant to improving health.  The Committee has responded with an expanded model of determinants that emphasizes a context for change. In our review, we realized that many of the answers are already known; we have learned many ways to improve the nation’s health.  We have learned that health care cannot do it all, nor can the public health system nor personal actions.  We have to make the proper public policy decisions to support those three domains of action.

Our focus on health improvement cannot be passive nor ignore the likely sources of improvement in health status, which, for America, will come from our social and economic fabric, as well as, the technical contributions of medicine and public health.  Increases in life expectancy in the United States have often been attributed to advances in social and economic well-being.  Thomas McKeown[1] pointed out that of the 23 years gained in life expectancy that occurred in the first half of the twentieth century, only two of those years could be attributed to medical care.  Improved diet, greater availability of clean water, and basic public health protections were responsible for the rest.  The widespread application of immunizations, better septic techniques and the use of antibiotics made medicine’s contribution substantial but were overwhelmed by general social progress.  Little gain in longevity was realized through developments in surgery and the use of therapeutic drugs. 

The greatest improvements in mortality in the first fifty years of the century were achieved in the reduction of overall mortality rates for children and decreases in death from infectious disease for all ages[5].  Pneumonia, influenza and tuberculosis were the scourges of the young and the weak.  The pattern of mortality changed in the second half of the century and chronic disease among older populations became the primary cause of death.  The disease of old age, cardiovascular disease and cancer, increased steadily from 1900 until the middle of the century, the rate increasing around a percent a year.  Influenza and pneumonia decreased more rapidly by 3.9 percent and 2.4 percent per year between 1900 and 1940.

David Cutler points out that the replacement of infectious disease with chronic conditions of the elderly as the leading cause of death led to a perception that there was little that could be done to further extend life expectancy[6].  However, after the mid-1960s cardiovascular disease death rates began to fall and much of that reduction has been attributed to medical care.  Cancer death rates remained stubbornly high until very recently where the application of more widespread treatments and preventive practice appear to have reversed a persistent trend upward[7].

The age of death and the cause of death for Americans both have changed dramatically over the last hundred years.  As a nation, we have dealt successfully with primary and contributory causes either through social and economic progress and later with frank application of medical treatments and preventive measures.  This displacement of one cause with another resulted in a shift of the age of death toward what some see as the natural lifespan of humans.  This trend has been termed the “compression” of mortality toward the natural end of life, or the “rectangularization” of mortality, where death occurs most often at the beginning or end of the life span[8].  The result is a longer average lifespan that is actually a function of changes in the distribution of the age when people die.  Little progress, it has been pointed out, has been made in extending the limits of lifespan. 

There is a debate among demographers over whether we will see an extension of lifespan or whether changes in lifestyle that have increased the obesity rate, will cause Americans to experience a decline in life expectancy.  The argument that lifespan will increase progressively with many more people reaching the age of 100 or more was posited by two demographers, James Vaupel of Max Planck Institute for Demographic Research of Rostock, Germany and Jim Oeppen of Cambridge University writing in the journal Science.  The reaction to that was an immediate concern over the future of pension and retirement funds and how medical care would need to be structured to cope with far more very old people.  Countering that prediction, Jay Olshansky and his colleagues predicted that rising rates of obesity would create a decline in life expectancy in the United States[9].  The costs associated with that increase in morbidity would outstrip the current $100 billion spent annually to cope with the consequences of severe overweight including diabetes, renal disease, blindness, amputation and cardiovascular disease.  The authors say that ,“The U.S. population may be inadvertently saving Social Security by becoming more obese”, but the larger costs to productivity that ripple through the economy will likely overwhelm that perverse benefit.

Both of these predictions challenge public health and medicine.  Key to the overall extension of lifespan is continued awareness on the part of individuals that the quality of these additional years will depend on how they care for themselves.  Medicine will have to respond by managing the increasing frailty of organs and systems as they naturally age.  Orthopedic care, for example, will likely be in much greater demand for the older old who remain active.  If the trend toward higher rates of obesity continues, its management will require greater emphasis on personal control of diet as well as public health interventions to assist people to make better choices.  Medicine will also be challenged to both prevent the morbid consequence of overweight as well as the biological pathway that contribute to it.  Medical, surgical and pharmaceutical management of its consequences will continue to be a priority.

Future trends in obesity and longer “natural” lifespans aren’t the only specific scenarios that generate pressures to cope with population health that are seemingly at odds.  We are facing “new” diseases and clinical challenges that require difficult choices for priorities.  The emergence of Alzheimer's as a growing cause of death is being countered with specific therapies that draw upon very high technology like imaging for early diagnosis and genetic interventions for potential cures and treatment.  It is likely that very technology intensive approaches will deal with a substantial portion of the emerging new diseases that will limit lifespan. 

One thing is clear as we examine causes of death in the United States, it is behavior that is key to preventing premature death.  Tobacco use, obesity and its consequences, unsafe sex, alcohol abuse, and illicit drug use continue to contribute to mortality rates and reduce the quality of life by causing disability and sickness.  The prominence of ischemic heart disease and lung, trachea or bronchial cancer among the top contributors to lost function and disability speaks to the continued role of smoking as a cause of death and illness.  Road traffic injuries, homicide and violence, self-inflicted injuries, drug use, alcohol and HIV/AIDS, combined contribute 17.8 percent of disability and 22.7 percent of life years lost for American males[10].

Choosing what disease to target and how to treat them is a broad social and political problem.  The Centers for Disease Control and Prevention (CDC) tracked the correlation of its programmatic funding to the burden of disease for 34 conditions and causes and found a positive relationship.[``]  But there were “preferences” that favored infectious diseases over other causes of illness and death.  This analysis didn’t speak to the type of program interventions, whether focused on treatment and medical intervention versus prevention and behavioral approaches.   

There is no reason to cast the challenge to medical care and public health as an either-or situation.  The health of the public depends on our ability to prevent as well as treat disease and disability.  There are, however, preferences for one or the other approaches when it comes to specific diseases and conditions.  It makes no sense to treat the consequences of a condition, whether they are environmental, genetic, or behavioral, if it can be cost-effectively prevented.  The decision of whether and how to prevent when that decision takes away from a cure presents an interesting paradox.  Ken McLeroy and Jim Burdine present both sides of the paradox of prevention in the accompanying discussion.
 

Wennberg, J. E., E. S. Fisher, et al. (2002). "Geography and the debate over Medicare reform." Health Aff (Millwood) Supp Web Exclusives: W96-114.

[9] Olshansky SJ, Passaro DJ, Hershow RC, Layden J, Carnes BA, Brody J, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med 2005;352(11):1138-45.

[10] McKenna MT, Michaud CM, Murray CJ, Marks JS. Assessing the burden of disease in the United States using disability-adjusted life years. Am J Prev Med 2005;28(5):415-23.

[11] Curry CW, De AK, Ikeda RM, Thacker SB. Health burden and funding at the Centers for Disease Control and Prevention. Am J Prev Med 2006;30(3):269-76.

The Paradox of Prevention

The Shift to Chronic Disease Gives us Priorities
Ken McLeroy, Ph.D.
Professor of Social and Behavioral Health
School of Rural Public Health,
Texas  A & M

One way of understanding the current emphasis within public health on preventing chronic disease is to examine the changes in causes of death that have occurred during the 1990s.  Prior to the 1930s, the leading causes of death in the United States were infectious diseases, for example pneumonia, tuberculosis and diarrheal related diseases.  The groups most affected were the very young and women of childbearing age.  In 1900, life expectancy at birth was relatively low at 47.3 years. 

By 1940, the U.S. had witnessed a dramatic change in causes of death from infectious disease to chronic disease with the leading causes of death becoming heart disease, cancer, stroke and injury.  Largely because of the decline in mortality among infants and children, life expectancy at birth increased dramatically to 75 years in 1987 and has risen to 77.6 years today. 

Despite the advances in medical care and health services, most researchers attribute the vast majority (80-90 percent) of increased life expectancy to improvements in living conditions, including housing, nutrition, working conditions and basic public health measures, such as, sanitation and water and food supply.  With fewer children dying, the birth rate declined from an average of 3.1 children per woman of childbearing age to 2.2 in 1988.

These changes have resulted in an increase in the elderly population.  In 1900, 4.1% (3.1 million) of the U.S. population was over 65 years of age, and by 2000,  this number increased to almost 13.2% (13.1 million).  Along with this increase, since the prevalence of chronic diseases increases with age, we also have witnessed a dramatic increase in the number of individuals with chronic diseases, even though the risk of mortality from certain diseases has declined over the past 30 years.

Spending for medical care in the U.S. has similarly risen much faster than in other sectors of the economy.  In 1929, for example, we spent approximately 3.5% of all goods and services produced in the U.S. on health care ($29 per person).  By 1987, we were spending 11.1% ($2000 per person) and, in 2006, health care expenses exceed 14% of GDP.  Thus, preventing chronic disease not only can reduce the individual and societal burdens of suffering and death from chronic diseases, but also can reduce health care expenditures.

Rose’s Paradox of Prevention

A reply from
Jim Burdine, Ph.D.
Professor of Social and Behavioral Health
School of Rural Public Health
Texas A & M

Based on what Ken has said, we should focus all of our efforts on the prevention of chronic disease, however, nothing is as straightforward or as easy as we might like.  And, that is certainly the case with prevention.   One of the challenges to community-based prevention research and practice is that some of our “professional” assumptions have little validity in the real world.  For example, we invest significant resources in pursuit of the elusive “high risk” individuals or populations so we can “intervene” in their lives and help avoid some disease or condition.  But that may be a significant misapplication of effort and resources.  Geoffrey Rose described this challenge as the “paradox of prevention” which occurs when “a large number of people at small risk may give rise to more cases of disease than the small number at high risk.”[1] 

Rose made the argument using data on the rates of Down’s syndrome births.  The risk of a woman giving birth to a child with Down’s syndrome increases dramatically with age (almost 50 times higher at age 45 than under 30.)  However, when you look at the absolute number of children born with Down’s syndrome, more than 50% are to women in the under 30 age group.  Similar arguments can be made for condition such as cholesterol and hypertension as they relate to cardiovascular disease, unprotected sex and AIDS and others. 

Rose’s paradox raises the question about where to invest our energies as a nation.  Conventional prevention thinking has focused on the small group with the big risk.  But if we think in terms of overall impact—the greatest number of folks likely to develop disease as a result of that risk—perhaps a much smaller change in behavior achieved in a much larger population in the more cost-effective strategy. 

The paradox further confuses the issue when we consider the impact of unintended consequences and ethical implications.  If we use the small risk/big population strategy, many we ask to make changes are doing so unnecessarily.  Do we have an ethical obligation to reveal this information?  What does this do to our credibility?

Rose’s paradox of prevention illustrates the importance of broad community-based interventions for chronic diseases, particularly when a risk factor is broadly distributed in a population (such as hypertension, cholesterol, sedentary lifestyles, etc.).  However, when risk is concentrated or clustered in a segment of a population, such as youth violence, then high risk approaches may be appropriate. 

We would suggest that individuals interested in pursuing this to also refer to:

• Murrary, C.J.L., et. al. (2006) Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States PLoS Med 3(9): e260. DOI:10.1371/journal. pmed.0030260. Note: This article explores the causes of disparities among eight groups within the United States in order to inform specific intervention policies and programs.

• Schoen, C., et. al. U.S. Health System Performance: A National Scorecard  Health Affairs 25 (2006): w457-w475; 10.1377/hlthff.25.w257.  Note: This article presents international, state and target benchmarks for numerous aspects of the U.S. healthcare system.

• Mokdad, A.H., et. al. Actual Causes of Death in the United States, 2000 Journal of the American Medical Association. 2004;291:1238-1245. Note: The analysis shows that smoking remains the leading cause of mortality followed closely by poor diet and physical inactivity. See graph.

• New Hampshire Institute for Health Policy and Practice. Best Practices, E-Roadmap to Evidence-based Public Health University of New Hampshire, Durham, NH www.publichealthsolutions.org/bestpractices.html