I posted this as a copied page vs a direct link because the direct link brings no subscribers into the subscriber area. Unfortunately, this method loses the slides but the main verbiage of the article is complete.
In any case here is one lecturer's opinion. I do not offer it as the gospel, or necessarily my view, but just as one distinguished doctor's opinion. Thoughts are most welcome:
The New England Journal of Medicine
Shattuck Lecture
Volume 357:1221-1228 September 20, 2007 Number 12
We Can Do Better — Improving the Health of the American People
Steven A. Schroeder, M.D.
***The United States spends more on health care than any other nation in the world, yet it ranks poorly on nearly every measure of health status. How can this be? What explains this apparent paradox?
The two-part answer is deceptively simple — first, the pathways to better health do not generally depend on better health care, and second, even in those instances in which health care is important, too many Americans do not receive it, receive it too late, or receive poor-quality care. In this lecture, I first summarize where the United States stands in international rankings of health status. Next, using the concept of determinants of premature death as a key measure of health status, I discuss pathways to improvement, emphasizing lessons learned from tobacco control and acknowledging the reality that better health (lower mortality and a higher level of functioning) cannot be achieved without paying greater attention to poor Americans. I conclude with speculations on why we have not focused on improving health in the United States and what it would take to make that happen.
Health Status of the American Public
Among the 30 developed nations that make up the Organization for Economic Cooperation and Development (OECD), the United States ranks near the bottom on most standard measures of health status (Table 1).1,2,3,4 (One measure on which the United States does better is life expectancy from the age of 65 years, possibly reflecting the comprehensive health insurance provided for this segment of the population.) Among the 192 nations for which 2004 data are available, the United States ranks 46th in average life expectancy from birth and 42nd in infant mortality.5,6 It is remarkable how complacent the public and the medical profession are in their acceptance of these unfavorable comparisons, especially in light of how carefully we track health-systems measures, such as the size of the budget for the National Institutes of Health, trends in national spending on health, and the number of Americans who lack health insurance. One reason for the complacency may be the rationalization that the United States is more ethnically heterogeneous than the nations at the top of the rankings, such as Japan, Switzerland, and Iceland. It is true that within the United States there are large disparities in health status — by geographic area, race and ethnic group, and class.7,8,9 But even when comparisons are limited to white Americans, our performance is dismal (Table 1). And even if the health status of white Americans matched that in the leading nations, it would still be incumbent on us to improve the health of the entire nation.
Pathways to Improving Population Health
Health is influenced by factors in five domains — genetics, social circumstances, environmental exposures, behavioral patterns, and health care (Figure 1).10,11 When it comes to reducing early deaths, medical care has a relatively minor role. Even if the entire U.S. population had access to excellent medical care — which it does not — only a small fraction of these deaths could be prevented. The single greatest opportunity to improve health and reduce premature deaths lies in personal behavior. In fact, behavioral causes account for nearly 40% of all deaths in the United States.12 Although there has been disagreement over the actual number of deaths that can be attributed to obesity and physical inactivity combined, it is clear that this pair of factors and smoking are the top two behavioral causes of premature death (Figure 2).12
Addressing Unhealthy Behaviol
Clinicians and policymakers may question whether behavior is susceptible to change or whether attempts to change behavior lie outside the province of traditional medical care.13 They may expect future successes to follow the pattern whereby immunization and antibiotics improved health in the 20th century. If the public's health is to improve, however, that improvement is more likely to come from behavioral change than from technological innovation. Experience demonstrates that it is in fact possible to change behavior, as illustrated by increased seat-belt use and decreased consumption of products high in saturated fat. The case of tobacco best demonstrates how rapidly positive behavioral change can occur.
The Case of Tobacco
The prevalence of smoking in the United States declined among men from 57% in 1955 to 23% in 2005 and among women from 34% in 1965 to 18% in 2005.14,15 Why did tobacco use fall so rapidly? The 1964 report of the surgeon general, which linked smoking and lung cancer, was followed by multiple reports connecting active and passive smoking to myriad other diseases. Early antismoking advocates, initially isolated, became emboldened by the cascade of scientific evidence, especially with respect to the risk of exposure to secondhand smoke. Counter-marketing — first in the 1960s and more recently by several states and the American Legacy Foundation's "truth®" campaign — linked the creativity of Madison Avenue with messages about the duplicity of the tobacco industry to produce compelling antismoking messages16 (an antismoking advertisement is available with the full text of this article at
www.nejm.org). Laws, regulations, and litigation, particularly at the state and community levels, led to smoke-free public places and increases in the tax on cigarettes — two of the strongest evidence-based tobacco-control measures.14,17,18 In this regard, local governments have been far ahead of the federal government, and they have inspired European countries such as Ireland and the United Kingdom to make public places smoke-free.14,19 In addition, new medications have augmented face-to-face and telephone counseling techniques to increase the odds that clinicians can help smokers quit.15,20,21
It is tempting to be lulled by this progress and shift attention to other problems, such as the obesity epidemic. But there are still 44.5 million smokers in the United States, and each year tobacco use kills 435,000 Americans, who die up to 15 years earlier than nonsmokers and who often spend their final years ravaged by dyspnea and pain.14,20 In addition, smoking among pregnant women is a major contributor to premature births and infant mortality.20 Smoking is increasingly concentrated in the lower socioeconomic classes and among those with mental illness or problems with substance abuse.15,22,23 People with chronic mental illness die an average of 25 years earlier than others, and a large percentage of those years are lost because of smoking.24 Estimates from the Smoking Cessation Leadership Center at the University of California at San Francisco, which are based on the high rates and intensity (number of cigarettes per day plus the degree to which each is finished) of tobacco use in these populations, indicate that as many as 200,000 of the 435,000 Americans who die prematurely each year from tobacco-related deaths are people with chronic mental illness, substance-abuse problems, or both.22,25 Understanding why they smoke and how to help them quit should be a key national research priority. Given the effects of smoking on health, the relative inattention to tobacco by those federal and state agencies charged with protecting the public health is baffling and disappointing.
The United States is approaching a "tobacco tipping point" — a state of greatly reduced smoking prevalence. There are already low rates of smoking in some segments of the population, including physicians (about 2%), people with a postgraduate education (8%), and residents of the states of Utah (11%) and California (14%).25 When Kaiser Permanente of northern California implemented a multisystem approach to help smokers quit, the smoking rate dropped from 12.2% to 9.2% in just 3 years.25 Two basic strategies would enable the United States to meet its Healthy People 2010 tobacco-use objective of 12% population prevalence: keep young people from starting to smoke and help smokers quit. Of the two strategies, smoking cessation has by far the larger short-term impact. Of the current 44.5 million smokers, 70% claim they would like to quit.20 Assuming that one half of those 31 million potential nonsmokers will die because of smoking, that translates into 15.5 million potentially preventable premature deaths.20,26 Merely increasing the baseline quit rate from the current 2.5% of smokers to 10% — a rate seen in placebo groups in most published trials of the new cessation drugs — would prevent 1,170,000 premature deaths. No other medical or public health intervention approaches this degree of impact. And we already have the tools to accomplish it.14,27
Is Obesity the Next Tobacco?
Although there is still much to do in tobacco control, it is nevertheless touted as a model for combating obesity, the other major, potentially preventable cause of death and disability in the United States. Smoking and obesity share many characteristics (Table 2). Both are highly prevalent, start in childhood or adolescence, were relatively uncommon until the first (smoking) or second (obesity) half of the 20th century, are major risk factors for chronic disease, involve intensively marketed products, are more common in low socioeconomic classes, exhibit major regional variations (with higher rates in southern and poorer states), carry a stigma, are difficult to treat, and are less enthusiastically embraced by clinicians than other risk factors for medical conditions.
Nonetheless, obesity differs from smoking in many ways (Table 2). The binary definition of smoking status (smoker or nonsmoker) does not apply to obesity. Body-mass index, the most widely used measure of obesity, misclassifies as overweight people who have large muscle mass, such as California governor Arnold Schwarzenegger. It is not biologically possible to stop eating, and unlike moderate smoking, eating a moderate amount of food is not hazardous. There is no addictive analogue to nicotine in food. Nonsmokers mobilize against tobacco because they fear injury from secondhand exposure, which is not a peril that attends obesity. The food industry is less concentrated than the tobacco industry, and although its advertising for children has been criticized as predatory and its ingredient-labeling practices as deceptive, it has yet to fall into the ill repute of the tobacco industry. For these reasons, litigation is a more problematic strategy, and industry payouts — such as the Master Settlement Agreement between the tobacco industry and 46 state attorneys general to recapture the Medicaid costs of treating tobacco-related diseases — are less likely.14 Finally, except for the invasive option of bariatric surgery, there are even fewer clinical tools available for treating obesity than there are for treating addiction to smoking.
Several changes in policy have been proposed to help combat obesity.28,29,30 Selective taxes and subsidies could be used as incentives to change the foods that are grown, brought to market, and consumed, though the politics involved in designating favored and penalized foods would be fierce.31 Restrictions could also apply to the use of food stamps. Given recent data indicating that children see from 27 to 48 food advertisements for each 1 promoting fitness or nutrition, regulations could be put in place to shift that balance or to mandate support for sustained social-marketing efforts such as the "truth®" campaign against smoking.16,32 Requiring more accurate labeling of caloric content and ingredients, especially in fast-food outlets, could make customers more aware of what they are eating and induce manufacturers to alter food composition. Better pharmaceutical products and counseling programs could motivate clinicians to view obesity treatment more enthusiastically. In contrast to these changes in policy, which will require national legislation, regulation, or research investment, change is already under way at the local level. Some schools have banned the sale of soft drinks and now offer more nutritionally balanced lunches. Opportunities for physical activity at work, in school, and in the community have been expanded in a small but growing number of locations.
Nonbehavioral Causes of Premature Death
Improving population health will also require addressing the nonbehavioral determinants of health that we can influence: social, health care, and environmental factors. (To date, we lack tools to change our genes, although behavioral and environmental factors can modify the expression of genetic risks such as obesity.) With respect to social factors, people with lower socioeconomic status die earlier and have more disability than those with higher socioeconomic status, and this pattern holds true in a stepwise fashion from the lowest to the highest classes.33,34,35,36,37,38 In this context, class is a composite construct of income, total wealth, education, employment, and residential neighborhood. One reason for the class gradient in health is that people in lower classes are more likely to have unhealthy behaviors, in part because of inadequate local food choices and recreational opportunities. Yet even when behavior is held constant, people in lower classes are less healthy and die earlier than others.33,34,35,36,37,38 It is likely that the deleterious influence of class on health reflects both absolute and relative material deprivation at the lower end of the spectrum and psychosocial stress along the entire continuum. Unlike the factors of health care and behavior, class has been an "ignored determinant of the nation's health."33 Disparities in health care are of concern to some policymakers and researchers, but because the United States uses race and ethnic group rather than class as the filter through which social differences are analyzed, studies often highlight disparities in the receipt of health care that are based on race and ethnic group rather than on class.
But aren't class gradients a fixture of all societies? And if so, can they ever be diminished? The fact is that nations differ greatly in their degree of social inequality and that — even in the United States — earning potential and tax policies have fluctuated over time, resulting in a narrowing or widening of class differences. There are ways to address the effects of class on health.33 More investment could be made in research efforts designed to improve our understanding of the connection between class and health. More fundamental, however, is the recognition that social policies involving basic aspects of life and well-being (e.g., education, taxation, transportation, and housing) have important health consequences. Just as the construction of new buildings now requires environmental-impact analyses, taxation policies could be subjected to health-impact analyses. When public policies widen the gap between rich and poor, they may also have a negative effect on population health. One reason the United States does poorly in international health comparisons may be that we value entrepreneurialism over egalitarianism. Our willingness to tolerate large gaps in income, total wealth, educational quality, and housing has unintended health consequences. Until we are willing to confront this reality, our performance on measures of health will suffer.
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