Improving the Health of American People Discussion Board

Improving the Health of American People Discussion Board

INSTRUCTIONS- THE INITIAL POST- should contain 400–500 words and adhere to AMA writing style guidelines. This

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word limit promotes writing that is thorough yet concise enough to permit your peers to read all the posts. If the Discussion Board Forum prompts you to answer a series of questions, make sure you address all of them thoroughly within the word limit. Do not restate the questions in your post; simply begin a new paragraph for each new thought. The goal is to have a seamless written argument closed by a brief conclusion tying together your individual responses. Use your best critical reasoning skills, employing the Universal Intellectual Standards as a guide, but not a strict outline. Refer to specific statements of the author(s) whenever appropriate but limit direct quotations to a maximum of 25 words for your entire post. Since this is a personal discussion, you may use first person; however, you should maintain professional decorum at all times. REPLYS TO CLASSMATE- Each reply should contain 200–250 words and adhere to AMA writing style guidelines. ……………………………………………………………………………………………………. Reply to classmate #1According to the article provided, the two explanations that Schroeder gives to describe why the US ranks poorly on many health measures in spite of spending more money than other countries on health care are that better individual health does not necessary equal the need for a better health care delivery system and that good health care systems do not necessarily mean that people will be able to receive those services1. I believe that personal behaviors and choices play a large role in individual health status. Even with great resources available, individuals might not want to utilize those resources. The problem of obesity and tobacco use in America share similarities as well as differences. Both share high prevalence rates, earlier onset (younger population), involve major health complications, and are difficult to treat1. Both obesity and tobacco usage involves stigmas surrounding the issues, are 20th century phenomenons, and are influenced heavily by the promotion industry1. Alternatively, tobacco use is harmful even in smaller percentages, can be harmful to others, contains chemically addictive components, and has a strong evidence history for treatment while obesity does not have these aspects1. Currently, the pie chart illustrating the 5 proportional categories contributing to premature death in the US are based on total US population mortality show that behavioral patterns rank at 40 percent, genetic predisposition at 30 percent, social circumstances at 15 percent, health care at ten percent, and environmental exposure at five percent1. If these numbers were manipulated to reflect the populations living in poverty in inner cities, I believe, based off of readings from our text book, they would rank differently with behavioral patterns ranked at 45 percent due to lower education levels and income levels, genetic predisposition at 20 percent due to genetic behavioral patterns, social circumstances at 15 percent due to lower education levels and lower incomes, health care at ten percent due to lower income levels and access to services, and environmental exposure at ten percent due to the location of living3. Alternatively, if these numbers were manipulated to reflect the populations living poverty in rural areas, I believe they would rank differently with behavioral patterns ranked at 25 percent, genetic predisposition at 15 percent due to genetic behavioral patterns, social circumstances at 30 percent due to lower access to health care services and lower incomes, health care at 25 percent due to lower income levels and a decreased access to services, and environmental exposure at five percent due to the location of living3. One social determinate of health is education2. As Christians and health care professionals, we can work towards bettering the level of health education by providing or support public health education efforts as well as better options for those communities such as fresh food stores2. The bible states in Galatians 6:2, “Carry each other’s burdens, and in this way you will fulfill the law of Christ”. Through helping to educate and encourage healthier behaviors, we can help to increase the health of these populations. Work Count: 497 References 1 2 3 Schroeder S. We Can Do Better — Improving the Health of the American People. New England Journal of Medicine. 2007;357(12):1221-1228. doi:10.1056/nejmsa073350 Adler N, Glymour M, Fielding J. Addressing Social Determinants of Health and Health Inequalities. Jama. 2016;316(16):1641. doi:10.1001/jama.2016.14058 DiClemente R, Salazar L, Crosby R. Health Behavior Theory for Public Health: Principles, Foundations, and Applications. Burlington, MA: Jones & Bartlett Learning; 2019. REPLY TO CLASSMATE #2Schroeder explains there are two reasons the U.S. ranks poorly on many health measures. 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.1 I believe another contributing factor to this paradox of why the U.S. spends so much on health care but still ranks poorly on health measures is personal behavior. Unhealthy behaviors contribute to leading causes of early mortality.2 Obesity in America has now become the new tobacco issue. These two have numerous similarities according to Schroeder. 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.1 Although Obesity and tobacco share many similarities, they do still have their differences. Obesity does not contain any additive chemical components or cause harm to others around you. Eating in moderation is also recommended and not harmful, unlike in smoking. I believe if a pie chart were drawn for the inner city there would not be much difference from how it currently looks. However, in a rural area I feel there would be a big shift in social circumstances. Social circumstances would be 45%, Health care 5%, Environmental exposure 5%, Behavorial patterns 30% and Genetic predisposition 15%. A lot of health measures depend on people making healthful changes in their lives but that may be hard to do for people who are struggling economically.3 Rural areas are prone to poverty, unequal access to health care, and lack of education. A social determinant that could be incorporated easily in many churches would be social support. As stated in Proverbs 17:22 “A joyful heart is good medicine, but crushed spirit dries up the bones”.4 Integrating social support groups in churches could help many people cope with behavioral changes. According to the World Health Organization, it defines health as the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.4 Churches could form a weekly mental health group which could aid in a persons’ overall health and well-being. References 1 Schroeder S. We Can Do Better – Improving the Health of American People. New England Journal of Medicine. 2007; 357: 1221-8. 2 DiClemente R, Salazar L, Crosby R. Health Behavior Theory for Public Health. Second Edition. Burlington, MA: Jones and Bartlett Learning; 2019 3 Collins P. Local health rankings highlight problems for city, county. Martinsville, VA: Martinsville Bulletin. March 13 2017. 4 World Health Organization. Frequently asked questions. https://www.who.int/about/who-weare/frequently-asked-questions. Updated 2019. Accessed March 18 2019. RUBRIC Criteria Levels of Achievement Content Advanced Proficient Developing Thread: Completeness 6 points 5 to 6 points Student answers all question prompts and all questions prompts are answered correctly. 3 to 4 points Student answers all question prompts and most are answered correctly. 1 to 2 points Student answers some question prompts correctly. Some question are answered incorrectly or some elements are missing. Thread: Support of Major Points 3 points 3 points Major points are supported by all of the following: • Current week’s reading • At least one other peerreviewed or governmental source • Pertinent, conceptual or personal examples • Biblical concepts • Thoughtful analysis 2 points Support is missing from one of the following: • Current week’s reading • At least one other peerreviewed or governmental sources • Pertinent, conceptual or personal examples • Biblical concepts • Thoughtful analysis 1 point Support is missing from 2 of th following: • Current week’s reading • At least one other peerreviewed or governmental sources • Pertinent, conceptual or personal examples • Biblical concepts • Thoughtful analysis Replies: Completeness 4 points 4 points Replies significantly contribute to the discussion and content expands upon fellow student’s original thread (does not merely acknowledge content of post). 2 to 3 points Replies contribute to the discussion. The reply goes beyond simply acknowledging content of post. 1 point Replies does not contribute to th discussion OR merely acknowledges content without expansion… Replies: Support of Major Points 3 points 3 points Major points are supported by all of the following: • Current week’s reading OR • At least one other peerreviewed or governmental source • Pertinent, conceptual or personal examples • Thoughtful analysis 2 points Support is missing from one of the following: • Current week’s reading OR • At least one other peerreviewed or governmental source • Pertinent, conceptual or personal examples • Thoughtful analysis 1 point Support is missing from two o the following: • Current week’s reading OR • At least one other peerreviewed or governmental source • Pertinent, conceptual or personal examples • Thoughtful analysis Structure Advanced Proficient Developing Thread: Student Expectations and Word Count 3 points 3 points Communication follows Student Expectations and word count is between 400-500 words. 2 points Communication follows all student expectations but word count is less than 400 words. 1 point Communication follows some student expectations but not all an the word count is less than 400 words. Replies: Student Expectations and Word Count 3 points 3 points Communication follows Student Expectations and word count is between 200 to 250 words. 2 points Communication follows all student expectations but word count is less than 200 words. 1 point Communication follows some student expectations but not all an the word count is less than 200 words. Mechanics 3 points 3 points Proper spelling AND grammar are used. 2 points Minor spelling OR grammar errors are present. 1 point Multiple spelling OR grammar errors are present. The n e w e ng l a n d j o u r na l of m e dic i n e special article Shattuck Lecture We Can Do Better — Improving the Health of the American People Steven A. Schroeder, M.D. T he 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. From the Department of Medicine, University of California at San Francisco, San Francisco. Address reprint requests to Dr. Schroeder at the Department of Medicine, University of California at San Francisco, 3333 California St., Suite 430, San Francisco, CA 94143, or at schroeder@ medicine.ucsf.edu. N Engl J Med 2007;357:1221-8. Copyright © 2007 Massachusetts Medical Society. He a lth S tat us of the A mer ic a n Publ ic 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).1-4 (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.7-9 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. Path wa ys t o Improv ing P opul at ion He a lth Health is influenced by factors in five domains — genetics, social circumstances, environmental exposures, behavioral patterns, and health care (Fig. 1).10,11 When it n engl j med 357;12 www.nejm.org september 20, 2007 1221 The n e w e ng l a n d j o u r na l Table 1. Health Status of the United States and Rank among the 29 Other OECD Member Countries. Health-Status Measure U.S. Rank Top-Ranked United States in OECD Country in OECD* Infant mortality (first year of life), 2001 All races 6.8 deaths/ 1000 live births 25 Whites only 5.7 deaths/ 1000 live births 22 All races 9.9 deaths/ 100,000 births 22 Whites only 7.2 deaths/ 100,000 births 19 of m e dic i n e Proportional Contribution to Premature Death Social circumstances 15% Genetic predisposition 30% Environmental exposure 5% Iceland (2.7 deaths/ 1000 live births) Health care 10% Maternal mortality, 2001† Switzerland (1.4 deaths/ 100,000 births) Life expectancy from birth, 2003 All women 80.1 yr 23 White women 80.5 yr 22 All men 74.8 yr 22 White men 75.3 yr 19 All women 19.8 yr 10 White women 19.8 yr 10 All men 16.8 yr 9 White men 16.9 yr 9 Japan (85.3 yr) Behavioral patterns 40% Figure 1. Determinants of Health and Their Contribution RETAKE 1st AUTHOR: to Premature Death.Schroeder ICM 2nd FIGURE: 1 of 2 10 REG F Adapted from McGinnis et al. 3rd CASE Iceland (79.7 yr) Life expectancy from age 65, 2003‡ Japan (23.0 yr) Iceland (18.1 yr) * The number in parentheses is the value for the indicated health-status measure. † OECD data for five countries are missing. ‡ OECD data for six countries are missing. 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 (Fig. 2).12 Revised Line 4-C SIZE ARTIST: ts H/T H/T 16p6 Enon attempts to change behavior lie outside the provCombo 13 ince of traditional medical care. AUTHOR, PLEASE NOTE: They may exFigure has been redrawn and type has been reset. pect future successes to follow the pattern wherePlease check carefully. EMail by immunization and antibiotics improved health 35712 century. If the public’s health ISSUE: 09-20-07 in JOB: the 20th is to im­ prove, 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 Addressing Unhealthy Behavior and the American Legacy Foundation’s “truth®” Clinicians and policymakers may question wheth- campaign — linked the creativity of Madison Ave­ er behavior is susceptible to change or whether nue with messages about the duplicity of the to1222 n engl j med 357;12 www.nejm.org september 20, 2007 Shat tuck Lecture n engl j med 357;12 435 450 400 No. of Deaths (thousands) bacco 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 evidencebased 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 365 350 300 250 200 150 85 100 50 0 43 20 Sexual Alcohol Behavior Motor Vehicle 29 17 Guns Drug Induced Obesity Smoking and Inactivity Figure 2. Numbers of U.S. Deaths from Behavioral Causes, 2000. AUTHOR: Schroeder ICM from smoking, the horizontal bar indicates the approxiAmong the deaths 2nd 2 of mental 2 REG F FIGURE: mately 200,000 people who had illness or a problem with 3rd substance CASE Revised abuse. Adapted from Mokdad et al.12 RETAKE EMail Enon ARTIST: ts Line H/T Combo 4-C H/T 1st SIZE 22p3 AUTHOR, PLEASE NOTE: postgraduate education and residents thereset. Figure has(8%), been redrawn and type hasof been Please check carefully. states of Utah (11%) and California (14%).25 When Kaiser Permanente of northern California impleJOB: 35712 ISSUE: 09-20-07 mented 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 shortterm 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 pre­ mature 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 charac- www.nejm.org september 20, 2007 1223 The n e w e ng l a n d j o u r na l Table 2. Similarities and Differences between Tobacco Use and Obesity. Characteristic Tobacco Obesity High prevalence Yes Yes Begins in youth Yes Yes 20th-century phenomenon Yes Yes Major health implications Yes Yes Heavy and influential industry promotion Yes Yes Inverse relationship to socioeconomic class Yes Yes Major regional variations Yes Yes Stigma Yes Yes Difficult to treat Yes Yes Clinician antipathy Yes Yes Relative and debatable definition No Yes Cessation not an option No Yes Chemical addictive component Yes No Harmful at low doses Yes No Harmful to others Yes No Extensively documented industry duplicity Yes No History of successful litigation Yes No Large cash settlements by industry Yes No Strong evidence base for treatment Yes No Economic incentives available Yes Yes Economic incentives in place Yes No Successful counter-marketing campaigns Yes No teristics (Table 2). Both are highly prevalent, start in childhood or adolescence, were relatively uncom­ mon 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 wide­ ly 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 1224 n engl j med 357;12 of m e dic i n e 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 diseas­ es — 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.28-30 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-market­ ing 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 pharma­ ceutical 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 envi- www.nejm.org september 20, 2007 Shat tuck Lecture ronmental 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.33-38 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.33-38 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 wellbeing (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 analy­ ses. 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 entrepreneurialn engl j med 357;12 ism 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. One nation attempting to address the effects of class on health is the United Kingdom. Its 1998 Acheson Commission, which was charged with reducing health disparities, produced 39 policy recommendations spanning areas such as poverty, income, taxes and benefits, education, employ­ ment, housing, environment, transportation, and nutrition. Only 3 of these 39 recommendations pertained directly to health care: all policies that influence health should be evaluated for their effect on the disparities in health resulting from differences in socioeconomic status; a high priority should be given to the health of families with children; and income inequalities should be reduced and living standards among the poor improved.39 Although implementation of these recommendations has been incomplete, the mere fact of their existence means more attention is paid to the effects of social policies on health. This element is missing in U.S. policy discussions — as is evident from recent deliberations on income-tax policy. Although inadequate health care accounts for only 10% of premature deaths, among the five determinants of health (Fig. 1), health care receives by far the greatest share of resources and attention. In the case of heart disease, it is estimated that health care has accounted for half of the 40% decline in mortality over the past two decades.40 (It may be that exclusive reliance on international mortality comparisons shortchanges the results of America’s health care system. Perhaps the high U.S. rates of medical-technology use translate into comparatively better function. To date, there are no good international compar­ isons of functional status to test that theory, but if it could be substantiated, there would be an even more compelling claim for expanded health insurance coverage.) U.S. expenditures on health care in 2006 were an estimated $2.1 trillion, accounting for 16% of our gross domestic product.41 Few other countries even reach double digits in health care spending. There are two basic ways in which health care can affect health status: quality and access. Although qualitative deficiencies in U.S. health care www.nejm.org september 20, 2007 1225 The n e w e ng l a n d j o u r na l have been widely documented,42 there is no evidence that its performance in this dimension is worse than that of other OECD nations. In the area of access, however, we trail nearly all the countries: 45 million U.S. citizens (plus millions of immigrants) lack health insurance, and millions more are seriously underinsured. Lack of health insurance leads to poor health.43 Not surprisingly, the uninsured are disproportionately rep­ resented among the lower socioeconomic classes. Environmental factors, such as lead paint, polluted air and water, dangerous neighborhoods, and the lack of outlets for physical activity, also contribute to premature death. People with lower socioeconomic status have greater exposure to these health-compromising conditions. As with social determinants of health and health insurance coverage, remedies for environmental risk factors lie predominantly in the political arena.44 The c a se for C oncen t r at ing on the L e s s For t unate Since all the actionable determinants of health — personal behavior, social factors, health care, and the environment — disproportionately affect the poor, strategies to improve national health rankings must focus on this population. To the extent that the United States has a health strategy, its focus is on the development of new medical technologies and support for basic biomedical research. We already lead the world in the per capita use of most diagnostic and therapeutic medical technologies, and we have recently doubled the budget for the National Institutes of Health. But these popular achievements are unlikely to improve our relative performance on health. It is ar­ guable that the status quo is an accurate expression of the national political will — a relentless search for better health among the middle and upper classes. This pursuit is also evident in how we consistently outspend all other countries in the use of alternative medicines and cosmetic surgeries and in how frequently health “cures” and “scares” are featured in the popular media.45 The result is that only when the middle class feels threatened by external menaces (e.g., secondhand tobacco smoke, bioterrorism, and airplane exposure to multidrug-resistant tuberculosis) will it embrace public health measures. In contrast, our investment in improving population health — whether judged on the basis of support for re1226 n engl j med 357;12 of m e dic i n e search, insurance coverage, or government-sponsored public health activities — is anemic.46-48 Although the Department of Health and Human Services periodically produces admirable population health goals — most recently, the Healthy People 2010 objectives49 — no government department or agency has the responsibility and authority to meet these goals, and the importance of achieving them has yet to penetrate the political process. W h y D on’ t A mer ic a ns Fo cus on Fac t or s Th at C a n Improv e He a lth? The comparatively weak health status of the United States stems from two fundamental aspects of its political economy. The first is that the disadvantaged are less well represented in the political sphere here than in most other developed countries, which often have an active labor movement and robust labor parties. Without a strong voice from Americans of low socioeconomic status, citizen health advocacy in the United States coalesces around particular illnesses, such as breast cancer, human immunodeficiency virus infection and the acquired immunodeficiency syndrome (HIV–AIDS), and autism. These efforts are led by middle-class advocates whose lives have been touched by the disease. There have been a few successful public advocacy campaigns on issues of population health — efforts to ban exposure to secondhand smoke or to curtail drunk driving — but such efforts are relatively uncommon.44 Because the biggest gains in population health will come from attention to the less well off, little is likely to change unless they have a political voice and use it to argue for more resources to improve health-related behaviors, reduce social disparities, increase access to health care, and reduce environmental threats. Social advocacy in the United States is also fragmented by our notions of race and class.33 To the extent that poverty is viewed as an issue of racial injustice, it ignores the many whites who are poor, thereby reducing the ranks of potential advocates. The relatively limited role of government in the U.S. health care system is the second explanation. Many are familiar with our outlier status as the only developed nation without universal health care coverage.50 Less obvious is the dispersed and relatively weak status of the various www.nejm.org september 20, 2007 Shat tuck Lecture agencies responsible for population health and the fact that they are so disconnected from the delivery of health services. In addition, the American emphasis on the value of individual responsibility creates a reluctance to intervene in what are seen as personal behavioral choices. How C a n the Nat ion’s He a lth Improv e? Given that the political dynamics of the United States are unlikely to change soon and that the less fortunate will continue to have weak representation, are we consigned to a low-tier status when it comes to population health? In my view, there is room for cautious optimism. One reason is that despite the epidemics of HIV–AIDS and obesity, our population has never been healthier, even though it lags behind so many other countries. The gain has come from improvements in personal behavior (e.g., tobacco control), social and environmental factors (e.g., reduced rates of homicide and motor-vehicle accidents and the introduction of fluoridated water), and medical care (e.g., vaccines and cardiovascular drugs). The largest potential for further improvement in population health lies in behavioral risk factors, especially smoking and obesity. We already have tools at hand to make progress in tobacco control, and some of these tools are applicable to obesity. Im- provement in most of the other factors requires political action, starting with relentless measurement of and focus on actual health status and the actions that could improve it. Inaction means acceptance of America’s poor health status. Improving population health would be more than a statistical accomplishment. It could enhance the productivity of the workforce and boost the national economy, reduce health care expenditures, and most important, improve people’s lives. But in the absence of a strong political voice from the less fortunate themselves, it is incumbent on health care professionals, especially physicians, to become champions for population health. This sense of purpose resonates with our deepest professional values and is the reason why many chose medicine as a profession. It is also one of the most productive expressions of patriotism. Americans take great pride in asserting that we are number one in terms of wealth, number of Nobel Prizes, and military strength. 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