The Health of Americans

The Lancet is a British medical journal that has been in continuous publication since 1823. Arriving each week in my mailbox (though not since its inception!), The Lancet has always been worth more than the routine glance I give to the rest of my mail. Unlike any US medical journal, it provides a truly global perspective on health. Only from The Lancet can you learn about health crises in countries experiencing political turmoil, natural disasters, or massive population shifts from forced immigration. You can read about the progress against AIDS in Africa or how an impoverished country is coping (or not) with a rise in polio, Ebola, or widespread hunger.

The cover of last week’s journal caught my eye immediately. Emblazoned with the 1958 Jasper Johns painting Three Flags, which I’d seen less than a month earlier at the Whitney in New York, the headline read “The Health of Americans.”

“Well,” I thought, noticing it was the July 5^th issue, “This should be interesting.”

The burdens and challenges of chronic disease

In many ways, the health of Americans doesn’t differ all that much from the challenges facing the citizenry of other developed countries. Our greatest risks–the real threats affecting not only our longevity but also our functional independence–lie in the realm of chronic disease.

The leading causes of both disability and death in the US are heart and lung disease, cancer, diabetes, cerebrovascular/Alzheimer’s disease, and kidney disease. Two thirds of all deaths in the US are caused by one or more of these conditions. About half of us have one of them already, and a quarter of the population is saddled with two. And yet these terrible burdens, which seriously compromise our lives and those of our families, are largely preventable.

The list of factors setting these conditions in motion is surprisingly short:

• Tobacco use
• Poor diet and physical inactivity (both linked to obesity)
• High cholesterol
• Excessive alcohol

Not a long list by any means, but one that’s challenged by costs, political agendas, and special interest groups.

Editors at The Lancet applaud the US Affordable Care Act (the ACA, or Obamacare) as the most profound shift in healthcare since Medicare was signed into law more than 50 years ago. Since the US is virtually the last developed country to offer universal health care to its citizenry, it’s almost as if The Lancet is announcing to its worldwide readership that the US has finally arrived in the 21^st century.

Providing health insurance for eight million Americans (and more soon as enrollment increases) goes a long way to reducing the fear of facing illness alone without access to the health care system. What doctors from states with a disproportionate number of poverty-level families are seeing is that the rate of major depression has visibly declined, at least in states where the poor are allowed by their governor to purchase subsidized health insurance. It’s definitely premature, though, to know if the very act of having health insurance will yield a healthier population.  Based on info to date, many obese/inactive/smoking US diabetics dying in their 40s and 50s had health insurance.

But the ACA is different, with disease prevention the name of the game and physician reimbursement very much pegged to keeping patients healthy. One challenge for the US is our huge and heterogeneous population with significant income disparities (and the political agendas of numerous well-funded special interest groups). The Lancet rightly points out this is less of a problem in smaller countries. In the US, whites can expect almost four more years of life than blacks. The infant mortality rate for blacks is double that of whites. Among Hispanics, obesity and diabetes are reaching epidemic proportions.

Ultimately, it’s all about education and income, long recognized to have profound effects on healthful longevity. The poorest states (Mississippi et al.) have an age-adjusted death rate 59% higher than the richest.

Tragically–and there’s no other word to use—the political agenda of the leaders of the poorest states led to their rejecting the federal subsidies that would allow those who need affordable care to purchase it.

Tobacco and food

Although smoking rates have dropped dramatically over the past 50 years (from 42% of the population in 1965 to 18% in 2012), there are still 42 million US adults and 3 million children who smoke. Because no one in government was actually paying attention, the tobacco industry got away with altering its product to make it even more addictive (by increasing nicotine), luring children into smoking by adding flavors like chocolate (recently banned), and making cigarettes even more deadly by increasing levels of carcinogens.

This year the Surgeon General reported that cigarettes manufactured in 2014 were more dangerous with regard to lung cancer and emphysema than those from 1950.

The food industry lobby is right up there with tobacco lobbyists working to block substantive legislation that might make a difference in our lives. We continue to gorge ourselves on overly- salted or corn-syruped, fat-saturated, chemically-laced prepared foods. If you have any doubt this government-subsidized food supply doesn’t have an impact, read this sad piece on non-alcoholic fatty liver disease in children.

America has no GMO ban, but take a quick glance here to see where they’ve been banned by the European Union. It’s important to note that genetically engineered crops in the US have required a substantial increase in herbicide use, with its known and unknown effects on our bodies.

US violence

Under age 30, violence is by far the most common cause of death. (I’ll pause here so you can read that sentence again if you winced the first time through.) Half these deaths are classified as “unintentional injury,” including motor vehicle accidents–happily, down significantly during the past 50 years–falls, drowning, and drug overdoses. The other half are related to gun ownership, with the number of suicides more than double the number of homicides.

In other words, if you must own a gun and shoot a living being, the odds are in your favor the victim will be you.

Returning to the power of special interest groups, President Obama’s choice for Surgeon General, Vivek Murthy, MD, while testifying publicly that his focus as Surgeon General would be on obesity, immunizations, tobacco, and mental health, found his appointment delayed by a letter-writing campaign mobilized by the National Rifle Association (NRA). It seems Dr. Murthy once dared to say that guns are a health issue.

Parenthood

Although the 1993 Family and Medical Leave Act (FMLA) ensures that men and women during any 12-month period can take 12 weeks of unpaid leave to care for a newborn or sick family members, FMLA does have restrictions. The employee needs to have worked for more than one year and the company must have 50+ employees. So the young woman who starts at a Dunkin’ Donuts and finds after a month that she’s pregnant has no guarantee of a job when she’s ready to return to work.

I learned from The Lancet that the US is the only developed country that doesn’t guarantee paid maternity leave. Typical countries like Germany and New Zealand grant 14 weeks of paid leave and the most progressive (Canada, Norway, Sweden) give fathers paid leave as well. How these leaves are funded varies widely, but most are a shared expense among government, employer, and health insurer.

Just last month at the White House Summit on Working Families, President Obama called for a change in US policies toward more a family-friendly workplace, including paid maternity leave.

Here’s an article by the President via Huffington Post.

Our future

Overall, the July 5 issue of The Lancet seems optimistic about the future of US health. The editors feel the ACA–with not only its access to health insurance, but its specific regulations regarding electronic medical records, changes in physician reimbursement, and ways to face the challenges of healthful eating, exercise, blood pressure control, tobacco, and gun control–all bode well for our collective good health and well-being.

It’s clear we need a conscious awareness of what’s healthful and what’s not for ourselves, as well as for our kids and grandkids. Their lives and our own also demand activism. As always, you’re in charge. Start educating yourself about the dangers of processed food and always check to see who paid for the research when you see a questionable headline. Make your own meals from actual food (scroll down at this site for ideas), unplug and go outside to play, plant a garden and grow some of what you eat.

Obviously don’t smoke and do make exercise a priority. Drink carefully. And ponder long and thoughtfully the idea of keeping a firearm at home.

The choice of whether your grandchild dies young or at a nice old age depends mightily on who you vote for today, how you spend your food dollars, and the angry (or supportive) letters you take time to write to CEOs and Congresspeople.

Be well,
David Edelberg, MD