21^st Century Health Challenges: Can We All Become Healthy, Wealthy, and Wise?

 

Introduction                                                                                                         

The title of my talk – Can We All Become Healthy, Wealthy, and Wise? – comes of course from Ben Franklin’s adage: “Early to bed, early to rise, makes a man healthy, wealthy and wise.”  If only it were that simple . . .

I don’t want to lecture you about your sleeping patterns, but Ben Franklin’s aphorism correctly appreciates that there is a relationship between these three conditions and I’d like to explore some of these connections with you.  Entering a new century, we have unprecedented  opportunities to improve the health of all Americans, but doing so will require applying our wealth and our wisdom in ways that might not be self-evident.

In my remarks today, I’d like to give you a public health perspective on where these opportunities lie. The public health perspective is broad and compelling and based on a record of extraordinary accomplishment.

For example, if we look back at the beginning of the century we’ve just completed, we can see a dramatic change in one of the prominent markers of overall health status: life expectancy.  A person born in 1900 could expect to live, on average, to the age of 45.  Today, life expectancy is nearly 80 years.   What may surprise you about this statistic is not that we’ve gained 35 years of longevity, but rather where these gains have come from.  In fact, only 5 or so of these “extra” years can be attributed to advances in clinical medicine.  Public health can take the credit for the other 30 years, thanks to improvements in sanitation, health education, the development of effective vaccines, and other advances.  As the eminent British historian of the Wellcome Institute, Roy Porter, has observed, “the retreat of the great lethal diseases was due in the first instance, more to urban improvements, superior nutrition and public health than to curative medicine.”

 I don’t mean to minimize the phenomenal and exciting contributions of clinical medicine and technology.  We can and should expect great things from the exploration of the frontiers of medicine (many of these advances will come from this city and people in  this room).  But I would argue that for the population as a whole, the less visible contributions of public health have historically yielded a disproportionate pay-off in longevity and quality of life.

 

20^th Century Accomplishments

Last year, my colleagues and I at CDC compiled a list of the greatest public health achievements of the 20^th century, in terms of the numbers of lives saved and the extent of both suffering and costs averted.  I won’t go into the details of each one, but here’s the list we came up with includes:

·                    vaccinations.  Childhood vaccinations have made once-common diseases – diphtheria, measles, mumps, pertussis – diseases of the past.  Polio has been eradicated from this hemisphere.  Smallpox, once a fierce global killer, has been eradicated from the globe, saving an estimated $150 million each year.  In fact, cases of all vaccine-preventable diseases are down more than 97% from peak levels before vaccines were available.  Vaccines are now available to protect children and adults against 15 life-threatening or debilitating diseases.

·                    healthier mothers and babies.  At the turn of the century, 140 of every 1,000 babies born alive died within their first year of life.  Today, that rate is 6.3 deaths per 1,000 live births 

·                                                                                                                                                                    family planning.  Safe contraception and family planning have not only improved the health of women by preventing unintended pregnancies, but also contributed to one of the century’s most dramatic social revolutions: freeing women to enter the workforce. 

·                                                                    safer and healthier foods.  Today, we enjoy a much safer, uncontaminated food supply, and a far more varied diet, than our parents and grandparents did.  This has produced successively taller, sturdier, and healthier generations in this century.  In addition, fortifying food with various nutrients, such as iodine added to salt and B vitamins added to flour, has prevented hundreds of thousands of cases of debilitating disease, and has done so in a manner that requires little or no effort from the people who benefit.     

·                    fluoridation of drinking water.  Until the 1950s, dental decay and pain were accepted as inevitable, common afflictions, by rich and poor alike.  During World War II, nearly 10 percent of Armed Forces recruits were disqualified from serving because of dental defects – mostly missing teeth that had been extracted because of dental caries.  Selective service dental criteria had to be reduced twice during the war to maintain an adequate level of recruits.  Fluoridated water changed this picture dramatically (even though its benefits are enjoyed by only 60 percent of the population).  Today, thanks largely to fluoridation, more than half of all American children are free from dental caries 

·                    the control of infectious diseases through sanitation and antibiotics.  STDs, most types of pneumonia, infected wounds or lacerations, and most other bacterial infections are routinely treatable now, but were far more debilitating or even lethal just a few decades ago. 

·                    the decline in deaths from heart disease and stroke.  Between 1972 and 1992, death rates from heart disease plunged by 51 percent, but coronary heart disease is still the leading cause of death in the United States.  The decrease was driven by combinations of screening, education, cholesterol and blood pressure medications, dietary changes, and exercise regimens.

·                    the recognition of tobacco use as a health hazard, which I’ll talk about in greater detail in a moment...

·                    motor vehicle safety.  Between 1966 and 1990, safety belts, air bags, safer cars and roads, and enforcement of drunk driving and other laws saved an estimated 243,400 lives in this country alone. 

·                    safer workplaces.  In 1900, the Interstate Commerce Commission reported that one out of every 28 railroad employees was injured, and one of every 399 had been killed on the job.  These injuries were so common that they sustained 6,000 railway surgeons -- a medical specialty that even had its own journals and national professional associations.  Within the past two decades, fatal occupational injury rates have declined 41 percent – our tenth landmark achievement of the 20^th century.

We are proud of these achievements and the progress they represent.  However, embedded in this progress is a great deal of unfinished business – knowledge that we have not been able to apply as comprehensively as we’d like.

To improve health in the next century, we will have to do a better job of applying the knowledge we already have.  In addition, we will have to be able to take advantage of new knowledge, and be as well prepared as possible for threats we can’t even define at this point.

Challenges/achievements 

Our challenges and thus our achievements for the next century can be categorized in 3 areas:

            2.                  Using new discoveries , techniques, pharmaceuticals and devices to improve health.

            3.                  Addressing the unanticipated health threats which will certainly appear throughout the decades to come.

Let’s first look at current opportunities.

Current Opportunities

To give you an idea of what we could achieve in the next few decades by applying what we already know –  without any new breakthroughs – let me pose the following question:

“What would our health indicators look like if we achieved the best rates possible (and ‘possible’ is the key word) for some of the leading health problems affecting Americans?”

There are dozens of examples to choose from, but I’d like to concentrate on three:

·                    preventing diseases caused by tobacco use

·                    preventing diabetes, and

·                    reversing the obesity epidemic that has emerged over the last decade or so.

Tobacco

Tobacco use represents a significant health problem around the world.  In the United States alone, tobacco use is responsible for 430,000 deaths each year, or about 20 percent of the 2.3 million deaths.  In the past 40 years, we have come a long way indeed.  In the mid-1960s, over 40 percent of the population smoked.  The figure was even higher for males, 60 percent of whom smoked – including the Surgeon General and other physicians.  This seems incredible to me today, but I remember, as a medical student, attending physicians and house staff smoking at nursing stations and in conference rooms.

Today, prevalence rates have dropped to a national average of 25 percent.  As with all averages, some states have done better than others, and your state of California is one of the leaders in reducing smoking rates.  At 19 percent, your prevalence rates are the second lowest in the nation, second only to Utah’s, which are just under 14 percent.

If the entire country had smoking rates as low as California’s, we would eventually prevent 86,000 premature smoking death each year.  (I say “eventually,” because of the decades-long lag time between smoking initiation and the manifestation of cancers and heart disease later in life.)  Each of these smokers, who would otherwise have died from a tobacco-related disease, would gain an average of 10 to 12 years of life – 10 to 12 years of enjoying retirement, seeing kids grow up and start their own families, getting to know grandchildren, etc.  And, as many of you know from witnessing these diseases in your own families, a tobacco-induced end of life can be a particularly painful way to go, for patients and their families alike.

How has California achieved these low rates, and what should the rest of the country emulate?  California has traditionally had lower smoking rates than the rest of the country, but there are still a few salient features that distinguish your tobacco control programs from others.  These are:

·                    higher tobacco taxes (which are higher in California than in all but two other states)

·                    creative and effective anti-smoking ads

·                    smoke-free workplaces. 

Other states that have followed your lead with comprehensive tobacco control programs – particularly Massachusetts, Oregon, Florida, and Mississippi – have also documented declines in tobacco consumption.

As any of you who have succeeded in quitting smoking can attest, ridding yourself of nicotine addiction is extraordinarily difficult.  The late Jerry Garcia of the Grateful Dead once said that he had an easier time quitting his heroin habit than quitting smoking – and indeed he never did succeed in giving up cigarettes.

On the individual level, we now have better medical tools to help people quit, such as nicotine patches and new drugs that counter nicotine’s effect on brain chemicals.  Yet California’s experience shows that it is a comprehensive package of public policies, changes in social norms, and health education that work in tandem to reduce smoking levels and – most importantly – encourage people to avoid this deadly habit altogether.

Diabetes

Let me turn from smoking to another example: different rates of diabetes.  For smoking, I compared California’s rates to those of other states.  With diabetes, we looked at different rates among different racial groups in the United States.  Here in the U.S., the lowest diabetes mortality rates are among Asians and Pacific Islanders – although there are some subgroups within that group that experience higher rates. 

Still – if whites, African Americans, Native Americans, and Hispanics all had the same age-specific diabetes mortality rates as that of Asians and Pacific Islanders, we would avoid 19,160 deaths each year.  This represents a 31 percent decline in diabetes deaths, and a saving of 360,774 years of life each year.

These differences are also stark when we look at not just deaths from diabetes, but serious complications as well.  These include kidney failure, amputations of legs damaged by poor circulation, and blindness.  We don’t have reliable data on these complications for every racial and ethnic group, but we do know that African Americans have a 4-fold higher risk of developing kidney failure than whites, and a 3-fold higher risk for lower extremity amputations than whites.  (You may have seen the recent special on Ella Fitzgerald, from which I learned that she had both legs amputated because of complications from diabetes.)

Diabetes and its complications have swung from a uniformly fatal disease before the discovery of insulin in 1921, to a disease whose severity can, in most cases, be controlled through properly timed medical care, monitoring, and lifestyle changes.

Preventable cases of diabetes and diabetes-related complications represent the vexing problem inherent in many chronic diseases, including heart disease.  In many cases, we can prevent or treat these diseases, but in order to do so, we need to persuade people to make changes in diet, physical activity, and their own awareness and monitoring of the disease’s progression – changes that are psychologically difficult and that present formidable barriers for individuals and health systems alike.  While genetic predisposition may play a role in type II diabetes, its onset and severity can be modified by diet and activity.  Complications can be reduced by addressing these risk factors and achieving blood pressure control and avoiding tobacco use.

Obesity

One of the risk factors for diabetes – obesity – is also a factor in other premature deaths.  Together, overweight and physical inactivity account for over 300,000 premature deaths each year, second only to tobacco-related deaths.

Obesity means having a  Body Mass Index, or BMI, of over 30, or in common parlance being at least 30 pounds overweight.  The trend is very alarming. Obesity has reached epidemic proportions in this country.  Between 1991 and 1998 – in less than a decade – the proportion of obese people in the United States has increased 50%; from 12 percent to 17.9 percent.  Some groups – people between the ages of 18 and 29, Hispanics, and people with some college education – accounted for the largest increases.  The largest regional increases were in the South. 

Obesity is much less common among college graduates than among the rest of the population.  A college education translates into a variety of income and lifestyle advantages that make this so.  For example, a recent survey of American adults found that 37% of college graduates participate in regular physical activities, while only 18% of people who did not graduate from high school do so.  This is quite a departure from the early years of this century, when lower-income people incorporated more physical activity into their daily lives through labor and walking, while higher-income people had the luxury of being lazier and eating richer diets.

Currently, nearly 248,000 of deaths among adults each year – 11.6% of all deaths –  are attributed to obesity.  If prevalence rates were the same for everyone as they are for college graduates, 73,000 deaths (or 3 percent of all deaths), could be averted.

What’s going on here?  I believe that an increasingly rushed culture of convenience, along with flawed urban design and the proliferation of fast food and snack food marketing,  have converged to create this epidemic.  The technological advances that brought us automation, TV satellites, and urban sprawl have also removed many routine sources of physical activity from our daily lives and from the lives of our children.  In the Steve Martin movie “L.A. Story,” there’s a scene in which Steve Martin gets in his car and drives about 30 feet to his next-door neighbor’s house.  Sadly, this is not too far from the truth for many of us.  This is particularly true for children, who watch more TV, have less P.E. in their schools, and don’t play outside or walk or ride their bikes.  Sixty percent of overweight children – that’s children between the ages of 5 and 10 – already have at least one risk factor for heart disease; 20% of these overweight children have 2 or more risk factors.  Seventy-five percent of children live within 1 mile of their schools, but only 25% of these students walk or bicycle to school.

What can we do about it?  Like smoking, a combination of individual efforts – in this case, to eat a healthier diet and become more active – and broader policies offers the best chance to reverse this epidemic. 

·                    Health care providers can counsel obese patients,

·                    workplaces can offer healthier food choices and opportunities in their cafeterias and opportunities for physical activity,

·                    schools can offer not only more physical activity but the types of activities help kids form the habit of daily, lifelong activity

·                    Urban planners and residents can push for more sidewalks, bike paths, and other safe alternatives to cars, and

·                    Parents can encourage their kids to get away from screens and monitors and out into yards and parks.

Basically, we need a significant societal change in our attitudes and practices toward food, physical activity, transportation and urban design.

Because of time constraints, I’ve just highlighted three areas where we can make relatively modest adjustments in our personal habits and public policies – not necessarily easy ones, but certainly not radical ones – and reap tremendous benefits in terms of both longevity and improved quality of life.

There are, of course, other comparisons and other opportunities.  No discussion of health trends in the United States should overlook the fact that in terms of health status, we have the equivalent of a developing country within our borders.  Our health status progress, admirable in so many respects, is unevenly distributed.  In four contiguous counties in South Dakota, the life expectancy for Native American males is 56.51 years.  That’s comparable to the life expectancy for men in countries like Bangladesh and the Sudan. Infant mortality rates in inner cities are persistently double the national average, placing us in an unenviable rank among industrialized countries. 

The evidence linking socioeconomic status and health status is compelling, and researchers like Len Syme at UC Berkeley have helped make it so.  Being healthy and wealthy are not independent variables.  Increased polarization by income and health status is morally suspect, wastes human capital, and is costly to boot.  By the way, being wealthy and being wise have no proven relationship –  as the country song goes, “If you’re so smart, why aren’t you rich?”

Discrepancies in health status force us to grapple with other inequities and with social problems traditionally considered to be outside the purview of the health sector.  A social issue that is also a public health one is violence.  The difference between homicide rates here and in other developed countries is striking.  For example, across the border in Canada homicide rates are much lower than ours.  If our rates were as low as Canada’s, our annual homicide deaths would be reduced by 80 percent, saving 16,000 lives and over 700,000 years of life (because of the relative youth of homicide victims). 

Undoubtedly, a complex tangle of cultural, social, and legal differences contribute to this differential.  The Canadians, for example, abide by the motto “Peace, order, and good government,” as opposed to our own “life, liberty, and the pursuit of happiness.”  We need to learn more about which of our behavioral, policy, or other sociocultural differences are causal or contributory to our markedly different rates of homicide.

Future Challenges

Let me return to our future challenge

·                    We’ve just discussed applying what we know.

·                    Lets now consider the role of biomedical advances in improving the public’s health, and

The new frontiers of medicine offer tantalizing possibilities for public health – for preventing disease, for catching it in its earliest and most easily treated manifestations, and for improving the health of populations on a large scale.  These include diagnostic and screening technologies that let us detect what was formerly hidden (as with newborn screening for rare diseases), new generations of antibiotics and even vaccines for chronic diseases, and gene therapy...among many others. 

But we need to be thinking of the challenges that these advances pose.

For example, we need to consider economic and access issues.  Relatively large increases in cost for vaccines and antibiotics have implications for the financing of our health care system, for equity issues in the U.S. and for worldwide benefits of biotech advances.

We also need to consider the changes occurring around us as we progress through the first decades of the next century.  We will be an older society.  According to the Census Bureau’s projections, the elderly population will more than double between now and 2050, to 80 million.  At that point, as many as 1 in 5 Americans could be elderly.  And that’s just defining those 65 and over as elderly.  The “oldest old”  – those aged 85 and above – are the most rapidly growing elderly age group.  The baby boom survivors will number 19 million in 2050 – making us 24 percent of elderly Americans and 5 percent of all Americans.  This has dramatic health and social implications, if we can expect to live 17 more years once we reach the age of 65. 

We also will be an increasingly ethnically diverse society with a larger Latino proportion of our population.  The Latino population has grown faster than the overall U.S. population since 1990, and is projected to become the largest U.S. minority group by 2005.  In California, Latinos are likely to become the largest single racial/ethnic group at some point between the years 2014 and 2021.

The Unknown and the Unanticipated (Sounds like a new thriller...)

Of course the unknown threats to health seem the most daunting, since they could take so many forms – ranging from bioterrorist attacks to environmental disasters.  (These remind me of the old joke about the telegram from your grandmother (actually, this only works if it’s my grandmother, etc.): “Begin worrying.  Details to follow.”)

At CDC, we have begun worrying, and are trying to be prepared for any number of scenarios.  This means creating a strong infrastructure that includes sophisticated laboratory surveillance and communication networks that enable us to respond quickly and effectively to any number of threats.  Given recent history of bioterrorist events in Japan and Oregon and the presence of malevolent angry individuals and groups bent on terrorist “statements,” future events are quite possible and may be likely.  A wide variety of biological or chemical agents could be used, singly or in combination.  There may be isolated incidents or carefully planned multifocal attacks. 

I’d like to return for a moment to the list of achievements I mentioned at the beginning of my talk.  A striking aspect of the list is that a century ago, some of the greatest threats to health were completely unrecognized because they did not yet exist.  Tobacco was not the consumer product it later became, there were only 4,000 cars at the turn of the century so motor vehicle collisions and deaths wouldn’t have been on anyone’s future challenges list, and dentition was considered a cosmetic frill rather than a health issue- so the success of fluoridation with its huge impact on quality of life would have been thought peripheral to improving health.  HIV was to become the scourge of the end of the century.  Thirty new emerging infectious diseases have become apparent in the past 30 years, including Lyme Disease, toxic shock syndrome, Hantavirus respiratory illness, Legionnaire’s disease, etc.   Dementias were not appreciated as a great health issue, in part because people died in what we would now consider middle age.

My point is that we can’t anticipate some of the greatest health threats of this new century, and that, alas, we are quite likely to manufacture our own once again.  This is, and should be, a humbling and sobering thought.

Conclusion

I hope I’ve provoked a sense of possibility in you -- a sense that improvements in smoking rates, obesity, and poor diagnosis and management of diabetes are truly within our reach.  In other areas, such as violence, we do not have the definitive science base to move forward, but we know that we can apply the tools of epidemiology to increase our understanding and intervene in that type of epidemic as well. 

Moreover, reaching these goals – which we know can be done – will yield a significant pay-off.  It is rare for health interventions to dramatically alter life expectancy, but these – singly or in combination – will. 

As we invest more and more in the “new, new thing” – the dazzling frontiers of medical and scientific technology – we should keep in mind our goals.  Do we want to push our lifespans as far as possible?  Or do we want to prevent the rarest deaths?   There are many ways to configure our health system and the outcomes we expect of it, but we do have choices to make. For families faced with those rarest diseases, it is understandable that one life saved is worth a comprehensive and expensive screening program.  From a public health perspective, I see a moral and practical imperative for applying equitably within society that which we know, as well as the new knowledge we will gain in the future.  (I’m in favor of what Jim Fries at Stanford has called the rectangularization of the life cycle- meaning that when displayed as a graph, keep the quality of life as high as possible to a time very near death, when a very precipitous decline in health occurs followed rapidly by death.  Or, restated – having a healthy well functioning life until a ripe old age, and then a quick, painless exit...)