Home   >   Congregation   >   Ministry   >   Sermons   >   Read a Sermon

Health Care Reform:
A Cure That Leaves The Disease Untreated?

Dr. Stephen Bezruchka

Edmonds Unitarian Universalist Church
July 11, 2010

Thank you for having me back annually.  I’ve talked about a lot of aspects of health and today is no different.

I want to tell the Story of Health.  Maybe you’ve seen the story of stuff.  So what is health?  It depends on who you ask.  In 1948 the World Health Organization described health as a state of complete mental, physical and social well being and not merely the absence of disease.  That is utopian. But it suggests what is possible.

If you ask your doctor she might say it is about taking your medicines. If you ask your teacher he may reply it is about not smoking, and just saying no. If you asked your parents they might have said it used to be about eating your vegetables. If you ask your children they might reply that health is about working out and doing yoga. If you ask your boss he would say it is about doing your job efficiently and cutting costs.  Your friends may think of health as about having the latest smart phone or neat app.  So what does health mean to you?  Probably nothing very specific.

How healthy are you?  Again, it depends on the perspective or point of view.  If you are a health care insurance company, everyone is healthy and doesn’t need any treatment.  If you are a doctor working fee for service, no one is healthy since if they do enough tests they can find something wrong with everyone and make more money.  If you are a worried parent of a sick child, then it depends on whether you can seek help and know whether your child will be all right.  If you are of modest economic means (that is struggling on a low income with a temporary job), then it means being able to go to work.  If you are a worried patient, it is being told by the doctor that all your tests are normal.  If you are elderly, then you are healthy if can you do what you planned for the day.

Health means so many different things. 

We live in the US, so maybe there is a way we can look at us all as people in this country and see what our average health is like.  People call this population health, how healthy is our population.  It is hard to know exactly how healthy a single person is, but if we look at how long we live, or what our chances of dying are, what does that tell us?  That sounds pretty grim, looking at death rates, but most of us would rather live longer than shorter lives.

What is the standard of health when looking at populations, or nations?  Why not the healthiest nation, the one with the longest lives.

Looking at deaths can be difficult if you consider a place full of old retirees, since you would expect people to die more often than if you looked at a young active community where people do more interesting things than play golf and bingo.  There are standard ways of considering health by looking at deaths that avoid these problems.

Let’s look at rates of death as measures of health of populations.  Infant mortality or child mortality rates are important since we all feel that babies and children shouldn’t die.  Then there are measures that look at the chances of not dying before retirement, since if you don’t get to retire, you haven’t lived. Then one can look at our health in older age.  There have been tremendous improvements in health in the United States.

How healthy is the US?  What are the chances of a child born today dying before they reach the age of 5.  In the US it is almost 7 chances out of thousand of dying, meaning 993 chances out of a 1000 of not dying which sounds like very good odds.  But in quite a few countries the chances of dying are less than half of ours.

If we rank countries by chances of dying before reaching age 5, then some 41 nations do better than we do, and these include all the other rich countries and some middle income or poorer ones.  Our nearest competitors, doing better than the US is Slovakia and doing slightly worse is Lithuania.  That’s surprising!  Maybe even shocking. 

We can look at the same measure back in 1970.  Our chances of dying as a young child were almost four times greater.  So we’ve improved.  Back then only 19 countries did better, whereas in 2010 more than twice as many nations had seen better improvements in noting fewer deaths than we have in the US.  That doesn’t seem right, since times were tougher back then and we have made great strides.

What are the chances of dying in the prime of life?  If you are 15, what are your chances of living to be 60 years old?

For an American boy aged 15 today the chances of dying before reaching age 60 are 13 in a hundred.  That means that 87 of a 100 boys will reach age 60 if things stayed as they are today.  That’s good news, suggesting the odds are good that you won’t end up like Michael Jackson dying after only 50 years.

How do other countries do?  Well the chances are twice as good in a few, and better than us in over 40 nations.  That means that teenage boys have a better chance of not dying before reaching age 60 in all the other rich nations.  Doing slightly better than the US is Peru, while we are tied with Algeria, and a little ahead of Barbados.  That doesn’t seem right either. 

What if you are a girl aged 15?  Chances of dying before reaching age 60 are less than if you are a boy.  They are better than 92% that you will be alive when you are 60 if death rates stay the same.    But some 45 countries do better.  We are a little worse than the Maldives, that island country in the Indian Ocean that may be submerged in a few years if the oceans keep rising.  We are tied with Armenia, and Macedonia and slightly healthier than Poland.  The chances of girls dying during the prime of life in the best performing nations are half of ours. 

There are other measures such as the chances of women dying from childbirth-related causes which don’t look any better.  Deaths of women in childbirth have actually increased in the US today from what they were in 1990.  That is not a good sign. 

Life expectancy is a number measuring the average length of life lived by people in a country if the death rates stayed as they are today.  Again, almost fifty nations do better, that is people in them have longer lives than we do in the USA.  Notice that for all of these measures, every one, at least forty nations are healthier than the United States of America. 

On June 30 a report was released by our National Academy of Sciences that had assembled experts from all around the world to look at differences in health among rich nations for people age 50 or older.  You know now that we have poor outcomes for infants and children, and many homicide deaths of younger people, so if we removed those from the analysis, then maybe our health is really quite good, at least on a par with other rich nations. 

Did you hear about the release of the report in the newspapers or on television news or on the radio?  I couldn’t find any mention of this report anywhere in the country, not even a sentence.  It just isn’t news.  What did the Panel on Understanding Divergent Trends in Longevity in High-Income Countries discover about international differences in mortality at older ages?  That at all parts of the age spectrum, well into retirement, we die far too young if the standard is comparing ourselves with other nations.   

The report, which is over 400 pages long is available to read free on the web.  Some of its highlights confirm that back in 1950 we were one of the healthiest nations on the planet.  But since then our health has not improved as fast as those in all the other rich nations.  They point out that 94% of all Americans survive to age 50. 

So how are we doing at age 50?  Well, no better really than we do at birth.  The experts found that the group of Americans who had the worst health improvements turned out to be women.  Women are always healthier than men.  But studies have pointed out that the health advantage for US women has decreased immensely in the last fifty years.  Sometimes this is spun as saying that men are catching up to women, but it is really because women’s health is not improving as much as it should, again if the standard is comparing our women with those in other rich nations.  American women at age 50 live less long than women in Australia, Austria, Belgium, Canada, Finland, France, Germany, Iceland, Ireland, Italy, Japan, Luxembourg, the Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, and the United Kingdom.  In 1950, American women at age 50 were some of the longest living in the world.   The pace of health improvements after age 50 for women began to falter especially after 1980 and women here saw half the improvement in length of life compared to women in Italy, France and Australia for example, and having less than half the gains, compared to Japan.

US men weren’t the healthiest in 1950 but today they still aren’t the worst off, as is true for US women.  So men have been holding their own, rather than dying ever younger, again if the standard is comparing ourselves to other rich nations.

It gets even worse when you consider that older women, those over age 65, and over 75, are not doing so well compared to those in other rich nations.  For many of you, you have waited to retire and then expect many more years.  But the other rich countries give their older women longer lives.

Back in 1950 Japan was less healthy than all the other rich nations but by 1978 health there improved so much that it became the healthiest country in the world and remains so today.

You might say that those data don’t matter to me because I take care of myself.  I eat right, exercise, don’t smoke, get my shots and see the doctor.  But if we take the healthiest fifth of women in the US, they aren’t as healthy as the least healthy fifth of women in Japan.  That is how bad it gets.  You can’t do the right thing as an individual and hope to escape the sickle of the grim reaper as the sand in his hour glass falls faster in the US than in the other rich nations.  We suffer from PDS, premature death syndrome. 

This can’t be true.  It isn’t true.  Maybe living longer and not dying younger isn’t so bad.  If it is true, why? These are all good questions. 

I’ve presented some facts.  Facts are statements that can be tested to see whether or not they are true.  Some facts are difficult for the average person to test.  We all used to believe that the sun goes around the earth, but when that was tested, it turned out not to be true.  None of us did the tests ourselves, but relied on other people to do them and report to us.  In the case of the sun and the earth, it took several hundred years for people to believe it and to be honest, it didn’t matter on a day to day basis, which way was it is.  Whether the earth went around the sun or the sun went around the earth only mattered when we landed a human on the moon, and today it matters because of all the satellites in orbit that do good things for us. 

Are these facts true?  The factual data on deaths are the best data we have, since it can be a problem trying to decide how healthy someone is, but it is pretty easy to tell whether they are alive or dead.  That is all we need to calculate death rates, namely know when they are born, and when they die. No one who has studied these facts deny them.

Whether it is worth it to live longer, and not die sooner is a personal issue.  We each think differently about it.  But given how desperately we seek to extend life by going to hospitals and seeing doctors wanting heroic treatments, and wanting them without having to wait a minute, it is clear that most of us would rather live longer lives than shorter ones.  Americans seem to be unwilling to die at almost any cost.  We will spend any money we have to not pull the plug.  So it must be that the healthier life, the better life, is the longer life.

Why are most Americans unaware of dying younger than they should, of being less healthy than people in the other rich nations? Why do they not know how fast the sand in the grim reaper’s hourglass of mortality is falling?

The story of health in the USA could say that we really are very healthy.  We are much healthier than Zambia, Haiti or Afghanistan.  Should we be satisfied with this accomplishment?  Shouldn’t we be one of the healthiest countries on the planet?

I call these rankings of countries in measures of mortality the health Olympics.  If any one of these events were a part of the Olympics or World Cup, then we wouldn’t be there for the final day’s event as we would be disqualified in the trials.  That is pretty sad since in the Olympics we always win the most medals.  But we wouldn’t be anywhere close in health events.

What makes us healthy?  We mostly assume that our personal behaviors are very important for producing health, and medical care is the other critical factor.  Is that true?

We have the most advanced medical treatments in the world, yet we don’t live long.  Is it possible that medical care doesn’t really work in prolonging life?  Is it the problem of the uninsured, who drag our averages down?  Surely all that will be fixed with the new health care reform legislation we passed?

The unfortunate truth is that medical care’s ability to produce health is quite limited.  Yes, doctors can treat heart attacks and high blood pressure, fix broken bones and treat infections such as pneumonia and AIDS, but that may not be enough to produce a long life. 

Research studies point out that medical care is not so important for a population’s health as we think.  If asked “do you want health or health care?” most of us would think the question is stupid, since it is health care that produces health.  We spend half of the world’s health care bill in the USA, which amounts to 18% of our economy, yet over forty countries do better in averting death.  So medical care producing good health isn’t as true as we would like it to be.  The National Academy of Sciences report just released is pretty clear about that.

What about personal behaviors?  We die younger because we eat too much and don’t exercise and smoke cigarettes.  Again, just as for medical care, personal behaviors aren’t as important as we think them to be.  Eating your vegetables is good for you.  Exercising is good for you.   Most of the healthier countries have higher rates of men smoking for example, than we do.  I’m not saying smoking is good for health. 

There may be other things people in the healthier countries do that are more important than those behaviors.   I used to think smoking was the worst thing someone could do to die young, but once I discovered the facts on smoking behaviors in other nations, I had to change the way I viewed what produced health in a society. 

The just released report had a large section on possible effects of smoking to explain our poor health.  What may be happening is that smoking may be more toxic in one society than in another.  When we travel to Spain or France or Japan, we see so many smokers and yet their health is not impacted so much by smoking as it is for people in the US. 

The studies on personal behaviors suggest their impacts on our health are much less than we think.  Less than a quarter of our health depends on what we eat, how we exercise, whether or not we smoke and also on having medical care. 

Health of societies depends on how they structure early life.  About half of our health as adults is programmed between conception and before we go to school.  This is long before we make any personal choices about our behaviors, what we eat, or whether we smoke. Yet this is when the building blocks for health are laid down.  That is when the important developmental trade-offs are made.  The most important time is when we are in the womb.  The fertilized egg divides about 42 times to produce a newborn and then about another 5 times to make an adult.  So early life is critical and lasts a lifetime. 

Mothers who face a great deal of stress while pregnant are more likely to deliver a stillborn baby.  Studies suggest that stress on the mother when she is carrying the baby produces more illness and worse health later in that baby’s life. Early years matter for our health. 

Stress in babies and in young children changes the wiring of the nervous system and requires adaptations that may result in the chronic diseases most of us get as we age.  If our early life is not so good, then as we age, we are more likely to get heart attacks, strokes, diabetes, obesity, and so many illnesses that medical care can not cure, but just helps us cope with as we age. 

What is happening is that so many of the illnesses that we face as we get older turn out to be adaptations that the body makes to deal with the uncertainty in our lives so that we can survive as a species.  The ravages of diabetes, high blood pressure, heart disease, lung disease, and cancers that plague us as we age don’t stop us from producing newborns and being around for the early years as they develop.  The price we pay for creating this stressful society then shows up as we get older and have to get treatment for all those ills. 

Americans take more drugs for high blood pressure, diabetes, cholesterol and to elevate our mood than people in all other nations.  So we are paying a big price for creating stress in our lives. 

What is the good early life, the one that produces better health in adults?

A mother’s lifetime nutrition before she gets pregnant is more important than what she eats while carrying a baby.  Having security and the support of a family while she is pregnant matters a great deal.  Then when the baby is born, time to parent is critical.  A newborn needs a single care-giver for the first year of life.  It doesn’t have to be the mother.  It could be the nanny or his boy friend.  A single pair of eyes needs to nurture the baby.  A second pair of eyes is good to have around in the second year of life.  If both pairs of eyes are there as the person grows older, that is healthy too.

So how do we produce healthy early lives?  We could just tell parents to do the right thing as we do in the United States, but other countries make it easier.  Most rich countries provide paid pre-natal leave.  If a woman is pregnant she has to take some paid time off.  Most working pregnant women find there are times when they shouldn’t be stressing out at work.  It would be good to make that mandatory with paid leave laws.  Most rich nations guarantee at least one week of paid pre-natal leave. We don’t offer a minute’s paid time off work if you are pregnant.  This is part of the reason the others are all healthier than we are. Some countries that are healthier, such as Chile, mandate 6 weeks or more of paid pre-natal leave.  That is healthy policy. 

Almost all countries in the world, not just rich ones, have laws guaranteeing a mother paid parental leave for varying periods.  Only the United States, Liberia, Swaziland and Papua New Guinea do not have such laws.  Many countries guarantee a year at close to full pay and some are even more generous.  That makes for better health in later life.  Many in this country might say that we can’t afford such a policy, but you get what you pay for. 

What we are talking about with paid pre-natal and paid parental leave is time.  Carl Sandberg said “time is the coin of your life.  It is the only coin you have, and only you can determine how it will be spent. Be careful lest you let other people spend it for you.”  Our problem is that as a nation, we live to work and let our bosses spend our coin of time for us.  The price we pay is Premature Death Syndrome.  We can change that.

More unequal societies have worse health than those where everyone shares in the fruits of that nation.  Poorer people have poorer health is a consistent finding.  The greater the gap between those who have too much and those who know how little they have in comparison to the over-consumers, the more stress falls on those lower down.  Economists use the term “the great compression” to refer to the leveling of inequality in the US that took place up to the early 1970s.  The gap between rich and poor was much less then.  Inequality in the United States has soared since the 70s and is one explanation for our falling ranking in the health Olympics.  The reason the income and wealth gap has grown is due to government policies that make it easier for a few to have much more than the rest of us.

Living in a stressful society where people don’t have time to raise children, where they don’t have time to be with friends and family and support one another, where they worry about whether they will be evicted is not good for health.  The other rich nations have better societal welfare systems that care for the less fortunate.  But we believe in the individualist mentality, namely we have to each pull ourselves up by our bootstraps and not depend on the good will or generosity of the government.  That value is not healthy.

In more unequal societies, those who have a great deal can afford to buy time for child care, to have personal trainers, to seek massages, and to join exclusive clubs.  If they have difficulties in some aspect of life, they can pay for help.  They are deaf to the needs of those who have less and hence don’t support a governmental framework to look after people.  Since they take care of their own needs, they feel other people should as well.  The concept of a smaller government takes hold and helping others gets sidelined.

The United States has the highest rates of child poverty among rich nations.  It is one of the reasons why our children and later the adults they become don’t live as long as we might.

The US mentality is fostered that only what you do as an individual without help from others, including the government, matters.  So poorer people don’t expect benefits from societal structures, or governments they way they do in other nations.  The demonstrations in Europe over possible cuts in social spending attest to how they feel.  We don’t protest here.  We just blame ourselves for not working harder.

There are many studies linking worse health outcomes to inequality both among nations and within those such as the US.  But these studies are not seriously considered in the United States.

Where are we in the story of health now?

If you take measures of length of life at various points from childhood to death and compare ourselves with other countries, the sickly news is that we don’t have good health if the standard is comparing ourselves with others.

The just released report by the National Academy of Sciences is very clear about our dying young if we compare ourselves to other rich nations.  That report makes it clear that health care is not the reason.  The Patient Protection and Affordable Care Act passed in March will make no difference in our overall health status.  We can’t treat PDS, Premature Death Syndrome with health care.  It is like trying to reach the moon on the back of a cow.  It won’t get you there.

Since we win the most Olympic medals, have the most billionaires, have the best universities and have won the most Nobel prizes in the world, this is shocking news. 

The reasons for our poor health are mostly not about our personal behaviors nor about health care but about something more fundamental, namely how we structure early life and create a society of health-promoting relationships.  This is a revolutionary way of looking at health as it doesn’t depend on consuming particular products, be they organic foods, or certain exercise programs, or taking the latest wonder drugs. 

We have made a variety of choices based on a do-it-yourself mentality that has not supported early life adequately and has produced a very stressful society based on greed to get ahead of others.  We used to be one of the healthiest nations 60 years ago and we could go back to some of the political choices the healthy policies we made back then that worked to produce health.  Consider ‘medicines’ which are political choices made by either of the two major parties in the US.  They all had to do with decreasing inequality. 

President Roosevelt proposed a hundred percent tax on incomes above $25,000 in 1942 to limit inequality.  What passed was a 94% tax, which later went up to 96% which, as a maximum tax, would be quite effective on limiting extremes of income.  Today that $25,000 is around $500,000.  Many of us could survive on if we had to.

President Nixon proposed a guaranteed income for all American families with children in 1969.  That legislation made its way through the House of Representatives then languished in the Senate.  As Nixon got embroiled in Watergate, it never became law.  Imagine a Republican president trying to make sure everyone had enough income for life’s basics.

What should be done at the national level to further our health are enacting policies not unlike our Presidents have proposed back when we were much healthier as a nation compared to other countries. 

We know that the rich in the US have many lobby groups to pressure the government to look after their welfare and help them get richer. The news is full of how effective the rich are in getting richer.  I talked about Roosevelt’s high tax rates.  Last year the highest income was two million dollars an hour, that’s right, two cool million bucks every hour if the person who made four billion dollars worked an eight hour day and took two weeks off. Nice work if you can get it, and we believe we can get it if we try.  That is why we tolerate such extremes of wealth and poverty, because we think we can become just as rich as the man making two million dollars an hour if we try hard enough.

We need lobby groups for the rest of us, or we need to ban lobbying.  That would be hard to do today, as we aren’t used to organizing the way we did back in the 1950s and 60s when we were one of the healthiest nations in the world.  Recall the Civil Rights Movement, the labor movement, the protests against our invasion of Vietnam, the war on poverty.  There is a pattern there.  When people look after their society, they achieve good health.  If we leave government to those with lots of money, then we get the best democracy money can buy.  The Supreme Court ruling removes any limits of how much money can be spent by corporations to buy the government they want.  We are likely to see our health continue to decline compared to other nations.

Today we need to get government looking out for all of us and not only the rich.  This means rethinking who and what should be taxed and what use should be made of those revenues.  Much is at stake today regarding uncertainly on the role of government’s in lives of citizens as evidenced in Europe and in the US during our great recession.  This is no time to leave plans for the future structure of our society to the rich and powerful.  We must get involved or have our children and grandchildren face the grim reaper far too soon.

Political and economic policies must be seen as health policies.  They are the key factors that produce better or less good health depending on what they do to the hierarchy in society and who benefits from the various choices. 

Our health results from political biomedicine or health politics.  If we choose to be healthy as a nation then our individual health will improve. 

We need policies, real medicines for health, impacting early life dispensed nation-wide.  The best drug would be parental leave policies beginning with pregnancy and those to provide enough financial support for the mother and father.  They would allow a pregnant woman to take paid work leave, say six weeks like Chile.  If Chile can afford it, then we can.  Then after the birth, moms or dads would be able to stay home with the baby for a year at full pay.  That is what many rich nations do.  The most generous country parental leave policies are in some of the longest lived.  For the second year give the parents more paid leave and follow this in subsequent years with good day care where experts are there to help the children socialize.  Give everyone paid vacations as the European nations do.  We need time to be with friends and family and not be continuously in the rat race.  Such steps would be a great use of stimulus funds.

The money needed would come from a restructured government that would be focused on seeing our health improve.  We must be patient as it will take a generation or two for big changes.  It took a couple of generations to see our relative health standing decline and it will take a similar time once we take the right medicine which focuses on early life.  We won’t have cures by Christmas. This is how we must treat the disease PDS, Premature Death Syndrome, once we recognize that we have this scourge.

You get what you measure.  We need to measure how fast the sand falls in the grim reaper’s hourglass and report changes regularly.  We need a goal to be in the top twenty of nations in health in twenty years.  Top twenty in twenty is possible. We can’t sit back and wait for health care reform to kick in since it won’t affect our health. 

Our challenge, once we realize that we die young, is to ask what produces health in our nation and whether we accept dying considerably younger than we should for living in the richest and most powerful country in world history.  Health is something we have to produce together as a society.  It doesn’t depend on what we do as individuals.  Let’s work for health together.

Thank you.

Stephen Bezruchka, MD, MPH
Senior Lecturer, Departments of Health Services and Global Health
University of Washington
Box 357660
Seattle, WA 98195-7660

Given on July 11, 2010 at
Edmonds Unitarian Universalist Church
8109 224 Street SW
Edmonds, Washington 98026-8247

Links for more information

National Academy of Sciences Report released June 30, 2010 Crimmins,  E. M., S. H. Preston, et al., Eds. (2010). International Differences In  Mortality At Older Ages: Dimensions And Sources. Washington, D.C., National Academies Press. http://www.nap.edu/catalog.php?record_id=12945

Our standing in early life

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60703-9/fulltext but you have to pay for the full article cited as Rajaratnam, J. K.,  J. R. Marcus, et al. (2010). "Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970-2010: a systematic analysis of progress towards Millennium  Development Goal 4." The Lancet 375(9730): 1988-2008.

At age 15 the chances of reaching age 60

http://www.sciencedirect.com/science/article/B6T1B-4YYV5C9-3/2/8c9bf77a3da0523bc59c1a47acaf9157 again, having to pay for the full article Rajaratnam, J. K., J. R.  Marcus, et al. (2010). "Worldwide mortality in men and women aged 15-59 years  from 1970 to 2010: a systematic analysis." The Lancet 375(9727): 1704-1720.

Maternal mortality

http://www.sciencedirect.com/science/article/B6T1B-4YTJP4S-2/2/db3b115da107e2b91f88fbcbd74ebdf8 Hogan, M. C., K. J. Foreman, et al. (2010). "Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5." The Lancet 375(9726): 1609-1623

Our population health forum's meetings at UW and other material

http://depts.washington.edu/eqhlth/ and if someone wants to read a college textbook summary of my ideas,  they are there under Resources, and under Readings as the Chapter titled Epidemiological Approaches to Population Health.

 

Listen to the sermon     Read a summary