“Beyond Health Care” (Part 1)

The  Robert Wood Johnson Foundation’s Commission to Build a Healthier America has just released a new report: Beyond Health Care. At a time when all eyes are trained on the debate over providing access to medical care for all Americans, the report looks beyond health care, to the health of the population. As it turns out our health—public health—has less to do with health insurance than one might think.

 “Beyond Health Care” does a masterful job of pointing out that the conventional wisdom about what we need to do to improve the health of our population is blinkered.  Many pundits assume that  providing access to medical care will solve our problems. Others insist that lecturing Americans on “personal responsibility” will do the trick. The report makes it clear that the received wisdom is wrong on both counts.

First, the report observes that, while medical care is important, “Health is More Than Health Care”:  “Although medical care is essential for relieving suffering and curing illness, only an estimated 10 to 15 percent of preventable mortality has been attributed to medical care [or lack thereof.]  A person’s health and likelihood of becoming sick and dying prematurely are greatly influenced by powerful social factors such as education and income and the quality of neighborhood environments.”

Secondly, the report’s lead authors, the Brookings Institution's  Mark McClellan  and Alice Rivlin, acknowledge that: “Many people live and work in circumstances and places that make healthy living nearly impossible . . .Unquestionably, we must take individual responsibility for our health and the health of our families. At the same time, we must recognize that, in many instances, the barriers to good health exceed an individual‘s abilities, even with great motivation, to overcome these barriers on his or her own. In seeking a healthy society, we must consider the choices available to individuals and the contexts in which choices occur—including conditions in homes, neighborhoods, schools and workplaces—that can constrain or enable healthier living.”

Health Is More than Health Care

If you compare the U.S. to other countries, you recognize that the RWJF report is right when it declares that “More health care spending will not solve our health problems. Even with technologically advanced care for conditions such as preterm births, diabetic complications and heart disease, we cannot expect this care to close the global health gap. Infant mortality and life expectancy rates in the United States lag behind most of Europe, Japan, Canada and Australia, and in the last two decades, U.S. rankings have fallen lower on the scale relative to other nations, despite our rapid increases in spending. In 1980, the United States ranked 18th in infant mortality rates among industrialized nations. By 2002, 24
industrialized nations—including Korea, Hungary, the Czech Republic and Greece—had lower infant mortality rates than the United States.”

 As I have pointed out in the past, even when you narrow the comparison to Caucasians in the U.S. to Caucasians in other countries, the U.S. fares poorly.   Overall, the United States slipped from 14th among industrialized countries in life expectancy at birth in 1980 to 23rd by 2004. We need to look beyond medical care to other factors that can improve America’s health.

Where you live plays a major role in how well  you are.  “Many Americans do not have access to grocery stores that sell nutritious food” the report observes.  “Still other  live in communities that are unsafe or in disrepair, making it difficult or risky to exercise. While individuals must make a commitment to their own health, our society must improve the opportunities to choose healthful behaviors, especially for those who face the greatest obstacles.

“For example, members of disadvantaged racial and ethnic groups are more likely to live  . . . near toxic wastes, abandoned or deteriorating factories, freeway noise and fumes; and exposure to crime and violence and other hazards—increase the chances of serious health problems. “

Being poor also means having less control over your life, and this can be incredibly stressful. “Limited economic means can make everyday life a struggle, leaving little time or energy to adopt healthy behaviors and crushing motivation. Chronic stress associated with financial insecurity can seriously damage health, causing wear and tear on the heart and other organs and accelerating aging.

Living in health-damaging situations often means that individuals and families don’t have healthy choices they can afford to make. Protecting and preserving good health will mean focusing on communities and people, how and where they work, where their children learn; fixing what impairs our health and strengthening what improves it. The road to a healthier nation requires us all to understand that this is about everyone, rich and poor, minority and majority, rural and urban. We cannot improve our health as a nation if we continue to leave so many far behind.”

Ultimately, the report appeals to our sense of justice, and the nation’s basic values: “This shouldn’t be the case in a nation whose highest ideals and values are based on fairness and equality of opportunity. Where people live, learn, work and play affects how long and how well they live—to a greater extent than most of us realize. What constitutes health includes the effects of our daily lives—how our children grow up, the food we eat, how physically active we are, the extent to which we engage in risky behaviors like smoking and our exposure to physical risks and harmful substances—as well as the neighborhoods and environments in which we live. We must identify where people can make improvements in their own health and where society needs to lend a helping hand..”

The Status Quo: A Relentless Search for Better Health for the Middle and Upper Middle-Classes

Reading the Robert Wood Johnson  report, I can’t help but think of Dr. Steven Schroeder’s landmark Shattuck lecture, published in the New England Journal of Medicine in  September of 2007, titled “We Can Do Better: Improving the Health of the American People.” Schroeder pulls no punches: “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 . . . These efforts are led by middle-class advocates whose lives have been touched by the disease.”

 He continues: “To the extent that the United States has a health strategy, its focus is on the development of new medical technologies . .  . We already lead the world in the per capita use of most diagnostic and therapeutic medical technologies . . . But these popular achievements are unlikely to improve our relative performance on health.. . ”    As HealthBeat readers know, many of these advanced technologies are marginally effective — or helpful only for a small group of people who fit a particular profile  Yet, we squander billions  applying these technologies to patients who will not benefit.

Meanwhile, Schroeder writes “the biggest gains in population health would come from attention to the less well off.”  In other words, we need to invest more money in public health, less in cutting edge technology. “But little is likely to change,” says Schroeder, “unless [the poor] have a political voice and use it to argue for more resources to  . . .  reduce social disparities . . .”

He is not optimistic that this will happen: “It is arguable 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.”           

Poverty in the U.S. and Other Developed Nation

 “But," Schroeder asks, "aren't class gradients a fixture of all societies? And if so, can they ever be diminished?”  In other words, won't the poor always be with us?

We don't have to tolerate the degree of inquality that we see in the U.S. today.  "“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," Schroeder points out, "resulting in a narrowing or widening of class differences. “

In the 1950s and 1960s, socio-economic gaps were much narrower among white Americans.  This is in part because absurd CEO salaries (which came into vogue in the 1980s,  along with Celebrity CEOs smiling out at you from magazine covers. ) had not yet set a multi-million-dollar standard as to what it means to be “well off.”  Soon, other professionals began to feel that if they weren’t earning at least $750,000 –and preferably something closer to $2 million — they were falling behind in the scramble for fame and success.  Stockbrokers, divorce lawyers, baby bankers,  real estate brokers,  interior designers, and TV pundits all judged themselves miserable failures if they couldn’t command high six-figure incomes.

In the 1950s and 1960s a very different tax policy also promoted greater economic equality. Today, few remember that in 1945, the marginal tax-rate on individuals earning over $200,000 was 94%. It stayed over 90% until 1964 when it was lowered to 77%.  (Note: in 1960, $200,000 was worth roughly $1.4  million in today’s dollars. And  of course a “marginal rate” is what a taxpayer laid out for every dollar over $200,000—he was not paying  90% on the first $200,000.)

When President Reagan came to office in 1980, he began slashing tax rates for the wealthy. By 1988, the tax on the top tier hit a low of 28%.

In the early 1990s,  President George H.W. Bush realized that more money was needed to run the government, and he did the only thing that made sense at the time–he raised  taxes to 31% –despite campaign promises not to do so. By then, the wealthy had become accustomed to Reaganomics—an economic policy that had the effect of redistributing wealth upward– and they punished Bush Sr. for the 3 point raise by voting him out of office

What most people do not realize is that while the very wealthy have been paying relatively low taxes since the 1980s, historically this is an anomaly. During much of the twentieth century the top rate was far higher. During the Great Depression, ,money was needed, and those who could afford it paid 63%. After World War II started, the tax rate skyrocketed—and, as noted, remained high in the decades that followed.

The chart below shows  the top marginal rate for the wealthiest 1 percent from 1944 to 2005–  and an even more important number, the top effective rate (the share of their income that people in a particular bracket actually wind up paying in taxes, after taking advantage of whatever deductions and legal loopholes are available to them.  You can see how taxes suddenly plummeted in the 1980s.  Today, the top marginal rate remains around 35%– down from over 75% in the 1950s and 1960s–and the effective rate is a little lower. (The numbers behind the chart come from the Congressional Budget Office

Image001
“The taxes paid by those at the top matter a great deal for government finances” notes Lane Kenworthy, a professor of political science and sociology  at the University of Arizona.   On  his blog “Consider the Evidence,” Kenworthy writes: “As of 2005 the top 1%  accounted for 28% of federal government tax revenues. That isn’t because they are taxed at an outlandish rate,” he adds. “An effective tax rate of 30-40% is hardly confiscatory. Instead, it’s because they get a very large share of the country’s income — 18% as of 2005.”  Think about it: the wealthiest 1 percent salt away close to one-fifth of all income.

In part 2 of this post, I will discuss what share of taxes affluent, but not super-rich Americans (households earning over $150,000) pay when compared to those who earn less than $150,000; the myth that higher taxes lowers productivity;  the correlation between better health and the higher taxes paid in other developed countries , and what the Robert Wood Johnson Foundation recommends as a remedy to lift the health of all Americans.

22 thoughts on ““Beyond Health Care” (Part 1)

  1. Populism is being conflated with public health. Why is it that we see large numbers of women in their 30’s and 40’s getting breast cancer?
    Why is it that we see wealthy men having heart problems?
    It is true that poor wealth distribution and excessive spending on militarism have diverted funds from those at the bottom of the economic ladder, but that doesn’t explain the other issues.
    There are fundamental things wrong with the affluent lifestyle. The greens and foodies have been preaching this for decades, but the scope of the problem is still not appreciated. The issue with BPA being used in consumer products ranging from baby bottles to canned goods is just a single example.
    Of the tens of thousands of chemicals used in the market only a handful have been evaluated for health effects (as opposed to toxicity). To do something about our modern lifestyle would take a wholesale restructuring of modern civilization. This isn’t about to happen.
    Better food inspection may reduce the massive recalls of the past few years, but the corn/beef/pork/chicken economy which is subsidized by the government isn’t going to change.
    Look we haven’t even been able to get rid of cigarettes in 50 years, I don’t think hamburgers are going to removed from the menu.
    We are poisoning ourselves and the planet and all the pols want to do is get the economy back to where it was a few years ago.

  2. Robert–
    Thanks for your comment.
    Actually, large numbers of women in their 30s and 40s are Not getting breast cancer.
    More women are being Diagnosed with breast cancer at an very early stage–often it is breast cancer “in situ”–cancer that has not spread and may well disappear.
    This is because we are doing more screening with MRIs and other screening tools that detect smaller, but often harmless cancers. As the New YOrk Times recently reported:
    ” What women are not told, is that for every woman whose life is saved by breast cancer screening, up to 10 healthy women are given diagnoses — and, often, surgery — for a cancer that is so slow-growing it would never have threatened a woman’s life. . .
    “The idea that mammography may do more harm than good may be alien to many American women. The prevention message has emphasized that screening protects women from breast cancer, and one survey of 479 women found that only 7 percent were aware that some cancers grow so slowly that even without treatment they will not affect a woman’s health.
    “A 2006 analysis by the Nordic Cochrane Center collaborative, an independent research and information center based in Copenhagen, found that for every 2,000 women age 50 to 70 who are screened for 10 years, one woman will be saved from dying of breast cancer, while 10 will have their lives disrupted unnecessarily by overtreatment.”
    Thus the “worried well” are diagnosed with breast cancer, and treated for breast cancer that never would have hurt them. Other recent research reports that, particularly in the case of younger women, these lesions often disappear.
    Similarly, affluent men are often diagnosed with heart disease when, in fact, the problem is small and will not be fatal. Nevertheless they have angioplasties.
    The fact is that the number of people with heart disease is decreasing–and we’re not sure why. (Dr. Nortin Hadler provides the facts in his book Worried Sick.)
    Though we do know that fatal heart disease is more common place among the poor. The rich live 5 or 6 years longer than the poor, on average, adn this is one reason.
    As for smoking: “Thirty-four percent of the lowest income Americans smoke, compared with 13 percent earning $90,000 a year or more.”
    At one time affluent people smoked. Our campaign against smoking has, in fact, been very effective–among the wealthy and well-educated.
    Among upper-middle class people, smoking in someone’s home, or in a restaurant is now considered poor manners.
    You write about toxic chemicals: “A study by Duke University researchers finds that minority and low-income communities are more likely to be adversely affected by a 2006 U.S. Environmental Protection Agency ruling that exempts some industries from reporting detailed information about the toxic chemicals they release into the environment. . . Overall, we found that communities in proximity to industrial facilities no longer required to report detailed information about their chemical releases, have significantly higher percent minority, minority under age 5, and low-income populations compared to communities where all of the information is still available,” said Miranda. ‘We also found significant differences in these demographics between regions and at the state level.'”
    Bottom line: we take care of our middle-class and upper-middle class communities: industries there must report emissions. But we do not take care of our poor.
    Finally, a wealth of evidence shows that obesity is much more commonplace in low-income families, neighborhoods and states.
    I’m not sure if you read the entire post, Robert, but this is not a “confliation of populism and public health.”
    The facts are that the poor are sicker, are far more likely to suffer from
    chronic diseaes, and die much sooner, and this is Not because of lack of access to health care. That accounts for only 10%
    of premature deaths.
    Their poor health is all tied up with being poor—and as both the RWJF and Schroeder make clear, it is not their fault. The live in an environment where taking good care of yourself is difficult, sometimes impossible.
    Meanwhile the affluent “worried well” fall victim to “disease-mongering”– an epidemic of diagnosis as too many diagnostic tests tell essentially well people that they are sick.
    (The people at Dartmouth have also done much reserach on this.)
    Perhaps if the worried well worried less about themselves, and more about those who are less fortuate, we would all be healthier.

  3. Excellent item, really good people who truly believe in this solution, mainly because it supports that medicine evolved satisfactorily and helps many people with this information, since many can not visit a doctor for lack of money that the economy is much less due to across the world.

  4. Bruce Lipton, Ph.D., in his book, The Biology of Belief, says it very succinctly – “It’s the environment, stupid.” Our environment shapes our beliefs and our beliefs determine our biology. The treatment is only a small part of our “environment” influncing our health and well-being. What can be done in all healthcare settings is to change the environment – which means change the experience – to support healing. Move from “sick care” to healing experiences in all that we do. For more ideas to leverage science to empower each person to be an agent of healing, see: http://tinyurl.com/c8fgk3

  5. Indeed, health is a multi-variable function, and health care is only one of the independent variables. Curious how under-appreciated this simple fact is.
    But don’t under-estimate what medical care can do. I saw a 20-year old with acute appendicitis last Wednesday. He’s now out of the hospital and doing fine, expecting 50 or more years of life. Without health care he’d most likely be dead or dying.
    Also, of course, many of the social and environmental factors influencing health are beyond the control of practicing physicians, so we’d don’t spend a lot of time on them.

  6. Deb:
    Thanks for providing some of the thoughts expressed by Bruce Lipton.
    I concur from my own experiences.
    I used to believe I was “my own person,” that I lived “according to the beat of a different drummer.”
    What I realized, after many years of misbelief, was that I am heavily influenced by my culture and those I spend the most time with.
    That’s probably why I have chosen not to hang out with too many people!
    Don Levit

  7. Deb–
    Imagine that you are a single mother in the South Bronx. You work two jobs.
    (The father of your children was shot a few years ago–just in the wrong place at the wrong time.)
    You work two jobs–and was just laid off from one of them.
    How exactly do you “just change your environment”??
    Your comment ignores the whole point of the report: the poor you do not have the many options
    that others do.
    I have a feeling you didn’t read the post–just saw it as an occasion to express your views on healing . . .
    Jrossi–
    Yes, medical care can save lives. Appendictis is a good example. Cataract operations can save people from going blind, and are now painless. Without eye-drops, I wouldn’t be able to control my Glaucoma.
    And I agree that there is little practicing physicians can do about the larger, deeper problems of poverty–except to vote for politicians who do seem willing to do something, and maybe take at least a few Medicaid patients or SCHIP patients and try to help them as best you can.
    But acute care– the medicine that most doctors are taught in medical school–really isn’t designed to address public health.
    Don– Yes, we are influenced by our culture, and where we spend most of our time. But if you’re middle-class you can choose to spend time in a different place. If you’re poor, you’re trapped (certainly in this economy.)

  8. I wasn’t commenting on over treatment or unnecessary tests, just that modern society gets sick from diseases that were much less common in earlier periods.
    Of course with people dying earlier and of more infectious diseases it is hard to compare, but we do have studies which show that when “civilization” reaches isolated populations the incidence of rich man’s diseases increases.
    I’m not disputing that the poor are worse off either, but it is impossible for us to live a healthful lifestyle in a society where we are exposed to unknown and uncontrollable risks.
    I’m all in favor of improving health care (broadly construed) for those in most need, which is why I favor expanding care first and figuring out how to pay for it second, but the general problems of an unhealthful environment need to be addressed as well.
    This all fits in with my underlying campaign of reforming modern, wasteful, societies so that they are in harmony with nature and use resources in a sustainable fashion.
    Right now the world is consuming at an unsustainable rate with the US being the biggest offender. I’m not a modern Rousseau preaching the return to Nature, but there are societies which do quite well without consuming as much as we do. Apparently some of them are even healthier.

  9. Much of this has been known for decades but IT ALWAYS BEARS REPEATING
    If we really focus on public health much of the debate about medical care and its costs goes away.
    But in addition to the environment my big three causes of poor US health are
    -poverty
    -joblessness
    -fear of joblessness
    Toxins in the enviornment need to be taken seriously but the three issues I cite are by far the most important.
    Dr.Rick Lippin
    Southampton,Pa

  10. Maggie-
    Thanks for reporting on this good RWJ report. But do we really want to trust the report’s Commission with the likes of former Sen. Bill Frist and Bush appointee (FDA and Medicare) Mark McClellan on it? (McClellan is Co-Chair)
    Is this called “reaching out to the other side or consorting with those who broke our health care system”
    I am surprised the Robert Wood Johnson Foundation recruited them?
    Any comments from you or others?
    Thanks,
    Dr.Rick Lippin
    Southampton,Pa

  11. Hi Maggie:
    I have read this statistic in more than one place: The Urban Institute estimates that 22,000 people died in 2006 because they lacked health insurance. How do you think they arrived at that number? And is the problem really that many of those 22,000 were poor people stuck in unhealthy and “sick” circumstances? I am not saying that these people do not deserve health insurance. I am just wondering if that is really what caused the 22,000 deaths. What do you think?

  12. A bit about comments on breast cancer, which is something I spent a lot of my career involved in.
    The rate of breast cancer death in the US is declining sharply over the last 15 years. This is not just the rate of survival for patients with breast cancer — something that could be due to increased diagnosis of non-lethal cancers, as Maggie says. It includes an actual decline in the population death rates.
    There are undoubtedly three known factors in this, and possibly several unknown.
    Mammography and early detection is one of them. Although theoretically non-lethal cancers and lead time issues do cloud the picture, research — especially the Swedish Two County Study — have shown that mammography does decrease population breast cancer mortality overall when it is an isolated variable.
    Improved chemotherapy is a second factor. Many women who would have died from metastatic breast cancer in the past are being cured or are surviving for very long periods of time. Again, there is some problem with theoretical issues and quesitons of overtreatment, discussed previously on this blog.
    An article from the NCI a few years back tried to estimate the impact of mammography and chemotherapy on the decline in mortality, and decided that the split was 2/3 due to chemo, 1/3 mammography — although the people doing the article were oncologists, which may bias the analysis somewhat.
    One other factor has emerged in just the last 5 years. There has been a second downward blip in breast cancer death and an actual downward blip in breast cancer occurance. This appears to coincide with the sharp decline in the use of hormone replacement therapy following a series of alarming studies a few years ago. Because this is population observation, not a scientific study, this is a bit more questionable.
    The impact of breast MRI, as Maggie says, is more problematic. Breast MRI is extremely sensitive for breast cancer — it detects a very large percent of cancers present — but is not specific — it causes suspicion or misdiagnosis of a lot of breast conditions that turn out not to be cancerous. In particular, it has an alarming tendency to lead to the false diagnosis of widespread cancer, leading in turn to some mastectomies when lumpectomy would work, or even when no cancer is present at all. As a result it remains unclear what the role of MRI is in breast cancer. It has a lot of strong proponents, mostly excited about the sensitivity, but most observers would suggest it really has only a limited role in certain special applications.
    One other issue is the role of mammography in causing biopsies that most people would like to avoid if possible. In the very best hands, only 20 to 30% of breast cancer biopsies obtained as a result of mammographic findings are cancers. Added to the question of non-lethal cancers that Maggie mentions, this leads many people to be very concerned. Biopsies have become less invasive in the last 20 years, since minimally invasive techniques developed in Europe were introduced here by Steve Parker and others, but still are a physical and emotional trauma to women, especially some women who, because of certain patterns in their breast tissue, end up with repeated biopsies, sometimes year after year.
    Unfortunately, since chemo is not reliable enough and other tests too questionable to risk ignoring potential early findings and potentially leading to deaths that could be avoided, we are stuck on this treadmill. Hopefully, sometime in the future this will change and breast cancer issues become easier to deal with, with less need for early interventions.

  13. Great post.
    Most of the increase in life span in the US last century is due to sewers and clean drinking water– long before antibiotics were used. Most of the healthcare outcome parameters are socio-economic indicators. This is way pay for performance will fail.
    Patient selection is much more important than medical care in outcome. The best care in Roxbury will yield poorer outcomes than mediocore care in Rochester, MN or Las Alamos, NM (The best educated town, in PhD terms in the nation).
    I have to agree with Dr. Pat regarding mammography. Essentially all the improvement in Breast Cancer survival is due to early diagnosis*. Surgery has not really progressed, and advanced breast cancer has the same poor prognosis now that it did for George Crile, Jr, a lifetime ago. Chemotherapy has often only a marginal benefit.
    In a liability free world, mammography would save tens of thousands of lives just finding the obvious cancers. I agree (I think)with Maggie that way too many biopsies are done working up findings that are almost certainly not breast cancer, with a corresponding low yield. This occurs because two different functions are confused. Finding cancers and excluding cancer are two entirely different enterprises. Mammography regularly dicovers clinically unsuspected obvious cancers. While it can do this for a majority of cancers, a negative mammogram cannot assure a woman she does not have cancer.
    Breast MR is also useful for surgical planning. Is it worth it? Compared to what? Two tiers, anyone? Why not let the rich pioneer new expensive things for the rest of us? If it really works, incorporate it into the basic federal plan.
    As was first pointed out to me by Dr. Ferris Hall, a breast cancer is ten years old when it is clinically discovered. So, every woman who undergoes regular mammography and develops breast cancer, will have had that cancer for a long time and on many previous mammograms. So an expert-for-hire will always be available to say that he could see the invisible cancer on last year’s examination. Blinded studies have shown this to be largely untrue, but try explaining that to a jury. This is why you can hardly get a mammogram in Florida.
    The best article on this is in The New Yorker in 2004, and can be read online, for free. (Search the archive for the key word “Mammography”.)
    The bottom line is that we could find almost all the cancers we find now for a lot less fuss and money, if we were willing to accept missing some early cancers. But we aren’t. This is why the standard of care must be set by doctors, not by courts.
    This is the medical rationing debate in small.
    If we are unwilling to “miss” any prostate cancer, any aortic disections, any fractures, any subdural bleeding, any ante-natal birth defects, any marginal improvement in survival with a drug at a cost that would make Tom Dashiel or Larry Summers with all their (ill-gotten) millions blush, it is going to be very very expensive with drastically diminishing returns. The problem of diminishing returns in breast cancer diagnosis is similar to a hundred other examples in the Medical World.
    *Interestingly, finding DCIS, pre-invasive lesions, has had essentially no effect of breast cancer mortality.

  14. It is interesting how morbidity and mortality rates have been used in the following argument: “The US can’t have the best health care since our mobidity/mortality rates are greater than ________”
    Most physicians I know agree (more or less) with the statement in your article “only an estimated 10 to 15 percent of preventable mortality has been attributed to medical care”. Certainly the percentage can be argued and depends on what mortality you expect would occur without good OB care and proper Peds care, (which includes vaccination). But on the whole the point is correct – how patients live is more important than what doctors do for them.
    This puts the lie to comparisons of various countries health care based on morbidity and mortality rates. I am not saying that the US has the best healthcare in the world (I think it can be in some cases) but just that morbidity and mortality rates don’t tell us that much about the quality of health care.
    I hope I won’t see this canard quoted again in Health Beat (although I bet I will)

  15. Legacy Flyer–
    What you are saying is that
    our morbidity and mortality rates don’t measure the quality fof our healthcare when compared to other developed countires, but, rather the amount of poverty in theU.S.–much higher htan in other developed countires, which tend to be primarily middle-class.
    I agree. One shouldn’t pin our comparative poor health in the U.S on poor health care, Poverty has more to do with our poor international scores.
    But I also have to say that the medical establishment in the U.S. is less cocerned with public health than in many other developed countries.
    In the U.S. you don’t hear much about public health in medical school. In general, public health is seen as a poor cousin of medical care. People who go into public health and get a MPH, are looked down upon by many MDs and medical students.
    So, in that sense,
    our health care system and medical profession is partially respnsible for the poor public health–and thus, lower level of the health in the U.S.
    populations.
    I think that public health should be a mandatory course in med school, and that more of med school training shoud
    focus on how to help chronically ill, poor patients.
    This isn’t easy.But I think we need more M,D’s who also are MPH’s (public health experts.) . And I’m guessing that it would be very helpful if more of thse MD/MPh’s were CEOs of hospials.
    Not for profit hopsitals that are exempt from taxes should be in the vanguard of trying to figure out how to improve public health –particuarly in the poorest communities in their regions.

  16. Several points:
    Your argument depends on how you measure poverty. You seem to be saying that poverty is a relative wealth phenomenon rather than an absolute wealth phenomenon. I happen to agree with you but there are many who would not. They would say that poverty is an absolute phenomenon and that the US has less poverty than other poorer countries that have better morbidity and mortality rates.
    As for your statement: “more of med school training should
    focus on how to help chronically ill, poor patients”, – as you probably know, most training hospitals are located in urban areas with a large poor population. This is exactly the type of patients that doctors see during their training.
    As for what proportion of a physicians training should be devoted to public health – that is certainly a valid question. Medical students are pulled many different ways during their training and every “expert” has their own pet ideas about what the curriculum should look like. Suffice it to say that time spent studying one topic is time not spent on another

  17. Everyone, Daniel, Martha, Dr. Rick, Christopher, Legacy Flyer
    Everyone– this post is about poverty and the connection between poverty and health.
    It’s a bit daunting to see how many comments focus on anything and everything except poverty.
    I realize that poverty is not a popular subject . . but that’s why I wrote I wrote the post. It really is something that we have to think about . . .
    Daniel– Thank you. I know your blog; it’s on my “favorites” list. I should put it on the blogroll.
    Martha-
    Of the 22,000 people who died because they didn’t have health insurance, many were poor.
    IT would be impossible to untangle their lack of insurance from their poverty and say which was the primary cause of death.
    But we do know that, overall, poverty (and the disaseds associated with poverty)leads to the premature deaths of one MILLION Americans annually.
    Dr. Rick-
    I have known Alice Rivlin for a long time.
    She is a superb civil servant.
    Mark McClellan was head of Medicare under Bush but chafed under Bush’s insistance that he focus on the Modicare Modernization Act rather than Medicare Reform
    McClellan has written some good things . . .
    Frist is not one of the lead writers.
    I know you got some e-mail about this report and Robert Wood Johnson–perhpas because they don’t support single-payer. I’m not sure.
    I like RWL very much because they are concerned about poverty. (Somehow, the single-payer folks never talk about the poor.)
    And I greatly admire Dr.
    Steve Schroeder, former presdent of RWJ who I quote in this post.
    If anyone questions the reports authors, or its politics, I would ask that person: “Have you read the report? What did you think about the Ideas?
    Christopher Geroge–
    Thanks– and yes, you’re entirely right, public health measures have been far more important than modern medicine in extending our lives.
    And I agree, the patient in Roxbury will not be as healthy as the higher-income patient who lives in a better environment, even if the patient in Roxbury has a great doctor.
    Poverty kills.
    On screening for breast cancer: For an average-risk woman, I think the danger of MRI’s, false positives and discoverieng cancers that would disappear with time greatly outweighs the benefits.
    (We have recently learned that some of these cancer would disapper on their own, if they hadn’t been detected and treated.
    Even mammograms are now controversial. The number of women needed to test in order to save one woman from dying of breast cancer is suprisingly large (I don’t have the number in front of me.)
    Meanwhile, the number of women who are tested and treated unncessarily is, I believe 10–compared to the one saved.
    So 10 women have a lumpectomy or lose a breast NEEDLESSLY but one woman is saved. . .
    When I look at the odds, I’d rather take the risk of being the one who dies of breast cancer rather than risk being one of the 10 who is treated needlesssly. (I am going to die of something eventually; but I don’t necessarily have to go through an unncessary, mutilating operaton –and then die of something else. If possible, I’d like to keep my harrowing medical experiences down to one.)
    But that’s just me. I’m not against mammograms, But I understand why mammorgrams are no longer recommended for average risk younger women.
    As Nortin Hadler puts it in “Worried Sick”, “It turns out that the public awareness program for cancer screening has been far more effective in provoking enthusiasm than
    reason.”
    Legacy Flyer– I define
    poverty as living in conditions that lead to premature death.
    In the U.S. the poor die six years earlier than the upper-middle class.
    This is not true in any other developed country. The gaps between poor and middle class are not that great– and on average, both groups live longer than Americans, even if you compare white Americans to white Europeans. (People forget that we have many poor white Americans, particularly in rural areas.)
    Sure, other developed countires they have poor neighbohoods, and poor rurl areas. But public education in these
    neighborhoods and rural areas is much better. ( (Teachers are well-respected, and they are paid and treated as professionals.)
    Housing is cleaner; public areas are cleaner; pre-natal care is universal, And there are so many social safety nets. In many countires, a nurse visits your home for a period of weeks after you have a baby. Affordable, safe childcare is available for working mothers.
    And inexpensive, healthy food is available everywhere in countires like Italy, France, Denmark, Sweden. Sure they have junk food, but they have other very appetizing inexpensive soups, sandwiches, salads, (as long as you get out of tourista areas.)
    On med schools training people to care for poor, chronically ill patients–
    Not long ago, Christine
    Cassels (sp?), head of the American Board of INternal Medicine–told me that
    in most academic medical centers, “residents take care of poor (uninsured and Medicaid) patients in the basement somewhwere–without records, or any support. Upstairs, the teaching faculty treat insured patients.”
    Apparently primary care docs who train at a place like Mayo or Kaiser have a very different and much better experience. But at most academic medical centers, caring for the poor and chronically ill is just not considered “interesting” work. Of course so many of our academic medical centers put far more emphasis on research than on patient care.

  18. Maggie,
    I would strongly recommend mammography. It saves thousands of lives because, unlike almost all other malignancies, if can reliably be cured. It is silly to die of colon cancer, thyroid cancer or breast cancer. They are reliably cured, if caught early. Don’t die needlessly to prove a political point.
    Screening for lung cancer? NEVER.

  19. The most under utilized asset for improving our nation’s health is our American democracy, and as for a strategic approach, the WHO’s Ottawa Charter written 23 years ago provided us with the road map we needed -we finally seem to be waking up! Phil