The state of US health: The truth stings

It’s going to be hard to anesthetize this one with compassion. I’m sorry, but the report card on US health is not good. We aren’t heading in the right direction, and everyone involved knows that it’s because of a failure to accept the truth.

You have probably already heard the news concerning the state of US health. This week, a mega-group of health researchers (who call themselves the US Burden of Disease Collaborators) published an exhaustive report detailing the health of this nation. (The actual study is available (free) at JAMA. Ron Winslow from the WSJ has this excellent summary.)

On the upside, and I could only find one upside of the report, life expectancy in the US increased 3 years, from age 75 in 1990 to age 78 in 2010. That’s it. We spend almost 20% of our GDP on healthcare, and we get three years.

The bad news is really bad. First, this small gain in longevity actually decreased our standing among other nations, We fell to 27th place, down from 20th in 1990. Imagine: the United States of America, with all the fury of its healthcare-on-demand, the stents, the ICDs, the chemo, the brand-name medicines, the fish oil, the vitamins, and all that, grabs 27th place.

And it gets worse.

The three added years of life are not always good ones. We may live longer, but the gap between healthy years and years with chronic disability changed little over the past two decades. The report documents what we all know: rates of chronic disability are on the rise.

A Failure of Compression of Morbidity:

The old term for the gap between living well and living with disability is compression of morbidity. To compress morbidity means to shorten the time between onset of illness and death. The ideal is to live well into our ninth (or tenth) decade and then take a nap and not wake up. That’s complete compression of morbidity. We aren’t accomplishing this at all. Despite all of our healthcare fury, or perhaps because of it, we are accumulating years without compressing the time of disability. Death may come later, but disability comes earlier. Not a win, clearly.

If you care about health and helping people live better lives, this sort of data presents a real dilemma. Put yourself in a cardiologist’s shoes for a moment. Most of what we treat is acquired illness. People don’t have to have it. Take high blood pressure: we treat it with medicines (and maybe soon, burning nerves in the kidneys), but the majority of patients I see could treat high blood pressure with simple choices—really simple choices. It’s the same with diabetes, sleep apnea and a host of other chronic diseases.

Perhaps an even more obvious example of needless disability is the issue of skeletal disease. The JAMA report documents bone and joint disease as a leading cause of disability. This lies at the core of the problem: our society’s richness, our automation, our technology, our damn inactivity, opposes our basic biology. The human body needs to be fed well, used often and rested regularly.

No sign of a solution:

What ‘we’ have to figure out, and by ‘we,’ I refer to both society and health professionals, is how best to balance sick care with health care. Right now, we aren’t even close. US patients expect sick care, and US doctors find it easy to deliver. Yes of course, from time to time most of us benefit from sick care, but we all know that good health ultimately depends on consistently stringing together smart choices. It’s not complicated. And caregivers can’t make these choices for people. That’s not mean; it’s true.

My pessimism in this matter comes from the reality that even the leaders of Medicine don’t seem to see the problem. Here’s how Harvey Fineberg, MD and PhD and leader of the Institute of Medicine closed his JAMA editorial:

Setting the United States on a healthier course will surely require leadership at all levels of government and across the public and private sectors and actively engaging the health professions and the public.

You see the problem? Setting the US on a healthier course does not depend on leadership from government or health professions. We have had plenty of that over the last decade. That got us to 27th place among other nations.

What is needed is truth.

When the sedentary man with a 40 inch waist presents with high blood pressure, glucose intolerance and a sore back, the fact is that he doesn’t need a doctor to prescribe any more than just the truth. And when the truth becomes normal, not mean or exceptional, we will have turned to the good.

I hope I’m around to see that.

American history is replete with stories of strength. It’s sad and frustrating to see us so unhealthy and decrepit. How in the world did this happen? This is the United States of America.

JMM

Comments

  1. TruthBeTold says

    “How in the world did this happen?”

    The “unhealthy and decrepit” (and irresponsible) giving birth to greater and greater numbers of “unhealthy and decrepit” (and irresponsible).

    A simple numbers game that has given birth to (and sustained) a profit-driven health care industrial complex that promotes the insertion of Medicare-reimbursed stents into diseased hearts, instead of attempting to prevent those diseases in the first place.

    The best is yet to come.

    • VBM says

      Dear Truth Be Told: Yes, it’s the evil profit driven health care system. Let’s do take the profit out so that we can descend to a health care system worthy of the Soviet Union, Cuba, Venezuela, Red China, Belarus, Mozambique, etc. Wait. On second thought, I think I’ll stick with the evil profit driven system, since it worked pretty nicely when I got a stent after I had a total blockage of the LAD at age 52 (total cholesterol at time of the MI, by the way, was 130, HDL 64/LDL about 50, total triglycerides 51 and all of 158 pounds on a 6 foot frame). That evil profit driven system got me from my house to the cath lab and re-profused in 72 minutes. Try doing that in Havana. IMHO.

  2. says

    Yup. I’ve been saying the same thing on my own site. I hadn’t seen the new report but it doesn’t surprise me. I started out in internal medicine but found that most of what I was treating was what people had done to themselves. Now I do anesthesia for gastric bypass. Go figure.

  3. sarah francisco says

    America earned the ranking by believing that conveniences that promote lack of physical activity (remote control everything) and being “mindless” when it comes to making choices about what is fed to our children and adults. We could blame companies for marketing such things, but each individual person has the power within to research and make good choices (eat a whole apple instead of a fruit leather). It is so easy to get a plethora of facts about almost anything with today’s technology. There is no excuse for not knowing that what you eat makes you fat or healthy. Who had the idea to eliminate recess once kids start public middle school? Lack of exercise and being outside starting at an early age sets the stage for a normalcy of lack of physical activity. Video games and texting and TV with 100 channels….Our culture is promoting this with these and other small mindless choices.

    • says

      Thanks SF. Your point about the children is especially poignant. Like KG said, it is so sad. One can only hope common sense and basics will take root. Saying we don’t have time for gym class–It’s hard to believe smart people can be that dumb.

  4. Joe says

    First, a bit of optimism – spending on fitness gear, health club memberships, sporting goods, and other active lifestyle indicators are higher than ever (and higher than the rate of population growth). More people are getting the message, but you don’t see them in your office.

    Where I live the greenways are busy (often with newbies), cyclists are on the roads, and the parking areas for local hiking trails are almost always in use (not just on sunny weekends).

    For each person who walks into your practice with an easily preventable disease, there are many others who you never see – selection bias.

    That said, pundits like to talk about 2 Americas and the haves and the have nots when it comes to economic issues. The health have and the health have nots will be a major issue over the next decade.

    One group understands the small daily choices that compound over time and have real impacts on health and quality of life. The other group continues to think they’re the exception (I’m a healthy fat!).

    Expect policy conflicts as the exceptions expect those who ‘get it’ to pay for the consequences of their exceptionalism!

    • says

      You make a good point about the role of socioeconomic strata. Yes, of course, it is important that we take care of all citizens. The less fortunate clearly face higher burdens for good health, access to nutritious food and places to exercise are obvious issues. That said, any electrophysiologist will tell you that wealth does not necessarily confer wellness, nor the common sense to make good choices. We see plenty of rich people who fail to master the obvious, and then pay the price of physical disability. It still comes down to basic choices; string together good ones and wellness is likely, rich or poor.

      • Joe says

        Actually, I think I failed to make my point :) My fault as the one who didn’t explain well.

        Socioeconomic is a big separator now – the gap between the upper and lower class has widened over the past 20 years.

        I predict the same thing will happen over the next 20 when it comes to the healthy and the unhealthy (talking about preventable disease here). The worst will get sick sooner, and the healthiest will stay healthy longer, the vast middle that just muddles along will shrink. It won’t fall along current socioeconomic lines.

        We’ll all all end up in the same place, dead, but we get at least some chance to try and pick the path.

      • Jeff says

        What are those good choices, Dr John? What would it take to put together the little booklet that Jan Carr is looking for? Spell it out for us. Why not make a start here?

      • Joe says

        Are there really people out there who can’t find advice on making healthy choices? If anything, we’re are bombarded with too many choices, and too many people who want to argue about details.

        At the risk of plagiarizing our host:

        Eat less, move more, sleep well, smile. Every day.

        If you can get someone on-board with with those 4 simple steps, they’ll figure out the rest.

      • Jeff says

        If it were that easy, this wouldn’t be an issue. Things that seem obvious to those whose business it is to know can be elusive to those outside the ken. It’s the tendency of those who are not fired by a subject to just let it ride. It might be particularly true with respect to the health of forty somethings.

        Think of it this way. Our bodies are useful to our genes for the purpose of reproducing themselves. Add a decade or two to the few fleeting years it takes to reach sexual maturity for rearing the resulting perversely helpless little bodies that carry the next generation of genes and then the usefulness is at an end. Nevermind the ability of the minds these bodies house to see into the Infinite and to dream to follow that vision, usefulness is at an end. It even seems to be our collective nature to struggle against the extension of healthy life beyond the span our genes find us useful for, conscious desire notwithstanding. It’s a logical expression of the gene’s own interest, insidious only to the peculiar view of the conscious mind. After all, this mind and its products – art, culture, accumulated wisdom, a somewhat enhanced longevity – are, at best, anomalies unhelpful to the central human animal business of uncoiling and recombining chromosomes. It’s our elaborate capacity to reimagine and impart meaning to the pleasures our genes provided us for complying in this “useful” period that keeps us from just lying down when it’s over.
        We need to learn how to overcome our own natures to get ourselves together.

        Write me the booklet.

  5. TruthBeTold says

    Dr. Mandrola (and all of your colleagues who ascribe to a similar philosophy regarding health and healthy living), how does a person who is not unhealthy, decrepit or irresponsible (when it comes to their own health) locate a physician who believes that good food, good exercise, good sleep and good attitude are the pillars of good health?

    I am a 56 year-old lifetime athlete who lives in Southern California (the Palm Springs area) and tries to adhere to Dr. Mandrola’s sage advice. But, I am 56 and, to my chagrin, and despite my efforts, some things don’t quite function as well as they did in the past, i.e., borderline “prehypertension”, PVCs and PACs, increasing resting heart rate, etc.

    I have been trying in vain to locate a physician/cardiologist who thinks like Dr. Mandrola when it comes to health — someone whose primary focus is on preventing (and slowing the progression of) illness and disease, so that I don’t become another (irresponsible) person who is unnecessarily burdening an already overburdened health care system.

    I have searched for “preventative” cardiologists. No one seems interested in providing quality advice and appropriate screening to assist in such prevention. Rather, when one visits their clinics and/or offices one sees overweight, sick, diseased-ridden patients for whom “preventative” medicine is, unfortunately, no longer a viable alternative.

    I would greatly appreciate it if someone, anyone, can direct me to a medical professional/organization that can put me in touch with a physician that is truly committed to (and truly believes in) “preventative’ medicine, and can relate to a person, such as myself, who has spent a lifetime trying to be responsible for my own health.

    Thank you!

    • says

      Hello Truth-Be-Told – There aren’t many like Dr. John … That said – treatment of prehypertension, PVCs/PACs, increased resting heart rate by prevention with focus on lifestyle intervention is well within the realm of many (most) family physicians. Many family physicians have a secondary area of special interest (such as prevention) – so my strong suggestion (as a longterm family physician educator) is that you look for someone suited to your needs/desires in this area. I briefly searched for family physicians in the Palm Springs, CA area – Here is the LINK: http://www.healthgrades.com/family-practice-directory/ca-california/palm-springs – I do not know any of these individuals personally – but years of practice and location are listed for each physician. I’m sure you can easily find phone numbers – and perhaps speak to someone in the office (a nurse?) who can tell you more about the particular physician’s interest areas. A major goal of well trained family physicians is prevention/implementation of healthy lifestyle – so the chances are good with some calling around (and perhaps talking to others in your area) that you’ll find someone. BEST of LUCK!

      • TruthBeTold says

        Thank you, Dr. Grauer! Just wish there were more like Dr. John. Almost impossible to find. And, Dr. John, the “trial and error” method is simply too time consuming and is clearly disfavored by my insurer who wouldn’t like billing from six docs as I tried to find an “enlightened” one.

        Anyway, I will keeping reading this blog and following Dr. John’s philosophy.

    • Joe says

      When you look for a new Doc, ask the receptionist if there’s anyone there who enjoys triathlon, biking, or running. It’s not foolproof, but it works most of the time.

      Another option is to google their name (first and last, or first initial and last) and ‘race results’. Most races post times on places like active.com and it’s not hard to find if someone enjoys those kind of hobbies.

      • says

        Sports Medicine is one of the newest specialty areas – and these days it is a “hot specialty area” for family medicine residents who vigorously compete for the limited number of sports medicine fellowships available nationally. Family physicians who do 1-2 years of highly specialized training in Sports Medicine (after completion of their 3-year family medicine residency) are OPTIMAL candidates for applying preventing and healthy lifestyle choices. Most of them by definition are athletes themselves (without being a “written requirement” – in this competitive field being an athlete of some type is I think needed for insight to be a better sports medicine doctor – and most of the residents I know selected for slots were highly athletic and in wonderful physical shape). That said – I searched in the Palm Springs, CA area – and did NOT come up with sports medicine certification among any of the available primary care clinicians at the link I previously provided above for Truth-Be-Told. Not living in that area of the country – I did not explore other potential options (like calling the County Medical Society and asking about specialty interest of clinicians in the area, or searching in towns that may be close to Palm Springs …. ). That said – ingenuity in calling offices, talking to friends, reading local magazine articles, etc may yield names of some clinicians who “live what they preach” – and hopefully will provide the capable clinician that Truth-Be-Told is looking for.

        As a teacher of family medicine for >30 years – in my opinion the BEST clinicians in caring for patients desirous of healthy lifestyle choices were those who themselves “lived what they preached”. I myself learned about healthy diets (and losing weight techniques) simply because I’ve lost weight, kept it off, and have made healthy choices for well over 30 years.

      • SF says

        You may also want to look into Mindfulness Based Stress Reduction (MBSR) classes. Dr. Jon Kabat-Zinn , founder of the Stress Reduction Clinic at U Mass Medical Center, has researched mind/body interactions for prevention and healing. He has helped people with heart , cancer, chronic pain , blood pressure. MBSR classes are easier to find on the west and east coasts of the US. By using MBSR techniques the patient learns how to use his/her own inner strength to make positive changes and deal with the negatives without attachment.

  6. Jeff says

    We have enormously complex brains and, therefore, minds. As a species, we’re capable of delving into the nature of the universe, creating art that transports and transcends, creating technology that is seemingly limitless, and we are capable of looking into and perceiving the nature of ourselves, of humanity — to a degree. The species ego seems too proud, too shamed, too fearful to do the real job. When it comes to ourselves we’re shown to be all too human — tentative and messy. The way science is applied to medicine is tentative and messy.

    In other words, how to live in a healthful fashion is not truly understood. Not yet. The physician that touts preventative medicine is either naively trusting in the mixed bag of “established” concepts he chooses, or he is a unique genius that truly understands and therefore will likely not, himself, be understood.

  7. Jan Carr says

    Dr. John has been a tireless advocate for more healthful living. But I can’t say that for all the doctors I know.

    The problem is truly pervasive, and I would agree with Fineberg that we need to have “leadership at all levels of government and across the public and private sectors……….”

    Take for instance the food industry. And no, I am not saying they should not manufacturer whatever foods they think will sell to the public. But I picked up a loaf of Brownberry 100% Whole Wheat bread today, and read the ingredients, only to find out sugar is the fourth ingredient listed. Who would ever think that a mfg would include sugar in bread?? — particularly a relatively high end brand that touts their products as “healthy.”

    I would suggest that every doctor in the country should have a simple, plainly written booklet of information on healthy practices. If a person wants to consume large quantities of ice cream every day, they need to know there are consequences. Maybe something like this already exists, but I have never, ever seen it in a doctor’s office. Nor has any doctor in my experience spent more than 30 seconds during a visit talking about diet and exercise.

    • jane says

      The books on health put out by the Hesperian Foundation (e.g., Where There Is No Doctor) are pretty good at putting concepts in simple, direct language – with little cartoons, too.

  8. Jan Carr says

    More on the “Healthy Living” booklet:

    First, a good writer (Dr. John) + conviction + knowledge = a book/booklet.

    I would suggest you start keeping an idea file on your computer, and use it to record your thoughts ideas etc.

    Finally, I would further suggest your effort be be roughly patterned after Robert Fulghum’s ALL I REALLY NEED TO KNOW I LEARNED IN KINDERGARTEN: http://www.goodreads.com/work/quotes/2399046-all-i-really-need-to-know-i-learned-in-kindergarten

    This is: short, simple, pithy, and personal (skip the research citations).

    Your could probably find a publisher straight out of the gate, but instead, I would recommend a smaller, more informal approach — print a few cheap copies (one color, no illustrations, side saddle wired). Use it in your office, tell other docs about it, and offer them copies at your cost to hand out to their patients.

    It will eventually reach critical mass, and you will have publishers and larger organizations knocking on your door asking for the rights to publish it. But by going the informal route, you avoid the inevitable pressures that would be applied to force you to change/alter the content to suit vested interests. You get to say exactly what you want, and publishers are forced to accept or reject it on that basis.

  9. Joe says

    Jan -

    I’m not so sure about booklets, but have you seen the series of videos by DocMikeEvans?

    Start here:

    • Jan Carr says

      This video was brilliantly done — and persuasive. Exactly the style and message I’m advocating.

      Too bad docs can’t hand one out in the office.

      Gotta go take my dogs for a walk now…………….. : )

      • Joe says

        My kids pediatrician plays cartoons in the waiting room. My dentist has a TV playing ads for teeth whitening.

        I’d love to sit in a waiting room and see a loop of DocMikeEvans videos playing.

  10. says

    Well done John. Let me know if you’d like to lead a discussion on the topic at our next Healthcare Pioneers event. We usually have 40-50 docs attending our meetings, nationwide.