Itâ€™s going to be hard to anesthetize this one with compassion. Iâ€™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. Thatâ€™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. Thatâ€™s complete compression of morbidity. We arenâ€™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 cardiologistâ€™s shoes for a moment. Most of what we treat is acquired illness. People donâ€™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 choicesâ€”really simple choices. Itâ€™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 societyâ€™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 â€˜weâ€™ have to figure out, and by â€˜we,â€™ I refer to both society and health professionals, is how best to balance sick care with health care. Right now, we arenâ€™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. Itâ€™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 donâ€™t seem to see the problem. Hereâ€™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. Itâ€™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.