By SANDRO GALEA
May
24, 2017
These
are divided times. In Washington, a new administration has deepened the
polarization of an already gridlocked political process. In the media, our
disagreements are expressed, and often amplified, by a host of competing
voices. The questions they address include: How should the Constitution be
interpreted? Should we embrace free trade or focus on rebuilding our industrial
base? What is the role of immigrants in our society? With so much to debate,
issues that inspire true consensus are hard to come by. Yet there is one item
on which everyone can agree: We all want to be as healthy as possible.
The
proof is in our investment. The US spends 18% of its annual gross domestic
product (GDP) on health. In 2015, this amounted to $3.2 trillion, a figure
equal to the Germany’s economy. The country next in line in health spending,
Sweden, invests 12% of its annual GDP — about two-thirds of what we spend. For
additional comparison, most other peer countries spend
about 9% of their GDP on health. Clearly, the US values well-being and is
willing to pay for it.
But
are Americans healthier as a result of this investment? They are not — in fact,
far from it. American heath is, by most metrics, worse than that of all other
rich countries. US child mortality, for example, is about seven per 1,000
children. Compare this to Finland, where child mortality is two per 1,000
children. Then there is life expectancy. A Japanese child born today can expect
to reach the age of 84, while an American child can expect to reach age 79.
This gap exists despite the fact that the U.S. spends about 7% more on health
than Japan. America still manages to beat, barely, a country like Qatar, where
life expectancy is age 78. This achievement becomes less impressive, however,
when we consider that the US spends about eight times more per capita on health
than Qatar. It is also worth factoring in the unique health challenges the US
faces, such as the obesity epidemic,
which costs the nation between $147 billion and $210 billion per year and adds
to the burden of chronic illnesses, such as diabetes and heart disease. Would a
truly healthy nation have such morbidity in its midst?
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It
was not always like this. America’s current poor health is principally the
result of a decline that began around 1980. While the U.S. been able to improve
life expectancy and reduce mortality from a number of diseases in the last 35
years, it have done so at a far slower rate than its peer countries. This has
led other countries, in some cases, to outpace the US. For example, in 1980,
life expectancy in Chile was 68; by 2014, it was 81. In the US, life expectancy
also rose, but far less. It was 74 in 1980; by 2014, it was behind Chile at 79.
And
we do not just suffer in comparison to other high-income countries. In 1980,
Cuba had a life expectancy of 74, and of 79 in 2005. By contrast, according to
the most recent data from the U.S. Center for Disease Control, the US had a
life expectancy of 77 in 2005. Is this decline acceptable? How would we
react if we saw a similar trend in another area where the US invests heavily
— defense spending? Would
we spend more and more on a military that grows weaker and weaker by the year?
Doubtful. We would make a change.
How
is it that we can care so much about health, and spend so much money on it, yet
still fail to achieve a standard of well-being that equals or exceeds that of
our peer countries? I tackle these questions in my upcoming book, Healthier:
Fifty Thoughts On The Foundations Of Population Health. The answer is best
expressed by the following metaphor:
Imagine
you have a goldfish. You love this goldfish and want it to be healthy. So you
tell it to swim 10 times counterclockwise in its bowl everyday so it can stay
fit. You tell it not to eat too much of the food you provide so it can avoid
obesity. You invest in the best veterinary care money can buy, so you can cure
the fish when it is sick.
One
day you wake up, only to find that your goldfish is dead. What happened? You
were so busy telling it what to eat and how to exercise, and seeking out
expensive treatments for its every sick care need, that you neglected a key
aspect of its care: You forgot to change its water. And no amount of good
behavior on the part of the goldfish—no matter how much exercise it got or how
unimpeachable its diet—could make up for the fact that it lived in a
fundamentally unhealthy context. Even the best doctors and treatments,
sustained by sky-high medical costs, can only do so much when the conditions of
poor health are allowed to become ubiquitous.
The
goldfish in this metaphor is us. The water is the social, economic, and
environmental conditions in which we live. These conditions shape the health of
populations at a level that is deeper than our lifestyle choices or the
capacity of curative care to treat us when we are sick. Indeed, these
conditions determine whether or not we get sick in the first place. If we wish
to avoid disease, and reap richer returns on our investment in health, we must
work to create a healthier context. This means building safer neighborhoods,
broadening the accessibility of quality education, investing in accessible non-polluting public transportation, and
pushing for agricultural policies that put better
ingredients in our foods, to name just a few areas of potential focus. It means
making sure that the forces that govern our social relationships, our
technology, our arts, and our industries all align towards a culture that
promotes health—toward cleaner water. There is also the issue of the proposed
repeal of Obamacare. While repeal would not help some of the poor trends I
mention, health care can only do so much if
we neglect the core determinants of health.
I
realize that I am asking for a big shift in how the U.S. thinks, investing not
only in drugs to restore Americans to health but in the conditions that keep
them healthy to begin with. But, importantly, unless the nation does this,
unless it cleans its ‘water,’ the country is going to continue to get sicker
than people in peer nations and be less healthy, and die younger. This will
take time, commitment, money, and a willingness to rethink where that money
should go. Luckily, the U.S. is well-positioned to take these steps, despite
the setbacks of recent decades. America has shown an encouraging willingness to
invest in health. It must now invest smarter, so Americans can live healthier.
Sandro Galea is a professor and Dean of
Boston University School of Public Health. His book, Healthier:
Fifty Thoughts On The Foundations Of Population Health, will be published in
June.
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