By Liz Szabo February 26,
2020
For much of the
20th century, medical progress seemed limitless.
Antibiotics
revolutionized the care of infections. Vaccines turned deadly childhood
diseases into distant memories. Americans lived longer, healthier lives than
their parents.
Yet today, some of
the greatest success stories in public health are unraveling.
Even as the world
struggles to control a mysterious new virus known as COVID-19, U.S. health
officials are refighting battles they thought they had won, such as halting measles
outbreaks, reducing deaths
from heart disease and protecting young people from tobacco.
These hard-fought victories are at risk as parents avoid vaccinating children,
obesity rates climb, and vaping spreads like wildfire among teens.
Things looked
promising for American health in 2014, when life expectancy hit 78.9 years.
Then, life expectancy declined for three straight years — the longest sustained
drop since the Spanish flu of 1918, which killed about 675,000 Americans and 50 million people worldwide, said Dr.
Steven Woolf, a professor of family medicine and population health at Virginia
Commonwealth University.
Although life
expectancy inched up slightly in 2018, it hasn’t yet regained the lost
ground, according to the Centers for Disease Control and Prevention.
“These trends show
we’re going backwards,” said Dr. Sadiya Khan, an assistant professor of
cardiology and epidemiology at Northwestern University Feinberg School of
Medicine.
While the reasons
for the backsliding are complex, many public health problems could have been
avoided, experts say, through stronger action by federal regulators and more
attention to prevention.
“We’ve had an
overwhelming investment in doctors and medicine,” said Dr. Sandro Galea, dean
of the Boston University School of Public Health. “We need to invest in
prevention — safe housing, good schools, living wages, clean air and water.”
The country has
split into two states of health, often living side by side, but with vastly different life
expectancies. Americans in the fittest
neighborhoods are living longer
and better — hoping to live to 100 and beyond — while residents of
the sickest communities are dying from preventable causes decades
earlier, which pulls down life expectancy overall.
Superbugs — resistant to even the strongest antibiotics —
threaten to turn back the clock on the treatment of infectious diseases.
Resistance occurs when bacteria and fungi evolve in ways that let them survive
and flourish, in spite of treatment with the best available drugs. Each year,
resistant organisms cause more than 2.8 million infections and kill more than
35,000 people in the U.S.
With deadly new
types of bacteria and fungi ever emerging, Dr. Robert Redfield, the CDC
director, said the world has entered a “post-antibiotic era.” Half of all new gonorrhea
infections, for example, are resistant to at least one type of
antibiotic, and the CDC warns that “little now stands between us and
untreatable gonorrhea.”
That news comes as
the CDC also reports a record number of combined cases of gonorrhea, syphilis and
chlamydia, which were once so easily treated that they seemed like minor
threats compared with HIV.
The United States
has seen a resurgence of congenital syphilis, a scourge of the
19th century, which increases the risk of miscarriage, permanent
disabilities and infant death. Although women and babies can be protected with
early prenatal care, 1,306 newborns were born with congenital syphilis in 2018
and 94 of them died, according to the CDC.
Those numbers
illustrate the “failure of American public health,” said Dr. Cornelius “Neil”
Clancy, a spokesperson for the Infectious Diseases Society of America. “It
should be a global embarrassment.”
The proliferation
of resistant microbes has been fueled by overuse, by doctors who write unnecessary
prescriptions as well as farmers who give the drugs to livestock,
said Dr. William Schaffner, a professor of preventive medicine at Vanderbilt
University Medical Center in Nashville, Tennessee.
Although new
medications are urgently needed, drug companies are reluctant to develop antibiotics because of the financial
risk, said Clancy, noting that two developers of antibiotics recently went out of business. The federal government needs to do more
to make sure patients have access to effective treatments, he said. “The
antibiotic market is on life support,” Clancy said. “That shows the real
perversion in how the health care system is set up.”
A Slow Decline
A closer look at
the data shows that American health was beginning to suffer 30 years ago. Increases in
life expectancy slowed as manufacturing jobs moved overseas and
factory towns deteriorated, Woolf said.
By the 1990s, life
expectancy in the United States was falling behind that of other developed
countries.
The obesity epidemic,
which began in the 1980s, is taking a toll on Americans in midlife, leading to
diabetes and other chronic illnesses that deprive them of decades of life.
Although novel drugs for cancer and other serious diseases give some patients
additional months or even years, Khan said, “the gains we’re making at the tail
end of life cannot make up for what’s happening in midlife.”
Progress against
overall heart disease has stalled since 2010. Deaths from heart failure — which can be caused by high blood pressure and
blocked arteries around the heart — are rising among
middle-aged people. Deaths from high blood pressure, which can lead
to kidney failure, also have increased since
1999.
“It’s not that we
don’t have good blood pressure drugs,” Khan said. “But those drugs don’t do any
good if people don’t have access to them.”
Addicting A New
Generation
While the United
States never declared victory over alcohol or drug addiction, the country has
made enormous progress against tobacco. Just a few years ago, anti-smoking
activists were optimistic enough to talk about the “tobacco endgame.”
Today, vaping has
largely replaced smoking among teens, said Matthew Myers, president of the
Campaign for Tobacco-Free Kids. Although cigarette use among high school
students fell from 36% in 1997 to 5.8% today,
studies show 31% of seniors used electronic cigarettes in the previous
month.
FDA officials say they’ve taken “vigorous enforcement actions
aimed at ensuring e-cigarettes and other tobacco products aren’t being marketed
or sold to kids.” But Myers said FDA officials were slow to recognize the
threat to children.
With more than 5 million teens using e-cigarettes, Myers said, “more kids are
addicted to nicotine today than at any time in the past 20 years. If that trend
isn’t reversed rapidly and dynamically, it threatens to undermine 40 years of
progress.”
Ignoring Science
Where children live
has long determined their risk of infectious disease. Around the world,
children in the poorest countries often lack access to lifesaving vaccines.
Yet in the United
States — where a federal program provides free vaccines — some of the lowest
vaccination rates are in affluent communities, where some parents disregard the medical
evidence that vaccinating kids is safe.
Studies show that
vaccination rates are drastically lower in some private schools and “holistic kindergartens” than in public schools.
It could be argued
that vaccines have been a victim of their own success.
Before the
development of a vaccine in the 1960s, measles infected an estimated 4 million
Americans a year, hospitalizing 48,000, causing brain inflammation
in about 1,000 and killing 500, according to the CDC.
By 2000, measles cases
had fallen to 86, and the United States declared that year that it
had eliminated the
routine spread of measles.
“Now, mothers say,
‘I don’t see any measles. Why do we have to keep vaccinating?’” Schaffner said.
“When you don’t fear the disease, it becomes very hard to value the vaccine.”
Last year, a
measles outbreak in New York communities with low vaccination rates spread to almost 1,300
people — the most in 25 years — and nearly cost the country its measles
elimination status. “Measles is still out there,” Schaffner said. “It is our
obligation to understand how fragile our victory is.”
Health-Wealth
Disparities
To be sure, some
aspects of American health are getting better.
Cancer death rates
have fallen 27% in the past 25 years, according to the American Cancer Society. The teen birth rate is at an all-time
low; teen pregnancy rates have dropped by half since 1991, according to the Department of
Health and Human Services. And HIV, which was once a death sentence,
can now be controlled with a single daily pill.
With treatment, people with HIV can live into old age.
“It’s important to
highlight the enormous successes,” Redfield said. “We’re on the verge of ending the HIV
epidemic in the U.S. in the next 10
years.”
Yet the health gap
has grown wider in recent years. Life expectancy in some regions of the country
grew by four years from 2001 to 2014, while it shrank by two years in others,
according to a 2016 study in
JAMA.
The gap in life
expectancy is strongly linked to income: The richest 1% of American men live 15
years longer than the poorest 1%; the richest women live 10 years longer than
the poorest, according to the JAMA
study.
“We’re not going to
erase that difference by telling people to eat right and exercise,” said Dr.
Richard Besser, CEO of the Robert Wood Johnson Foundation and former acting
director of the CDC. “Personal choices are part of it. But the choices people
make depend on the choices they’re given. For far too many people, their
choices are extremely limited.”
The infant
mortality rate of black babies is twice as high as that of white newborns,
according to the Department of Health and Human Services. Babies born to
well-educated, middle-class black mothers are more likely to die before their
1st birthday than babies born to poor white mothers with less than a high
school education, according to a report from the Brookings Institution.
In trying to
improve American health, policymakers in recent years have focused largely on
expanding access to medical care and encouraging healthy lifestyles. Today,
many advocate taking a broader approach, calling for systemic change to lift
families out of the poverty that erodes mental and physical health.
“So many of the
changes in life expectancy are related to changes in opportunity,” Besser said. “Economic
opportunity and health go hand in hand.”
Several policies
have been shown to improve health.
Children who receive early childhood education, for example,
have lower rates of obesity, child abuse and neglect, youth violence and
emergency department visits, according to the CDC.
And earned income tax credits — which provide refunds to
lower-income people — have been credited with keeping more families and
children above the poverty line than any other federal, state or local program,
according to the CDC. Among families who receive these tax credits, mothers
have better mental health and babies have lower rates of infant mortality and
weigh more at birth, a sign of health.
Improving a
person’s environment has the potential to help them far more than writing a
prescription, said John Auerbach, president and CEO of the nonprofit Trust for
America’s Health.
“If we think we can
treat our way out of this, we will never solve the problem,” Auerbach said. “We
need to look upstream at the underlying causes of poor health.”
This story also ran
on The Washington
Post.
Liz Szabo: lszabo@kff.org, @LizSzabo
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