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Challenges for Health and Health Care in the 21st Century
From: Columbia University
| By:
Steven A. Schroeder |
EDITOR'S INTRODUCTION |
Unhealthy foods and emerging diseases grab most of society's attention and blame for ill health; but health, quite logically, is a product of factors of living.  Diet, exercise, socioeconomic status and health care are far more important manipulators of population health than frightening but confined new viruses. No amount of government spending and scientific advance, however, can better the health of the population unless personal habits--physical activity, hygiene and stopping smoking--are improved, advises Steven A. Schroeder, M.D. (right), president of the Robert Wood Johnson Foundation. |
 edical historians will look back on the twentieth century as a blend of scientific progress and social calamities. By century's end, infectious diseases, long the scorn of humanity, were no longer the No. 1 killer in most countries, thanks to improved sanitation, antibiotics and vaccines. New breakthroughs in diagnosis and treatment have vastly expanded our capacity to cope with most medical illnesses and trauma. Life expectancy has greatly increased, especially for women. Medical care has evolved from a set of traditions based on folklore, which too often caused more harm than benefit, to a science based on evidence and technology that comes with a price often outstripping a nation's capacity to pay. |
But not all that transpired in the past century was beneficial to health. We saw two world wars and far too many local conflagrations, using increasingly sophisticated weaponry to inflict heavy casualties on combatants and often deliberately on civilians. Though, to date, nuclear bombs have been used only twice in wartime, we have lived the latter part of the twentieth century in the shadow of the threat of local and worldwide nuclear attacks. More recently, we have confronted terrorist attacks and the possibility of biological and chemical warfare on civilian populations. |
Not all the human carnage has been self-inflicted. Within my generation, some had the temerity, sparked by the remarkable global eradication of smallpox, to declare that the threat of infectious diseases had passed. Shortly thereafter, the Dracula of infections rose from its coffin in the form of the HIV virus, along with the emerging threats of Ebola, Hanta virus and multidrug-resistant tuberculosis. The old enemies of tuberculosis, malaria and childhood diarrhea are still with us. Environmental pollution of our air, our water and the food chain continues to threaten the health of the public, with old and potential new hazards. Finally, we have witnessed an ever-expanding gulf between the haves and the have-nots, both among and within nations, with a corresponding widening gap in health status and life expectancy. |
Behavioral impact on health
Today, health is determined by a collection of factors: genetics, behavior, environment, socioeconomic status, educational level and health care. My colleague at Robert Wood Johnson, Mike McGinnis, estimates that behavior accounts for 50 percent of premature mortality, more than any other factor. Health care deficiencies, which command the most attention from academic medical centers and health policy leaders, account for only 10 percent. Until recently, genetics has been considered an immutable risk factor, but new developments offer opportunities for gene therapy and stratified approaches to screening and prevention. |
The shift from infectious diseases to chronic illnesses mandates a shift from treatment to prevention, with sanitation and immunization strategies meant to improve personal health behavior. The most alarming cause of preventive disease is use of harmful substances; for each of the nine most common causes of early mortality, harmful substances are implicated in 20 percent to 75 percent of deaths. |
Harmful substances and disease
Tobacco is the main culprit in cases of cancer and chronic lung disease, and it contributes significantly to heart disease and stroke. Alcohol is a major factor in four of the nine conditions: accidents and trauma, suicide, homicide and liver disease. Tobacco and alcohol act synergistically in many of the cancers of the gastrointestinal system. Intravenous drug use now accounts for more than 50 percent of the HIV cases in the United States. These data reveal the most important challenge facing health care: how to promote healthy personal behavior. |
A decade ago, I had the privilege of serving as a visiting professor at an Israeli medical school. While doing rounds on an internal medicine ward, I was impressed that most of the cardiac patients, and there were a great many of them, were smokers. Patient discharge procedures seldom focused on stopping smoking, even though medical crises such as acute myocardial infarction are among the best opportunities to get smokers to stop. |
When I asked a host doctor, also a smoker, to explain the situation, the answer was unexpected. He explained that to live in Israel is to face daily the threat of loss of life and country. "In the face of such uncertainty, how can we plan for the long-range benefits of prevention?" he asked. "We know that tobacco is bad for us in the long run, but we are comforted by its short-run pleasures. Who knows what will happen by tomorrow?" |
In the United States, where there is much less insecurity about the future of our country, the lure of tobacco is equally strong. Despite widespread knowledge about the dangers of tobacco, 23 percent of adults and 25 percent of college students, our future leaders and most educated youth, smoke regularly. By contrast, the smoking prevalence among US physicians is only 5 percent. Consider how our health statistics would improve if general population smoking rates were at the level of US physicians. |
Exercise and health
Though tobacco is the single most important behavioral risk factor, diet and exercise are close behind.One of the consequences of our industrial society is that people are less active. Compared with lifestyles in 1970, we are driving more, we are watching more television and we are working more sedentary jobs; consequently we are expending fewer calories per day. Physical activity is a powerful factor in preventing or postponing common chronic illnesses and improving function in those with cardiovascular illness, hypertension, non-insulin dependent diabetes mellitus, osteoporosis, obesity and depression or anxiety. |
Incidence of cardiovascular disease is 1.8 times higher for low-activity persons than for those with the highest levels. Low activity translates into higher resting blood pressure levels, while exercise alone is proven therapy for controlling hypertension. The relative risk for stroke is six times lower in men who exercise regularly than for those who are not active. Physical activity protects against the onset of Type 2 diabetes, and, as in hypertension, is an important therapy. With respect to osteoarthritis, increased physical activity is associated with a 10 to 15 percent increase in bone density. The number of quality life years is much higher in patients with arthritis, asthma and heart disease who exercise. |
The negative association between physical activity and obesity is so obvious that it hardly needs telling. Less well known is the influence of physical activity on fat distribution. Active people tend to have less central fat distribution, which is a risk factor for both heart disease and diabetes. There is good evidence that physical activity lowers the risk for depression, one of the world's most disabling conditions. |
Physical activity is an excellent intervention that if widely used could reduce both the burden of disease and overall mortality. Yet only 20 percent of adults in the US get regular moderate exercise, and only 8 percent exercise at the rigorous level recommended for health benefits. Instead, 60 percent report irregular or no leisure-time physical activity. Generally, men are more active than women. |
A similar set of arguments could be developed for dietary factors. We are in the midst of a shocking national epidemic of obesity. The increase in obesity between 1985 and 1998 is one of the most dramatic changes in population that I have ever seen. In the interest of improving population health, the increasing global trends toward smoking, sedentary lifestyle, obesity and diets high in fat are of great concern. |
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Socioeconomic effects on health
The final factor influencing public health is socioeconomic status. During a 50-year span, the United Kingdom saw a profound widening of the standardized mortality rates between the professional class and unskilled workers.In 1931, during the Depression, the rates among the five classes of society were closely bunched together, while 50 years later the poorest class was dying more than twice as fast as the richest. These patterns are seen all over the world. They are seen in this country. They are seen in this state. They are seen in this city. Harold Freeman has shown that the mortality rates for black men in Harlem are higher than the rates in Bangladesh. |
Why do these disparities exist, and why are they widening? One obvious factor is access to medical care. Another is basic sanitation. These explain some of the gap, especially in less-developed countries, but they seem to be lesser factors in the established market economies like the US, where behavioral risk factors such as smoking, diet, physical activity and sexual behavior are more important. |
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| Schroeder speaks about publicizing health issues. | |
In general, better-educated and wealthier people are more likely to live healthier lives. Yet even after correcting the data for behavior and medical care differences, large gaps persist. There is growing evidence that income inequality may be more important than absolute level of income. Countries with the longest life expectancies are not necessarily the wealthiest countries but, rather, are those with the smallest income spread and the lowest proportion of those living in relative poverty. |
This seems to relate to the level of social support available to a person and the degree of perceived control over one's environment at work and at home. The concept of allostatic stress load has been advanced as one explanation of how stress translates into poor health. This concept holds that metabolic, immunologic and neurologic mechanisms employed during short-term stress exert a cumulative toll over time. |
The two most important challenges to improving the health of the public seem to be how to encourage healthier lifestyles and how to reduce the toll exerted by low socioeconomic stress. |
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