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JAMA published a seminal investigation documenting the
Health of America compared to other developed countries broken down by disease,
risk factors, morbidity and mortality. The massive undertaking involved
hundreds of collaborators in thirty-four countries and some highly
sophisticated statistics comparing the burden of disease, disability and risk
factors. The report here includes the developed countries participating in the Organization
for Economic Co-operation and Development.
The State of US Health, 1990-2010, Burden of Disease, Injuries and Risk
Factors appears in the August 14 issue of JAMA.[1]
If you have any interest in the shortcomings of our health care system or the
health of US’s vital human resource, this landmark document is worth the study.
Harvey Fienberg’s editorial on page 585 observes the decline
in the US standing among developed nations.
Herein, “results for the United States are presented in detail for the
first time.” The statistics utilized in
the study were extremely complex and all inclusive. However, Fienberg points that
socioeconomic status relates strongly with mortality[2]
and that socioeconomics was not included as a risk factor in this study. The
collaborators agreed. The difficulty was in equating socioeconomics across the
many cultures in the thirty-four nations that took part in this study. Fienberg further observes that the assessment
for the US as a whole does not account for significant regional differences. However,
he does suggest that the framework for assessing the burden of disease is
scalable and applicable to states, counties and municipalities.[3]
The statistical terms used in this study include: Years of Life Lost (YLL) due to premature
mortality, Years Lived with Disability (YLD), Disability Adjusted Life Years
(DALY), which combines YLL and YLD and, Healthy Life Expectancy (HALE). The
article compares these attributes in the thirty-four countries between 1990 and
2010. This monumental study goes beyond all previous reports by including risk
factors for disease.
The diseases causing premature mortality, YLL, differed
dramatically from those causing morbidity and disability, YLD. In 2010 in the
US the big eight YLL were in order: Ischemic heart disease, lung cancer,
stroke, COPD, road injury, self-harm, diabetes and cirrhosis. In sharp
contrast, the first eight YLD were: Low
back pain, major depression, other musculo-skeletal, neck pain, anxiety
disorder, COPD, disorders resulting from drug use, and diabetes.
The risk factors underlying the leading causes for both YLL
and YLD diseases were almost the same. The list of risk factors included:
Dietary, tobacco, HBP, high BMI, physical inactivity, high serum glucose,
ambient particulate pollution, alcohol, drug use and high cholesterol. Dietary
risks accounted for over 650 thousand deaths while tobacco use and hypertension
accounted for some 450 thousand deaths. Obesity followed closely behind as
insurance actuaries have long established. Dietary risks are by far the
greatest, but tobacco, obesity, high BP, high blood glucose, sedentary life
style, alcohol, cholesterol, drug abuse and air pollution follow in descending
parabolic order as causes of disability.
The figure 4 illustration on page 604 in the journal and
below reflects the US’s low YLL ranking compared with the thirty three other
countries. The cross-index lists countries on one axis and diseases on the
other with the ranking for each in the cross-index. The US is 7th
from the bottom following the Check Republic and Chile in overall ranking. Our
ranking by the raw longevity score, infant mortality and perinatal mortality
reported elsewhere[4] are
even worse.[5]
The US comes in 38th in both longevity and infant mortality. The
perinatal mortality rates are even worse.[6]
Figure 4.
Rank of Age-Standardized YLL Rates Relative to
the 34 OECD Countries in 2010
Numbers in
cells indicate the ranks of each country for each cause, with 1 representing
the best-performing country. Countries are sorted on the basis of
age-standardized all-cause years of life lost (YLLs) for 2010. Diseases and injuries
contributing to YLLs are ordered by the difference between the US rate and the
lowest rate in the Organization for Economic Co-operation and Development
(OECD) countries for each cause. Colors indicate whether the age-standardized
YLL rate for the country is significantly lower (green), indistinguishable
(yellow), or higher (red) from the mean age-standardized YLL rate across the
OECD countries. HIV indicates human immunodeficiency virus.[7]
Fienberg writes that setting us on a healthier course will
require leadership at all levels of government engaging the
profession and the public. Indeed it will, but there has to be more. Fienberg
mentions social economic status as a risk factor. One might add the
environmental and behavioral factors and look more closely to the dietary risk
that jumps out as, not only the leading risk factor, but by a large margin. Poverty and relative poverty may play as important role as nutrition. The prevalence of ischemic heart disease, diabetes, hypertension
and stroke implicate diet and obesity as the underlying cause. These too may reflect poverty as the major risk factor. However, looking
at chronic kidney disease(CKD) poisoning, cirrhosis, congenital anomalies, pre-term
birth problems, the cancers and the neurological, one wonders if there might
not be environmental factors present in the US that are not present in the
other countries. Staring at fig 4, one notices a divergence between countries
that is hard to attribute to genomics, behavior or health care as outlined.
Studying this somewhat overwhelming research should not be
limited to government and public health leaders etc. but may be a lesson in
diagnosis itself. A medical history without a social, behavioral, environmental
and psychological risk assessment will miss many of the causes of and early
diagnosis of disease. One must distinguish between a problem and a diagnosis.
Look for a primary underlying cause. “Peal away the layers of the onion.” Fienberg
urges inquiry at both the social and biological levels. I love his quote, “Trying
to understand the causation of disease using only one of these lines of
research is like trying to clap with one hand.” Furthermore, we need to study the
burden of disease on a smaller scale. It would be fruitful to analyze the
burden of disease on a state, county and municipal level. Risk factors may vary
by municipality and indeed by individual. Just as Hippocrates tasted the urine,
examined every bodily orifice; he considered the weather the environment and nutrition.
We too must consider, social, economic, environmental, behavioral,
psychological, dietary and genomic attributes -- critical knowledge for the
physician diagnostician.
One might take exception to vague final diagnoses such as
cardiomyopathy, chronic kidney disease, lower respiratory infection, community
acquired pneumonia etc. One should look
at the specific cause whether a specific organism or a specific exposure. If
disease is by definition a maladaptation to the environment, then one must pay
as much attention to the environment as to one’s patient. The same must apply
to the social and behavioral factors. Asclepian physicians paid great head to
the environment, the air, the winds, the weather, the dampness and the water. Great
physicians of the past, like Sherlock Homes saw things in the surroundings that
others did not. Look again at figure 4. Some of the US rankings are hard to
explain by today’s medical knowledge. Why do we have such excellent medical
education and such sad outcomes? Hippocrates prescribed diets in detail.
Perhaps our front line clinics should provide a nutritionist as part of the
team.
Food additives in the US have become a poison. Studies clearly show the deleterious effects
of pesticides, sodium, sugars etc. Anything remotely addictive added to
packaged food products enhances sales but at the expense of consumer health.
The lassie-fair food regulatory policies in the US differ strikingly from those
in European countries where fresh foods dominate in the markets over packaged
foods. Like grandmother said, eat your vegetables! However, you had better wash
them first.
Poverty is an unlisted risk factor and may account for some
of the dietary problems. Depletion of living standards for the entire middle
class may also lead to dietary and other self-abusive behaviors. The
sequestration of wealth --as in the dark ages -- may add to the behavioral
risks as well. Herman Boerhaave U. of Lyden and French Academy of Science 1728 said, “The poor are my
best patients because God pays for them.” That sentiment may be hard to find in
today’s busy practices. The Affordable Care Act at least establishes a
principal of health as a critical infrastructure for us all. The perpetuation
of insurance, fee for service and administrative burden may fall short of expectations.
The European models of health care are more egalitarian. The medical schools
represent our only source for the more equitable distribution of health care.
University medical schools have a long history of means testing and free care
in support of the poor and the medical community, but they are limited in
number and distances between. Today fee for service and insurance mandates
silence much of the egality that was once universal in medical schools It would be naive to think that economics and
politics are not risk factors.
We have made great strides in reducing smoking, but one has
only to look to see the obesity epidemic. Drug use remains an embarrassment,
and environmental pollution is still with us -- perhaps more of a problem here
than in Europe. These factors too may
account for some of the discrepancies in outcome between the US and Europe.
Accessibility to care, mal distribution of physicians, the
licensing of or exemption of fringe-providers, and continuity of care also play
a role in our unfavorable outcomes. We are improving but at a retarded pace and
at incredible cost. Diagnosis suffers also from the recent trend – all but
eliminating autopsies. In the past, autopsy -- the single one thing historically
that propelled us forward in scientific and medical knowledge -- has gone out
of style. The CT scan is no substitute. Marie Francois Bichat, 1793, brought
pathology to the bedside correlating autopsy with clinical observation. The
sign over the door to his autopsy room in Paris read, “Death comes to the aid
of the living” and indeed it did for two hundred years. There is no substitute
for the Clinical Pathologic Conference (CPC). Even the NEJM today presents
cases today without autopsy.
If you don’t do a rectal, you don’t use a head mirror, you
don’t feel a pulse and you don’t look at the feet, or take off the shirt to
examine the chest, then your diagnosis and your outcome will be as limited as
your investment in the patient. These are but some of the shortcuts that characterize
today’s “industrialized medicine.” When we practice medicine as a business, it
is more profitable to skim the diagnostic caldron for high priced procedures,
high patient volume and cover the missed and wrong diagnosis with liability
insurance and silence. By industrializing medicine we have opened the door for
any and all business ventures to feed at the health care trough no matter how
marginal or how harmful. By denying
local medical societies the control over professional privileges and
professional behavior, we have left the legislature valorized by lobbyists in
control of behavior and the hospital, insurance and drug company free reign.
All the great doctors in history had three things in common:
they traveled widely to medical centers all over the world, they translated
Hippocrates and they had the Gout. I could do without the gout but would add
attendance and participation in CPCs. It is time that we visited the successful
healthcare systems in Europe and the East to see what works. Instead of
revising curriculum by invention, visit the medical schools in other countries,
much older than our own and examine their methods. We were leaders in health
care for only a brief span of history, mainly during WWI and WWII while 45
years of Cold War brought both the US and Russia the four horsemen of the Apocalypse.
Perhaps it is time for another Flexner
Report -- now a hundred years later.
[1]
JAMA,2013;310(6):591-608. Doi:10.1001/jama.2013.13805
[2]
National Research Council; Institute of Medicine. US Health in International
Perspective: Shorter Lives Poorer Health. National Academies Press; 2013
[3]
Katz B. Bradley J. the Metropolitan Revolution. Brookings Institution; 2013
[4] http://www.enagic.com/enagic_life.php
[5] http://data.worldbank.org/indicator/SP.DYN.IMRT.IN
[6] http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf
[7]
Figure 4 reproduced with permission JAMA RightsLink and Copyright Clearance
Center Aug 14 JAMA, Christopher Murray et al; Copyright © 2013, American
Medical Association
