Saturday, September 22, 2007

Millennial Challenges: Lessons from the health status of poor and rich nations

Global Strategic Enterprises, Inc for Peace and Prosperity-

Re: Lessons from the health status of poor and rich nations.

It is generally accepted that health is not the mere absence of disease and disability but a positive spiritual, emotional, psychological and physical well being.

The majority of global population go without care

Within this broad construct of the concept of health and well being it is apparent that the global population of 6.5 million or so people, the majority do not have access nor experience holistic and proactive sense of well being.

Disruptive environments and toxic ecosystems

Some of the spiritual, emotional and social and physical factors that create a positive environment for nurturing health communities include access to healthy ecology, nurturing social and emotional environment at home, community and the nation at large. However, the challenge remains disruptive environments and toxic ecosystems that impact population health negatively.

Nature Vs Nurture and has man to do any thing with it?

Scientists and philosopher have for a long time considered nature (genetic as well as natural resources); and nurture (socio-economic and cultural development status) as the critical factors that determine the quality of health;however, these two factors are not presenting themselves in a fair and equitable manner across the globe and cultural communities.

Geographic and economic barriers to health

Countries below and above the equator, by and large show different levels of socio-economic and cultural diversity that impact the health status of the animal and human populations in their respective ecosystems. The geographic, economic and cultural barriers remain.

Population density and quality of life

Within the limited advances in the habitats of human development areas, the old world (known for their high density and deprivation); by and large,are highly hostile to human existence; while the relatively new communities( the less dense population settlements, and rather rich ecosystems) tend to offer more opportunities for higher quality of life to their proportionately less dense populations.

Managing climate change and population explosion.

Population control, managing climate change and organic or rather eco-conservational principles are considered to be a positive approach in dealing with the ever increasing population and disease explosions in some parts of the world. Managing climate change and population explosion is the challenge of the millennium and it seems we are doing very little to avert the impending catastrophe.

Immune deficiency diseases and the ecology.

However, the new exotic diseases such as HIV/AIDS pandemic; human immune deficiency syndromes, malnutrition be it protein energy malnutrition common in the south and the obesity epidemics of the north will continue to be a serious challenge of the new millennium. It is becoming clear that as humans are exposed to zoonotic diseases-animal to human transmission; the human immune system is being challenged to adapt or respond to new disease processes, making the pool of pathogens much wider and a challenge to modern epidemiology and vaccine research.

Human behavior the most serious challenge to health

Most importantly, the now common destructive human behavior, supported by mood altering and addiction forming substances, is becoming an ongoing challenge to our common security and well being. The ever increasing civil conflicts and high level of unemployed youth who are inclined to be involved in abusing their own health and some organized to activate global terror via targeted homicides and suicides are becoming a new security and health challenge. The medical profession has not yet responded appropriately to this damaging and rather explosive social and cultural problems.

Lessons from the HIV Epidemics and modern medical technology

The following two reports about health status in the rich and poor communities across the world is a clear indication that there needs to be a proactive, dedicated response to the ever increasing challenges of the global security and well being.

Disruptive sexual practices and substance abuse

The HIV epidemics continues to spread due to a mix of zoonotic viruses and rapidly changing human behavior that encourages unusual interaction between humans and animals, as well as those behaviors that mix infected body fluids into the human circulatory system. Some of these disruptive behaviors such as the intravenous drug use and reckless sexual behavior that disrupts the normal protective mucosa and exposes the circulatory system to dangerous pathogens continues to explode.

Globalization of Disrupting human behavior

Unfortunately the permissive culture and changing western social values encourage rather than discouraging these dangerous unhealthy practices. The animal pathogens such as avian flue viruses, are finding their way into the normal human disease cycles aided by global jet travel and spreading diseases across continents and making the whole globe vulnerable. With the advent of digital communication and instant global travel, disruptive human behaviors and their exotic pathogens are transported across the globe with such ease that the health profession can never be prepared to prevent or pre-empt these dormant great outbreaks before the explosion of new exotic diseases.

This report is interesting and a timely review of pubic health in poor and rich nations and communities. More importantly, it shows clearly that vulnerable communities regardless of where they live below or above the equator, among the rich or poor continue to loose out in their health status and well being on a regular basis.

Serving vulnerable populations across the world continues to be a sad scar in the consciousness of humanity from time immemorial. This century, this millennium is no different. However, this generation is more accountable as the technology and medical and social know how is better available than any time in history, and it appears the profession and the health commissioner's around the world, are intentionally ignoring our respective unique role.

The future generation, especially the young health professionals and community leaders should be alerted that they should compensate for the delinquency of this generation that has allowed events to evolve to such depravity and incompetence.

The United States health care system is the best example of how delinquent and incompetent the health professionals and the respective health payor systems have become.

Whereas, the health professionals make money out of the misery of the population they are trained to serve; the insurance system is operating as though it is designed to intentionally exclude patients and the general populations including those who have paid all their lives into the health insurance system. This is the sad shameful secret of modern medical care in the US.

Watching the latest Michael Moore satirical documentary film provides a clear indictment in the health care system, that compares, Canadian, UK, French,Scandinavian, Cuban and the US health care system. Ironically, even Cuba seems to fair better than its neighbor the United States of America. The current presidential contenders, specifically Hilary Rod ham Cinton, Barrack obama and Mit Romney have very interesting proposals.

The rest of the world should learn from the tragedy of how communities around the world are responding to the HIV Pandemic and how the technological advances in health in the US is not responding to the ever changing needs of their respective communities.

I have taken the liberty of subtitling some of the paragraphs to indicate the gross disparities in health and quality standards across the presentations for your convenience. I trust, the discuss generated will proved an interesting series of discussions and research opportunities for the readers; and hope you will make a difference by making the democratic system of your respective communities accountable to the most vulnerable amongst us regardless of their social station and economic status.

with regards

Dr Belai of GSE for Peace and Prosperity
www.; 703.933.8737

1). challenges of poor nations- Poverty and HIV related immune suppressive diseases

Hopkins Report: Focusing on Family Planning Lessens HIV Impact

Preventing infants from HIV

Baltimore, MD-Current family planning use prevents over one million HIV-positive births worldwide each year and has great potential to further reduce the number of infants born with HIV, according to the latest issue of Population Reports, "Family Planning Choices for Women With HIV," published by the INFO Project at Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs.

Women make 50% of HIV carriers

Women account for nearly half of the estimated 40 million people living with HIV worldwide. The majority of these women are in sub-Saharan Africa, where there are three infected women for every two infected men. An estimated one-fourth of pregnancies in sub-Saharan Africa are unintended.

Reducing an intended HIV infected pregnancies

In sub-Saharan Africa, family planning currently prevents an estimated 190,000 unintended HIV-infected births each year, or more than 515 HIV-infected births per day. An additional 120,000 HIV-positive births could be averted per year if all unintended pregnancies among women with HIV were prevented. These new estimates of family planning's contribution to reducing HIV were prepared by Family Health International for this issue of Population Reports.

Relative cost of preventing HIV infection and HIV treatment

Preventing unintended pregnancies in women with HIV is one of the most cost-effective strategies to prevent new HIV infections, according to the report. In some African countries money spent on avoiding unintended pregnancies would prevent more HIV-positive births than spending the same amount on antiretroviral (ARV) prophylaxis for HIV-positive women giving birth. By extension, preventing unintended pregnancies also will reduce the number of abortions and the number of children orphaned by AIDS.

Making HIV tests mandatory before sexual activity?

To prevent pregnancy, women with HIV can safely use most contraceptive methods, with just a few exceptions. Even women using ARV therapy can choose any method available. Fears about the IUD have proved too broad. According to the latest guidance from the World Health Organization, any woman with HIV can use an IUD unless she actually has AIDS and is not well.

The cost of HIV status and paternity

For women with HIV who are thinking about a baby, the new Hopkins report puts the risk in perspective. "Couples with HIV who are thinking about having children need facts on the actual risks and how to reduce the chances of HIV transmission, " write authors Catherine Richey and Vidya Setty.

Who is the parent of HIV infected children?

Without treatment, 15% to 30% of infants of women with HIV are born infected. Another 10% to 20% are infected during breastfeeding. ARV prophylaxis and appropriate feeding practices can significantly lower these chances.

Why not focus on HIV prevention instead of Family Planning?

"The facts in this report should reassure both HIV-care practitioners and family planning practitioners that providing family planning to women with HIV is not difficult and not dangerous," says author Catherine Richey. Co-author Vidya Setty adds, "It also should reassure practitioners that, if a woman with HIV chooses pregnancy, the risks of mother-to-child HIV transmission can be reduced if care is available, although they cannot be avoided entirely."

Population report should focus on preventing HIV instead of FP

Family planning and HIV-care providers can use the 24-page Population Reports issue and its companion 8-page INFO Reports issue, "Women and HIV: Questions Answered," to:

€ ¦· Understand how HIV affects women's reproductive health,

€ ¦· Learn the latest evidence behind global guidance on family planning methods for women with HIV, and

€ ¦· Help women with HIV think through the risks of childbearing and learn how to reduce these risks.

Find These Reports and Related Resources Online:

The full-text version of this Population Reports issue is available at http://www.infoforh pr/l15/l15. pdf

The full-text version of the INFO Reports companion issue is available at http://www.infoforh inforeports/ women_hiv/ womenhiv. pdf

Highlights of these and other INFO Project publications are also available as PowerPoint Presentations, which you can download and use to prepare talks and presentations, at http://www.infoforh pr/powerpoints. shtml
r>Join the authors in a blog discussion September 24 through October 5, 2007: http://www.infoforh blog/

To order this latest Population Reports issue and its companion INFO Reports issue in print, go to http://www.jhuccp. org/cgi-bin/ orders/orderform .cgi. For a listing of all Population Reports issues online, go to http://www.populati onreports. org.

Should Johan Hopkins focus on encouraging Healthy populations?

Population Reports is published three times a year in English, French, and Spanish by the INFO Project at the Johns Hopkins Bloomberg School of Public Health's Center for Communication Programs. The INFO Project receives support from the US Agency for International Development.

For more information, contact Jeffrey Bernson, jbernson@jhuccp. org

2) Lessons from Rich Countries: How the US fails its population health?

It has been said repeatedly that the health systems of less developed countries need to be strenthened. This requires not only money and health professionals, but also a clear commitment to a balanced,fair, people-oriented rather than profit- driven health care.

" Among the 30 developed nations that make up the Organization for Economic Cooperation and Development (OECD), the United States ranks near the bottom on most standard measures of health status (Table 1).1,2,3,4 "

Improving the Health of Americans?

Previous Volume 357:1221-1228 September 20, 2007 Number 12 Next
We Can Do Better € ¦’· Improving the Health of the American People

Steven A. Schroeder, M.D.

PubMed Citation We Can Do Better € ¦’· Improving the Health of the American People --> Steven A. Schroeder, M.D.

The US throws money at medical care without results?

The United States spends more on health care than any other nation in the world, yet it ranks poorly on nearly every measure of health status. How can this be? What explains this apparent paradox?

Why throwing money at Medial care has failed?

The two-part answer is deceptively simple. First, the pathways to better health do not generally depend on better health care, and second, even in those instances in which health care is important, too many Americans do not receive it, receive it too late, or receive poor-quality care.

Who is the beneficiary of this wasted money?

The standing of US in international ranking

In this lecture, I first summarize where the United States stands in international rankings of health status. Next, using the concept of determinants of premature death as a key measure of health status, I discuss pathways to improvement, emphasizing lessons learned from tobacco control and acknowledging the reality that better health (lower mortality and a higher level of functioning) cannot be achieved without paying greater attention to poor Americans.

Why Americans are not focused on health improvement?

I conclude with speculations on why we have not focused on improving health in the United States and what it would take to make that happen. Health Status of the American Public Among the 30 developed nations that make up the Organization for Economic Cooperation and Development (OECD), the United States ranks near the bottom on most standard measures of health status (Table 1).1,2,3,4 (One measure on which the United States does better is life expectancy from the age of 65 years, possibly reflecting the comprehensive health insurance provided for this segment of the population.)

The US Performs poorly among 192 nations

Among the 192 nations for which 2004 data are available, the United States ranks 46th in average life expectancy from birth and 42nd in infant mortality.5, 6

It is remarkable how complacent the public and the medical profession are in their acceptance of these unfavorable comparisons, especially in light of how carefully we track health-systems measures, such as the size of the budget for the National Institutes of Health, trends in national spending on health, and the number of Americans who lack health insurance.

Compleceny or incompetence of the worst kind?

One reason for the complacency may be the rationalization that the United States is more ethnically heterogeneous than the nations at the top of the rankings, such as Japan, Switzerland, and Iceland.

Is racism the reason for the gross disparity in health?

It is true that within the United States there are large disparities in health status € ¦’· by geographic area, race and ethnic group, and class.7,8,9 But even when comparisons are limited to white Americans, our performance is dismal (Table 1). And even if the health status of white Americans matched that in the leading nations, it would still be incumbent on us to improve the health of the entire nation.

The US Compares poorly in almost every indicator of health

Table 1. Health Status of the United States and Rank among the 29 Other OECD Member Countries.

Pathways to Improving Population Health

Health is influenced by factors in five domains € ¦’· genetics, social circumstances, environmental exposures, behavioral patterns, and health care (Figure 1).10,11

The minor role of medical care in reducing early deaths!

When it comes to reducing early deaths, medical care has a relatively minor role. Even if the entire U.S. population had access to excellent medical care € ¦’· which it does not € ¦’· only a small fraction of these deaths could be prevented. The single greatest opportunity to improve health and reduce premature deaths lies in personal behavior.

What has Medical care to do with personal behavior?

In fact, behavioral causes account for nearly 40% of all deaths in the United States.12 Although there has been disagreement over the actual number of deaths that can be attributed to obesity and physical inactivity combined, it is clear that this pair of factors and smoking are the top two behavioral causes of premature death (Figure 2).12

Why Premature death?

Figure 1. Determinants of Health and Their Contribution to Premature Death. Adapted from McGinnis et al.10

Figure 2. Numbers of U.S. Deaths from Behavioral Causes, 2000. Among the deaths from smoking, the horizontal bar indicates the approximately 200,000 people who had mental illness or a problem with substance abuse. Adapted from Mokdad et al.12

Medical care has failed to address unhealthy behaviors!

Addressing Unhealthy Behavior Clinicians and policymakers may question whether behavior is susceptible to change or whether attempts to change behavior lie outside the province of traditional medical care.13 They may expect future successes to follow the pattern whereby immunization and antibiotics improved health in the 20th century.

How can we make behavioral health attractive? Shift money?

If the public's health is to improve, however, that improvement is more likely to come from behavioral change than from technological innovation. Experience demonstrates that it is in fact possible to change behavior, as illustrated by increased seat-belt use and decreased consumption of products high in saturated fat.

Seat Belt and tobacco prevention? Accident and Cancer

The case of tobacco best demonstrates how rapidly positive behavioral change can occur. The Case of Tobacco The prevalence of smoking in the United States declined among men from 57% in 1955 to 23% in 2005 and among women from 34% in 1965 to 18% in 2005.14,15 Why did tobacco use fall so rapidly? The 1964 report
of the surgeon general, which linked smoking and lung cancer, was followed by multiple reports connecting active and passive smoking to myriad other diseases.

Early antismoking advocates, initially isolated, became emboldened by the cascade of scientific evidence, especially with respect to the risk of exposure to secondhand smoke.

What is the Countermarketing strategy of the drug and knife peddlers?

Counter-marketing € ¦’· first in the 1960s and more recently by several states and the American Legacy Foundation's "truth€ ¦®" campaign € ¦’· linked the creativity of Madison Avenue with messages about the duplicity of the tobacco industry to produce compelling antismoking messages16 (an antismoking advertisement is available with the full text of this article at .

Can we litigate on behalf of fitness and postive health?

Laws, regulations, and litigation, particularly at the state and community levels, led to smoke-free public places and increases in the tax on cigarettes € ¦’· two of the strongest evidence-based tobacco-control measures.14, 17,18 In this regard, local governments have been far ahead of the federal government, and they have inspired European countries such as Ireland and the United Kingdom to make public places smoke-free.14, 19

Challenges of the new malnutrition or Obesity epidemic!

In addition, new medications have augmented face-to-face and telephone counseling techniques to increase the odds that clinicians can help smokers quit.15,20,21 It is tempting to be lulled by this progress and shift attention to other problems, such as the obesity epidemic. But there are still 44.5 million smokers in the United States, and each year tobacco use kills 435,000 Americans, who die up to 15 years earlier than nonsmokers and who often spend their final years ravaged by dyspnea and pain.14,20

Health Professionals who smoke are poor too/

In addition, smoking among pregnant women is a major contributor to premature births and infant mortality.20 Smoking is increasingly concentrated in the lower socioeconomic classes and among those with mental illness or problems with substance abuse.15,22, 23 People with chronic mental illness die an average of 25 years earlier than others, and a large percentage of those years are lost because of smoking.24

Is prevention of substance abuse possible? Ask Colombians and Afganis

Estimates from the Smoking Cessation Leadership Center at the University of California at San Francisco, which are based on the high rates and intensity (number of cigarettes per day plus the degree to which each is finished) of tobacco use in these populations, indicate that as many as 200,000 of the 435,000 Americans who die prematurely each year from tobacco-related deaths are people with chronic mental illness, substance-abuse problems, or both.22,25

Any wonder about the Smoking, Whisky and Hashish Adds?

Understanding why they smoke and how to help them quit should be a key national research priority. Given the effects of smoking on health, the relative inattention to tobacco by those federal and state agencies charged with protecting the public health is baffling and disappointing. The United States is approaching a "tobacco tipping point" € ¦’· a state of greatly reduced smoking prevalence. There are already low rates of smoking in some segments
of the population, including physicians (about 2%), people with a postgraduate education (8%), and residents of the states of Utah (11%) and California (14%).25

Why not assist the tobacco, drug and alcohol peddlers?

When Kaiser Permanente of northern California implemented a multisystem approach to help smokers quit, the smoking rate dropped from 12.2% to 9.2% in just 3 years.25 Two basic strategies would enable the United States to meet its Healthy People 2010 tobacco-use objective of 12% population prevalence: keep young people from starting to smoke and help smokers quit. Of the two strategies, smoking cessation has by far the larger short-term impact. Of the current 44.5 million smokers, 70% claim they would like to quit.20

Preventing premature deaths may not be sexy medicine!

Assuming that one half of those 31 million potential nonsmokers will die because of smoking, that translates into 15.5 million potentially preventable premature deaths.20,26 Merely increasing the baseline quit rate from the current 2.5% of smokers to 10% € ¦’· a rate seen in placebo groups in most published
trials of the new cessation drugs € ¦’· would prevent 1,170,000 premature deaths.

Obesity prevention can learn from the tobacco campaign!

No other medical or public health intervention approaches this degree of impact. And we already have the tools to accomplish it.14,27 Is Obesity the Next Tobacco? Although there is still much to do in tobacco control, it is nevertheless touted as a model for combating obesity, the other major, potentially preventable cause of death and disability in the United States.

Chronic dieases have great friends with tobacco and obesity

Smoking and obesity share many characteristics (Table 2). Both are highly prevalent, start in childhood or adolescence, were relatively uncommon until the first (smoking) or second (obesity) half of the 20th century, are major risk factors for chronic disease, involve intensively marketed products, are more common in low socioeconomic classes, exhibit major regional variations (with higher rates in southern and poorer states), carry a stigma, are difficult to treat, and are less enthusiastically embraced by clinicians than other risk factors for medical conditions.

Eating and smoking have different pathways!

Table 2. Similarities and Differences between Tobacco Use and Obesity.

Nonetheless, obesity differs from smoking in many ways (Table 2). The binary definition of smoking status (smoker or nonsmoker) does not apply to obesity. Body-mass index, the most widely used measure of obesity, misclassifies as overweight people who have large muscle mass, such as California governor Arnold Schwarzenegger. It is not biologically possible to stop eating, and unlike moderate smoking, eating a moderate amount of food is not hazardous.

Nicotine and fat? similarities and differences

There is no addictive analogue to nicotine in food. Nonsmokers mobilize against tobacco because they fear injury from secondhand exposure, which is not a peril that attends obesity.

The food industry is less concentrated than the tobacco industry, and although its advertising for children has been criticized as predatory and its ingredient-labeling practices as deceptive, it has yet to fall into the ill repute of the tobacco industry. For these reasons, litigation is a more problematic strategy, and industry payouts € ¦’· such as the Master Settlement Agreement between the tobacco industry and 46 state attorneys general to recapture the Medicaid costs of treating tobacco-related diseases € ¦’· are less likely.14

Has treating addiction been successful?

Finally, except for the invasive option of bariatric surgery, there are even fewer clinical tools available for treating obesity than there are for treating addiction to smoking. Several changes in policy have been proposed to help combat obesity.28,29, 30 Selective taxes and subsidies could be used as incentives to change the foods that are grown, brought to market, and consumed, though the politics involved in designating favored and penalized foods would be fierce.31 Restrictions could also apply to the use of food stamps.

Can we promote fitness like the Tobacco and Fashion industry?

Given recent data indicating that children see from 27 to 48 food advertisements for each 1 promoting fitness or nutrition, regulations could be put in place to shift that balance or to mandate support for sustained social-marketing efforts such as the "truth€ ¦®" campaign against smoking.16,32 Requiring more accurate labeling of caloric content and ingredients, especially in fast-food outlets, could make customers more aware of what they are eating and induce manufacturers to alter food composition.

Can we keep pharmaceuticals out of this?

Better pharmaceutical products and counseling programs could motivate clinicians to view obesity treatment more thusiastically. In contrast to these changes in policy, which will require national legislation, regulation, or research investment, change is already under way at the local level.

Making schools the battle ground between addiction anf fitness!

Some schools have banned the sale of soft drinks and now offer more nutritionally balanced lunches. Opportunities for physical activity at work, in school, and in the community have been expanded in a small but growing number of locations. Nonbehavioral Causes of Premature Death Improving population health will also require addressing the nonbehavioral determinants of health that we can influence: social, health care, and environmental factors.

Is there a need to change genes and behavior?

(To date, we lack tools to change our genes, although behavioral and environmental factors can modify the expression of genetic risks such as obesity.)

Social factors: The poor are not competing with the rich?

With respect to social factors, people with lower socioeconomic status die earlier and have more disability than those with higher socioeconomic status, and this pattern holds true in a stepwise fashion from the lowest to the highest classes.33,34, 35,36,37, 38 In this context, class is a composite construct of income, total wealth, education, employment, and residential neighborhood.

Unhealthy behaviors have nothing to do with wealth?

One reason for the class gradient in health is that people in lower classes are more likely to have unhealthy behaviors, in part because of inadequate local food choices and recreational opportunities. Yet even when behavior is held constant, people in lower classes are less healthy and die earlier than others.33,34, 35,36,37, 38 It is likely that the deleterious influence of class on health reflects both absolute and relative material deprivation at the lower end of the spectrum and psychosocial stress along the entire continuum.

Disparities in health care: Fact or fiction?

Unlike the factors of health care and behavior, class has been an "ignored determinant of the nation's health."33 Disparities in health care are of concern to some policymakers and researchers, but because the United States uses race and ethnic group rather than class as the filter through which social differences are analyzed, studies often highlight disparities in the receipt of health care that are based on race and ethnic group rather than on class. But aren't class gradients a fixture of all societies? And if so, can they ever be diminished?

Social class gradient could not be changed with Communist revolutions, so why bother?

The fact is that nations differ greatly in their degree of social inequality and that € ¦’· even in the United States € ¦’· earning potential and tax policies have fluctuated over time, resulting in a narrowing or widening of class differences. There are ways to address the effects of class on health.33 More investment could be made in research efforts designed to improve our understanding of the connection between class and health. More fundamental, however, is the recognition that social policies involving basic aspects of life and well-being (e.g., education, taxation, transportation, and housing) have important health consequences.

Health impact analysis? the new lingo to abandon responsibilities?

Just as the construction of new buildings now requires environmental- impact analyses, taxation policies could be subjected to health-impact analyses. When public policies widen the gap between rich and poor, they may also have a negative effect on population health. One reason the United States does poorly in international health comparisons may be that we value entrepreneurialism over egalitarianism. Our willingness to tolerate large gaps in income, total wealth, educational quality, and housing has unintended health consequences. Until we are willing to confront this reality, our performance on measures of health will suffer. One nation attempting to address the effects of class on health is the United Kingdom.

Health Disparity and the 1998 UK Acheson Commission

Its 1998 Acheson Commission, which was charged with reducing health disparities, produced 39 policy recommendations spanning areas such as poverty, income, taxes and benefits, education, employment, housing, environment, transportation, and nutrition.

The health care system should change to be relevant

Only 3 of these 39 recommendations pertained directly to health care: all policies that influence health should be evaluated for their effect on the disparities in health resulting from differences in socioeconomic status; a high priority should be given to the health of families with children; and income inequalities should be reduced and living standards among the poor improved.39

Social policy in health? Socialist medicine for the Republicans

Although implementation of these recommendations has been incomplete, the mere fact of their existence means more attention is paid to the effects of social policies on health. This element is missing in U.S. policy discussions € ¦’· as is evident from recent deliberations on income-tax policy.

Premature death and medical care have nothing in common!

Although inadequate health care accounts for only 10% of premature deaths, among the five determinants of health (Figure 1), health care receives by far the greatest share of resources and attention. In the case of heart disease, it is estimated that health care has accounted for half of the 40% decline in mortality over the past two decades.40 (It may be that exclusive reliance on international mortality comparisons shortchanges the results of America's health care system.

Medical technology and health status- The US example

Perhaps the high U.S. rates of medical-technology use translate into comparatively better function. To date, there are no good international comparisons of functional status to test that theory, but if it could be substantiated, there would be an even more compelling claim for expanded health insurance coverage.) U.S. expenditures on health care in 2006 were an estimated $2.1 trillion, accounting for 16% of our gross domestic product.41 Few other countries even reach double digits in health care spending.

Quality and Access remain to be the real challenge

There are two basic ways in which health care can affect health status: quality and access. Although qualitative deficiencies in U.S. health care have been widely documented,42 there is no evidence that its performance in this dimension is worse than that of other OECD nations.

45/350 Million US population have no access to care?

In the area of access, however, we trail nearly all the countries: 45 million U.S. citizens (plus 12 millions of immigrants) lack health insurance, and millions more are seriously underinsured. Lack of health insurance leads to poor health.43 Not surprisingly, the uninsured are disproportionately represented among the lower socioeconomic classes. Environmental factors, such as lead paint, polluted air and water, dangerous neighborhoods, and the lack of outlets for physical activity, also contribute to premature death.

Environmental risk factos- the common denominator?

People with lower socioeconomic status have greater exposure to these health-compromising conditions. As with social determinants of health and health insurance coverage, remedies for environmental
risk factors lie predominantly in the political arena.44 The Case for Concentrating on the Less Fortunate Since all the actionable determinants of health € ¦’· personal behavior, social factors, health care, and the environment € ¦’· disproportionately affect the poor, strategies to improve national health rankings must focus on this population.

Who said the US has a health strategy? Ask Hilary and Obama?

To the extent that the United States has a health strategy, its focus is on the development of new medical technologies and support for basic biomedical research. We already lead the world in the per capita use of most diagnostic and therapeutic medical technologies, and we have recently doubled the budget for the National Institutes of Health. But these popular achievements are unlikely to improve our relative performance on health.

Who said per capita use of diagnostic medical technology has any thing to do with health status?

Outspending other nations means we have corrupt health professionals

It is arguable that the status quo is an accurate expression of the national political will € ¦’· a relentless search for better health among the middle and upper classes. This pursuit is also evident in how we consistently outspend all other countries in the use of alternative medicines and cosmetic surgeries and in how frequently health "cures" and "scares" are featured in the popular media.45 The result is that only when the middle class feels threatened by external menaces (e.g., secondhand tobacco smoke, bioterrorism, and airplane exposure to multidrug-resistant tuberculosis) will it embrace public health measures.

The secret is having evaluation tools for promoting health outcomes!

In contrast, our investment in improving population health € ¦’· whether judged on the basis of support for research, insurance coverage, or government-sponsore d public health activities € ¦’· is anemic.46,47, 48 Although the Department of Health and Human Services periodically produces admirable population health goals € ¦’· most recently, the Healthy People 2010 objectives49 € ¦’· no government department or agency has the responsibility and authority to meet these goals, and the importance of achieving them has yet to penetrate the political process.

Why Don't Americans Focus on Factors That Can Improve Health?

The comparatively weak health status of the United States stems from two fundamental aspects of its political economy. The first is that the disadvantaged are less well represented in the political sphere here than in most other developed countries, which often have an active labor movement and robust labor parties.

Wow! America and Democracy are at odds? what an admission!

Without a strong voice from Americans of low socioeconomic status, citizen health advocacy in the United States coalesces around particular illnesses, such as breast cancer, human immunodeficiency virus infection and the acquired immunodeficiency syndrome (HIV€ ¦’¶AIDS), and autism. These efforts are led by middle-class advocates whose lives have been touched by the disease.

Public advocacy campaign? What about K Street lobbyists?

There have been a few successful public advocacy campaigns on issues of population health € ¦’· efforts to ban exposure to secondhand smoke or to curtail drunk driving € ¦’· but such efforts are relatively uncommon.44 Because the biggest gains in population health will come from attention to the less well off, little is likely to change unless they have a political voice and use it to argue for more resources to improve health-related behaviors, reduce social disparities, increase access to health care, and reduce environmental threats.

Fragmened social advocacy? What about

Social advocacy in the United States is also fragmented by our notions of race and class.33 To the extent that poverty is viewed as an issue of racial injustice, it ignores the many whites who are poor, thereby reducing the ranks of potential advocates. The relatively limited role of government in the U.S. health care system is the second explanation.

US: the only rich nation without universal health care?

Many are familiar with our outlier status as the only developed nation without universal health care coverage.50 Less obvious is the dispersed and relatively weak status of the various agencies responsible for population health and the fact that they are so disconnected from the delivery of health services. In addition, the American emphasis on the value of individual responsibility creates a reluctance to intervene in what are seen as personal behavioral choices.

How Can the Nation's Health Improve? Change the system!

Given that the political dynamics of the United States are unlikely to change soon and that the less fortunate will continue to have weak representation, are we consigned to a low-tier status when it comes to population health? In my view, there is room for cautious optimis

Obesity and HIV epidemics? Will they make a difference?

One reason is that despite the epidemics of HIV€ ¦’¶AIDS and obesity, our population has never been healthier, even though it lags behind so many other countries. The gain has come from improvements in personal behavior (e.g., tobacco control), social and environmental factors (e.g., reduced rates of homicide and motor-vehicle accidents and the introduction of fluoridated water), and medical care (e.g., vaccines and cardiovascular drugs).

Behavior risk factos and medical profession?

The largest potential for further improvement in population health lies in behavioral risk factors, especially smoking and obesity. We already have tools at hand to make progress in tobacco control, and some of these tools are applicable to obesity. Improvement in most of the other factors requires political action, starting with relentless measurement of and focus on actual health status and the actions that could improve it.

Political action needs K Street Lobbyist collaboraiton?

Inaction means acceptance of America's poor health status. Improving population health would be more than a statistical accomplishment. It could enhance the productivity of the workforce and boost the national economy, reduce health care expenditures, and most important, improve people's lives. But in the absence of a strong political voice from the less fortunate themselves, it is incumbent on health care professionals, especially physicians, to become champions for population health.

Politicising health care needs Neocon/ and American enterprise attention? They too need to be healthy!

This sense of purpose resonates with our deepest professional values and is the reason why many chose medicine as a profession. It is also one of the most productive expressions of patriotism. Americans take great pride in asserting that we are number one in terms of wealth, number of Nobel Prizes, and military strength.

We need a nobel prize for health! forget the others

Why don't we try to become number one in health? Supported in part by grants from the Robert Wood Johnson and American Legacy Foundations. The sponsors had no role in the preparation of the Shattuck Lecture. No potential conflict of interest relevant to this article was reported. I thank Stephen Isaacs for editorial assistance; Michael McGinnis, Harold Sox, Stephen Shortell, and Nancy Adler for comments on an earlier draft; and Kristen Kekich and Katherine Kostrzewa for technical support.
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