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[Carney] Welcome to
Controversies in Public Health,

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module one lecture,
"Health versus Healthcare".

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This is Dr. Jan Carney.

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At the end of this module,
you should be able to,

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compare health outcomes
in the United States

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and trends over time to
16 of our peer countries.

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Identify actual causes of
death in the United States.

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Describe all determinants
of health and their impact

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on the health of people
in the United States.

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Compare, contrast, and critically assess

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public health models outlined
by the Institute of Medicine.

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Discuss the role of
socioeconomic factors on health,

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including the role of geographic location,

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and identify strategies
to improve health outcomes

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in the United States.

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So, what could possibly be
controversial about this?

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Well, in the Institute of Medicine report,

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"US Health and International Perspective

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of Shorter Lives and Poor Health",

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they said that US health is lousy compared

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with their peer nations.

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They looked at US health
and our peer countries.

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They looked at a variety
of health outcomes.

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And then, this report and
then later reports in 2019

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and 2021, unfortunately
had similar themes.

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So, how do we compare
to our peer countries?

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Our health ranks lower, our
health improvements are slower,

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our life expectancy is shorter.

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And there is a concept
evolving from all this,

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called health disadvantage,
and that really describes

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the differences between the
United States and peer countries

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for all age groups under the age of 75,

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which is a great deal of the population.

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These same disadvantages, with
regards to health outcomes,

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are seen in all socioeconomic
groups in the United States.

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So one question that I have is,

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do we even think people are
aware of these findings?

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Let's look at all of the data.

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In this figure, we can
look at life expectancy

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in females compared to our peer countries.

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And you can see that the
longest average life expectancy

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is in Japan and the
shortest one is in Denmark,

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followed by the United States.

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Next, let's look at the
same figure in males.

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And you can see that the
longest life expectancy

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is seen in Switzerland and Australia,

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and the shortest in the United States.

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And also, we notice that each
life expectancy is shorter

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in males than females.

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So here's another report
that we'll be looking at,

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which is "US Healthcare
from a Global Perspective:

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Higher Spending and Worse Outcomes",

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from the Commonwealth Fund.

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Here are some of the
highlights from this report.

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We spend more on healthcare
as a share of the economy,

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almost twice as much as other countries,

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yet we have the lowest life expectancy

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and the highest suicide rate

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among 11 nations that
comprise this report.

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We have the highest chronic disease burden

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and an obesity rate that
is twice the average

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than the other participating countries.

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We had fewer physician
visits than our peers,

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and that may relate to a
lower supply of physicians

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in the United States, we use
more expensive technologies

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and procedures and we
do outperform our peers

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in terms of preventive measures,
one of the highest rates

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of breast cancer screening
among women 50 to 69,

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and the second highest
rate of flu vaccinations

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among people 65 and older.

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But these findings,
unfortunately, pale in comparison

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to statistics of the United States,

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has among the highest
number of hospitalizations

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from preventable causes
and the highest rate

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of avoidable deaths.

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Here's another report that
echoes the same generic findings,

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which are, it's called
"Mirror, Mirror 2021:

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Reflecting Poorly", and
again, this is healthcare

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in the United States compared

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to other high-income countries.

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And this has like, the
previous report compared

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the performance of health systems

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in 11 high-income countries,
and you can see that,

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overall, top performing
countries were Norway,

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the Netherlands, and Australia.

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We ranked last overall,
despite a much higher spending.

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There were four features
that distinguished

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the top-performing countries
and their health systems

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from the United States.

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First, they provided
for universal coverage

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and they eliminate cost barriers.

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Second, they invest in
primary care systems.

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Third, they reduce administrative burdens.

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And fourth, they invest
in social services,

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especially for children
and working-age adults.

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In my opinion, this is
particularly important,

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as we know that there
are many social factors

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that influence our health
in addition to healthcare.

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This is from the Centers for
Disease Control and Prevention

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and shows that leading cause of death

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in the United States
overall, and if you just look

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at the age groups along the top,

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and you can look at the rank,
in terms of the top causes,

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you notice a few things.

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First, for populations
up to the age of 45,

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unintentional injury is really prominent.

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Suicide is a leading cause of death

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among individuals age
10 to 14 and 25 to 34.

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It's also a leading cause
overall from ages 10 to 35.

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And again, in some older
age groups, you can look

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at similarly, where the highest rates

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and contributions of homicide fall

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in different age groups
in the United States.

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One thing we should be thinking about is,

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one of the things that ties
many of these conditions

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together is the fact there are
opportunities for prevention

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and that's where public health comes in.

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This is another slide from CDC that shows

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the age-adjusted death rates
for the 10 leading causes

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of death in 2021 in the United States.

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And you can see, in 2020 and 2021,

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heart disease and cancer

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and Covid-19 deaths were noticeable

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as a contributor for both of these years.

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This is followed by unintentional
injuries and stroke,

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and you can see the other chronic
conditions that contribute

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to our leading cause of
death in the United States.

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Determinants of health, when
people think about health,

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they first and foremost
think about healthcare,

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but what determines
health goes way beyond.

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One of the important
considerations is, if you step back

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and look at our population
overall, and you say,

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"What are those population
demographic trends?"

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Well, we know as a whole, our
population is getting older,

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meaning a higher proportion
of older individuals over time

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and we're also becoming more diverse.

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There are market geographic
differences in health outcomes.

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Sometimes, health is determined
more by zip code than,

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for example, genetics or other factors,

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or the determinants of
health includes social

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and economic factors, habits
and behaviors, genetics,

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the environment and access to
primary and preventative care.

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The evolution of public health
has spanned multiple decades.

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There was a couple of foundational reports

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by the Institute of
Medicine, first in 1988,

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"The Future of Public Health",
and another one called,

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"The Future of the Public's
Health in the 21st Century"

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in 2003.

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One of the features of these reports were,

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there were changes in the
perceived role of government.

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Public health expanded way
beyond health departments

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and really included a whole variety

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of sectors working in partnership.

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There were many laudable
public health achievements

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throughout this time, and one

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of the current Healthy People 2030 goals,

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which are measurable goals
and objectives in the nation,

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the theme of Healthy People has spanned

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over multiple decades, and
these are very important

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in terms of setting priorities

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and measuring our
progress to improve health

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for the entire population
in many different areas.

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These are just some of
the factors contributing

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to health determinants and
how the United States fares

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compared to similar countries.

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Embedded in this are many,
many controversial areas.

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And when we think about,
why can't we make progress

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in things that seem so
logical, from a public health

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and healthcare perspective, it may help us

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to understand a little bit
about these controversies.

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So I would ask you, as
you're doing the readings

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and preparing for a discussion,

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think about these controversies
in a structured way.

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Look at the significance,
the evidence for prevention.

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What specific strategies should we use?

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There are some specific
questions for this topic

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that will be covered in just a moment.

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And then thinking about the controversy.

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What are the controversies?

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What are the reasons that we
can't make forward progress?

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Sometimes, we discover that
controversy's a very bad thing,

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but it can also be an
opportunity to shine a light

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on something that we need to make better.

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Why is this health issue so controversial?

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What are the specific
factors, such as economics,

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government, scientific
uncertainty, or politics?

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Does the media play a role?

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And what do you think we should do?

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How should we respond to the
controversies in front of us?

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So for these questions,
in our yellow discussions,

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think about and discuss
how does health differ

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from healthcare?

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What approaches might be
used to educate the public

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about the determinants of health?

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And how might that 2013 report

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and the later reports we've looked at

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be used as a catalyst
for health improvements

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in the United States?

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Thank you, and if you have any questions,

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email me at any time.