[Carney] Welcome to Controversies in Public Health,
module one lecture, "Health versus Healthcare".
This is Dr. Jan Carney.
At the end of this module, you should be able to,
compare health outcomes in the United States
and trends over time to 16 of our peer countries.
Identify actual causes of death in the United States.
Describe all determinants of health and their impact
on the health of people in the United States.
Compare, contrast, and critically assess
public health models outlined by the Institute of Medicine.
Discuss the role of socioeconomic factors on health,
including the role of geographic location,
and identify strategies to improve health outcomes
in the United States.
So, what could possibly be controversial about this?
Well, in the Institute of Medicine report,
"US Health and International Perspective
of Shorter Lives and Poor Health",
they said that US health is lousy compared
with their peer nations.
They looked at US health and our peer countries.
They looked at a variety of health outcomes.
And then, this report and then later reports in 2019
and 2021, unfortunately had similar themes.
So, how do we compare to our peer countries?
Our health ranks lower, our health improvements are slower,
our life expectancy is shorter.
And there is a concept evolving from all this,
called health disadvantage, and that really describes
the differences between the United States and peer countries
for all age groups under the age of 75,
which is a great deal of the population.
These same disadvantages, with regards to health outcomes,
are seen in all socioeconomic groups in the United States.
So one question that I have is,
do we even think people are aware of these findings?
Let's look at all of the data.
In this figure, we can look at life expectancy
in females compared to our peer countries.
And you can see that the longest average life expectancy
is in Japan and the shortest one is in Denmark,
followed by the United States.
Next, let's look at the same figure in males.
And you can see that the longest life expectancy
is seen in Switzerland and Australia,
and the shortest in the United States.
And also, we notice that each life expectancy is shorter
in males than females.
So here's another report that we'll be looking at,
which is "US Healthcare from a Global Perspective:
Higher Spending and Worse Outcomes",
from the Commonwealth Fund.
Here are some of the highlights from this report.
We spend more on healthcare as a share of the economy,
almost twice as much as other countries,
yet we have the lowest life expectancy
and the highest suicide rate
among 11 nations that comprise this report.
We have the highest chronic disease burden
and an obesity rate that is twice the average
than the other participating countries.
We had fewer physician visits than our peers,
and that may relate to a lower supply of physicians
in the United States, we use more expensive technologies
and procedures and we do outperform our peers
in terms of preventive measures, one of the highest rates
of breast cancer screening among women 50 to 69,
and the second highest rate of flu vaccinations
among people 65 and older.
But these findings, unfortunately, pale in comparison
to statistics of the United States,
has among the highest number of hospitalizations
from preventable causes and the highest rate
of avoidable deaths.
Here's another report that echoes the same generic findings,
which are, it's called "Mirror, Mirror 2021:
Reflecting Poorly", and again, this is healthcare
in the United States compared
to other high-income countries.
And this has like, the previous report compared
the performance of health systems
in 11 high-income countries, and you can see that,
overall, top performing countries were Norway,
the Netherlands, and Australia.
We ranked last overall, despite a much higher spending.
There were four features that distinguished
the top-performing countries and their health systems
from the United States.
First, they provided for universal coverage
and they eliminate cost barriers.
Second, they invest in primary care systems.
Third, they reduce administrative burdens.
And fourth, they invest in social services,
especially for children and working-age adults.
In my opinion, this is particularly important,
as we know that there are many social factors
that influence our health in addition to healthcare.
This is from the Centers for Disease Control and Prevention
and shows that leading cause of death
in the United States overall, and if you just look
at the age groups along the top,
and you can look at the rank, in terms of the top causes,
you notice a few things.
First, for populations up to the age of 45,
unintentional injury is really prominent.
Suicide is a leading cause of death
among individuals age 10 to 14 and 25 to 34.
It's also a leading cause overall from ages 10 to 35.
And again, in some older age groups, you can look
at similarly, where the highest rates
and contributions of homicide fall
in different age groups in the United States.
One thing we should be thinking about is,
one of the things that ties many of these conditions
together is the fact there are opportunities for prevention
and that's where public health comes in.
This is another slide from CDC that shows
the age-adjusted death rates for the 10 leading causes
of death in 2021 in the United States.
And you can see, in 2020 and 2021,
heart disease and cancer
and Covid-19 deaths were noticeable
as a contributor for both of these years.
This is followed by unintentional injuries and stroke,
and you can see the other chronic conditions that contribute
to our leading cause of death in the United States.
Determinants of health, when people think about health,
they first and foremost think about healthcare,
but what determines health goes way beyond.
One of the important considerations is, if you step back
and look at our population overall, and you say,
"What are those population demographic trends?"
Well, we know as a whole, our population is getting older,
meaning a higher proportion of older individuals over time
and we're also becoming more diverse.
There are market geographic differences in health outcomes.
Sometimes, health is determined more by zip code than,
for example, genetics or other factors,
or the determinants of health includes social
and economic factors, habits and behaviors, genetics,
the environment and access to primary and preventative care.
The evolution of public health has spanned multiple decades.
There was a couple of foundational reports
by the Institute of Medicine, first in 1988,
"The Future of Public Health", and another one called,
"The Future of the Public's Health in the 21st Century"
in 2003.
One of the features of these reports were,
there were changes in the perceived role of government.
Public health expanded way beyond health departments
and really included a whole variety
of sectors working in partnership.
There were many laudable public health achievements
throughout this time, and one
of the current Healthy People 2030 goals,
which are measurable goals and objectives in the nation,
the theme of Healthy People has spanned
over multiple decades, and these are very important
in terms of setting priorities
and measuring our progress to improve health
for the entire population in many different areas.
These are just some of the factors contributing
to health determinants and how the United States fares
compared to similar countries.
Embedded in this are many, many controversial areas.
And when we think about, why can't we make progress
in things that seem so logical, from a public health
and healthcare perspective, it may help us
to understand a little bit about these controversies.
So I would ask you, as you're doing the readings
and preparing for a discussion,
think about these controversies in a structured way.
Look at the significance, the evidence for prevention.
What specific strategies should we use?
There are some specific questions for this topic
that will be covered in just a moment.
And then thinking about the controversy.
What are the controversies?
What are the reasons that we can't make forward progress?
Sometimes, we discover that controversy's a very bad thing,
but it can also be an opportunity to shine a light
on something that we need to make better.
Why is this health issue so controversial?
What are the specific factors, such as economics,
government, scientific uncertainty, or politics?
Does the media play a role?
And what do you think we should do?
How should we respond to the controversies in front of us?
So for these questions, in our yellow discussions,
think about and discuss how does health differ
from healthcare?
What approaches might be used to educate the public
about the determinants of health?
And how might that 2013 report
and the later reports we've looked at
be used as a catalyst for health improvements
in the United States?
Thank you, and if you have any questions,
email me at any time.