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How healthy is the U.S.?

An overview of the societal environment and health trends that underlie the management of health care costs.

The Twentieth Century has seen dramatic improvements in the longevity and health status of Americans. Yet, these very achievements in our nation's health have bred the problems that now face our health care systems.

Since 1900, the life expectancy of American has grown by 28.1 years, from 47.3 to a record-breaking 75.4 years in 1990. During that time, the mortality rate for all age groups dropped precipitously. For example, in the early 1900s, one baby in 10 died before its first birthday; now 99% of all infants survive.

Controlling Infectious Disease

The control of communicable diseases and advances in nutrition were two major contributors to health improvements during the first half of this century. Many infectious diseases came under control through effective sanitation ranging from sewage systems to clean food and water, from anti-spitting laws to washing hands. The development and use of effective immunizations reduced dreaded childhood illness dramatically. With the near-miraculous development of

antibiotics and other effective therapies later in the century, what had previously been life-threatening emergencies became short-term tractable episodes.

Improved Nutrition and Food Supply

Scientific research identified the causes, and led to the potential elimination, of virtually all nutritional deficiencies. Improvements in agricultural and food processing technology, and in transportation and distribution methods, made an adequate and nutritious diet available to most Americans wherever they lived. This produced not only general improvement in the growth and development of the muscles and bones of children but probably also of the nervous system, vascular system, and immune system, which promoted longevity and vitality in older persons.

Technological Advances in Medicine

The victories against pestilence and inadequate nutrition were coupled, during the second half of the century, with extraordinary progress in medical sciences and technologies which cured the illnesses and relieved the sufferings of countless Americans. To take only one, but very significant, example, premature babies that a generation or two ago would almost automatically be given up for dead at the moment of birth now survive to healthy and productive adulthood with normal life expectancies.

Aging Population

These gains have not been achieved without a grave price, much of which impacts on our health care system today. Increased longevity (coupled with a declining birth rate) has produced an aging population. In 1900, only 4% of the population was age 65 and older; now almost 13% is that age. Many Americans now survive heart attacks, stroke, and major trauma -- which were highly fatal conditions only a few decades ago. These survivors, however, often require intensive health and rehabilitative services to recover and regain their health or to deal with lasting disabilities.

In contrast with the successes in postponing mortality from most of the leading causes of death, relatively little progress has been made in reducing the prevalence of disabling conditions associated with aging (e.g., Alzheimer's disease, ataxias, arthritis, loss of hearing and sight, and incontinence). Furthermore, individuals with handicapping conditions such as Down's Syndrome, who rarely survived into late adulthood a generation ago, now can be expected to outlive their parents who had been providing care for them. This increase in longevity, aging of the population, and what has been dubbed "the expansion of morbidity," have placed accelerating demands on the country's health care system.

Increased Risk of Disease, Disability, and Death

At least three major trends portend further pressures on our health care system. One is the persistence and evolution of individual, social, and economic forces that increase risks of disease and disability among certain segments of the population.

Environmental hazards, for example, have always been with us, but until this century, the most important environmental hazard was filth, causing infectious diseases. Now we must deal with "filth" that causes chronic diseases. With the reduction in wood and coal burning, especially in homes, environmental quality may have actually improved, but the plethora of new chemicals, radiation sources, and other pollutants have produced new risks.

Another example is the continued endemic use of illicit drugs, directly related to the patterns of violence in American society. More than 25,000 homicides occurred in the U.S. last year, and this number is increasing. Illegal drug use results in the tragic "crack babies." And drug abuse contributes to the rising rate of sexually transmitted diseases, the more than 186,000 cases of AIDS to date in the United States, and the increasingly serious problem of hepatitis.

Likewise, much still remains to be done to reduce cigarette smoking, improve physical fitness, and encourage people to engage in healthy lifestyles. The Secretary of Health and Human Services and the Surgeon General vigorously advocate programs to promote health and prevent disease. While much has been accomplished, we must continue to motivate and empower people to adopt the personal habits that reduce or delay chronic disease.

Rising Expectations of Better Health and Health Care

A second major trend affecting the health care system is the rising expectations for lengthening of life, cure of illnesses, reduction of disabilities, relief of impairments, and general improvement in the physical and emotional quality of life. These increased expectations arise from past successes and an increasing belief in our ability -- and right -- to control our fate, not only in regards to economic, social, and political circumstances but also with regard to health and longevity.

This belief has major implications for increasing demands for services and their availability, affordability, and quality. Individual citizens demand more accountability from community leaders to improve health, control disease, and treat and rehabilitate those who become ill or disabled. Meanwhile, community leaders are stressing individual and family responsibilities for healthy life styles, prevention and avoidance of risk, early diagnosis, and some aspects of care.

Demand for Health Equality

These rising expectations lead directly to the third trend -- the demand for the elimination of inequities in access to care and disparities in health status and outcomes, whether on a geographic, social, economic, or ethnic basis. Disparities in the health of minorities are of particular concern. Black women have a life expectancy almost 5 years less than their white counterparts. The gap between black and white men is greater -- more than 6 years. And while life expectancy has improved steadily for white men and for women of either race, black mens' life expectancy decreased from 1984 to 1988, followed by an increase from 1988 to 1990. Whether the recent improvement heralds a continuing trend remains to be seen.

Similarly, there is a great disparity in infant mortality rates: Black infants are more than twice as likely to die during the first year of life than are white infants. Many of these disparities can be related directly to social and economic conditions, but there are also inequities in the availability and quality of health care, as well as other factors we've only begun to identify and still others we've yet to discover.

The Future

The Institute of Medicine, in its recent report on the Future of Public Health, identified three areas that are the unique responsibility of the public health system of this country: * Assessment of the health status of the population and the services available. In view of the foregoing trends there will be a growing need for more detailed data about the health of more discrete subgroups of the population and about a wider array of conditions and behaviors. * Policy formation. Using information about the health of the people, together with information about the availability, efficacy, and costs of current services, public health officials must establish policies for guiding programs to improve the health of the population. * Assuring that the services and programs decided upon are made available to the people through private, philanthropic, or public means.

Although the private sector plays a role in all three of these areas, it is particularly in regard to the assurance function that businesses and industries will have a greater role to play in the future. Businesses will have a major role in educating the work force and the public about hazardous behaviors and personal risk factors, providing screening programs for the early detection of disease, working with health care providers to enhance the availability and efficacy of care at reasonable costs, and providing for the rehabilitation and, if needed, long-term care of their workers.

The demands for better health are intimately connected, yet also competitive, with the demands from a wide range of other social concerns: urban blight, pollution, poverty, family disruption, better education, and economic and political opportunity.

Today, Americans spend $540 billion on health -- 11% of our GNP. This is up from $3.6 billion and a 3.5% share of the GNP in 1929, when data were first available. When we spend at that level for health, much is expected and much is diverted from other societal and individual needs. Through cooperative efforts by the public and private sectors, priorities can be established, resources directed appropriately, and costs controlled or managed -- all with the goal of improving the quality of life for all Americans. Manning Feinleib, M.D., DrPH, is Director of the National Center for Health Statistics, the principal health statistics agency of the United States federal government, and part of the Centers for Disease Control, Public Health Service, Department of Health and Human Services. At NCHS, he directs a comprehensive program of data collection, analysis, research, and dissemination designed to provide the data needed to monitor and improve the nation's health. Before his appointment as NCHS Director in 1983, Feinleib was Associate Director for Epidemiology and Biometry at the National Heart, Lung and Blood Institute, National Institutes of Health.
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Title Annotation:Chairman's Agenda: Managing Health Care Costs; Americans' health status
Author:Feinleib, Manning
Publication:Directors & Boards
Date:Jan 1, 1992
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