Missing in the 'Health Care' Debate: Health

December 26, 1993|By ALFRED SOMMER

In a recent article in the Journal of the American Medical Association, Drs. Michael McGinnis (deputy assistant secretary for health) and William Foego (former director of the Centers for Disease Control) confirm that half of all deaths in the United States are fully preventable if we attack their root causes rather than try to pick up the pieces through treatment of late-state disease.

While not necessarily meant to do so, this article highlights the hollowness of much of our national debate about so-called "health care reform."

Most discussions about "health care reform" reflect the concerns of special interest groups: Who can do what to whom and how often? How much should a health care provider be reimbursed? Who pays? Will the consumer have choice? While these are important details, they miss the central purpose which is, after all, to improve our health.

To keep our eye on the real prize, we need to be clear about the major detriments to the health and longevity of Americans. At the turn of the century, life expectancy was barely 40 years. It has increased an average of three months every year since then.

The extraordinary achievement has had little to do with expensive, often heroic tertiary care at the geriatric margin, and everything to do with relatively inexpensive practices that promote health and prevent disease in the first place.

When we look at our health care system and our resultant health in comparison to other countries, paradoxes abound.

* We have the finest medical centers but far from the finest health.

* Costa Rica, with one-tenth our per capita GNP, enjoys the same life expectancy we do.

* Japanese infant mortality is the lowest in the world and life expectancy the longest. Yet, in the early 1930s, Japanese health indices were far worse than those of most of today's Third World countries. Rapid improvement in Japanese health is largely credited to a simple manual providing basic advice on pre- and perinatal care that was first distributed to Japanese women in the mid-1930s.

* Our health status fails to improve as rapidly as that of other nations while we continue to gut our public health infrastructure -- the nation's health safety net -- to pay for increasingly costly curative services often of doubtful or trivial value.

* Nigeria's children are better vaccinated than Baltimore's.

* Measles, which should have been virtually eradicated from the United States more than a decade ago, struck 50,000 American children over the past few years and killed more than 100.

* Tuberculosis is on the rise. There were twice as many cases in the United States in 1992 as in 1985. People who live in Harlem are 30 times more likely to develop tuberculosis than fellow New Yorkers on the Upper West Side.

This great national debate must move beyond parochial concerns of special interest groups and the narrow issue of treating those already sick. The only special interest group that matters is the public. The central issue of concern is its health.

Historically, community-based, societally driven activities and changes in individual behavior have accounted for the vast majority of health gains.

Today they remain the only approaches positioned to alter the onslaught of AIDS, resurgent tuberculosis, substance abuse, violence and lung cancer.

Biomedical research holds the promise for meaningful new approaches that will benefit large segments of society at moderate cost. Better, cheaper, safer vaccines effective against wider range of diseases would dramatically advance the health of Americans. But health behavior research, the key to immediately preventing a million or more unnecessary deaths every year, continues to receive short shrift.

Almost as many Americans die of smoking-related illnesses in the United States every year as all the Americans who died in all the wars we've fought since independence. In 1940, lung cancer was an oddity among American women. By 1990, more women were dying of lung cancer than of breast cancer.

"Universal access" to health care is a worthy beginning but not sufficient. Financial and geographical access do not ensure appropriate use of services.

For instance, the leading cause of blindness in East Baltimore is cataract, an entirely remediable condition. Those who are blind have "financial" and "geographic" access. Almost all are covered by Medicare, and almost all live within two miles of Hopkins' Wilmer Eye Institute.

Yet, for reasons we do not fully understand, they are not using these "accessible" services.

Low rates of childhood immunization in Baltimore have been blamed on socio-economic factors, yet welfare recipients are assigned to one of two HMOs paid to provide baby shots as part of routine services.

Immunization rates of children enrolled in these HMOs are appalling. One could blame the mothers. In fact, the government does, by withholding part of their welfare payments.

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