"I think this may be the best day of my life," Dr. Julie Gerberding, the director of the Centers for Disease Control and Prevention (CDC), said at the opening of the 2008 Leaders-to-Leaders Conference she convened last week, along with the country's state and county public health officials. The agenda: To build a bottom-up coalition to change how America deals with health, to shift our focus from health care to healthiness and to the bigger social factors that determine our national healthiness.
Over two days, I heard so many encouraging ideas from the conference stage that didn't reflexively demonize public policy-making as nanny-statism that, well, as I said, the whole thing left me looking nervously over my shoulder for political-correctness enforcers from The Cato Institute or The Heritage Foundation.
As one speaker after another pointed out, America today ranks first among industrial nations in terms of how much we spend on health care, but last in terms of how healthy we are as a country. Pick any national metric of healthiness -- life expectancy, infant mortality, birth weight, chronic diseases incidence -- and America's comparative performance is in the cellar. It's true even when you adjust for European populations' relative homogeneity: if you only count white Americans, we are still the low man on the healthiness totem pole.
We Americans spend more than 90 percent of our health dollars on health care (on doctors, hospitals, insurance, machines, pharmaceuticals and the like), but it turns out that only 10 percent of how healthy we are as a nation is determined by what those health care dollars buy.
How can that be? What could possibly determine whether America is among the industrial world's healthiest nations, if not the thing we're all clamoring for: universal heath insurance? The answer -- and this isn't a political opinion, it's an epidemiological finding -- lies in the social determinants of our physical condition. Determinants like income, class, education, racism, the availability of public transportation, land-use policy, environmental policy, participation in the political process and a host of other factors that don't depend on our genetic makeup or our propensity to take personal responsibility for diet and exercise. Determinants that flow not from luck or individual choices, but from laws, regulations and priorities set at all levels of government and in the private sector as well. (If you want an alarming eyeful about this, check out the new California Newsreel documentary "Unnatural Causes.")
The way we currently think about health in America -- about health care, that is -- is completely understandable. We all want access to the best possible health care for our parents, our kids and ourselves, and we want it to be affordable, and we want plenty of choices. What's astonishing is that even if we covered all the uninsured's health care, we would still likely rank at the bottom of industrial countries for healthiness. The major causes of our country's healthiness or unhealthiness are all upstream of the things that send us to doctors and hospitals and pharmacies. The causes are poverty, and stress, and the amount of control and autonomy we have at our jobs, and whether there are showers there, and what they put in the vending machines. The causes are access to early childhood education, and to day care, and whether schools are built near asthma-breeding freeways. They are whether your neighborhood offers public libraries and public transportation and walking trails, or public dumps and liquor stores and fast food franchises.
"I had a colonoscopy the other week," the CDC's Dr. Gerberding told the 400 public health officials, business leaders and nonprofits she was hoping would sign on to a "healthiest nation alliance." "Actually," she added, "I was billed for two colonoscopies, though I'm sure I only had one."
Clearly she's not unaware of the madness of our present health care system. No one facing a family medical crisis wants anything but the best possible treatment at that moment. No one should lack access to quality health care. But prevention is even more important to the country as a whole than treatment is, and the free market alone hasn't and won't deliver the level of prevention we need.
To me, the underlying reason America has fallen so far behind in the healthiest nation race is the exhausted dogmas that have dominated public discourse for something like 30 years -- Horatio Algerism, social Darwinism, the magic of the marketplace, deregulation is good, government is bad, pull yourself up by your own bootstraps and devil take the hindmost.
We now know what America looks like when those kinds of ideas rule, and not only in the health sector. I'm glad that, at long last, public officials are finding their voice to express politically transgressive thoughts, like the idea that income inequity and racism are bad for America's healthiness.
I just hope that the Ayn Rand Society doesn't get on their case.
Marty Kaplan is director of the USC Annenberg School's Norman Lear Center, where some work is supported by the CDC. His column appears weekly in this space. He can be reached at firstname.lastname@example.org.
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