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The US Health Disadvantage And Clinicians: An Interview With Paula Braveman



February 22nd, 2013

The US spends far more per person on health care than any other nation.  But a growing body of research demonstrates that Americans – rich or poor, minority or not – suffer from a widening “health disadvantage” when compared to citizens of other high-income countries. On January 9, the Institute of Medicine (IOM) and the National Research Council released “U.S. in International Context: Shorter Lives, Poorer Health.”  Commissioned by the National Institutes of Health, a panel chaired by Professor Steven H. Woolf at Virginia Commonwealth University painstakingly investigated whether Americans of all ages were affected by a growing health gap previously observed between older Americans and their foreign counterparts.

The panel examined several decades of data from the US and 16 comparable high-income countries, most of which are European. What they found is, or should be, alarming, even for seasoned health advocates and policymakers. The report’s authors sound the alarm at the outset: “We uncovered a strikingly consistent and pervasive pattern of higher mortality and inferior health in the United States, beginning at birth.”

What does this report mean for clinicians and health systems, especially at a time when doctors, nurses and other health care professionals are adjusting to a shifting landscape of structural reforms? Is this a clarion call for clinicians, educators and policymakers to engage in realigning the way we deliver care? Or will this news drive clinicians to sound a retreat from the front lines of population health-oriented system change?

On January 11, two days after the release of the IOM report, I talked with one of the IOM panelists behind the report, Paula Braveman MD MPH, Professor of Family and Community Medicine and Director, Center on Social Disparities in Health at UCSF. I spoke with her on behalf of HealthBegins, a social enterprise and online community of clinicians and others committed to improving health care and the social determinants of health. We discussed the report and what it means for America’s clinicians.

Manchanda: What were your objectives for this report?

Braveman: This is the first report to compare the US with other countries on a wide range of health indicators and across all ages. A couple of years ago, an IOM panel chaired by Eileen Crimmins and Samuel Preston produced a report titled International Differences in Mortality at Older Ages. They documented a growing mortality gap between Americans age 50 or above and their counterparts in other affluent nations and considered several factors that might account that this gap. Our panel was appointed by the NIH to answer if that gap also affected Americans below age 50. This was an 18 month study. We relied on existing data, but did some new analyses of data from the US and 16 nations of comparable economic status.

Manchanda: What did you find? What is the “US health disadvantage”?

Braveman: We found a persistent gap in health across all ages up until age 75, across a vast majority of health indicators with few exceptions. That’s the US health disadvantage. A key aspect is that this disadvantage is not confined to Americans who are poor or belong to minority groups. Affluent and white Americans also experience this health disadvantage. It’s a new and sobering recognition of how poorly the US is doing in terms of health.

It was not within scope of this report to examine the reasons deeply.  Our most fervent hope is that this will create public debate that will help more Americans understand this disadvantage and what we can do about it.  We also hope that, if more Americans really understand the gravity of this disadvantage, perhaps the US would be more open to consider approaches in other countries that have worked and how they can be modified for the US.

Manchanda: What’s driving the health disadvantage? And what is the most promising opportunity to help decrease it?

Braveman: The health system alone doesn’t account for the US health disadvantage. Health care is probably a factor but we did not think it is the big driver. From higher rates of injuries, accidents, and homicides to high rates of teen pregnancy and STIs and poor birth outcomes, we can infer that there are primarily social issues that need to be addressed  In the report summary, we stated,

No single factor can fully explain the U.S. health disadvantage. It likely has multiple causes and involves some combination of inadequate health care, unhealthy behaviors, adverse economic and social conditions, and environmental factors, as well as public policies and social values that shape those conditions.

So I think our emphasis should be on prevention. If I were forced to choose just one area, to pick the most promising opportunity, it would be addressing poverty, especially child poverty and the adverse conditions in homes and communities that are tightly linked with poverty. Incidentally, we lead other nations in child poverty rates.  That is not a distinction we can be proud of.

We know enough about the social determinants of health now to be able to trace out plausible pathways that can explain much of the US health disadvantage. And with that in mind, we’re really different from other countries in how we provide services that address the social determinants. From childcare and preschool to mental health services and family leave, our social safety net is relatively weak compared with those of our peer countries. That, as well as child poverty, may account for part of the US health disadvantage.

Manchanda: Your report found that the US health disadvantage was not limited to poor Americans; rich Americans are also unhealthier than their counterparts in other nations. That may be news to some.

Braveman: That’s right. One hypothesis that may explain this is that there is a certain level of anxiety for everyone associated with living in a society where the safety net is relatively weak. There is also research that suggests that the degree of economic inequality in a society is linked with poorer health outcomes. It’s possible that our sense of rugged individualism in America contributes to a lack of solidarity and support for social services that can improve health outcomes. And it might contribute to other risk factors like a lack of gun control measures that could decrease injuries and homicides.

Manchanda: What do you believe the report means for health care systems and professionals?

Braveman: I think there are two lessons for clinicians and health care systems.

First, I think it’s important to conceptualize and expand the ability of primary care services to link people to resources in the community that deal with prevention and the social determinants of health. We in health care need to do a better job of supporting efforts for prevention in other sectors –like child care, education, housing, and urban planning—that are the largest determinants of who gets sick in the first place. Doctors and other clinicians need to be part of that work and be involved in getting their clinics to do more to address social determinants of health. They need tools, examples and role models. That’s what makes groups like HealthBegins so interesting.

Advocacy is also essential. Convincing policymakers and the public that health is bigger than health care is something that clinicians can do really well if they are convinced.  When a physician speaks to the need for prevention, it’s very powerful. For most clinicians, this will mean getting active at the local level, working with local groups to change policies. This doesn’t mean physicians should drop their work just to do advocacy, but if they can occasionally show up at local events and support community prevention efforts, that’d go a long way. The same goes for health professions students. At a broader level, clinicians can join and insist that their professional organizations do everything possible to make decreasing the US health disadvantage a priority.

It’s not a realistic expectation for every clinician to lead that change, but many can join with other groups.

Manchanda: What are the biggest barriers facing clinicians who want to help address the ‘health disadvantage’ at a local level?

Braveman: Well, the role of profit-making in health care puts pressure on physicians to focus on a very different set of priorities. We’ll see if that changes any with the health care reforms underway, but I am not very optimistic. There’s also such a shortage of primary care clinicians in many communities. That makes it hard. And finally, more and more physicians work in large organizations and may have less autonomy than before to make changes in their health care system that can support community prevention.

Manchanda: What can large health care organizations do?

Braveman: Kaiser Permanente does an admirable job as a large organization to address prevention. But they’re under pressure to compete with for-profit entities. These entities have to be part of improving health in their communities, not just treating the patients in their buildings. It’s up to health care professionals and policymakers to influence these entities.

——

I thank Dr. Braveman for being so generous with her time in discussing the IOM report and the state of health in the US.  Our conversation left me with an increased sense of urgency. Coordinated action is needed at multiple levels and across many sectors to tackle the US health disadvantage. As I reviewed the report, this passage struck me.

Without action to reverse current trends, the health of Americans will probably continue to fall behind that of people in other high-income countries. The tragedy is not that the U.S. is losing a contest with other countries, but that Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary.

How should and will America’s clinicians and health care systems respond to the tragedy of the US health disadvantage? This question may be a lot to ask at a time of so much change in health care. But, as the 405 pages of statistics and analyses in the IOM report make clear, it’s one that deserves an answer. Readers are invited to share comments and answers below; you are also invited to participate in a brief online survey sponsored by HealthBegins, which will post the results and comments publicly in March 2013 and share results with health care professional associations and medical schools.

Whether this question is asked online, in lecture halls, clinic corridors, or during professional meetings, it is likely that the answer will require health care providers to be equipped with new tools and opportunities, particularly if we are to follow Dr. Braveman’s recommendations to realign health care to enable and advocate for improvements in the social determinants of health. What do you think?

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1 Response to “The US Health Disadvantage And Clinicians: An Interview With Paula Braveman”

  1. sabez Says:

    The Shorter Lives, Poorer Health report and the discussion with one of its author’s Paula Braveman, by Rishi Manchanda is a first step in trying to do something about our dying so young. The IOM report was a compilation of research findings that span decades. This report is the most significant document the National Research Council has produced. Its authors did an amazing job of aggregating studies and being unequivocal about the findings.

    There has been active denial of those findings in this country. Recall in the recent presidential debates, one candidate said: “we have the best health records in the world.” Whatever he meant by that comment, no media coverage tried to discredit that. We certainly don’t have the best electronic medical records. Our President goes as far as to say that we spend a great deal of money on medical care but don’t get the results we should.

    The health care expenditures in the US alone add up to an amount that if they represented a country it would be the fifth richest in the world. Medical care is a very profitable industry that many salivate to get inside. But the President should ask whether we want health or health care.

    In the only survey of opinions on our health status in this country in 2002 fully a third of US medical students thought we were the healthiest country in the world. So let’s not delude ourselves. There is an enormous amount of work to do to inform not only doctors and medical students, but public health workers as well as the public. Most of them suffer serious delusions or have never even considered the question about how healthy we are.

    One interpretation of the report, and the decades of research previous to its publication that back up its findings, is that organized public health has totally failed this nation. The 1988 IOM’s report “ The Future of Public Health” resulted in an entire revamping of US public health activities to focus on assessment, policy development, and assurance. This was never accomplished if assessment meant considering our health in comparison to other nations. Assessment was carried on within a county, city, state or the nation. Our public health agencies have worn blinders so that we don’t truly see our health status, even today.

    The report discusses the findings of the limited impact of medical care on health of populations. They also discuss the importance of early life and suggest we live in a dysfunctional society. So the question of what health care workers can do about this comes down to a key recommendations in the report. Besides requiring more research, which is to be expected, they suggest that the public be alerted that they die younger than they should. The IOM suggests that this is not the government’s role but should be left to “philanthropy and advocacy communities (who) should organize a comprehensive media and outreach campaign to inform the general public about the U.S. health disadvantage and to stimulate a national discussion about its implications for the nation.” They go on: “Although the government has considerable resources that could be devoted to a communication effort on this scale, the panel believes that it may be more appropriate and effective for independent, objective, nonpartisan organizations to organize a communications effort on this topic.”

    I disagree with the expert committee on this recommendation. Only the government can change public opinion effectively. Recall back in 2002-3 a campaign was waged by the federal government to prepare us to invade Iraq by repeating over and over again that Iraq had WMDs. We were primed si the majority of us believed this despite the lack of evidence before or since. Endless repetition by our leaders that we are in trouble with our health status and this is mostly not about health care is the only way we can become informed and then take steps to not die so young.

    There are no other bodies within the United States that can present the mortal findings so clearly and effectively. It might take a year or two of repetition, but this process will work.

    In the meantime, how do we pressure the government to not continue policies that result in massive carnage in this nation? I believe we need to start with whatever mouthpiece we have and organize collectively. As a clinician who practiced emergency medicine for 30 years I would speak of our poor health status with patients or their family members when appropriate. In the public health courses I currently teach, I require my students to take the concepts into the community.

    I was quite energized by the initial media attention paid to the report in the first few days after its publication. It even garnered an editorial in the New York Times. But a report is only news for a day. The bloodshed it depicts is virtual. The violence is structural as we die from the usual conditions on a continual basis. There is no smoking gun. There is nothing like the steady beep coming from Sputnik back in 1957 that propelled our nation to action. How can we make the Shorter Lives, Poorer Health report our Sputnik moment?

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