Wednesday, Nov. 19, 2008

America's Health Checkup

What is the measure of a country's health? How do you take the temperature of a population that sprawls across nine time zones, 50 states and a global rainbow of cultures and communities? One way is by taking a close look at yourself.

If you're like 67% of Americans, you're currently overweight or obese. If you're like 27%, your blood pressure is too high. If you're like a whopping 96% of the population, you may not be able to recall the last time you had a salad, since you're one of the hundreds of millions of Americans who rarely eat enough vegetables. And what you do eat, you don't burn off — assuming you're like the 40% of us who get no exercise. Most troubling of all, if you're like any parent of any child anywhere in the world, you may be passing your health habits to your children, which explains why experts fear that this generation of American kids may be the first ever to have a shorter life span than their parents do.

(See the Year in Medicine A-Z.)

By too many measures, America is a lot less healthy than a developed nation has any business being. But just how sick — or just how well — are we? Broad national averages are limited things — very good at telling you the what, but notoriously bad at telling you much more. Who are the one-third of Americans who don't have a weight problem, and how can the rest of us become like them? Why do some of us get our cancer screenings and make sure our kids are vaccinated while others don't? It's hard enough to get a thorough profile of any one person's health outlook. Now imagine putting 300 million of us on the examining table together. That's where TIME's inaugural national health checkup can help.

For this first annual feature, we've gone straight to the numbers to measure the vital signs of a 232-year-old nation that, let's be honest, has let itself go a little lately. The results of such a collective physical are something that should concern us all. If Americans get flabby and inactive together, we can also get fit and healthy together, and a look at the national fever chart is one way to learn not only where any one person needs to improve, but where any one family or entire region should too.

Even a cursory glance at the stats gives us reason for both hope and worry. Each decade since 1980, the Department of Health and Human Services (HHS) has compiled what it calls its Healthy People report, a sort of prospective census in which it sets goals in 28 health areas, from weight and diabetes incidence to cholesterol levels and cancer screenings, and keeps track of how well those targets are met over the 10 years that follow. We are approaching the Healthy People 2010 report, and in an interim assessment, hhs revealed that 59% of its objectives had already been met or were on their way to being met. The goal of vaccinating 80% of babies under age 3 with a core series of shots was surpassed in 2005, with 81% of infants receiving the recommended doses. Half of adults ages 50 and older received a colon scan, meeting the target for colon-cancer screening. Yet at the same time, in 20% of the tracked trends, we have actually retreated from the goals. Only 33% of adults in 2003-06 were at a healthy weight, half the number who ideally should be and 10% fewer than in 1988-94. The prevalence of diabetes, which health officials hope to cap at 25 cases per 1,000 people, is more than double that and has actually risen since 1997.

With a new Administration promising much needed reform in the way health care is accessed, delivered and reimbursed, legislators, health officials, doctors and patients see this as a rare opportunity, a sweet spot in which national need could meet national will and we could actually fix a system that seems to be costing us more and more but delivering less and less. The improvements can't come too soon. In spite of our gleaming hospitals and cutting-edge technology that can detect the tiniest tumors and repair the most complex organ, on some basic health measures the U.S. is starting to fall behind — far behind.

(See the Year in Medicine A-Z.)

Fighting the Wrong War

The biggest problem with the U.S. health-care system is that it has long been designed to respond to illness rather than prevent it. According to an analysis by the Commonwealth Fund, a foundation that funds health-care research, half of American adults in 2005 did not receive recommended preventive care, which includes vaccinations, cancer screenings and blood-pressure checks. When we do get our cardiac health checked, too often it's because we've been rushed to the emergency room suffering from chest pains. When we do get a cancer evaluation, too often it's a diagnosis of advanced disease that has spread beyond the initial tumor site.

Not only is this a deadly way to practice medicine, but it's also a breathtakingly expensive one. In 2005 Americans paid out a record 16% of our gross domestic product for health care — a cool $2 trillion — making us the world's top spender on health care per capita. You might think we'd be getting some bang for those bucks, but our leading killer remains what it has been every year since 1900 (with the exception of 1918, when influenza claimed more lives): heart disease, which kills nearly 650,000 of us each year. "The reason we rank so poorly is that we don't provide a basic-wellness infrastructure," says Dr. Mehmet Oz, director of the cardiovascular institute at the Columbia University Medical Center and a host on the Discovery Health Channel.

There are a lot of ways to measure the effects of America's after-the-fact health-care philosophy, but the most telling might be what epidemiologists call preventable deaths. Certainly, plenty of deaths due to illness are not preventable, but there are many other conditions that a decent health-care system should be able to detect and fix well before they become life-threatening. Most of the leading killers in the U.S. — including pneumonia, diabetes and stroke — fall into this category. According to a Commonwealth Fund report issued this year, 101,000 deaths from 2002 to 2003 could have been avoided with access to timely and effective health care. This rate places the U.S. 19th — last — among industrialized nations.

President-elect Barack Obama's first challenge in improving the U.S.'s health scorecard will be to transform this entrenched symptom-centric mentality into a more proactive one, embedding prevention and wellness programs more aggressively into primary care and ensuring that every American takes advantage of these services by expanding insurance coverage to pay for them — beginning with mandated policies for children. (Read about Obama's health-care plan.) That's a good place to start, since by many measures, it's kids — particularly the very youngest — who most need help.

In 2005, the most recent year for which data are available, about 7 babies out of every 1,000 live births in the U.S. died before their first birthday. That rate represents a 2% reduction in deaths from the year before, which continues the steady improvement seen throughout the 20th century. But globally, it still places us 29th in the world, behind Cuba and Singapore and on a par with Poland and Slovakia.

It's not just the tragic nature of a dying baby that makes those numbers so terrible. It's also that infant-mortality rates can stand as a valuable proxy for many critical features of a health-care system — how accessible basic services such as prenatal care and birthing are, as well as the quality and affordability of that care. And our rate exposes a familiar but ugly truth about our system — that those variables change depending on where you are and who you are. Non-Hispanic black women, for example, are three times as likely as Cuban-American women and twice as likely as non-Hispanic white women to suffer the loss of a baby — mostly because of a disparity in access to birthing and postnatal care. And infant-mortality rates along the two coasts tend to be lowest, where denser populations translate to greater availability of these services. The wedge that continues to widen these gaps is insurance; non-Hispanic blacks make up half our nation's uninsured, which leaves them without access to the regular health care that can educate mothers-to-be about proper nutrition and pregnancy care. Without such services, more babies are born in distress and are unable to survive their first few months.

Also driving the infant-mortality rate are women at the other end of the economic spectrum, who take advantage of reproductive technologies such as in vitro fertilization. Such procedures boost the chances of multiple births, which in turn increase the likelihood of premature birth and consequently put babies at risk. From 2000 to 2005, the number of preterm births increased 9%, and in 2005, about one-third of infant deaths were directly due to a gestation period of less than 37 weeks.

If deaths at the beginning of life are one critical measure of a nation's health, the number of years we get before the end of our life is another. Life expectancy in the U.S. has steadily increased since the early 1900s, from 46 years for men and 48 years for women to 75 years for men and 80 years for women in 2004. Improvements in sanitation, innovations in vaccines and antibiotics, and control of infectious diseases account for much of the gain. But again, not everyone has equal access to these extra years.

African Americans increased their life expectancy nearly 1% between 2000 and 2002, compared with a 0.3% increase among whites, but blacks were starting from a lower figure, and are still expected to live 5.2 fewer years than whites. For all races, additional golden years aren't necessarily healthy years, with seniors increasingly burdened by such chronic illnesses as arthritis, cancer, diabetes, kidney disease and heart disease. Part of that is simply because the more years you pile up, the more opportunity you have to develop diseases associated with aging. "We are living longer, but we are not living healthier," says Dr. Nancy Nielsen, president of the American Medical Association. "Many Medicare recipients now have five or more chronic conditions."

(See the Year in Medicine A-Z.)

Doing It Right

If Americans have been slow to realize the worrisome state of our collective health, we have — as individuals and as a nation — at last begun to wake up. Take our long and almost always unhappy battle with weight. In recent years, the scale has been telling not just a distressing tale, but also a truly shocking one. Between 1980 and 2004, the prevalence of obesity in the U.S. doubled among adults, surging to 72 million, or one-third of people ages 20 and older. Worse, the percentage of overweight or obese kids rose to 17%. If all those numbers could be cut by even a third, the ripple effect would in turn slash rates of hypertension, heart disease, diabetes, cancer, joint damage and more, not to mention the myriad costs associated with fighting these illnesses.

And indeed, there may be flickers of hope. From 2005 to 2006, the percentage of women and children who are overweight appeared to stabilize, while the rate for men increased only slightly. "That's good, but it's not as if it's flattening at a good level," notes Cynthia Ogden, an epidemiologist at the National Center for Health Statistics, part of the Centers for Disease Control and Prevention. Still, the improvement is no accident, and for women and particularly children, it can be traced to aggressive nutrition and exercise messages promoted in schools, hospitals, community groups and churches — precisely the kind of low-cost, high-impact measures health experts love.

Similar preventive methods may help cap soaring cholesterol levels. Since the late 1960s, the average serum-cholesterol level of adults has continued to drop, from a high of 220 mg/dL down to 199 mg/dL in 2006. That cut the percentage of Americans with high cholesterol to 17%, precisely the goal set by the Healthy People 2010 targets — and it was reached four years ahead of schedule. Routine blood tests for low- and high-density lipoproteins, or bad and good cholesterol — as well as the use of cholesterol-lowering medications when needed — have played a major role in powering those improvements.

The same principles of education, prevention and early treatment can apply to mental health as well. One in 20 Americans over age 12 reported feeling depressed in 2006, with non-Hispanic blacks making up the largest percentage. Although 80% of Americans admitted that their symptoms interfered with their ability to work, only 29% had contacted a mental-health professional. Recent improvements in screening at primary-care facilities, one of the goals set by Healthy People 2010, may help address this problem: while 62% of primary-care facilities provided treatment for mental disorders in 2000, 74% do so now.

It took the U.S. health-care system a long time to get as broken as it is, and it will take a long time to set it right. A big, diverse land like ours may never be able to put up the glittering health numbers of smaller, more homogeneous countries. But we're not in the game to compete with the Swedens and Norways of the world. We're in the game to make America the healthiest place it can be. At the moment, we're nowhere near the goal, but slowly, we're edging closer.

(See the Year in Medicine A-Z.)