PLANETARY HEALTH WEEKLY

The entomologist E.O. Wilson, who died recently, wrote back in 1998 “We are drowning in information, while starving for wisdom. The world henceforth will be run by synthesizers, people able to put together the right information at the right time, think critically about it, and make important choices wisely.”   The situation today is even more extreme as our attention has been stolen and we can’t focus on concepts for long.  If you look at a story on the internet it may say “reading time 3 minutes.” Can I invest that much time now??

The first challenge is to attract attention, however you can.  For those who still read, a catchy headline or graphic can grab the reader to want to discover more.  Thus the title of this week’s blog:  “Dead first.”  For older folk perhaps they recall a rock band, the Grateful Dead.  Jerry Garcia was the first member to die in 1995.  What does it mean for the United States to be dead first?

First and last are the boundary markers.  From last week’s blog Japan is the winner in the Health Olympics, the ranking of countries by how long people live.  They are dead last.  In the bar graph presented, of the top 40 finishers for 2019 the United States was tied for 36th.  The U.S. is pretty close to dead first there.  How can we synthesize the right information to make sense of the reality that as a nation, people in the USA are not very healthy.  First the facts. 

A society’s health can best be measured by who is alive and who isn’t.  How long did they live?  Why did they die?  I worked as an emergency physician for 30 years.  The easiest diagnosis I could make on the job was whether someone was alive or dead.  I filled out a death certificate and my work was finished.  All rich countries and quite a few others collect and analyze such vital statistics.  You can easily discover what proportion of the population died at what age.  Consider how many died in childhood (up to age 5), in adulthood (age 15 to 60, say) and what was the average length of life or life expectancy?

These mortality measures are synthesized by many international agencies.  The actual results don’t vary among them.  Without splitting hairs, the United States has higher mortality rates for almost all such indicators than every other rich country and quite a few not so rich.  

Since such deadly facts are not broadcast widely perhaps it doesn’t matter whether you are alive or dead?  Read the obituary page and you’ll see the age of death is always in the headline.  This is an important moniker.  Garcia died at age 53.  Think of other prominent Americans who died before reaching age 60.  Michael Jackson, Steve Jobs, and Janice Joplin.  The oldest old person alive at any one time is never found in the U.S.  They typically hail from Japan.  Today Japan’s Kane Tanaka, a woman born in 1903, is the world’s longest living person.  

How to interpret these facts?  Could you imagine someone in the U.S. saying on their death bed:  “I’m glad a lived a shorter life, I wouldn’t want to live a longer one.”  No you can’t.  How to critically evaluate why those of us in the United States die so young?

The US boasts of having the world’s most advanced and sophisticated medical system so it can’t be that.  Japan has more than twice as many men smoking per capita than in the United States.  Similar arguments can eliminate personal behaviors as the critical reason, though that is a hard one to dispel since most of us we believe our health is under our own personal control.  Not true.

Yes, healthcare and behaviors matter for our health, just not that much.  Reviews of the impact of medical care on health say it amounts to about 10% of health production.  

Over the last 40 years research has uncovered the importance of structural societal factors in producing population health.   A very significant one is the amount of economic inequality present.  This is well summarized in a book The Spirit Level:  Why greater equality makes societies stronger by Richard Wilkinson and Kate Pickett.   The other major complementary ingredient is the amount and type of social spending that a society engages in.  Elizabeth Bradley’s group at Yale University presented this in a 2011 paper.

The required social spending to improve health must be targeted towards early life, the first few years after conception.  The required resources can come from decreasing the income or wealth gap. The United States suffers from extra-galactic income and wealth inequality.  As a nation it spends very little on the early years but focuses on remedial actions in later life which don’t do much for health.

Our challenge is to apply our critical thinking resources to verify these concepts, and create broad awareness so societies can make healthy choices wisely.  Public health’s biggest idea was enunciated by Rudolf Virchow, the founder of modern cellular pathology, over a hundred and fifty years ago with his statement:  “Medicine is a social science, and politics nothing but medicine at a larger scale.”  The phrase public health hadn’t been invented then.  Medicine was the catch-all term then.  This casts us into a larger scale, the political arena, where the most important health outcomes are determined.  We explore this in the next blog.