Copyright c 1992 by Nicholas Johnson
The Des Moines Register, Friday, November 6, 1992, p. 7A 
Iowa View/Nicholas Johnson

The non-medical aspect of our health crisis


There's lots of talk these days about health care -- and its soon-to-be $1
trillion cost.  As well there should be.  But most of it is missing the mark.

As a nation we are paying more and getting less than almost any country
on earth.  Medical services cost us $2600 per capita, over twice the cost
for Japan or the U.K. and 14 percent of our gross national product.  Yet
our ten infant deaths per 1000 births are roughly twice the rate of Japan's
or Sweden's.  For black Americans we rank with third world nations.

There are some 35-40 million Americans who have no health insurance at
all.  The inflation rate for medical costs is 60 percent greater than general
inflation.  Our medical bill is projected for 1992 to be $817 billion;  for
the year 2000 $1.6 trillion.

Clearly these are problems that need to be, and are being, addressed by 
President-Elect Clinton and health professionals, task forces, conferences,
and think tanks.  We can be proud of Iowa's contribution.  No one can, or
should, minimize this focus.  I don't.

But most of the discussion is focused on the wrong end of the conveyor
belt of human misery and its spiraling costs.

Part of our problem is the word "health."  It calls up images of doctors in
white coats, hospitals, pharmacies, and medical-research labs -- in short,
the delivery of _medical_ services.

But "health," in the sense of "public health," involves a different concept: 
the prevention of accidents and disease, the enhancement of good health,
the avoidance of the need for (and cost of) medical services.

Throughout history what has most improved our health is clean drinking
water.  Not very exciting; no white coats.  But more lives have probably
been saved, more disease avoided, through this single public health
measure than from all medical research combined.

Nor is this example behind us.  Some 15 million of the world's children
die every year from impure water supplies, or inadequate sewer systems.

Of the 2 million deaths a year in this country, some 450,000 involve
tobacco.  There are no more medical procedures for that problem than for
impure water; it's another one for public health professionals.  Through
their efforts the percentage of Americans who smoke dropped from 40
percent to 28 percent in the last 35 years.

Death rates for heart disease and strokes, two leading killers, declined 50
percent during the 1980s, thanks largely to reductions in dietary fat. 
There has been a four-fold increase in the number of persons with high
blood pressure who actually benefit from available medicine.

As a result of safer automobile and highway design, air bags and seat
belts, there are 40,000 alive this year who would have died in crashes.

Together, some 40 percent to 70 percent of premature deaths, two-thirds
of chronic disability, could be prevented through public health programs
involving individuals' choices about such things as tobacco, alcohol, diet,
exercise and seat belts.  The avoidable costs are substantial:  $180 billion
from preventable accidents and $86 billion from alcohol abuse, for
example.

Environmental health hazards in air, water, toxic dumps, lead paints, or
the ozone hole are just as surely self-inflicted causes of disease and
injury.

There are some hopeful signs.  Senator Harkin chairs the Appropriations
Subcommittee for Labor, Health and Human Services.  He thinks "disease
prevention and health promotion must be the centerpiece of any
fundamental health care reform" and has introduced a "prevention first"
package of seven bills to that end.  President-Elect Clinton wants to
"improve preventive and primary care."  Even President Bush's document
on health reform acknowledges that "preventive practices are . . . simple,
inexpensive and effective."

So far I have only referred to unnecessary lives lost and
multi-billion-dollar costs.  That's because even the most hard-hearted
scrooge can see the impact of a one-half-trillion-dollar savings on
shareholders' profits and international competitiveness. 

But from an humane perspective the most moving savings are not dollars,
or even lives.  They are the preventable suffering and sadness of those
individuals (and their families, friends and co-workers) who have _not_
been killed, but are living with diseases and injuries.

As the "health care" debate continues attention will be given to "cost
containment."  We may be able to make modest cuts.  Then again we may
not.

But there is nothing we can do at the medical services end of the pipeline
that remotely approaches the impact of "public health" on human health,
happiness -- and cost avoidance.

Of course we need to reform our medical services delivery system.  Of
course every citizen in a civilized society is entitled to such services.  Of
course we need to control those medical services' costs and quality.

But if we're really serious about genuine contributions to the health of our
nation, and dramatic cost avoidance, we're going to have to hear a lot
more about a public health perspective (and budget) than most of the
"health" experts have given us so far.
__________

Nicholas Johnson is co-director of the Institute for Health, Behavior and
Environmental Policy at the University of Iowa, and a former
commissioner of the Federal Communications Commission.

END OF OP-ED PIECE

[Some Notes on Sources:

"Health Costs $817 Billion for 1992; $1.472 Trillion by 1997," Public
Citizen Health Research Group Health Letter, Feb. 1992, p. 9 [1992 costs
$817 billion, p. 9; 14% GNP 1992, p. 9; 38-40 million without insurance
now compared with 34.7 million in mid-1990, p. 9]

Malcolm Gladwell, "Reforming the Health Care System:  An American
Paradox," The Washington Post, Feb. 6, 1992, p. A25 [$2600 per capita
cost; health cost increases 60% greater than inflation; $1.6 trillion by year
2000] 
John W. Wright, ed., The Universal Almanac 1990 ("Health and
Medicine," pp. 214-229)  ["Health Expenditures as Percentage of GNP,
1986," p. 217; "Comparison of Infant Mortality Rates in Industrialized
Nations," p. 226; "Infant Mortality Rate:  All Races, White, Black," p.
226]  And see chart, "Spending on Health Care," accompanying Clyde H.
Farnsworth, "Canadians Defend Care System Against Criticism," New
York Times (nat'l ed.), Feb. 17, 1992, p. C7. 
"The President's Comprehensive Health Reform Program," Feb. 6, 1992. 
[2.2 million deaths, p. 45; 40 to 70 % premature deaths and two-thirds of
chronic disability, p. 45; smoking decline from 40% 1965 to 28% 1990, p.
45; 40,000 lives saved from automobile accidents 1991 from projection at
1973 level, p. 45; 40% decline in heart disease, 50% for strokes, p. 45;
"preventive practices are, by and large, simple, inexpensive and effective,"
p. 46; $180 billion cost of injuries, p. 46, Table 5-3; $3.40 savings per
dollar spent on prenatal care, p. 46, Table 5-4]

Rice, D.P., Kelman, S., et al., The Economic Costs of Alcohol and Drug
Abuse and Mental Illness, 1985 (Report submitted to U.S. Department of
Health and Human Services 1990), quoted in Marin Institute, Media
Action Alert, Feb. 4, 1992, p. 4 [alcohol costs $85.8 billion]

Harkin, "Another Pound of Cure," JAMA, Sept. 25, 1991, pp. 1692-93. 
Clinton and Gore, Putting People First (1992), p. 110.]

*** Copyright c 1992 by Nicholas Johnson.  Conditions:  This material is
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