Americans spend more money on health than anyone else in the world, yet they live shorter, less healthy lives than citizens of other rich countries. The complex reason for this is the multiple factors that affect our health. The simple reason is the fact that people seldom talk about these factors. Here are five things that people should be talking about when they talk about health.
This month, the world saw the first-ever image of a black hole. The picture was captured by the Event Horizon Telescope, a network of radio telescopes operated by a global team of scientists. The black hole is 53.49 million light-years away, at the center of the Messier 87 galaxy. Taking a picture of such a distant object was an immense feat of science and engineering. The roots of this achievement stretch from Einstein’s first theorizing about the existence of black holes, all the way to the creation of cutting-edge technology that allowed us to finally see one.
Such stories are reminders of why it sometimes feels like science can do anything, from exploring the cosmos, to peering into the distant past, to blurring the boundary between life and death. And that feeling often extends to the science that informs our health. On that front, the 20th century brought a host of major discoveries, from penicillin to the double helix. As the Digital Age ushers in new advances, it is as easy as it has ever been to imagine that science really can solve all our health problems one day.
The United States spends more on health than any other country in the world, yet we are far from the healthiest. In recent years, our life expectancy has lagged, even declined. We have fallen behind our peer countries on a range of key health indicators, including heart disease, infant mortality and HIV/AIDS. And we face acute health challenges – from obesity, to opioids, to gun violence.
Why is our health so mediocre? The answer is we are not spending on health. We are spending on health care. Health is more than the doctors and medicines we turn to when we are unwell. It is a product of the world around us – the social, economic, and environmental conditions in which we live. Health care helps us when we are sick, but whether or not we get sick in the first place is decided by factors like the air we breathe, the water we drink, our income, neighborhood, schooling and overall social capital. These are the true foundations of health.
I am often asked, if I could choose just one policy intervention to improve health what would it be? The more I reflect on this question, the more convinced I am that the answer is to invest in quality education for all children, with special emphasis on education in early childhood. Education helps us live longer, think better, and be healthier. As graduation season is upon us, here are a few reflections on the central role of education in shaping our physical and mental health.
Study after study has shown that the higher our education level, the longer we will potentially live and the healthier those years are likely to be. College graduates live almost nine years longer than those who did not graduate from high school. Those years of higher education can also lead to a range of health benefits, including a lower risk of diabetes, heart disease, and obesity. The health effects of education are also intergenerational—the infant mortality rate per 1,000 live births for mothers who did not graduate from high school is close to double that of women who earned college degrees.
We live in a country that is in pain. Approximately 20% of Americans suffer from chronic pain. Through lost work and often ineffective treatment, chronic pain costs us $600 billion annually, more than cancer and heart disease combined. The emotional and social toll is uncountable.
Pain is lodged at the crossroads of the two epidemics that have distinguished this decade: opioid addiction and suicide. Pain and its mitigation were the rationale for the profligate (and deceptive) marketing of opioids when prescription pill sales quadrupled between 1999 and 2014. That widespread misuse and addiction followed was, perhaps, not surprising. Physical pain is sometimes at the root of psychic pain; sometimes isolation and despair produce another form of suffering, leading to suicide. Our two epidemics meet at a crisis of pain.
Our health is a public good.
I suspect that statement runs at odds with how most readers think about their health. Is our health not, after all, determined by what we do, what we eat, and how much we exercise? While that is indeed the case, fundamentally, our behaviors are shaped by the world around us, inescapably so. Let me explain.
Public goods are common resources that need to be supported by collective investment. Libraries, parks, highways, national security—these are all examples of public goods, supported by all and accessible to all. The reason they are public goods, rather than individual commodities, is we have decided that they are so fundamental to our wellbeing that they should not be entirely the province of private investment or market forces. Education, for example, benefits everyone—there is no one whose life it does not stand to improve. It is therefore supported by everyone, as a public good.
For 40 years, HIV has been our most politically charged illness and the defining health challenge of our time. Our recollection of these decades contains visceral images of Kaposi’s sarcoma, a quilt that covered the National Mall, bodies of Giacometti emaciation, of Silence=Death written under overpasses, of fake blood thrown on politicians. HIV has been a disease of private hiding and public protest. It has been the disease of demands: for civil rights, for medical rights, for open and shared science, for enhanced and coordinated funding. HIV and its trail of discontent has driven the study of health disparities and animated global health.
At the same time, the world of HIV care over the last two decades has seen a great, almost miraculous, revolution. Today, a 35 year old who was HIV-infected in 2018 and takes her daily medication adherently has the life expectancy of a 35 year old without HIV infection. Monthly injections of long-acting HIV drugs look to be as good as daily pills at suppressing the virus, creating easier treatment. Medication to prophylactically prevent infection is 95% effective. Recent reports of two persons “cured” of HIV have created hope and impatience.
Last year, Americans borrowed approximately $88 billion to pay for health care. One in four of us skipped medical appointments because of concern about costs. Such statistics reflect a trend that has been going on for decades. In 1970, the U.S. spent $74.6 billion on health. By 2000, this figure had risen to around $1.4 trillion and by 2017 it was $3.5 trillion. Not incidentally, medical debt is now the number one cause of personal bankruptcy in the U.S.
This question — Are we paying too much for health? — has defined much of the health conversation in the U.S. over the years. Unfortunately, it is the wrong question. Here’s the right one: Is our spending making us healthier?
The answer, sadly, is no.