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November 11, 2002

The health challenge of 2020

Corey Keyes is assistant professor of sociology

Throughout history and in most cultures, health has been valued as one of the highest goods in life. Without health, the Greeks believed that wealth, wisdom and talent would not be fully implemented or enjoyed.

Health is, therefore, a desired state that permits individuals and society to thrive. The mission of public health, as embodied in the mandate of the office of the Surgeon General, is “to protect and improve American health.” This mandate will be seriously tested in the 21st century, and the key to success will be the integration of behavioral and social sciences with medicine and public health.

By the year 2020, health care is projected to consume one-quarter of this country’s Gross Domestic Product (GDP); it already has become one of the most costly budget items for families and government. At the moment, health care consumes about one-seventh of the country’s GDP; whereas defense spending consumes about 4 percent and public education about 6 percent of GDP, health care devours 13 percent.

As the baby boom generation ages, health care expenditures are projected to rise. For the average American family, health care soon is likely to rival the cost of the purchase of a home, which historically has been a family’s greatest expenditure.

It doesn’t have to be this way. Much of the problem, along with a possible solution, resides in the cost and effectiveness of the health care system itself. Public health is a key agent of the health system, which the World Health Organization (WHO) defines to include “all activities whose primary purpose is to promote, restore or maintain health.” According to the WHO’s 2000 World Health Report that ranked health care systems in 191 nations, America ranked first in per capita health expenditures—but only 24th in life expectancy, 71st in level of health and 37th in terms of overall health system performance.

To put this into perspective, France ranked fourth in health expenditures, third in life expectancy, fourth in level of health and first in health system performance. Compared to the French, Americans spend more on health and get much less in return. Ironically, the United States is a global leader in health technology and research and training of health researchers and practitioners. Indeed, health research, technology and training constitute an important sector of the U.S. economy and the budgets of many universities.

While health technology and training have become ends unto themselves, access to and utilization of health care and resources have eroded over the past 20 years. The number of uninsured and inadequately insured individuals has risen, and coverage for mental health services remains incomplete. Access to and utilization of the array of health care information and technology is among the most pressing issues for public health, and the behavioral and social sciences have much to contribute to this challenge.

Second, leaders in the U.S. have an “astigmatism” when it comes to their vision of training and health outcomes. In the behavioral and social sciences, we continue to train the best and brightest minds to think as specialists in narrow fields of expertise. Within public health, people become specialists in a disease, and the National Institutes of Health (NIH) is classified by disease, funds research accordingly, and is led primarily by individuals trained in biomedical science (i.e., MDs).

This occurs despite countless articles and syntheses of the literature that reveal that health is a many splendored thing, with determinants at the biological, psychological and sociological levels and with multiple pathways and interactions.

Of course, writings about the biopsychosocial model of health date back to the late 1970s, and research continues to reveal that many physical diseases are highly co-morbid which means they can occur simultaneously, often one disease leading to another—and mental illnesses tend to be cross-cutting conditions that in turn are highly co-morbid with many physical diseases.

For these reasons, the future of medicine and public health rests on their ability to genuinely integrate the behavioral and social sciences. Yet we continue to train people and fund their research unidisciplinarily (though with collaboration); public health continues to study isolated diseases; and there have been no suggested changes in the funding mechanisms or leadership at NIH that would make truly interdisciplinary endeavors a reality.

Finally, medicine and public health continue to laud the accomplishment of increased life expectancy and focus on the causes of mortality. Life expect-ancy is a good indicator of the overall health of a population. In this regard, the United States has much to celebrate, because 30 years of life have been added to the life expectancy of a child born at the close of the 20th century. Likewise, behavioral and social scientists have much to celebrate because factors related to social and personal hygiene were largely responsible for this. As much as 85 percent of the drop in deaths due to infectious diseases occurred prior to the introduction of vaccines and antibiotics and could be traced to urban planning, nutrition and other hygienic factors.

If people are living longer, why does this country focus so much on death and the eradication of disease rather than health and well-being? Moreover, why do we continue to think that biomedical science and leadership will provide the “magic bullet,” when in fact history tells us it did not lead the way to longer lives in the 20th century.

This country faces vivid social inequalities, reflected in a dramatically lower life expectancy for blacks than whites; the risk for almost any disease is distributed unequally, and the brunt of it is shouldered by the most disadvantaged. The objective of reducing inequalities in death and disease is extremely important. Moreover, while most people want to live a long life, many also aspire to live fulfilling, meaningful, healthy lives. The term “promotion” must achieve equal status with the reigning terms of “prevention” and “eradication” in the lexicon of medicine and public health. The addition of quality life years should be as important as the addition of years of life.

My wish is that Atlanta and a consortium of its universities consider hosting an annual series of events to convene leaders and members of the leading societies of political science, sociology, anthropology, economics and psychology, with the goal of applying their sciences in a collective mission to solve the “challenge of 2020.” This challenge includes improving the performance of the U.S. health care system through promoting
access and utilization of it, so that health does not become the economic albatross that brings down this country.

This objective will require the genuine integration of behavioral and social science with medicine and public health at Emory and beyond. Let us be part of the solution—not a contributor—to the challenge of 2020.