Why National Health Policy Often Fails To Make A Dent In Disease Burden

Today, the political and media landscapes seem laser-focused on polarized, wide brush policy no matter the context. You don’t need to look very far to appreciate this reality. Restricting opioid prescribing for all causes in all situations is but one example where deeper discussion into the complexities of addiction get no platform and rare consideration. The problem is, when we lose the nuance, we lose the battle. Getting nuance to be in vogue is a challenge in our soundbite, instant gratification culture, and, sadly, adversely impacts real world solutions. This is reaffirmed by a work published in JAMA that underscores burden of disease is widely discordant at the state level.   

We know this.

In my article Population Well-Being Tied to Longevity (Shocker!), I address the life expectancy inequalities by region that are consistently researched. In December 2016, I wrote about a study published in JAMA detailing the mortality rates for major causes of death from 1980-2014 (see article here). The researchers explored cause-specific mortality per area and extended their study to include more top causes of death.

Geography played a pivotal role.

I wrote then:

“The goal and objective is on the right path to approaching eradication of disease and modifiable risks and causes of death… Casting a wide net and painting with a big brush are relics of ineffective public health policy. Personalization and population-specific measures are where health innovation begins. Lifestyle and treatment plans by region, for instance, could be tweaked to shift the pendulum toward greater health and well-being. A step in a beneficial direction.”

And, yet, the tendency remains to implement far-reaching initiatives that are disparate in priority level due to location dependence. The recent JAMA investigation into The State of US Health, 1990-2016: Burden of Diseases, Injuries, and Risk Factors Among US States reports the trends in health outcomes over that time period. Their comprehensive assessment looked into “prevalence, incidence, life expectancy, health life expectancy, years of life lost due to premature mortality, years lived with disability, and disability-adjusted life-years (DALYs) for 333 causes and 84 risk factors.”

Some of their notable findings (see study here):

  • Overall death rates have declined

  • Hawaii had highest life expectancy (81.3 years), Mississippi lowest (74.7 years)

  • 31 states plus Washington, DC showed probability of death among those ages 20-55 years declined - while 5 states reflect a 10% increased probability

  • For 1990 and 2016, leading causes of DALYs were ischemic heart disease & lung cancer (3rd leading cause differed: low back pain (1990) vs chronic obstructive pulmonary disease (2016)) - opioid use disorders jumped from 11th to 7th place

  • Each of these accounted for > 5% of risk-attributable DALYs:

    • Tobacco consumption*

    • High BMI (body mass index)*

    • Poor diet

    • High blood pressure

    • High fasting blood sugar (glucose)

    • Alcohol and drug use*

      • Those with an asterisk (*) reflect 1 of the 3 top risk factors across all states

The utility of this report is not in life expectancy trends which lump together and gloss over actionable data, but in its extensive breakdowns of various diseases, age bands and geography differences per state. It explicitly addresses successes as well as the trends for those conditions where we have not moved the needle. In an era of collecting data for data’s sake, this paper happens to hold vital information that should guide our allocation of resources, assist in strategic, targeted approaches to disease prevention and health promotion while helping us further understand why such disparities exist so we can eliminate them.

For instance,

“mortality reversals in 21 states for adults ages 20 to 55 years are strongly linked to the burden of substance abuse disorders, cirrhosis, and self-harm, and this study shows that the trends for some of these conditions differ considerably across states.”

In the real world of policy implementation, resources are finite in nature - unless augmented by the private sector. These economic and other actualities make strategic and targeted programming sensible measures. Though much of the US is seeing improvements in mortality, the impact of disability is ever present. Knowing where exactly to emphasize even more lifestyle and behavioral modification, how to influence positively socioeconomic factors and elucidate the root issues will get us much closer to a healthier nation. Though suffering is unfortunately inevitable under certain situations, eradicating it when it is unnecessary should be our ideal.

This publication and other annual investigations all point to the crucial role of geographic variability throughout a state as a significant risk factor. Now that we have the diagnosis, the best prescription to cure individual and compounding ails has become quite clear. Filling it serves us all.