Forty years ago this month I moved to Salt Lake City to continue my medical training. It was an exhilarating time in health care. Major advances in medical technology seemed to occur every week. The first clinical CAT (computerize axial tomography) scanners came online just as I started my residencies. That advance was bracketed by the “Babybird” respirator, infant incubators, MRIs, ultrasound, fiber optics, the Jarvik artificial heart, lithium batteries, lasers, and many others. These new technologies allowed clinicians to diagnose and treat conditions in ways unimaginable ten years earlier; saving smaller and smaller babies and more seriously ill children and adults than ever before.
During this time, our medical care system was transformed. The new medical technologies fostered the development and expansion of newborn intensive care units, tertiary care hospitals, implantable pacemakers, medical transports, in vitro fertilization, and new micro surgical techniques to name just a few. They accelerated the trend toward specialization within the medical profession. We had great hopes and expectations that a technology-enhanced clinical care system would lead to a new level of health in our country.
Last week I returned to Salt Lake City for the “State Health Departments’ Senior Deputies and Legislative Liaisons Meeting” conducted by ASTHO (Association of State and Territorial Health Officials). As I entered the city, I was struck by how much it had changed in forty years. The Wasatch Mountains and the Great Salt Lake appeared the same but, due greatly to the influence of the 2002 Winter Olympics, there were more hotels, light rail, and one could now purchase alcohol in restaurants. There was also a large homeless population – something non-existent in SLC forty years ago. But the biggest change for me was the focus of the meeting presentations and attendee conversations. They were not talking about the promise and potential of our medical care system to improve health; they were talking about its failures and limitations.
With forty years of hindsight it is evident that, despite all its benefits, technology has not made us healthier when compared with similar countries. In almost every health category, including infant mortality, longevity, and health disparities, the U.S. has fallen farther and farther behind other OECD (Organization for Economic Co-operation and Development, i.e. industrialized) countries. And we have achieved those poorer outcomes at a tremendous cost – both human and financial. Until 1975, the percentage of the U.S. GDP (gross domestic product) spent on health care paralleled that of other OECD countries. Since then, our skyrocketing costs have significantly outpaced every other country.
Our supersized investments in medical care have been mostly at the expense of investments in public health and human services. The U.S. has the lowest percentage of GDP spent on human services among the 28 OECD countries which spend more than 15% of their GDP on the combination of medical care and human services. Yet, it is these investments in public health and human services that are proving to be the most effective in improving health. Moreover, the huge investments in high-tech medical care has also lead to lost opportunity costs by stifling investments in education, housing, transportation and other social determinants of health.
As I sat in the room listening to how we need to create a new 21st century approach to protecting and improving health, I thought back to the Mormon and Utah history I learned during my three years in that unique state. On July 24, 1847, Brigham Young, sick with Rocky Mountain Spotted Fever, saw in the distance the Salt Lake Valley for the first time. Remembering an earlier vision about leading his followers to a place where they could "make the desert blossom like a rose," he proclaimed from the back of his wagon, "It is enough. This is the right place. Drive on." The Latter Day Saints did just that, they drove into the valley and helped make Young’s vision a reality.
The comments and questions from the senior deputies and legislative liaisons from state health departments throughout the country, made me aware that they were in one respect in the same place, both literally and figuratively, as Brigham Young. They understood that we’ve got enough data to know what creates health; that we’ve invested enough in the health care path we’ve taken over the last 40 years; that we know what needs to change to improve our health status; and that we don’t have to look further for the time and place to start. The question they had was how to instigate those changes? How do we invest in and implement a “health in all policies” approach that addresses the physical, emotional, environmental, and social determinants of health?
From what I heard last week in Salt Lake City and what I’m observing throughout Minnesota and the rest of the country, people are answering those questions. There is a growing consensus that, relative to our investment in health care, “it is enough.” There is a recognition that change needs to occur in the states because “this is the right place.”
The place and time are right to make our health deserts bloom so let’s “drive on” to create the policies, systems, programs, and conditions in which all people can be healthy. It’s a great time for you and me to be in public health and help shape the vision and the direction for all 21stcentury health pioneers.