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After reading the attached article please answer the following questions. and reply to the two classmates.Describe the 2 reasons Schroeder gives to explain why the US ranks poorly on many health measures in spite of spending more money than other countries on health care. What other single factor would you suggest that might also contribute to this paradox?In what ways is the problem of obesity in America like the now decreasing problem of tobacco use? In what ways is it different?The pie chart illustrating the 5 proportional categories contributing to premature death in the US are based on total US population mortality. How might these percentages change if the chart were to be redrawn to reflect populations living in poverty in inner cities? People living in poverty in rural areas? Suggest new percentages for each and explain why you think as you do.Social determinants of health are relatively new considerations as predictors of premature death, yet a growing body of research indicates their contribution is strong. Name a social determinant and describe a possible role for the Church in ameliorating it.
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INSTRUCTIONS-
THE INITIAL POST- should contain 400–500 words and adhere to AMA writing style
guidelines. This word limit promotes writing that is thorough yet concise enough to permit your
peers to read all the posts. If the Discussion Board Forum prompts you to answer a series of
questions, make sure you address all of them thoroughly within the word limit. Do not restate the
questions in your post; simply begin a new paragraph for each new thought. The goal is to have a
seamless written argument closed by a brief conclusion tying together your individual responses.
Use your best critical reasoning skills, employing the Universal Intellectual Standards as a guide,
but not a strict outline. Refer to specific statements of the author(s) whenever appropriate but
limit direct quotations to a maximum of 25 words for your entire post. Since this is a personal
discussion, you may use first person; however, you should maintain professional decorum at all
times.
REPLYS TO CLASSMATE- Each reply should contain 200–250 words and adhere to AMA
writing style guidelines.
…………………………………………………………………………………………………….
Reply to classmate #1According to the article provided, the two explanations that Schroeder gives to describe why the US
ranks poorly on many health measures in spite of spending more money than other countries on health care are that
better individual health does not necessary equal the need for a better health care delivery system and that good
health care systems do not necessarily mean that people will be able to receive those services1. I believe that
personal behaviors and choices play a large role in individual health status. Even with great resources available,
individuals might not want to utilize those resources.
The problem of obesity and tobacco use in America share similarities as well as differences. Both share
high prevalence rates, earlier onset (younger population), involve major health complications, and are difficult to
treat1. Both obesity and tobacco usage involves stigmas surrounding the issues, are 20th century phenomenons, and
are influenced heavily by the promotion industry1. Alternatively, tobacco use is harmful even in smaller percentages,
can be harmful to others, contains chemically addictive components, and has a strong evidence history for treatment
while obesity does not have these aspects1.
Currently, the pie chart illustrating the 5 proportional categories contributing to premature death in the
US are based on total US population mortality show that behavioral patterns rank at 40 percent, genetic
predisposition at 30 percent, social circumstances at 15 percent, health care at ten percent, and environmental
exposure at five percent1. If these numbers were manipulated to reflect the populations living in poverty in inner
cities, I believe, based off of readings from our text book, they would rank differently with behavioral patterns
ranked at 45 percent due to lower education levels and income levels, genetic predisposition at 20 percent due to
genetic behavioral patterns, social circumstances at 15 percent due to lower education levels and lower incomes,
health care at ten percent due to lower income levels and access to services, and environmental exposure at ten
percent due to the location of living3. Alternatively, if these numbers were manipulated to reflect the populations
living poverty in rural areas, I believe they would rank differently with behavioral patterns ranked at 25 percent,
genetic predisposition at 15 percent due to genetic behavioral patterns, social circumstances at 30 percent due to
lower access to health care services and lower incomes, health care at 25 percent due to lower income levels and a
decreased access to services, and environmental exposure at five percent due to the location of living3.
One social determinate of health is education2. As Christians and health care professionals, we can work
towards bettering the level of health education by providing or support public health education efforts as well as
better options for those communities such as fresh food stores2. The bible states in Galatians 6:2, “Carry each other’s
burdens, and in this way you will fulfill the law of Christ”. Through helping to educate and encourage healthier
behaviors, we can help to increase the health of these populations.
Work Count: 497
References
1
2
3
Schroeder S. We Can Do Better — Improving the Health of the American People. New England Journal
of Medicine. 2007;357(12):1221-1228. doi:10.1056/nejmsa073350
Adler N, Glymour M, Fielding J. Addressing Social Determinants of Health and Health Inequalities. Jama.
2016;316(16):1641. doi:10.1001/jama.2016.14058
DiClemente R, Salazar L, Crosby R. Health Behavior Theory for Public Health: Principles,
Foundations, and Applications. Burlington, MA: Jones & Bartlett Learning; 2019.
REPLY TO CLASSMATE #2Schroeder explains there are two reasons the U.S. ranks poorly on many health measures. First, the
pathways to better health do not generally depend on better health care, and second, even in those
instances in which health care is important, too many Americans do not receive it, receive it too late, or
receive poor-quality care.1 I believe another contributing factor to this paradox of why the U.S. spends so
much on health care but still ranks poorly on health measures is personal behavior. Unhealthy behaviors
contribute to leading causes of early mortality.2
Obesity in America has now become the new tobacco issue. These two have numerous similarities
according to Schroeder. Both are highly prevalent, start in childhood or adolescence, were relatively
uncommon until the first (smoking) or second (obesity) half of the 20th century, are major risk factors for
chronic disease, involve intensively marketed products, are more common in low socioeconomic classes,
exhibit major regional variations (with higher rates in southern and poorer states), carry a stigma, are
difficult to treat and are less enthusiastically embraced by clinicians than other risk factors for medical
conditions.1 Although Obesity and tobacco share many similarities, they do still have their differences.
Obesity does not contain any additive chemical components or cause harm to others around you. Eating
in moderation is also recommended and not harmful, unlike in smoking.
I believe if a pie chart were drawn for the inner city there would not be much difference from how it
currently looks. However, in a rural area I feel there would be a big shift in social circumstances. Social
circumstances would be 45%, Health care 5%, Environmental exposure 5%, Behavorial patterns 30% and
Genetic predisposition 15%. A lot of health measures depend on people making healthful changes in their
lives but that may be hard to do for people who are struggling economically.3 Rural areas are prone to
poverty, unequal access to health care, and lack of education.
A social determinant that could be incorporated easily in many churches would be social support. As
stated in Proverbs 17:22 “A joyful heart is good medicine, but crushed spirit dries up the bones”.4
Integrating social support groups in churches could help many people cope with behavioral
changes. According to the World Health Organization, it defines health as the state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity.4 Churches could form a
weekly mental health group which could aid in a persons’ overall health and well-being.
References
1
Schroeder S. We Can Do Better – Improving the Health of American People. New England
Journal of Medicine. 2007; 357: 1221-8.
2
DiClemente R, Salazar L, Crosby R. Health Behavior Theory for Public Health. Second Edition.
Burlington, MA: Jones and Bartlett Learning; 2019
3
Collins P. Local health rankings highlight problems for city, county. Martinsville, VA: Martinsville
Bulletin. March 13 2017.
4
World Health Organization. Frequently asked questions. https://www.who.int/about/who-weare/frequently-asked-questions. Updated 2019. Accessed March 18 2019.
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The
n e w e ng l a n d j o u r na l
of
m e dic i n e
special article
Shattuck Lecture
We Can Do Better — Improving the Health
of the American People
Steven A. Schroeder, M.D.
T
he united states spends more on health care than any other
nation in the world, yet it ranks poorly on nearly every measure of health
status. How can this be? What explains this apparent paradox?
The two-part answer is deceptively simple — first, the pathways to better health
do not generally depend on better health care, and second, even in those instances
in which health care is important, too many Americans do not receive it, receive it
too late, or receive poor-quality care. In this lecture, I first summarize where the
United States stands in international rankings of health status. Next, using the concept of determinants of premature death as a key measure of health status, I discuss pathways to improvement, emphasizing lessons learned from tobacco control
and acknowledging the reality that better health (lower mortality and a higher
level of functioning) cannot be achieved without paying greater attention to poor
Americans. I conclude with speculations on why we have not focused on improving
health in the United States and what it would take to make that happen.
From the Department of Medicine, University of California at San Francisco, San
Francisco. Address reprint requests to Dr.
Schroeder at the Department of Medicine, University of California at San Francisco, 3333 California St., Suite 430, San
Francisco, CA 94143, or at [email protected]
medicine.ucsf.edu.
N Engl J Med 2007;357:1221-8.
Copyright © 2007 Massachusetts Medical Society.
He a lth S tat us of the A mer ic a n Publ ic
Among the 30 developed nations that make up the Organization for Economic Cooperation and Development (OECD), the United States ranks near the bottom on most
standard measures of health status (Table 1).1-4 (One measure on which the United
States does better is life expectancy from the age of 65 years, possibly reflecting the
comprehensive health insurance provided for this segment of the population.)
Among the 192 nations for which 2004 data are available, the United States ranks
46th in average life expectancy from birth and 42nd in infant mortality.5,6 It is remarkable how complacent the public and the medical profession are in their acceptance of these unfavorable comparisons, especially in light of how carefully we
track health-systems measures, such as the size of the budget for the National Institutes of Health, trends in national spending on health, and the number of Americans who lack health insurance. One reason for the complacency may be the rationalization that the United States is more ethnically heterogeneous than the nations at
the top of the rankings, such as Japan, Switzerland, and Iceland. It is true that
within the United States there are large disparities in health status — by geographic
area, race and ethnic group, and class.7-9 But even when comparisons are limited to
white Americans, our performance is dismal (Table 1). And even if the health status
of white Americans matched that in the leading nations, it would still be incumbent
on us to improve the health of the entire nation.
Path wa ys t o Improv ing P opul at ion He a lth
Health is influenced by factors in five domains — genetics, social circumstances,
environmental exposures, behavioral patterns, and health care (Fig. 1).10,11 When it
n engl j med 357;12
www.nejm.org
september 20, 2007
1221
The
n e w e ng l a n d j o u r na l
Table 1. Health Status of the United States and Rank among the 29 Other
OECD Member Countries.
Health-Status Measure
U.S. Rank
Top-Ranked
United States in OECD Country in OECD*
Infant mortality (first year
of life), 2001
All races
6.8 deaths/
1000 live births
25
Whites only
5.7 deaths/
1000 live births
22
All races
9.9 deaths/
100,000 births
22
Whites only
7.2 deaths/
100,000 births
19
of
m e dic i n e
Proportional Contribution to Premature Death
Social
circumstances
15%
Genetic
predisposition
30%
Environmental
exposure
5%
Iceland
(2.7 deaths/
1000 live births)
Health care
10%
Maternal mortality, 2001†
Switzerland
(1.4 deaths/
100,000 births)
Life expectancy from birth, 2003
All women
80.1 yr
23
White women
80.5 yr
22
All men
74.8 yr
22
White men
75.3 yr
19
All women
19.8 yr
10
White women
19.8 yr
10
All men
16.8 yr
9
White men
16.9 yr
9
Japan (85.3 yr)
Behavioral patterns
40%
Figure 1. Determinants of Health and Their Contribution
RETAKE
1st
AUTHOR:
to Premature
Death.Schroeder
ICM
2nd
FIGURE:
1
of
2
10
REG
F
Adapted from McGinnis et al.
3rd
CASE
Iceland (79.7 yr)
Life expectancy from age 65,
2003‡
Japan (23.0 yr)
Iceland (18.1 yr)
* The number in parentheses is the value for the indicated health-status
measure.
† OECD data for five countries are missing.
‡ OECD data for six countries are missing.
comes to reducing early deaths, medical care has
a relatively minor role. Even if the entire U.S. population had access to excellent medical care —
which it does not — only a small fraction of these
deaths could be prevented. The single greatest
opportunity to improve health and reduce premature deaths lies in personal behavior. In fact, behavioral causes account for nearly 40% of all
deaths in the United States.12 Although there has
been disagreement over the actual number of
deaths that can be attributed to obesity and physical inactivity combined, it is clear that this pair
of factors and smoking are the top two behavioral
causes of premature death (Fig. 2).12
Revised
Line
4-C
SIZE
ARTIST: ts
H/T
H/T
16p6
Enon
attempts to change behavior
lie outside the
provCombo
13
ince of traditional
medical
care.
AUTHOR,
PLEASE
NOTE: They may exFigure has been redrawn and type has been reset.
pect future
successes
to follow the pattern wherePlease check carefully.
EMail
by immunization and antibiotics improved health
35712 century. If the public’s health
ISSUE: 09-20-07
in JOB:
the 20th
is to im­
prove, however, that improvement is more likely
to come from behavioral change than from technological innovation. Experience demonstrates
that it is in fact possible to change behavior, as
illustrated by increased seat-belt use and decreased
consumption of products high in saturated fat.
The case of tobacco best demonstrates how rapidly positive behavioral change can occur.
The Case of Tobacco
The prevalence of smoking in the United States
declined among men from 57% in 1955 to 23% in
2005 and among women from 34% in 1965 to
18% in 2005.14,15 Why did tobacco use fall so
rapidly? The 1964 report of the surgeon general,
which linked smoking and lung cancer, was followed by multiple reports connecting active and
passive smoking to myriad other diseases. Early
antismoking advocates, initially isolated, became
emboldened by the cascade of scientific evidence,
especially with respect to the risk of exposure to
secondhand smoke. Counter-marketing — first
in the 1960s and more recently by several states
Addressing Unhealthy Behavior
and the American Legacy Foundation’s “truth®”
Clinicians and policymakers may question wheth- campaign — linked the creativity of Madison Ave­
er behavior is susceptible to change or whether nue with messages about the duplicity of the to1222
n engl j med 357;12
www.nejm.org
september 20, 2007
Shat tuck Lecture
n engl j med 357;12
435
450
400
No. of Deaths (thousands)
bacco industry to produce compelling antismoking messages16 (an antismoking advertisement is
available with the full text of this article at www.
nejm.org). Laws, regulations, and litigation, particularly at the state and community levels, led to
smoke-free public places and increases in the tax
on cigarettes — two of the strongest evidencebased tobacco-control measures.14,17,18 In this regard, local governments have been far ahead of
the federal government, and they have inspired
European countries such as Ireland and the United
Kingdom to make public places smoke-free.14,19
In addition, new medications have augmented
face-to-face and telephone counseling techniques
to increase the odds that clinicians can help smokers quit.15,20,21
It is tempting to be lulled by this progress and
shift attention to other problems, such as the
obesity epidemic. But there are still 44.5 million
smokers in the United States, and each year tobacco use kills 435,000 Americans, who die up to
15 years earlier than nonsmokers and who often
spend their final years ravaged by dyspnea and
pain.14,20 I …
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