Address all of the questions in your post: why is this paper on US Health important? What are some of the positive and negative findings? Where has the US made the most and least progress in reducing years of life lost and years lived with disabilities from 1990-2010? What strategies can be implemented by the health care sector to reduce DALYs from the top 10 risk factors?
Clinical Review & Education
Special Communication
The Paradox of Disease Prevention
Celebrated in Principle, Resisted in Practice
Harvey V. Fineberg, MD, PhD
Author Audio Interview at
jama.com
Prevention of disease is often difficult to put into practice. Among the obstacles: the success
of prevention is invisible, lacks drama, often requires persistent behavior change, and may be
long delayed; statistical lives have little emotional effect, and benefits often do not accrue to
the payer; avoidable harm is accepted as normal, preventive advice may be inconsistent, and
bias against errors of commission may deter action; prevention is expected to produce a net
financial return, whereas treatment is expected only to be worth its cost; and commercial
interests as well as personal, religious, or cultural beliefs may conflict with disease prevention.
Six strategies can help overcome these obstacles: (1) Pay for preventive services. (2) Make
prevention financially rewarding for individuals and families. (3) Involve employers to
promote health in the workplace and provide incentives to employees to maintain healthy
practices. (4) Reengineer products and systems to make prevention simpler, lower in cost,
and less dependent on individual action. (5) Use policy to reinforce choices that favor
prevention. (6) Use multiple media channels to educate, elicit health-promoting behavior,
and strengthen healthy habits. Prevention of disease will succeed over time insofar as it can
be embedded in a culture of health.
CME Quiz at
jamanetworkcme.com and
CME Questions page 93
Author Affiliations: Institute of
Medicine, Washington, DC.
Corresponding Author: Harvey V.
Fineberg, MD, PhD, Institute of
Medicine, 500 Fifth St NW,
Washington, DC 20001
(fineberg@nas.edu).
JAMA. 2013;310(1):85-90.
W
hy is prevention such a difficult sell? This puzzling question surfaces daily in clinical practice and public health,
and it intrudes on policy makers wanting to make scientifically sound, evidence-based policy decisions. Because prevention is so deeply embedded in US culture, the relative neglect of preventive medicine seems paradoxical. Proverbs such as “a stitch in
time saves nine” and “an ounce of prevention is worth a pound of
cure” are repeated by grandparents and grandchildren alike. Culturally, prevention is valued. Yet despite familiar aphorisms and frequent lip service, prevention of disease is, in the words of Shakespeare’s Hamlet, “a custom more honour’d in the breach than the
observance.”1
Preventiondidmuchtoadvancehumanlongevitytothelevelseen
today. Fossil records suggest that early modern humans living 25 000
to40 000yearsagosurvivedonaveragetotheirmid-twenties.2 Inthe
millennia leading up to the beginning of the 20th century, average life
expectancyincreasedbyanother25years,arateofnotmorethan1year
perthousandyears.Then,inthespaceofjust100years,lifeexpectancy
inthemostdevelopedcountriesincreasedanother25years.Onlyinthe
20th century did accelerating economic growth, improved sanitation
practices, and recognition of infectious diseases allow development of
better nutrition and living conditions and eventually widespread use of
vaccinesandantimicrobials.Thegreatinfectiousdiseasesthatflourished
in the slum conditions of newly industrialized nations were no longer
asthreatening.By2010,noncommunicablediseasesaccountedfortwothirds of deaths in the world.3 This epidemiologic transition raises the
stakes for prevention of chronic disease.
The needed preventive approaches differ in several key ways
from the traditional curative approach most commonly emphajama.com
sized in practice (Table). When a patient seeks medical care because of symptoms, the physician’s goal is to make a diagnosis, understand the pathology driving the disease, and identify the optimal
treatment for that patient. For the care and cure of the individual
patient, it is not particularly relevant how many others in the community may experience a similar ailment.
Preventionreversestheusualorderofclinicalthinking:itoftenstarts
at the population level and then translates information back to the individual.Ratherthandwellonthepathologyofdisease,preventivemedicinefocusesonrisk.Incurativecare,thegoalisusuallytorestorepatients
to their earlier, normal state of health. In prevention, as in dealing with
hypertension or elevated cholesterol levels in a community, the goal is
to shift the entire population-wide distribution to a healthier level, thus
changing the norm. In curative care, the principal professional responsibility is to the individual patient, whereas in preventive care, focus is
often at the population level and entails a responsibility to the entire
community. In curative care, solutions involve prescribing medication,
performing operations, or delivering other clinical therapies; in prevention, there is a much wider array of possibilities, from changing behavior choices to altering social conditions, in addition to clinical interventionssuchasimmunizations.Ensuringthehealthofapopulationismore
difficult than delivering health care to an individual.
Obstacles to Prevention
At least a dozen reasons explain why prevention is so regularly resisted, regardless of how good it is in principle or celebrated in
cultural lore (Box 1).
JAMA July 3, 2013 Volume 310, Number 1
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 07/08/2013
85
Clinical Review & Education Special Communication
Table. Approaches to Curative and Preventive Medicine
Curative
Preventive
Identify pathology
Identify risk
Restore health (return to the
norm)
Reduce risk (shift in the norm)
Promote individual service
ethic
Responsibility is to the population
Clinical intervention
predominates
Behavioral and social interventions are
prominent, accompanied by clinical
intervention
Success Is Invisible
This first obstacle is fundamental and intrinsic to prevention. There
is no way to document or otherwise prove that an individual’s personal preventive efforts improved his or her health. One can only
assume that a lifelong effort to maintain a healthy diet, exercise regularly, or avoid smoking contributed to preventing a myocardial infarction. On the other hand, it is possible the individual could have
been among the hypertensive, sedentary smokers who do not experience a myocardial infarction. As another example, consider the
human papillomavirus (HPV) vaccine: if a researcher were to ask
women if the vaccine helped them avoid cancer, are they going to
know? Statisticians and scientists can count outcomes that occur,
such as the number of cases of cancer, the number of myocardial
infarctions, and the number of deaths. But when prevention succeeds, it creates an absence of events: indeed, when it works, prevention succeeds quietly, and it succeeds invisibly.
Invisibility leads to problems. Because of invisible success, some
individuals might no longer see the need for immunizations. Certain diseases, like pertussis or measles, may seem distant and remote, and claims of immunization risks may seem more threatening, even when no reliable evidence supports these claims. When
enough people stop getting vaccinated, as happened in the United
Kingdom4 and Japan,5 outbreaks occur. Antivaccine movements endanger communities and especially children.6-9 Deaths from recent pertussis outbreaks in California10 were avoidable, yet they occurred. When vaccination rates decline, disease may reappear, and
when vaccines are used, their success remains invisible.
Lack of Drama
There are television shows about emergency departments, but will
there ever be a show about prevention? Think about the plot line:
nothing happens. Certain types of curative interventions are, by contrast, dramatic and exciting. When a surgeon gives a child a chance
at life because of a successful liver transplant, the child, the family,
and the medical team are thrilled. However, does anyone think about
the other child who became the liver donor when she died in a car
crash because her parent did not put her in the car seat properly?
Tragedy that could have been prevented is not considered. Visible
drama in the foreground demands immediate attention; lack of
drama does not. If prevention is to be successful, satisfaction needs
to be derived from the absence of drama.
The Paradox of Disease Prevention
Box 1. Reasons Prevention Is Difficult
• Success is invisible.
• A lack of drama makes prevention less interesting.
• Statistical lives have little emotional effect.
• There is usually a long delay before rewards appear.
• Benefits often do not accrue to the payer.
• Advice is inconsistent or changes.
• Persistent behavior change may be required.
• Bias against errors of commission may deter action.
• Avoidable harm is accepted as normal.
• Prevention is expected to produce a net financial return, whereas
treatment is expected only to be worth its cost.
• Commercial interests may conflict with disease prevention.
• Advice might conflict with personal, religious, or cultural beliefs.
within minutes; cameras were focused on that well, and reporters
constantly updated an attentive public. When the fire department
succeeded at freeing the girl after 2 days, everyone was relieved, and
front-page headlines followed. In the United States, there are many
children whose lives are just as confined by poverty and family circumstances as that little girl stuck in the well. Why is there not continuous coverage of these impoverished and disadvantaged children? Personal stories touch others emotionally; everyone connects
to them and eagerly awaits the ending. It is difficult to become emotionally connected to a statistic. When it comes to health, every statistic is a number with a tear attached, but emotionally, it is just a
number.
Long Delay Before Rewards Appear
A study of delayed gratification examined how long 4-year-olds could
sit before eating a marshmallow placed in front of them.11 The young
children were told that if they did not eat the marshmallow until the
investigator returned, they would get 2 marshmallows instead of just
the 1 on the table. Some of the 4-year-olds just could not resist, while
others managed to wait until the experimenter returned later.12 The
investigators found that the children who were able to delay gratification were, as adolescents, more reliable and much better performers on aptitude tests. Prevention is a bit like waiting to obtain
that second marshmallow. However, people typically want what they
want right away. For example, a 2-panel cartoon begins with the physician counseling a patient, “Everything seems okay: you just need
to stop smoking, lose 20 to 30 lbs, cut down on your drinking, get
30 to 60 minutes of exercise daily, and try to reduce the stress in
your life.” In the second panel, the patient, staring plaintively at the
physician, asks, “Can’t you operate?” Prevention is often about doing things every day, and the reward is not only statistical and invisible, but also delayed. There is an analytic question of what a delayed payoff is worth relative to an immediate payoff (ie, considering
discounted present value and uncertainty about the future), but even
without such calculations, most people prefer tangible rewards in
the here and now.
Statistical Lives
Statistical lives have little emotional effect. Statistics can estimate
the number of lives saved by prevention, even though the actual individuals cannot be identified. Some years ago, a little girl known as
“Baby Jessica” got stuck in a well in Texas. News coverage began
86
Benefits Often Do Not Accrue to the Payer for Prevention
Whoever pays for preventive care is often not the party that reaps
the rewards from an eventual reduction in the burden of disease.
An insurance company concerned with profit may not reimburse for
JAMA July 3, 2013 Volume 310, Number 1
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 07/08/2013
jama.com
The Paradox of Disease Prevention
preventive counseling, supportive care, and patient encouragement if the payoff occurs many years in the future. From a commercial standpoint, supporting prevention is not a very smart proposition. Or suppose the board of a hospital were presented with an
opportunity to launch a program that helps manage diabetes in the
community. In this hypothetical situation, the hospital might hire a
group of health care workers led by nursing teams who would work
in the community to educate and motivate patients with diabetes.
The patients do self-assessments at home, and the nurses monitor
patients electronically (ie, via internet sites or e-mail) and receive
feedback on a daily basis. Any time a patient’s blood glucose levels
start to get out of control, a nurse goes directly to the house to help
ensure adherence with the therapeutic regimen. As a result, it is predicted that hospitalization could be reduced by half and patients will
feel better. The average cost might be only $1500 per patient per
year, paid by the hospital, which would also experience a reduction
in patient bed-days from the 50% decline in hospitalizations for patients with diabetes. This means the hospital bears the added costs
of the home-based program while losing inpatient revenue. The
board and the hospital leadership would have to ask whether they
were prepared to make this investment. Someone on the board is
bound to suggest it is probably an intrusion on patients’ rights to send
nurses into their homes and, besides, home care is not really the hospital’s mission.
Incentives for prevention are often misaligned in a system designed to treat disease after it occurs. A key policy goal in health reform is to better align financial incentives with superior care, often
including prevention. Too often still, the benefits of prevention do
not accrue to the payer. Until incentives are aligned with health and
not just diagnosis and treatment, true health care reform will be
delayed.
Changing or Inconsistent Preventive Advice
A debate over mammography guidelines arose during the health reform discussion in Washington. After examining data showing the
frequency with which mammography leads to false-positive findings, needless additional examinations, and biopsies, the US Preventive Services Task Force recommended that before age 50 years,
women and their physicians should decide on an individual risk basis whether to obtain a mammogram, rather than recommend routine screening for all women aged 40 to 50 years.13 In other words,
younger women with family history or other reasons should continue to undergo periodic mammography, whereas others should
not. Some heard this refined advice to mean, “We don’t care about
women in their 40s anymore.” Recent evidence suggests there has
been no change in reliance on mammography following the panel’s
recommendations.14 Nevertheless, the panel’s guidance highlights
the point that prevention, although overall the most successful strategy in health, is not always the right or smart thing to do. In preventive screening, the value to the patient depends on the risk of disease, the frequency and consequences of error, and the ability to
detect correctly and act accordingly.
To the public, the new guidance on mammography seemed like
another example of shifting and inconsistent advice. Science progresses by reexamining, refining, and discarding previously held beliefs. Action must be based on what is currently thought to be true,
yet this creates a weaker preventive message because there is no
guarantee the advice will not change in the future. There is substanjama.com
Special Communication Clinical Review & Education
tial confidence in some recommendations: it is unlikely that cigarettes are ever going to be redeemed as a healthy habit. With other
risk factors, such as nutritional counseling, more evidence over time
may produce new insights. Given the twin epidemics of obesity and
type 2 diabetes, consistent and specific recommendations about nutrition are particularly desirable.
Persistent Behavior Change May Be Required
Persistent behavior change is difficult yet often necessary to realize the benefits of prevention. It does not really help to control blood
pressure only occasionally, when patients remember to take medication. The “daily” part of daily exercise is the challenge. The difficult part of healthy behavior is adhering to those healthy decisions
day after day after day.
Bias Against Errors of Commission
Many people feel differently about adverse consequences due to action compared with consequences that follow from natural causes,
even if they could have prevented them. Consider the following hypothetical scenario: a worldwide avian flu–like disease is moving
steadily toward your country. Everywhere this outbreak has struck,
30% of the population has died. It is a horrific disease.
However, a new vaccine provides perfect protection against this
strain of avian flu but also has a 10% mortality from adverse effects; 1 in 10 recipients will die from the vaccine. Should this vaccine be deployed in the face of an inevitable spread of the pandemic?
Some people would say yes, despite the dangerous adverse effects, and others would say no, but at least all could agree it was a
debatable proposition. Now, imagine if the risk numbers were reversed: the flu carries a 10% mortality and the vaccine carries a 30%
mortality. Under these circumstances, no one would recommend
such a vaccine.
But why was this a relatively difficult decision when the disease was going to kill 30% and the vaccine was going to kill 10%,but
trivially easy when the vaccine kills 30% and the disease, 10%? One
reason is that most people do not feel the same about a death from
natural causes as a death caused by their own action.
Some people have become disciplined to say, “I want to feel the
same about it; I should feel the same about it; I should feel that adverse consequences of commission and omission are equivalent because in either case you are equally dead.” When it comes to prevention, most people regret errors of commission more than errors
of omission. Benjamin Franklin, who lost his 4-year-old son to smallpox in 1763, cautioned against weighing them unequally: “I long regretted bitterly, and still regret that I had not given it [the smallpox]
to him by inoculation. This I mention for the sake of parents who omit
that operation on the supposition that they should never forgive
themselves if a child died under it; my example showing that the regret may be the same either way, and therefore that the safer should
be chosen.”15
Acceptance of Avoidable Harm as Normal
Too often, many people accept avoidable harm as normal. Nightly
newscasts commonly report another murder and another deadly automobile collision. These unfortunate events happen. Most used to
think it was normal to smoke, but today smoking is generally socially unacceptable. Thinking things are normal when they are avoidJAMA July 3, 2013 Volume 310, Number 1
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 07/08/2013
87
Clinical Review & Education Special Communication
Box 2. Strategies to Overcome Obstacles to Prevention
• Pay for prevention.
• Make prevention cheaper than free.
• Involve employers.
• Reengineer to reduce need for individual action.
• Use policy to make the right choices easier.
• Use multiple channels to educate, reframe, and elicit positive
change.
able is a psychological obstacle to implementing strategies of prevention. Safer cars and safer highways can be built; indeed, Sweden
has adopted a goal it calls Vision Zero to eliminate highway fatalities, and some US jurisdictions are on the same path.16 And surely
the right norm for the number of murders is zero.
Double Standard in Evaluation of Prevention
as Compared With Treatment
When a new treatment for a particular disease is introduced, the main
question is whether and how well it works. People want to know
whether the chance of survival is better with or without a new treatment, and perhaps at what cost. That is the typical thinking when
trying to evaluate a therapy. For prevention, the question is asked
from a different perspective: a preventive intervention not only
should be efficacious and cost-effective, but also should produce net
savings in resources. The dollars saved to society from use of a vaccine should exceed the cost of the vaccine: in prevention, not only
is value for the money obtained, the intention is to save money. Preventive interventions are supposed to produce net savings, whereas
therapeutic interventions are only asked to produce better value,
and that is a substantial difference. A double standard exists in judging the merit of preventives compared with therapeutic interventions.
Commercial Conflicts of Interest
This is an obvious obstacle to prevention. For instance, how can tobacco companies promote their products oblivious to the overwhelming body of evidence on the harmful effects of tobacco smoke?
In 1994, 7 chief executive officers of Big Tobacco, one after another, affirmed under oath before the US House Energy and Commerce Committee that they did not believe nicotine was addictive.17
Is it possible that an executive of a tobacco company can truly believe that nicotine is not addictive? Human psychology is phenomenally adaptive so it is possible, but the rest of society should not
have to be the victim of that perversion of thinking. Strong commercial interests can be distorting and problematic, even when those
interests are promoting an effective preventive—as in the HPV vaccine controversy in the state of Texas.18 Commercial interests can
work against prevention both directly and indirectly. However, they
could be beneficial if incentives can be realigned so that both more
profits and greater health occur through the same actions.
Conflicts With Personal, Religious, and Cultural Beliefs
Preventive strategies sometimes run counter to religious or deeply
held personal beliefs. Some religious leaders teach that it is immoral to use condoms, even for the purpose of preventing the spread
of a lethal sexually transmitted disease. Some believe in faith heal88
The Paradox of Disease Prevention
ing and abjure modern medicine. When preventive actions run contrary to a deeply held conviction, it is a much more difficult sell.
Strategies to Overcome Obstacles to Prevention
Despite these barriers, prevention is partially succeeding—invisibly—
all around. The question is, how can that success be supported? How
can prevention overcome the obstacles in its way? Following are 6
ways to overcome the barriers (Box 2).
Pay for Prevention
Incentives should be aligned so that clinicians are paid for the preventive care they provide. This has proven to be successful with immunizations in children, with very high vaccination rates. It now
needs to be applied to other forms of care—nutritional counseling,
physical therapy, and health counseling, to name a few—so that clinicians and health care organizations are rewarded for keeping their
patients healthy.
Make Prevention Cheaper Than Free
Not only do incentives need to be realigned for the clinician, but they
also need to be established for the individual. In the current culture
that demands both better value and money savings from prevention, individuals and families will be most likely to take preventive
measures if they are financially rewarded for doing so. This is not a
novel idea: Mexico has had a program based on this model for many
years. Now combined with the health policy called Seguro Popular,
the Oportunidades program encourages low-income families to get
regular checkups, receive vaccinations, and take other preventive
measures by rewarding them with cash transfers if they do so.19 As
an example, this model could be applied to the United States, expanding on financial incentives for insurance, bonuses for staying
tobacco-free, and rewards for maintaining a healthy body weight.
Indeed, this approach could be incorporated into accountable care
organizations.
Involve Employers
Adults in the United States spend a large portion of their time and
energy at work, leaving employers with one of the most significant
opportunities to influence population health. Employers have often viewed health and fitness policies as a work benefit, traditionally including them only if they need to compete for employees. Instead, they could view prevention as an investment in their
workforce—and a positive contributor to the company’s success.
A study compared Johnson & Johnson, whose worksite health
promotion program has been in place for more than 30 years, to
other, similarly large companies on the basis of health care costs and
employees’ health risks. Not only were Johnson & Johnson employees found to be healthier, with meaningful reduction in rates of obesity, high blood pressure and cholesterol levels, tobacco use, and
physical inactivity, but the health promotion program also generated cost savings, with lower rates of absenteeism and a reduction
in high-cost interventions.20 Companies like Safeway are showing
that differential insurance premiums for employees based on tobacco usage, weight, blood pressure, and cholesterol levels can both
promote individual health and help control employer costs of
health care.21
JAMA July 3, 2013 Volume 310, Number 1
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 07/08/2013
jama.com
The Paradox of Disease Prevention
Special Communication Clinical Review & Education
Worksite programs that encourage employees to take better
care of their health can do much to boost the health of the population. The field is wide open for employers to get more involved
in prevention, and doing so will benefit both employees and the
employers.
Reengineer to Reduce Need for Individual Action
Engineering, when harnessed to the needs of public health and prevention, can increase health and safety. Airbags in cars and antilock
brakes have helped minimize avoidable risk. Taking it one step further, an intoxication screen to enable starting the car could reduce
driving after consuming alcohol. On another front, engineering multiple-dose vaccines into single doses makes it more convenient to
gain the vaccine’s protection. There are many ways engineering can
help prevention be less of a burden, and health care institutions
would benefit from involving engineers in both curative and preventive medicine.
Use Policy to Make the Right Choices Easier
Policies that support prevention exist in many states and municipalities but are not consistent across the United States. Laws and
regulations governing bike helmets, water fluoridation, and manufacturing requirements can do much to improve local health. Policies to reduce salt, eliminate trans fats in food products, and reduce sugar in the diet would lower population-wide risk of
hypertension, cardiovascular disease, and diabetes. In preventive
policy, New York City Mayor Michael Bloomberg’s decision to ban
smoking in public places, along with substantially increased taxes
on cigarettes and a community-level intervention effort helping
smokers to quit, has strikingly reduced smoking in the city, with adult
smoking rates declining 11.2% in the first 5 years.22 Policy makers can
do much to make prevention easier, and they should consider it part
of their civic responsibility.
Use Multiple Media Channels to Educate, Reframe, and Elicit
Positive Change
Making prevention easier, less expensive, and more convenient will
help, and it is equally important that the medical community does
a better job at explaining prevention to the population at large. In a
recent JAMA Forum post, Josh Sharfstein, MD, illustrated with examples from his experience as health commissioner of Baltimore,
principal deputy commissioner at the US Food and Drug Administration, and head of Maryland’s Department of Health and Mental
Hygiene how strategic communication and dialogue with constitu-
ARTICLE INFORMATION
Conflict of Interest Disclosures: The author has
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
REFERENCES
1. Shakespeare W. Hamlet. Act 1, scene 4, lines
15-16.
2. Trinkaus E. Late Pleistocene adult mortality
patterns and modern human establishment. Proc
Natl Acad Sci U S A. 2011. 108(4):1267-1271.
3. Lozano R, Naghavi M, Foreman K, et al. Global
and regional mortality from 235 causes of death for
jama.com
ents can pave the way for successful adoption of regulations to prevent disease.23 Avoidable health risks need to be exposed as avoidable, and a culture that celebrates everyday healthy choices needs
to be established. Prevention needs to be reframed: costs of commission and omission should be seen as equal, standards for measuring the value of prevention and treatment should be comparable, and statistics showing the success of prevention need to be
humanized.
Traditional media, such as print, radio, and television, and newer,
web-based and social media can be mobilized in this effort, along
with the entertainment industry. Unconventional use of communication tools can yield positive returns. For example, the US Centers
for Disease Control and Prevention recently made remarkably effective use of a graphic novella—a comic book—on the coming zombie invasion to inform the public about pandemic preparedness.24
Deeply held beliefs can be made to work in favor of prevention
as well as against it. Tony Schwarz, the late communication and advertising guru, argued that a product advertisement should never
try to teach a listener or viewer something totally new. Rather, an
ad should elicit something people already feel or believe but have
not yet expressed.25 Advertisers for commercial products succeed
when they can align with a person’s beliefs and desires and make
use of the product part of a daily habit. Maybe those in the health
and prevention field can similarly ask what is already in the mind of
the public and how these beliefs and desires can be elicited to promote prevention. What are effective ways to reach out and expose
something that people already care about and make it a healthy
habit? Prevention needs to be connected to things people already
value, to make prevention a daily reality.
Conclusion
The health care community cannot expect an overnight transformation; preventive messages must be repeated across many forms
of media and entertainment to become solidified over time as cultural norms. Success will require a sustained effort from individuals
and families in their daily lives; from physicians, nurses, pharmacists, and other health professionals; from cultural, entertainment,
and sports celebrities; from employers and insurers; from political,
civic, and business leaders; from public agencies at all levels; and from
philanthropies. In the end, prevention is truly worth the investment to make a difficult sell just a little easier and to put everyone
on the road to a healthier future.
20 age groups in 1990 and 2010: a systematic
analysis for the Global Burden of Disease Study
2010. Lancet. 2012;380(9859):2095-2128.
4. Church MA. Evidence of whooping-coughvaccine efficacy from the 1978 whooping-cough
epidemic in Hertfordshire. Lancet. 1979;2(8135):
188-190.
5. Sato H, Sato Y. Experience with diphtheria
toxoid-tetanus toxoid-acellular pertussis vaccine in
Japan. Clin Infect Dis. 1999;28(suppl 2):S124-S130.
6. May T, Silverman RD. “Clustering of exemptions”
as a collective action threat to herd immunity.
Vaccine. 2003;21(11-12):1048-1051.
7. Feikin DR, Lezotte DC, Hamman RF, Salmon DA,
Chen RT, Hoffman RE. Individual and community
risks of measles and pertussis associated with
personal exemptions to immunization. JAMA.
2000;284(24):3145-3150.
8. Gangarosa EJ, Galazka AM, Wolfe CR, et al.
Impact of anti-vaccine movements on pertussis
control: the untold story. Lancet. 1998;351(9099):
356-361.
9. Poland GA, Jacobson RM. Understanding those
who do not understand: a brief review of the
anti-vaccine movement. Vaccine. 2001;19(17-19):
2440-2445.
JAMA July 3, 2013 Volume 310, Number 1
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 07/08/2013
89
Clinical Review & Education Special Communication
10. Pertussis (whooping cough) in California and
New York State. Public Health Agency of Canada;
2010.
11. Mischel W, Shoda Y, Rodriguez MI. Delay of
gratification in children. Science. 1989;244(4907):
933-938.
12. The power of delayed gratification: kids
marshmallow experiment. LATorontoBlog YouTube
video. http://www.youtube.com/watch?v
=0mWc1Y2dpmY. Accessed June 6, 2013.
13. Screening for breast cancer. US Preventive
Services Task Force. http://www
.uspreventiveservicestaskforce.org/uspstf
/uspsbrca.htm. Accessed June 6, 2013.
14. Pace LE, He Y, Keating NL. Trends in
mammography screening rates after publication of
the 2009 US Preventive Services Task Force
recommendations [published online April 19, 2013].
Cancer. doi:10.1002/cncr.28105.
15. Franklin B. The Autobiography of Benjamin
Franklin. Philadelphia, PA: Henry Altemus; 1895.
90
The Paradox of Disease Prevention
16. The Vision Zero approach to traffic safety.
Vision Zero Initiative: Traffic Safety by Sweden.
http://www.visionzeroinitiative.com/en. Accessed
June 6, 2013.
17. Hearing of the House Energy and Commerce
Committee: Subcommittee on Health and the
Environment, Subject: nicotine and cigarettes:
1994. Tobacco Documents Online.
http://tobaccodocuments.org/lor/94668518-8672
.html. Accessed June 6, 2013.
18. Saul S, Pollack A. Furor on rush to require
cervical cancer vaccine. New York Times. February
17, 2007. http://www.nytimes.com/2007/02/17
/health/17vaccine.html?pagewanted=all&_r=0.
Accessed June 5, 2013.
19. Frenk J. Bridging the divide: global lessons from
evidence-based health policy in Mexico. Lancet.
2006;368(9539):954-961.
20. Henke RM, Goetzel RZ, McHugh J, Isaac F.
Recent experience in health promotion at Johnson
& Johnson: lower health spending, strong return on
investment. Health Aff (Millwood). 2011;30(3):
490-499.
21. Burd SA. How Safeway is cutting health-care
costs: market-based solutions can reduce the
national health-care bill by 40%. Wall St Journal.
June 12, 2009. http://online.wsj.com/article
/SB124476804026308603.html. Accessed June 6,
2013.
22. Li W, Kennedy J, Kelley D, Sun Y, Maduro G,
Shen S. Summary of Vital Statistics 2008. City of
New York: New York City Dept of Health and Mental
Hygiene. http://www.nyc.gov/html/doh
/downloads/pdf/vs/2008sum.pdf. Accessed June
6, 2013.
23. Sharfstein J. JAMA Forum: public health
regulation as a public process. http://newsatjama
.jama.com/2013/05/22/jama-forum-public-health
-regulation-as-a-public-process/. Accessed June 6,
2013.
24. Zombie novella. Centers for Disease Control
and Prevention Office of Public Health
Preparedness and Response. http://www.cdc.gov
/phpr/zombies_novella.htm. Accessed June 6, 2013.
25. Schwartz T. Media, the Second God. New York,
NY: Random House; 1981.
JAMA July 3, 2013 Volume 310, Number 1
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 07/08/2013
jama.com
Research
Original Investigation
The State of US Health, 1990-2010
Burden of Diseases, Injuries, and Risk Factors
US Burden of Disease Collaborators
Editorial page 585
IMPORTANCE Understanding the major health problems in the United States and how they
are changing over time is critical for informing national health policy.
Author Video Interview at
jama.com
OBJECTIVES To measure the burden of diseases, injuries, and leading risk factors in the
Supplemental content at
jama.com
United States from 1990 to 2010 and to compare these measurements with those of the 34
countries in the Organisation for Economic Co-operation and Development (OECD) countries.
DESIGN We used the systematic analysis of descriptive epidemiology of 291 diseases and
injuries, 1160 sequelae of these diseases and injuries, and 67 risk factors or clusters of risk
factors from 1990 to 2010 for 187 countries developed for the Global Burden of Disease 2010
Study to describe the health status of the United States and to compare US health outcomes
with those of 34 OECD countries. Years of life lost due to premature mortality (YLLs) were
computed by multiplying the number of deaths at each age by a reference life expectancy at
that age. Years lived with disability (YLDs) were calculated by multiplying prevalence (based
on systematic reviews) by the disability weight (based on population-based surveys) for each
sequela; disability in this study refers to any short- or long-term loss of health.
Disability-adjusted life-years (DALYs) were estimated as the sum of YLDs and YLLs. Deaths
and DALYs related to risk factors were based on systematic reviews and meta-analyses of
exposure data and relative risks for risk-outcome pairs. Healthy life expectancy (HALE) was
used to summarize overall population health, accounting for both length of life and levels of ill
health experienced at different ages.
RESULTS US life expectancy for both sexes combined increased from 75.2 years in 1990 to
78.2 years in 2010; during the same period, HALE increased from 65.8 years to 68.1 years.
The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart
disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury.
Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic
kidney disease, kidney cancer, and falls. The diseases with the largest number of YLDs in 2010
were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain,
and anxiety disorders. As the US population has aged, YLDs have comprised a larger share of
DALYs than have YLLs. The leading risk factors related to DALYs were dietary risks, tobacco
smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical
inactivity, and alcohol use. Among 34 OECD countries between 1990 and 2010, the US rank
for the age-standardized death rate changed from 18th to 27th, for the age-standardized YLL
rate from 23rd to 28th, for the age-standardized YLD rate from 5th to 6th, for life expectancy
at birth from 20th to 27th, and for HALE from 14th to 26th.
CONCLUSIONS AND RELEVANCE From 1990 to 2010, the United States made substantial
progress in improving health. Life expectancy at birth and HALE increased, all-cause death
rates at all ages decreased, and age-specific rates of years lived with disability remained
stable. However, morbidity and chronic disability now account for nearly half of the US health
burden, and improvements in population health in the United States have not kept pace with
advances in population health in other wealthy nations.
JAMA. 2013;310(6):591-608. doi:10.1001/jama.2013.13805
Published online July 10, 2013.
Members of the US Burden of
Disease Collaborators appear at the
end of this article.
Corresponding Author: Christopher
J. L. Murray, MD, DPhil, Institute for
Health Metrics and Evaluation, 2301
Fifth Ave, Ste 600, Seattle, WA 98121
(cjlm@uw.edu).
591
Downloaded From: http://jama.jamanetwork.com/ by a Arizona State University User on 10/09/2013
Research Original Investigation
T
he United States spends the most per capita on health
care across all countries,1,2 lacks universal health coverage, and lags behind other high-income countries for
life expectancy3 and many other health outcome measures.4
High costs with mediocre population health outcomes at the
national level are compounded by marked disparities across
communities, socioeconomic groups, and race and ethnicity
groups.5,6 Although overall life expectancy has
DALYs disability-adjusted life-years
slowly risen, the increase
HALE healthy life expectancy
has been slower than for
YLDs years lived with disability
many other high-income
YLLs years of life lost due to
countries.3 In addition, in
premature mortality
some US counties, life expectancy has decreased in the past 2 decades, particularly for
women.7,8 Decades of health policy and legislative initiatives
have been directed at these challenges; a recent example is the
Patient Protection and Affordable Care Act, which is intended to address issues of access, efficiency, and quality of
care and to bring greater emphasis to population health
outcomes.9 There have also been calls for initiatives to address determinants of poor health outside the health sector including enhanced tobacco control initiatives,10-12 the food
supply,13-15 physical environment,16,17 and socioeconomic
inequalities.18
With increasing focus on population health outcomes that
can be achieved through better public health, multisectoral action, and medical care, it is critical to determine which diseases, injuries, and risk factors are related to the greatest losses
of health and how these risk factors and health outcomes are
changing over time. The Global Burden of Disease (GBD)
framework19 provides a coherent set of concepts, definitions,
and methods to do this. The GBD uses multiple metrics to quantify the relationship of diseases, injuries, and risk factors with
health outcomes, each providing different perspectives. Burden of disease studies using earlier variants of this approach
have been published for the United States for 199620-22 and for
Los Angeles County, California.23 In addition, 12 major risk factors have also been compared for 2005.24
In this report, we use the GBD Study 2010 to identify the
leading diseases, injuries, and risk factors associated with the
burden of disease in the United States, to determine how these
health burdens have changed over the last 2 decades, and to
compare the United States with other Organisation for Economic Co-operation and Development (OECD) countries.
Methods
The GBD 2010, a collaborative effort involving 488 scientists
from 50 countries, quantified health loss from 291 diseases and
injuries, 1160 clinical sequelae of these diseases and injuries,
and 67 risk factors or clusters of risk factors for 187 countries
from 1990 to 2010. The overall aim of the GBD 2010 was to synthesize the world’s knowledge of descriptive epidemiology to
facilitate comparisons across problems, over time, and across
countries. Methods and summary results from the GBD 2010
for the world and 21 regions have been published.3,19,25-31 Sev592
The State of US Health, 1990-2010
Box. Glossary of Terms
Disability-adjusted life-years: a summary metric of population
health. DALYs represent a health gap and, as such, measure the state
of a population’s health compared to a normative goal. The goal is for
individuals to live the standard life expectancy in full health. DALYs
are the sum of 2 components: years of life lost (YLLs) and years lived
with disability (YLDs).
Healthy life expectancy: the number of years that a person at a given
age can expect to live in good health, taking into account mortality
and disability.
Years lived with disability: computed as the prevalence of different disease sequelae and injury sequelae multiplied by disability
weights for that sequela. Disability weights are selected on the basis
of surveys of the general population about the health loss associated with the health state related to the disease sequela.
Years of life lost due to premature mortality: computed by multiplying the number of deaths at each age by a standard life expectancy at that age. The standard selected represents the normative
goal for survival and has been computed based on the lowest recorded death rates across countries in 2010.
eral studies focusing on results for a specific disease or risk factor have also been published or are in preparation.32-34 Because the GBD 2010 uses a standardized approach for 187
countries, the results can be used to benchmark population
health outcomes across different groups of nations. National
burden of disease studies including a benchmarking component using the GBD 2010 have been completed for the United
Kingdom32 and China.35 Details on the data, approaches to enhancing data quality and comparability, and statistical modeling and metric s for the GBD 2010 are published
elsewhere.3,19,25-27,29-31
The GBD 2010 cause list has 291 diseases and injuries, which
are organized in a hierarchy with up to 4 levels of disaggregation. We identified the key sequelae for each disease or injury. Sequelae could include the disease, such as diabetes, or
the outcomes associated with that disease, such as diabetic
foot, neuropathy, or retinopathy. Some clinical disorders were
classified as a disease but could also be a consequence of another disease; for example, cirrhosis secondary to hepatitis B
is a consequence of hepatitis B but was classified as a disease.
Any outcome appears in the GBD cause and sequelae list only
once to avoid double counting. The full list of risk factors, diseases, and sequelae and further details on their development
since 1991 are published elsewhere.19 In total, the study included 1160 sequelae.
The GBD 2010 uses several metrics to report results on
health loss related to specific diseases, injuries, and risk factors: deaths and death rates, years of life lost due to premature mortality (YLLs), prevalence and prevalence rates for
sequelae, years lived with disability (YLDs), and disabilityadjusted life-years (DALYs) (Box). Years of life lost are computed by multiplying the number of deaths in each age group
by a reference life expectancy at that age. The life expectancy
at birth in the reference life table is 86.0 years based on the lowest observed death rates for each age group across countries
in 2010 and is intended to be an achievable outcome.19
JAMA August 14, 2013 Volume 310, Number 6
Downloaded From: http://jama.jamanetwork.com/ by a Arizona State University User on 10/09/2013
jama.com
The State of US Health, 1990-2010
Years lived with disability are calculated from the prevalence of a sequela multiplied by the disability weight for that
sequela, which reflects its severity on a continuum between
no loss of health (which has a disability weight of 0) and complete loss of health (which has a weight of 1.0). The meaning
of disability in the GBD differs from that in US legislation such
as the Americans with Disabilities Act; in the GBD, disability
refers to any short- or long-term health loss. DALYs are the sum
of YLLs and YLDs. The GBD uses another indicator, healthy life
expectancy (HALE), to summarize overall population health
in a single number accounting for both length of life and levels of ill health experienced at different ages.27
Estimation of prevalence for each sequela began with a systematic analysis of published studies and data sources providing information on prevalence, incidence, remission, and
excess mortality, such as the National Health and Nutrition Examination Surveys,36 State Inpatient Databases,37 the National Ambulatory Medical Care Survey,38,39 the National Hospital Ambulatory Medical Care Survey, 4 0 the Medical
Expenditure Panel Survey, 41 the National Comorbidity
Survey,42 the National Epidemiological Survey on Alcohol and
Related Conditions, and disease surveillance reports from the
Centers for Disease Control and Prevention. For most sequelae, estimates were made using a Bayesian metaregression tool developed for the GBD 2010 (DisMod-MR). The
DisMod-MR program estimates a generalized negative binomial model with nested random effects for regions and countries and fixed effects (see Vos et al25 for details on the equations and estimation procedure). Source code for DisMod-MR
is available at http://ihmeuw.org/dismod_mr. eTable 1 in the
Supplement provides the estimated prevalences for the 1160
sequelae for the United States in 2010.
For the GBD 2010, disability weights were measured for 220
unique health states that cover the 1160 disease and injury
sequelae.26 Disability weights were generated using data from
more than 30 000 respondents contacted through populationbased, random-sample surveys in the United States, Peru,
Tanzania, Bangladesh, and Indonesia and through an open
Internet survey. The US survey, conducted using computerassisted telephone interviews, consisted of 3323 respondents, and the Internet survey consisted of 7180 selfselecting respondents from the United States. Results from
population surveys in developing countries and the United
States were highly consistent, suggesting a common construct of health; likewise, the results from the well-educated
respondents to the Internet survey were highly consistent with
the population-based samples. For example, the correlation
between results from the United States and from the combined sample was 0.97.26 The 220 disability weights used in this
study and the lay descriptions used to elicit choices from survey respondents are published elsewhere.26 Uncertainty in the
disability weight for each sequela was propagated into the estimates of YLDs for each disease and injury using standard
simulation methods.43 Information on age-specific mortality
rates and on overall age-specific YLDs per person was combined into an overall measure of HALE, using a standard approach to extending the life table to capture adjustments for
nonfatal health outcomes.27
Original Investigation Research
We estimated the deaths or DALYs related to the 67 risk factors or clusters of risk factors (eTables 7 and 8 in the Supplement) following the conceptual framework for risk factors developed for the GBD, which identifies 3 layers of factors in a
causal web: distal socioeconomic, proximal behavioral and environmental, and physiological and pathophysiological
causes.44 Computation follows 3 key steps.
In the first step, risk-outcome pairs were included when
evidence met the criteria for “convincing” or “probable”
evidence.45 As defined by the World Cancer Research Fund
grading system, convincing evidence is evidence from epidemiological studies showing consistent associations between
exposure and disease, with little or no evidence to the contrary. The evidence must come from a substantial number of
studies including prospective observational studies and, when
relevant, randomized controlled trials of sufficient size, duration, and quality showing consistent effects. The association should be biologically plausible, such as the effect of salt
on fluid retention, increases in blood pressure, and ultimate
effect on cardiovascular diseases. Probable evidence is defined as evidence based on epidemiological studies showing
fairly consistent associations between exposure and disease
but for which there are perceived shortcomings in the available evidence or some evidence to the contrary, which preclude a more definite judgment; for example, the effects of diets
low in seafood omega-3 fatty acids on ischemic heart disease
mortality. Shortcomings in the evidence may be any of the following: insufficient duration of trials (or studies), insufficient trials (or studies) available, inadequate sample sizes, or
incomplete follow-up. Laboratory evidence is usually supportive and the association must again be biologically plausible. Relative risks of mortality and morbidity were estimated based on meta-analyses of the scientific literature.31
eTable 2 in the Supplement provides the published relative risks
used for each of the risk factors used in the analysis.
In the second step, the distribution of each risk factor exposure in each country, age, and sex group was estimated from
published and unpublished data sources.31
In the third step, deaths or DALYs associated with risk
factors were estimated by comparing the current distribution
of exposure with a theoretical minimum risk exposure distribution (TMRED) of exposure selected for each risk factor. The
TMRED is a feasible distribution of exposure that would
minimize population health risk. For example, the theoretical minimum risk distribution for tobacco is that no one has
smoked in the past; for systolic blood pressure, it is a distribution with a mean of 110 to 115 mm Hg and a standard
deviation of 6 mm Hg. The TMRED for each risk factor is the
same for all populations; Lim et al31 provides detail on these
distributions for dichotomous and continuous risk factors.
TMREDs have been defined for each of the 14 subcomponents of diet. The overall relationship of diet with health outcomes assumes the contribution of each component is multiplicative; that is, that the individual dietary contributions are
independent.
Each risk factor or cluster of risk factors was analyzed separately such that the sum of attributable fractions (see eTable
2 in the Supplement) for a disease or injury can be greater than
jama.com
Downloaded From: http://jama.jamanetwork.com/ by a Arizona State University User on 10/09/2013
JAMA August 14, 2013 Volume 310, Number 6
593
Research Original Investigation
100%. For example, a behavioral risk factor, such as some components of diet, may operate in part through reducing blood
pressure. We included only risks for which there was convincing or probable evidence for pairs of risk factors and specific
outcomes and that had sufficient epidemiological data to estimate risk factor–specific effect sizes, eg, relative risks. These
risks included a range of behavioral, environmental, and metabolic risk factors, but distal socioeconomic factors were excluded because much of the literature on these risk factors focuses on all-cause mortality and morbidity outcomes.
Using simulation methods,46,47 we took 1000 draws (unbiased random samples) from the uncertainty distribution of
the relative risks, prevalence of exposure estimates, theoretical minimum risk distributions, and background outcome rates.
Uncertainty intervals for burden related to a risk factor were
based on computation of the results for each of the 1000 draws;
the lower bound of the 95% uncertainty interval for the final
quantity of interest is the 2.5 percentile of the distribution and
the upper bound is the 97.5 percentile of the distribution. These
uncertainty intervals reflect all sources of uncertainty, including sampling error and model parameter uncertainty, from each
component of the analysis.
For outcomes measured for specific age groups (deaths,
YLLs, YLDs, and DALYs), we directly computed agestandardized rates using the World Health Organization’s age
standard.48 For each disease, injury, or risk factor, we ranked
countries in 1990 and 2010 by the age-standardized rates for
each outcome measure. We compared US outcomes with those
of the 34 countries that are members of the OECD. These OECD
members have been used in other comparative studies for the
United States.49 For a given country and disease, injury, or risk,
we tested whether a country was significantly above the mean
of all OECD countries, indistinguishable from the mean, or below the mean; we used a 1-sided test at the P
Order an Essay Now & Get These Features For Free:
Turnitin Report
Formatting
Title Page
Citation
Outline
