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November 23, 1994

CDC director preaches about the importance of preventive health care

The United States will spend nearly $1 trillion on health care this year, but only 1 percent of that will go toward preventive measures such as immunization and AIDS education.

"This relationship is severely out of balance, when we commit so little to prevention and so much to treating often terminal illnesses with very sophisticated technology," the director of the Centers for Disease Control and Prevention (CDC) said here Nov. 15.

David Satcher heads the agency of the U.S. Public Health Service that is responsible for promoting health and preventing disease, injury and premature death.

Satcher marked his first anniversary as CDC director by preaching to the choir. His audience at the 18th Thomas Parran Lecture of Pitt's Graduate School of Public Health was largely made up of public health professionals and students.

They nodded and laughed appreciatively when Satcher noted the built-in disadvantages of preventive medicine in capturing the imaginations (and funds) of Congress and the American people: "You never hear anybody say, 'Isn't it great that we didn't have anybody die of smallpox this year?' But if somebody has a heart attack and has to go to the intensive care unit, or someone has to get an organ transplant, then people get excited." The United States has the most sophisticated medical technology in the world, "but you can have a sophisticated system and still have a (health care) quality problem," Satcher said, pointing out that America's infant mortality rates are higher than those of most other industrialized nations, and about 40 percent of Americans lack health insurance. The United States spends a greater percentage of its gross national product (nearly 15 percent) on medical care than any other country, he said.

"The more problems we have in the personal health care delivery system, the greater the burden is on the public health infrastructure. In recent years, we have seen state and local health departments overburdened by the demands of backstopping the health care delivery system," Satcher said.

The CDC director argued for increased funding for public health as the most cost-effective way of improving Americans' health.

Of the 30 additional years of life expectancy that average Americans have gained since 1900, 25 of those years can be attributed to public health efforts such as sanitation reform, health education, vaccinations and other infectious disease control, Satcher said. The Pan-American Health Organization recently declared polio to be eradicated from the Western hemisphere, and scientists plan to destroy the last known surviving smallpox virus in 1995, Satcher said.

"Since 1970, we've seen a 60 percent decline in death rates from strokes and a 50 percent decline in coronary heart disease deaths" — improvements that can be attributed at least as much to disease prevention (healthier diets and more exercise, mainly) as to high-tech medicine, Satcher said.

Yet, of the 2 million deaths in the United States last year, an estimated 850,000 could have been prevented, said Satcher. He cited a Journal of the American Medical Association article that linked 400,000 of the deaths to smoking, 300,000 to unhealthy diets and 150,000 to physical inactivity. "Our studies show that 85 to 90 percent of new smokers begin as teenagers. About 3,000 teenagers become new smokers in the United States every day," Satcher said. That's why CDC has begun emphasizing anti-smoking education prior to the 7th grade, he said. "Traditionally, we haven't put a lot of emphasis on public health at the adolescent level," he noted.

Another preventable cause of death — one that has reached epidemic levels among young Americans — is violence, said Satcher.

Since 1985, homicides have increased 154 percent among Americans aged 15-34, according to CDC. African-American males in this age group are seven times as likely to be homicide victims as whites, Satcher said. "Yet, even if you look at just the majority population and remove the African-American population from the statistics, our rate of homicide is still three times that of the next closest country," which is Italy, he said.

Satcher said his most controversial action as CDC director has been to declare violence to be a public health problem.

"Our position is that violence is, in fact, a criminal justice problem. It is, in fact, a social problem. But it's still a public health problem. And we believe we can apply the public health approach to violence," Satcher said.

He likened the relationship between guns and homicide to the relationship between viruses and disease. But Satcher stopped short of calling for more gun control. "I won't even get into that politically laden issue," he said.

CDC funds violence-prevention programs in 16 U.S. cities. Each program, Satcher said, strives to:

* Use existing laws to limit teenagers' access to weapons, alcohol and the abandoned buildings where many violent crimes take place.

* Work with churches, schools and clubs to increase community awareness of violence. For example, CDC recently formed a partnership with the National Congress of Black Churches, representing 20 million worshippers. "We believe that the role of the church, especially in the inner city and rural areas, can be critical in violence prevention and HIV-AIDS prevention," Satcher said.

* Change individuals' attitudes toward violence through programs in conflict resolution, intervention, and mentoring between adults and at-risk children.

* Support education and employment programs aimed at changing social environments that breed violence. Homicide, like teenage pregnancy, often is a symptom of hopelessness, Satcher said.

CDC's work goes beyond domestic public health issues. As cheap air travel and U.S. immigration rates flourish, North America is becoming less of an immunological fortress than ever before, he said. Thirty percent of the new cases of tuberculosis in recent years in the United States came from visitors to the country, and the recent plague outbreak in India forced CDC to quarantine Indian visitors from infected regions, he said. "The world is a community now, and therefore we have to focus public health globally," said Satcher.

— Bruce Steele

Filed under: Feature,Volume 27 Issue 7

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