Getting What We Deserve: Health and Medical Care in America

5. THE CONSEQUENCES OF OUR OWN BEHAVIOR

37 6 6 6 5 The Consequences of Our Own Behavior Manyof our health problems are self-inflicted,things thatwe can do something about. One of “public health’s” greatest modern triumphs was turning back the epidemic of cardiovascular disease that struck the United States after World War II. The epidemic peaked in the late 1950s, just before the great fuss over saturated fats and cholesterol in our diets. Army physicians were widely reported as being shocked bythe levels of atherosclerosis theywere seeing among teenage soldiers killed in Korea. Americans (on average ) began to fret over their lipid levels and changed their diets. Over the ensuing thirty years, deaths from heart disease in the United States dropped by nearly half, long before potent lipid-lowering medications or bypass surgery was available (Figure 11). Wealthy countries today have widely varying rates of death from heart disease. Hungary,Scotland,England,andWales have some of the highest rates (Figure 12). This should be no surprise. As I explained to an audience atTrinity College, in Dublin, one had only to 38 Getting WhatWe Deserve reflect on what I’d been served for breakfast that morning: three fried eggs, sausage, ham, fried potatoes, fried tomatoes, and three pieces of toast soaked in butter. It was astonishing that I hadn’t keeled over en route to the lecture hall! The Use of Tobacco The U.S. epidemic of lung cancer has been even more dramatic than its epidemic of heart disease. U.S. women are understandably concerned about their risk of dying of breast cancer. Death rates from breast cancer were essentially unchanged from 1900 through 1990, though the picture has recently improved with more aggres1930 450 300 150 0 1900 1960 1990 1996 Deaths per 100,000 population Year Death Rate from Heart Disease United States Figure 11. Heart disease: a public health triumph. Death rate from heart disease in the United States, 1900–1996. U.S. death rates from heart disease, primarily coronary artery disease, reached a peak in the 1950s and have been falling ever since. This reflects the influence of better diets, more rigorous control of high blood pressure, and, recently, increasingly effective treatment options. Source: Adapted from Centers for Disease Control and Prevention, Morbidity and MortalityWeekly Report 48, no. 30 (August 6, 1999): 649, Figure 1. The Consequences of Our Own Behavior 39 sive screening and earlier treatment, particularly with tamoxifen and other estrogen-blocking agents. At the same time, the risk for U.S. women of dying from lung cancer has skyrocketed! (See Figure 13.) Virtually no U.S. women died of lung cancer in 1900; by 1940, large numbers of women had begun to die of lung cancer, but at only one-tenth the rate they died of breast cancer. By 1990, fifty years later, more U.S. women were dying from lung cancer than from breast cancer. Why? Because they’d “come a long way, baby.” U.S. women first began to smoke in large numbers afterWorldWar I, and even more took up smoking after World War II. Their rates of lung cancer rose, as one would expect, after the twenty to thirty years it takes for lung cancer to develop. 0 200 100 Deaths per 100,000 population/ ages 35 - 74 (age-adjusted) 300 500 400 Hungary Scotland England & Wales Norway USA Italy France Japan Death Rates from Coronary Heart Disease Males Figure 12. We are what we eat. Death rates for men from coronary artery disease in selected high-income countries . The death rates are highest in countries with diets rich in animal fats (Hungary , Scotland) and lowest where the diet is relatively low in animal fats (Japan). Source: Adapted from D. Levy and W. B. Kannel,“Searching for Answers to Ethnic Disparities in Cardiovascular Risk,”Lancet 356 (2000): 267. 40 Getting WhatWe Deserve I’ve never understood why American women still passionately organize “races for the cure” of breast cancer but seem indifferent to a preventable disease that kills more of them. Of course, something along the same lines could be said of men (Figure 14). Lung cancer is only one of the deadly consequences of smoking. Add to it greatly increased rates of emphysema, chronic bronchitis, cardiovascular disease (stroke and heart attacks), and a variety of other conditions. Smoking is responsible for atleast400,000 excess deaths in the United States every year. The numbers for Europe, Japan, and the rest of the developed...