Old diseases, other public health threats reemerge in the U.S.

Things looked promising for American health in 2014, when life expectancy hit 78.9 years. Then, life expectancy declined for three straight years — the longest sustained drop since the Spanish flu of 1918, which killed about 675,000 Americans and 50 million people worldwide, said Steven Woolf, a professor of family medicine and population health at Virginia Commonwealth University.

Although life expectancy inched up slightly in 2018, it hasn’t yet regained the lost ground, according to the Centers for Disease Control and Prevention.

“These trends show we’re going backwards,” said Sadiya Khan, an assistant professor of cardiology and epidemiology at Northwestern University Feinberg School of Medicine.

While the reasons for the backsliding are complex, many public health problems could have been avoided, experts say, through stronger action by federal regulators and more attention to prevention.

“We’ve had an overwhelming investment in doctors and medicine,” said Sandro Galea, dean of the Boston University School of Public Health. “We need to invest in prevention — safe housing, good schools, living wages, clean air and water.”

Superbugs — resistant to even the strongest antibiotics — threaten to turn back the clock on the treatment of infectious diseases. Resistance occurs when bacteria and fungi evolve in ways that let them survive and flourish, despite treatment with the best available drugs. Each year, resistant organisms cause more than 2.8 million infections and kill more than 35,000 people in the United States.

With deadly new types of bacteria and fungi emerging, CDC Director Robert Redfield said the world has entered a “post-antibiotic era.” Half of all new gonorrhea infections, for example, are resistant to at least one type of antibiotic. The CDC warns that “little now stands between us and untreatable gonorrhea.”

The United States has seen a resurgence of congenital syphilis, a scourge of the 19th century, which increases the risk of miscarriage, permanent disabilities and infant death. Although women and babies can be protected with early prenatal care, 1,306 newborns were born with congenital syphilis in 2018 and 94 of them died, according to the CDC.

Those numbers illustrate the “failure of American public health,” said Cornelius “Neil” Clancy, a physician and spokesman for the Infectious Diseases Society of America. “It should be a global embarrassment.”

Although new medications are urgently needed, drug companies are reluctant to develop antibiotics because of the financial risk, said Clancy, noting that two developers of antibiotics recently went out of business. The federal government needs to do more to make sure patients have access to effective treatments, he said. “The antibiotic market is on life support,” Clancy said.

A slow decline

A closer look at the data shows that American health was beginning to suffer 30 years ago. Increases in life expectancy slowed at a times when many manufacturing jobs moved overseas and factory towns deteriorated, Woolf said.

By the 1990s, life expectancy in the United States was falling behind that of other developed countries.

The obesity epidemic, which began in the 1980s, is taking a toll on Americans in midlife, leading to diabetes and other chronic illnesses that deprive them of decades of life. Although novel drugs for cancer and other serious diseases give some patients additional months or even years, Khan said, “the gains we’re making at the tail end of life cannot make up for what’s happening in midlife.”

“It’s not that we don’t have good blood pressure drugs,” Khan said. “But those drugs don’t do any good if people don’t have access to them.”

Vaping, nicotine addiction

While the United States never declared victory over alcohol or drug addiction, the country has made enormous progress against tobacco. A few years ago, antismoking activists were optimistic enough to talk about the “tobacco endgame.”

Today, vaping has largely replaced smoking among teens, said Matthew Myers, president of the Campaign for Tobacco-Free Kids. Although cigarette use among high school students has fallen from 36 percent in 1997 to 5.8 percent today, studies show that 31 percent of seniors have used electronic cigarettes in the past month.

Food and Drug Administration officials say they’ve taken “vigorous enforcement actions aimed at ensuring e-cigarettes and other tobacco products aren’t being marketed or sold to kids.”

But with more than 5 million teens using e-cigarettes, Myers said, “more kids are addicted to nicotine today than at any time in the past 20 years. If that trend isn’t reversed rapidly and dynamically, it threatens to undermine 40 years of progress.”

Ignoring science

Where children live has long determined their risk of infectious disease, with children in the poorest countries often lacking access to lifesaving vaccines.

Yet in the United States — where a federal program provides free vaccines — some of the lowest vaccination rates are in affluent communities, where some parents wrongly believe that vaccinating their children is unnecessary or dangerous, disregarding the medical evidence to the contrary.

Studies show that vaccination rates are drastically lower in some private schools and “holistic kindergartens” than in public schools.

It could be argued that vaccines have been a victim of their own success.

Before the development of a vaccine in the 1960s, measles infected an estimated 4 million Americans a year, hospitalizing 48,000, causing brain inflammation in about 1,000 and killing 500, according to the CDC.

“Now, [some parents] say, ‘I don’t see any measles. Why do we have to keep vaccinating?’ ” Schaffner said. “When you don’t fear the disease, it becomes very hard to value the vaccine.”

Last year, a measles outbreak in New York communities with low vaccination rates spread to almost 1,300 people — the most in 25 years — and nearly cost the country its measles elimination status.”

Health-wealth disparities

There’s no question that some aspects of American health are getting better.

Cancer death rates have fallen 27 percent in the past 25 years, according to the American Cancer Society. The teen birthrate is at an all-time low; teen pregnancy rates have dropped by half since 1991, according to Health and Human Services. And HIV, which was once a death sentence, can now be controlled with a single daily pill and people with the virus can live into old age.

“It’s important to highlight the enormous successes,” Redfield said. “We’re on the verge of ending the HIV epidemic in the U.S. in the next 10 years.”

Yet the health gap has grown wider in recent years with life expectancy in some regions of the country growing from 2001 to 2014, while shrinking in others, according to a 2016 study in JAMA. That life expectancy gap is strongly linked to income: The richest 1 percent of American men live 15 years longer than the poorest 1 percent; the richest women live 10 years longer than the poorest, according to the JAMA study.

The infant mortality rate of black babies is twice as high as that of white newborns, according to HHS. Babies born to well-educated, middle-class black mothers are more likely to die before their first birthday than babies born to poor white mothers with less than a high school education, according to a report from the Brookings Institution.

In trying to improve American health, policymakers in recent years have tended to focus on expanding access to medical care and encouraging healthy lifestyles. Today, many advocate a broader approach to lift families out of the poverty that erodes mental and physical health.

“We’re not going to erase that difference by telling people to eat right and exercise,” said Richard Besser, chief executive of the Robert Wood Johnson Foundation and former acting director of the CDC. “Economic opportunity and health go hand in hand.”

“So many of the changes in life expectancy are related to changes in opportunity,” Besser said. “Personal choices are part of it. But the choices people make depend on the choices they’re given. For far too many people, their choices are extremely limited.”

Several policies have been shown to improve health. Children who receive early-childhood education, for example, have lower rates of obesity, child abuse and neglect, youth violence and emergency department visits, according to the CDC.

And earned income tax credits — which provide refunds to lower-income people — have been credited with keeping more families and children above the poverty line than any other federal, state or local program, according to the CDC. Among families who receive these tax credits, mothers have better mental health and babies have lower rates of infant mortality and weigh more at birth, a sign of health.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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