Discovering Precision Health. Lloyd Minor
5 percent of the income distribution saw their life expectancy increase by 2.3 years between 2001 and 2014, it only grew 0.32 years for those in the bottom 5 percent. The gap was even larger among women—2.91 years and 0.04 years, respectively [7].
The gap is not just between the very rich and the very poor. In recent years, the mortality rate for men ages 65–79 in the top 1 percent of wealth distribution has been 40 percent lower than the average mortality rates for all tax filers in that age bracket, according to UC Berkeley economists Emmanuel Saez and Gabriel Zucman. From 1979 to 1983, the difference between the top 1 percent and everyone else was just 10 percent [8].
A study conducted by seven professors at the Stanford School of Medicine, led by Latha Palaniappan, documented the persistence of U.S. health disparities from 2003 to 2015. The study, which was published in November 2018, showed that while the age‐ and sex‐adjusted mortality rates decreased by 12 percent in the total population, high‐income counties experienced a 15 percent decline, while in low‐income counties the decline was only 7 percent. Similarly, adjusted mortality rates for heart disease declined 30 percent in high‐income counties, but 22 percent in low‐income counties. The study also showed that African Americans have a higher mortality rate than other groups (Asian Americans, Hispanics, non‐Hispanic whites, and American Indians/Alaska Natives) [9].
These disparities highlight the need for remedies that will help those who are falling behind. One of the most disturbing facts about U.S. health is the number of people who die prematurely each year and the causes of those deaths. The authors of a 2013 report sponsored by the National Institutes of Health wrote that “Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary” [10].
The causes of those deaths were spelled out in another comprehensive study, which was published in 2013 in the Journal of the American Medical Association. The researchers found that the primary causes of U.S. morbidity and mortality were poor diet, obesity, smoking, and high blood pressure [11]. The study has continued to be updated, and there is extensive data comparing current trends with those that existed in 1990. Some of the news is encouraging: the number of people dying from ischemic heart disease declined by nearly 100,000. On the other hand, heart disease was still responsible for nearly 545,000 deaths—well more than twice the number of deaths from any other condition. (The second‐biggest killer in 2016 was Alzheimer’s and other dementias, which were responsible for close to 239,000 deaths [12].)
When deaths were broken out by causes, and not specific diseases, one factor stood out from the rest: diet. The researchers found that “dietary risks” accounted for close to 530,000 deaths in 2016. Nearly 84 percent of the deaths stemmed from cardiovascular diseases, and the rest stemmed from a combination of neoplasms and diabetes, as well as urogenital, blood, and endocrine diseases [13].
The dietary risks are reflected in the expanding waistlines of the American people. Today, nearly 40 percent of American adults qualify as obese (meaning a body mass index of 30 or higher), as do 18.5 percent of children 19 and under [14]. The only countries with higher obesity rates (not counting a number of tiny Pacific and Caribbean islands) are Kuwait, Belize, Qatar, and Egypt.
What’s striking is how quickly the profile of the American population changed. As recently as 1980, just 10 percent of the U.S. population was obese. Although obesity rates have been rising globally—there’s been a tenfold increase in childhood obesity over the past 40 years [15]—the percentage point increase in American obesity since 1980 has been greater than in any other country in the world, according to a study published in 2017 in the New England Journal of Medicine [16].
The reasons for this decline in health are varied, and they speak to the need for new approaches to health—particularly focused on prediction and prevention. In later chapters, I highlight how select initiatives can not only treat obesity but try to prevent it (particularly in children) by emphasizing the value of both a healthy diet and regular physical activity.
THE U.S. HEALTH CARE CONUNDRUM
Health care is one of the most debated subjects in the United States. Consider the passionate feelings about the Affordable Care Act—better known as Obamacare—and whether to preserve it, reform it, or repeal it. What’s striking about U.S. public opinion related to health care is not the divide between Republicans and Democrats but rather the differences in how people feel about the care they receive versus the system that provides that care.
In November 2017, the Gallup organization asked more than 1,000 people to rate the quality of care that they received, and 77 percent said it was “excellent” or “good.” There’s been little fluctuation in that number dating back to 2001 [17]. But when people were asked to describe the state of the U.S. health care system, 71 percent said it was “in a state of crisis”—a sentiment that has not changed much since 2008 [18].
Although I will emphasize health care in later chapters, I want to focus here on the health care system and touch on some of the features that people find unsatisfactory. I am certainly familiar with the system’s inadequacies and will start with something that reflects those inadequacies: how it has been insulated from the technology disruptions that have shaken up countless other industries.
One way to gauge the slow pace of innovation in how the health care system operates is the absence of any game‐changing products or companies akin to, say, Google, Uber, Airbnb, Amazon, etc. I certainly recognize the obstacles to disruption, such as extremely complex billing systems, restrictive government regulations, and the high stakes associated with any innovation that involves the care and treatment of human lives. Nonetheless, the effect is striking: how health care is delivered, and the environments in which medicine is practiced, have not changed much since I graduated from medical school in 1982. Yes, there have been some modifications, such as the adoption of electronic health records (which have brought their own set of issues, as I describe below), but the foundation of the system remains the same. That’s problematic for everyone involved, but primarily for patients and the health care professionals who serve them.
THE “SOPHISTICATED” TECHNOLOGY IN DOCTORS’ OFFICES
Emblematic of the lack of innovation is the fact that many (if not most) physicians’ offices still rely on a device that disappeared in just about every other industry two decades ago: the fax machine. “It’s been the most sophisticated piece of technology in many doctors’ offices for decades,” points out Bill Evans, CEO of the venture capital firm Rock Health. Here’s how one journalist, Sarah Kliff, writing in 2017, described the situation:
In the medical sector, the fax is as dominant as ever. It is the cockroach of American medicine: hated by doctors and medical professionals but able to survive—even thrive—in a hostile environment. By one private firm’s estimate, the fax accounts for about 75 percent of all medical communication. It frustrates doctors, nurses, researchers, and entire hospitals, but a solution is evasive.
Kliff goes on to point out that one of the reasons fax‐based communications endure in the medical field is that hospitals don’t necessarily want to share patient information with each other:
While patients might want one hospital to exchange information with another hospital, those institutions have little incentive to do so. A shared medical record, after all, makes it easier to see a different doctor. A walled garden—where records only get traded within one hospital system—can encourage patients to stick with those providers [19].
The persistence of the fax machine (and the paper that accompanies it) demonstrates how technology has often been treated as a cost of doing business and not a tool for progress (as it has been in just about every other industry). The fax machine is also an administrative headache that saps the productivity of all health care professionals who are subject to it. Today, about one‐third of physician practices insist on doing business with paper forms and fax machines. It is often used when a physician’s office fills out a claims form on paper and faxes it to the payer, who pays someone to transcribe it into their