Tagged Tobacco

As The Coronavirus Spreads, Americans Lose Ground Against Other Health Threats

For much of the 20th century, medical progress seemed limitless.

Antibiotics revolutionized the care of infections. Vaccines turned deadly childhood diseases into distant memories. Americans lived longer, healthier lives than their parents.

Yet today, some of the greatest success stories in public health are unraveling.

Even as the world struggles to control a mysterious new virus known as COVID-19, U.S. health officials are refighting battles they thought they had won, such as halting measles outbreaks, reducing deaths from heart disease and protecting young people from tobacco. These hard-fought victories are at risk as parents avoid vaccinating children, obesity rates climb, and vaping spreads like wildfire among teens.

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 Dr. 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 Dr. 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 Dr. 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.”

The country has split into two states of health, often living side by side, but with vastly different life expectancies. Americans in the fittest neighborhoods are living longer and better — hoping to live to 100 and beyond — while residents of the sickest communities are dying from preventable causes decades earlier, which pulls down life expectancy overall.

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, in spite of 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 U.S.

With deadly new types of bacteria and fungi ever emerging, Dr. Robert Redfield, the CDC director, 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, and the CDC warns that “little now stands between us and untreatable gonorrhea.”

That news comes as the CDC also reports a record number of combined cases of gonorrhea, syphilis and chlamydia, which were once so easily treated that they seemed like minor threats compared with HIV.

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 Dr. Cornelius “Neil” Clancy, a spokesperson for the Infectious Diseases Society of America. “It should be a global embarrassment.”

The proliferation of resistant microbes has been fueled by overuse, by doctors who write unnecessary prescriptions as well as farmers who give the drugs to livestock, said Dr. William Schaffner, a professor of preventive medicine at Vanderbilt University Medical Center in Nashville, Tennessee.

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. “That shows the real perversion in how the health care system is set up.”

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 as 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.”

Progress against overall heart disease has stalled since 2010. Deaths from heart failure — which can be caused by high blood pressure and blocked arteries around the heart — are rising among middle-aged people. Deaths from high blood pressure, which can lead to kidney failure, also have increased since 1999.

“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.”

Addicting A New Generation

While the United States never declared victory over alcohol or drug addiction, the country has made enormous progress against tobacco. Just a few years ago, anti-smoking 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 fell from 36% in 1997 to 5.8% today, studies show 31% of seniors used electronic cigarettes in the previous month.

FDA 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 Myers said FDA officials were slow to recognize the threat to children.

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. Around the world, children in the poorest countries often lack 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 disregard the medical evidence that vaccinating kids is safe.

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.

By 2000, measles cases had fallen to 86, and the United States declared that year that it had eliminated the routine spread of measles.

“Now, mothers 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. “Measles is still out there,” Schaffner said. “It is our obligation to understand how fragile our victory is.”

Health-Wealth Disparities

To be sure, some aspects of American health are getting better.

Cancer death rates have fallen 27% in the past 25 years, according to the American Cancer Society. The teen birth rate is at an all-time low; teen pregnancy rates have dropped by half since 1991, according to the Department of Health and Human Services. And HIV, which was once a death sentence, can now be controlled with a single daily pill. With treatment, people with HIV 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. Life expectancy in some regions of the country grew by four years from 2001 to 2014, while it shrank by two years in others, according to a 2016 study in JAMA.

The gap in life expectancy is strongly linked to income: The richest 1% of American men live 15 years longer than the poorest 1%; the richest women live 10 years longer than the poorest, according to the JAMA study.

“We’re not going to erase that difference by telling people to eat right and exercise,” said Dr. Richard Besser, CEO of the Robert Wood Johnson Foundation and former acting director of the CDC. “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.”

The infant mortality rate of black babies is twice as high as that of white newborns, according to the Department of Health and Human Services. Babies born to well-educated, middle-class black mothers are more likely to die before their 1st 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 focused largely on expanding access to medical care and encouraging healthy lifestyles. Today, many advocate taking a broader approach, calling for systemic change to lift families out of the poverty that erodes mental and physical health.

“So many of the changes in life expectancy are related to changes in opportunity,” Besser said. “Economic opportunity and health go hand in hand.”

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.

Improving a person’s environment has the potential to help them far more than writing a prescription, said John Auerbach, president and CEO of the nonprofit Trust for America’s Health.

“If we think we can treat our way out of this, we will never solve the problem,” Auerbach said. “We need to look upstream at the underlying causes of poor health.”

Related Topics

Pharmaceuticals Public Health

The Golden State’s Mixed Record On Lung Cancer

It was a bewildering moment for Zach Jump, the American Lung Association’s national director of epidemiology and statistics. The numbers leaped off the computer screen and prompted an immediate question:

How could California, a leader in reducing lung cancer cases, fall so short on early diagnosis and treatment of the disease?

“It’s like you’d found the needle in the haystack of results,” said Jump. “I don’t know if anyone knew this was going to show up.”

It was right there in the association’s annual “State of Lung Cancer” report, published in November: California had the third-lowest rate of new lung cancer cases in the country, a laudable achievement. But among state residents diagnosed with the disease, nearly a quarter received no treatment — a dismal showing that landed California near the bottom of the heap. Worse, California screened high-risk patients at a lower rate than every state but Nevada.

Nationally, the report showed a dramatic increase in the five-year survival rate of people diagnosed with the disease. That finding was reinforced by an American Cancer Society report released last month showing that from 2016 to 2017, the U.S. experienced the largest single-year drop in cancer mortality ever reported — driven by a decline in deaths from lung cancer.

California’s low rate of new lung cancer cases makes sense given its aggressive anti-tobacco laws and high taxes on tobacco products. Between 85% and 90% of people who die of lung cancer in the U.S. were smokers, and “California is the poster child for tobacco control,” said Jump.

But what explains the state’s dramatically weaker performance on early diagnosis and treatment?

The answer is complicated in a state as large as California, but lung cancer experts agree on the influence of several factors: the state’s large income inequality, broad cultural and linguistic diversity, inconsistency of health care access by region — and neighborhood — and a financial reluctance by many medical professionals to treat poor people, who smoke at higher rates than those of the general population.

“People aren’t getting screened in the places where the incidence of smoking is the highest,” said Dr. Jorge Nieva, an oncologist with Keck Medicine of the University of Southern California.

A low-dose CT scan, the only recommended screening exam for lung cancer, is highly effective, research shows. In one large clinical trial, it reduced lung cancer deaths by 20% among people at high risk, who were defined as those between ages 55 and 80 with a history of heavy smoking, even if they had quit within the previous 15 years.

The lung association study shows that just 4.2% of patients in the United States who are at high risk for lung cancer get screened for it — seen as an alarmingly low figure by those who work in the area of prevention. But compared with that low national figure, California’s screening rate is woefully inadequate: just 0.9%.

Performing the exam is profitable — but only if insurance payments are high enough. Medi-Cal, the government-funded insurance program for low-income people that covers about a third of all Californians, has long paid rates far below the national average.

Not surprisingly, scans are performed much more commonly in areas where people are likely to have good private insurance. “Unfortunately, it’s the population that doesn’t have great insurance that needs the screening the most,” said Nieva.

Medical experts say the state’s low screening numbers help explain why 24% of California’s diagnosed lung cancer patients receive no treatment at all, well above the national average of around 15%. Without adequate screening, lung cancer generally is discovered at later stages, when treatment is far less effective and many clinical trials aren’t offered.

Other factors weigh heavily on California’s ability to boost screening and treatment, according to people with deep experience in the field. Among them:

Cultural barriers. Especially among immigrant groups, “we need culturally sensitive approaches that include materials, educational tools, awareness campaigns and doctors who can speak to people in their native languages,” said Laurie Fenton Ambrose, president and CEO of the GO2 Foundation for Lung Cancer, a patient advocacy group.

Homelessness. As California’s unhoused population has swelled to over 150,000, health care providers have more difficulty reaching those in need of services. “Many of the 60,000 homeless in L.A. County would very likely be considered at risk for lung cancer, and they are not being screened,” said Dr. Steven Dubinett, a pulmonologist at UCLA.

Access to primary care. “California has some uniqueness in how hard it is to see a doctor in lots of parts of the state,” Nieva said. “That’s incredibly important when it comes to getting things early on, like that persistent cough you’ve had for a few months.”

Lack of statewide coordination. The state’s Comprehensive Cancer Control Plan hasn’t been updated in almost a decade. “It is inefficient and slow to improve. You don’t even have a plan that lays out its goals for fighting lung cancer,” Fenton Ambrose said.

Numerous personal factors can also influence whether patients get screening and treatment, experts say. Some people may be reluctant to be tested for fear of learning they have a terrible disease — including medical problems unrelated to lung cancer that the exam might uncover.

Nieva and Fenton Ambrose said the stigma attached to lung cancer — the notion that patients caused it themselves by smoking — can contribute to a sense of fatalism in both patients and their doctors.

Dubinett favors rolling out screening programs throughout the state, especially in areas where access to health care is spotty. Given the effectiveness of the exams and follow-up treatment if lung cancer is detected early, the state might well improve upon its five-year survival rate for lung cancer patients, which stands at 21.5% — roughly matching the national average of 21.7%, according to the lung association.

Such an initiative may fall to the state, with help from academic medical systems including USC and UCLA.

Nieva noted that USC has begun an outreach program in South Los Angeles offering high-risk patients free rides to Keck Hospital for screening.

“This should be getting done everywhere, and at a 100% rate,” Nieva said. The fact that it’s not is “a real indictment of our health care system.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Related Topics

California Multimedia Public Health States

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! And Happy Valentine’s Day, where we at KHN have compiled some of the best #HealthPolicyValentines from Twitter (this seems the right group for that level of wonkiness!). Check out some great ones, like this from Laura Marston:

“One vial a week
Keeps me alive
Used to cost $20
Now it’s $275.”

Now on to equally fun things, like budgets!

President Donald Trump released his proposed budget this week with only the vaguest of a health care plan mentioned. A mystery pot of $844 billion signaled deep cuts to Medicaid and subsidies under the health law. In particular, an obscure passage referred to “ending the financial bias that currently favors able-bodied working-age adults over the truly vulnerable.” Critics were scratching their heads how the released budget aligned with Trump’s promise to protect people’s coverage. “You can’t cut $1 trillion from these programs and protect the most vulnerable,” said Aviva Aron-Dine of the Center on Budget and Policy Priorities.

The Associated Press: Mystery $844B Pot in Trump Budget Signals Medicaid Cuts

The budget also calls for an almost 16% cut to the CDC (yes, the agency handling the coronavirus outbreak). But top officials say that’s because the administration wants the CDC to narrow its focus to its core mission of preventing and controlling infectious diseases and handling public health crises.

The Washington Post: Trump Budget Cuts Funding for Health, Science, Environment Agencies

Trump also wants to cut the budget for the National Institutes of Health by 6.5%. (Yes, that would affect the National Institute of Allergy and Infectious Diseases, which is working on a vaccine for the coronavirus.)

The Wall Street Journal: Trump Proposes $4.8 Trillion Budget, With Cuts to Safety Nets

Another odd little nugget in the budget: Trump wants to strip the FDA of its authority over tobacco products and create an agency within HHS solely for that purpose.

Stat: Trump Doesn’t Want the FDA to Regulate Tobacco

For a full breakdown of the budget’s details, check out our roundup here.


This week, the coronavirus strain got an official name, which is — drum roll, please —COVID-19. Although the announcement probably set off celebrations among scientists and researchers who have been driven up a wall because everyone has been simply calling it “coronavirus,” I am here to report that a day into its official designation 95% of headlines are stilling using only the generic term.

— It is, however, important to note that WHO officials were careful not to name the disease after a particular region or people so as to avoid further stigmatization surrounding any outbreaks.

Time: What’s in a Name? Why WHO’s Formal Name for the New Coronavirus Disease Matters

— As the death toll climbs in China, officials have expanded their “wartime” campaign to round up all the people who may be infected. But, as you can imagine, that is not going perfectly. Not only is it stoking tensions among an angry and scared nation whose residents aren’t happy with how the government is handling the crisis, but also it’s thrusting people who haven’t even tested positive for the virus into situations where they become vulnerable to infection.

The New York Times: China Expands Chaotic Dragnet in Coronavirus Crackdown

— Readers of The Friday Breeze know I’ve been harping on the fact that our national attention has been focused on COVID-19 even though we have only 15 (non-fatal) confirmed cases of it here and the common flu is far more deadly to us. Well, there’s a psychological basis for why we tend to panic over things that statistically are unlikely to affect us. Pretty much we can be terrible at accurately assessing risk.

The New York Times: Coronavirus ‘Hits All the Hot Buttons’ for How We Misjudge Risk

— It was a bit of a roller-coaster week with data coming out of China. At first, it seemed the cases were slowing down, but then the diagnostic criteria were tweaked, and all of a sudden we had nearly 15,000 cases added in one night.

The New York Times: Coronavirus Cases Seemed to Be Leveling Off. Not Anymore.

— CDC Director Robert Redfield said that the United States is essentially trying to buy time with its containment strategy, but it is quite likely there will eventually be person-to-person transmission of the virus here. (Which means people other than evacuees from Wuhan will start getting it.)

Stat: CDC Director: More Person-To-Person Coronavirus Infections in U.S. Likely

— And you can see how easily that could happen, given a U.S. evacuee was mistakenly released from the hospital even though she was infected with the coronavirus.

CNN: First US Evacuee Infected With Coronavirus Was Mistakenly Released From Hospital

— In an update from the cruise from h-e-double-hockey-sticks: Tensions continue to rise along with COVID-19 cases among the passengers and crew of a ship quarantined off the coast of Japan. As one health official said this week: Remember, quarantines are to keep those outside of its boundaries safe, not those within.

The New York Times: Quarantined Cruise Passengers Have Many Questions. Japan Has Few Answers.

— WHO has been heaping praise on China for its response to the crisis. And while other experts acknowledge the organization is in the tenuous position of not wanting to anger China enough that they break off relations, critics say the excessive compliments are setting a bad precedent about what a good pandemic response looks like.

The Wall Street Journal: The World Health Organization Draws Flak for Coronavirus Response

— Meanwhile, the coronavirus research filed is quite small. That’s because, despite the buzz these kinds of outbreaks create, eventually the world’s attention will be caught by a different shiny object and both the funding and interest in researching the virus will fade.

Stat: Fluctuating Funding and Flagging Interest Hurt Coronavirus Research


Supporters of Sen. Bernie Sanders (I-Vt.) got their wrists slapped by a powerful Nevada union this week for “viciously attacking” members and their families online. At the heart of the matter: The union had released information critical of Sanders’ “Medicare for All” plan. The clash put Sanders — who denounced any harassment as “unacceptable” — in an awkward spot just before the Nevada caucuses next week.

Politico: Nevada Culinary Union Lays Into Sanders Supporters After Health Care Backlash


A new survey found that even when patients plan ahead, many are still hit with surprise medical bills, especially if they receive anesthesia during a procedure. With health care spending rising again (driven by high costs like the out-of-pocket price tag for an emergency room visit), the report is a reminder that the issue is likely to be top of mind with voters come November.

Meanwhile, lawmakers well aware of that fact are moving forward with legislation that would favor an arbitration method for dealing with the surprise costs. This strategy is favored by hospitals and providers, and not embraced by insurers.

Reuters: Surprise Surgery Bills Happen Even When Patients Plan Ahead

Modern Healthcare: House Committee Advances Provider-Friendly Surprise Billing Fix


In a little bit of breaking news, a federal appellate court just shut down CMS’ approval of Arkansas’ Medicaid work requirement. The panel upheld a lower-court ruling that found the requirements arbitrary and capricious.

Modern Healthcare: D.C. Circuit Nixes Arkansas Medicaid Work Requirement


Juul has vowed time and again that it hasn’t marketed its products to teenagers. But new revelations from a Massachusetts lawsuit that the vaping company bought ads on Nickelodeon and the Cartoon Network are challenging those promises.

The New York Times: Juul Bought Ads Appearing on Cartoon Network and Other Youth Sites, Suit Claims


The VA is no stranger to controversy, but the latest bout comes at a bad time for the agency. The abrupt firing of the agency’s well-liked undersecretary in combination with allegations that VA Secretary Robert Wilkie sought to dig up dirt on a woman after she said she was sexually assaulted at a VA facility have shaken the agency just as it is preparing to launch an ambitious health plan.

The New York Times: Veterans Affairs, a Trump Signature Issue, Is Facing Turmoil Again

Meanwhile, Trump continued to downplay brain injuries sustained by troops from an Iran missile strike even as the number of cases jumped past 100.

The New York Times: More Than 100 Troops Have Brain Injuries From Iran Missile Strike, Pentagon Says


In the miscellaneous file for the week:

— It’s notoriously hard to get any gun measures passed … except these advocates seem to be having some success. Their strategy? Go hyper-local.

NBC News: How Moms Are Quietly Passing Gun Safety Policy Through School Boards

— What’s going on with the Equal Rights Amendment and why has it become a fight over abortion? Politico takes a deep dive into its history about how the battle around the amendment has shifted in the nearly 40 years since it was introduced.

Politico: How the Debate Over the ERA Became a Fight Over Abortion

— New parents eager to better balance family and work life in the only industrialized country in the world without a paid family leave policy have started bringing their babies to their offices.

Stateline: You Can Bring Your Baby to Work (But Wouldn’t You Rather Be at Home?)

— In another crushing disappointment, an Alzheimer’s drug that had sparked high hopes was the latest to fail to live up to expectations.

The Associated Press: Drugs Fail to Slow Decline in Inherited Alzheimer’s Disease


That’s it from me. And remember, if you ever feel like flexing your poetic muscles outside of Valentine’sDay, we accept haiku submissions year-round. Have a great weekend!

Related Topics

Cost and Quality Courts Global Health Watch Health Care Costs Health Industry Insurance Medicaid Pharmaceuticals Public Health The Health Law