[MUSIC] Hello, I'm Dr Nancy M Bennett. I'm a professor of medicine at the University of Rochester and also the director of the Center for Community Health and Prevention. I've spent most of my career in public health and academic medicine and I'm looking forward to sharing some of my insights with you today. We're going to talk about the American healthcare system as a form of background for the rest of this course. I hope that what I can share with you today is just a few very clear cut and simple examples of the ways in which we struggle in the American health care system. Which is part of the reason why we believe that community engagement and working in communities is so critical to improving health. So I call it the American health paradox. As you will see later in the lecture, there are others who have used that exact term as well. But what we want to talk about today a little bit is what's missing. And we're going to talk about that throughout the course actually, you're going to learn a lot about the things that the health care system has been unable to implement to improve health. So first let's think about the US as a whole in the context of the world, as you probably know and have heard in the news, we don't have the best health status in the world. One would think we were a very advanced country. But if we look at other advanced countries, we find that actually we rank rather low with respect to our health status. And on this map it's just a series of colors to show which countries have the best health status. And you can see that Canada, Australia, Europe, Scandinavia, they all do a better job than we do with respect to keeping their populations healthy. That's a pretty disturbing acknowledgement that has come to be commonly known in the US but still really bothers most of us in public health. And these are just a few indicators of the ways in which we don't measure up. As you can see our life expectancy is not as high as many other countries. Our Infant mortality rates are not good, especially in a country that's as wealthy as we are. We have problems with obesity. We still have some difficulties with tobacco. The number on this slide, which is relatively low compared to other countries, actually hides the reality. Which is that in some populations in the US, the rates of smoking are as high as 20, 25, 30%. So we still have a long way to go in improving the health status of our country. And then there's the other issue which I know you've all heard about but that we have to point out which is how much we spend on health care. And this is a chart that shows over the years the increase in the percentage of the gross domestic product that gets spent on health care. And you can see starting back in 1980, many of these countries were grouped fairly closely. And we actually were all spending somewhere below 10% of the gross domestic product. However, over the intervening years, what's happened is that the US has increased its spending enormously and other countries have stayed much flatter. And as we saw on the slide before, nonetheless, they've done better with respect to how healthy their populations are. So, this is a really disturbing fact. It's beginning to level out a little bit as we're reaching 2016, 17, 18 we're beginning to flatten out a little. But you can see that we're still spending up to 18% of our gross domestic product on health care alone. This is a one picture tells a huge story slide that I really enjoy using and comes from the internet several years ago. But as you can see on this slide, if you compare spending to health status, most countries line up in a nice line, which shows that the more they spend, the better they do. Life expectancy increases with higher expenditures. But then there's the US, way out here our expenditures are way, way higher and our life expectancy is not. So we effectively are on mars compared to all of these other countries. So if you keep one thing in your mind from this lecture, this slide should be it. What do we spend money on? That's the question that gets asked very often, and you can see that a large percentage of our money is spent on care. So whether it's hospital care or ambulatory care, we also spend significant amounts on medications and devices. And there's this category called other, which we've broken out because actually public health and prevention make up a tiny percentage of what we spend. And that is one of the secrets as to why we have a problem with the health of our communities. We just don't spend anything on public health or prevention. 2% is the estimate, and 2% obviously isn't going to get you very far. So some of the things we'll be exploring in this lecture, are how can we do better with respect to prevention? How can we do better in our communities to enhance health? Remember, it's something that we all need to do together. It's not something that the system can do for our communities. So, again, another important fact to remember, which is that we do very little to really focus on public health and prevention. So another way of looking at this is to start to think about all the things that impact health. So it's not just the health care system, it's also people's lives, that is where do they live, how well are they educated, how much is their family income, etc, etc? And we're going to talk about the social determinants of health in much more detail further along in this series. But just to point out and this was pointed out in this book that was published a few years ago, we spend a lot on healthcare, 16% of our gross domestic product more than anyone else. But we spend less on social care and maybe that's the big issue in the US. Maybe that explains the paradox. It may be that actually spending on social care gets you more with respect to health than spending on health care. And I think that's one of the insights that we all need to keep in mind as we try to think about solutions to improving the health status of our country. Another way to look at it is to think about the ratio between healthcare spending and social spending. And this is just a graph of various different countries and the ratio of social to health spending. And you can see that we rank very, very low compared to all these other countries. The average is much much higher, the average ratio's somewhere between one and a half to two, whereas ours is less than one. So this again just points out that we don't spend enough on social care, we spend a lot on health care and we're not getting the results that we need. There was a study done quite a few years ago looking at 30 different countries and comparing social expenditures to health expenditures and that ratio I just showed you. And in this study they showed that that ratio correlates very directly with infant mortality, life expectancy, and decreased years of potential life lost. Those are all big measures of how well a population is doing with respect to health. [MUSIC]