С заботой о здоровье нации: США и Россия, или небо и земля

Александр Шиляев

Далеко не все ладно в системе здравоохранения США. Причем, уже давно. Денег тратится много (см. например здесь и здесь), а толку выходит мало. Успехи Европы в этой жизненно важной сфере не дают американцам покоя. Отсюда непрестанные реформы и попытки выправить положение. По количеству реформ на душу населения США, пожалуй, даже нас оставили далеко позади.

Впрочем, достаточно иронии. Она была бы уместна, если бы у них получалось все так же коряво, как и у нас, если бы они, действительно, не пытались постоянно искать что-то новое, а только обезьянничали. Однако новая инициатива, о которой пишет Lancet, и которую Америка хочет предпринять, чтобы поднять здоровье нации -- теперь речь идет уже не столько о медицине, не столько о лечении, сколько о предупреждении болезней и пропаганде здорового уровня жизни (и это при всем при том, что у них уже достигнуто в этой области) -- на невиданные прежде высоты, так вот эта инициатива с удивительной ясностью дает нам понять, где они и где мы, и, более того, где они и где мы можем оказаться в самом ближайшем будущем, если будем следовать каждый соответственно своим намеченным планам и избранным стратегиям.

В чем заключается суть предлагаемых шагов, взаимодействие какого количества структур и на каком уровне потребуется для реализации намеченной программы -- об этом в статье, предлагаемой вашему вниманию ниже. Прочитайте, а потом без эмоций сопоставьте сказанное со всем тем, что и как предпринимается в российской медицине сегодня. И почувствуйте разницу. (Boldface по тексту мой -- А.Ш.)

Кстати, вам попадались на глаза вот такие -- не программные, а популярные -- материалы, в которых бы правительство на пальцах объясняло своим гражданам, что, а главное почему, оно собирается делать? Вот в этом еще одна большая разница между ними и нами.

America takes action on disease prevention

Bob Kirsch

The Lancet, Volume 380, Issue 9843, Pages 715 - 716, 25 August 2012

The USA is taking strong actions within its national disease prevention strategy, which aims to increase the number of Americans who are healthy at every stage of life. Bob Kirsch reports.

America's release of its first-ever national disease prevention strategy last year was one thing, implementing it, however, was always going to be another. But concrete steps are now being taken by the US Government in no fewer than 200 areas, say experts, while cities like Chicago and San Diego and states like Massachusetts are modelling their own, local action plans on the federal plan.

Within the purview of the recently released National Prevention Council Action Plan: Implementing the National Prevention Strategy, people in Albuquerque are driving veterans to health facilities; exercise programmes have been shaped to the needs of American Indian youth; the Department of Labor is developing approaches to help firefighters across the nation cope with work stress; military bases in Florida are changing the types of foods served to recruits and the rules about smoking; in the Midwest, the Environmental Protection Agency and the Department of Transportation are working together to build sustainable communities; in the Deep South, access to recreation areas is being improved; and in Milwaukee the safety of workplaces is being shored up.

The action plan identifies the federal contribution to a nationwide prevention effort involving and coordinating with not only branches of state and local governments but also with tribal governments, health-care systems, businesses, communities, and faith-based, non-profit, and other local organisations. With a focus on local communities, health disparities, and the choices made by people, the strategy is placing particular emphasis, on tobacco, drugs, alcohol, food, exercise, violence, safety, reproductive and sexual health, and mental and emotional wellbeing.

One of the major legislative achievements of the Obama Administration, the Affordable Care Act (ACA) not only addresses health-care costs for individuals but also disease prevention measures. It created the National Prevention Council, led by Surgeon General Regina Benjamin with participation by 17 federal agencies. Furthermore, the ACA provides a US$15 billion 10-year budget for prevention efforts.

“One of my major goals is letting Americans know that being healthy can be enjoyable. We think making it fun is the way to motivate people. It's not about what people can't do and can't have. We have to start telling people what they can do and letting them decide what they want to do. We have to change the focus from sickness and disease to health, wellness, and prevention”, Benjamin told The Lancet.

“In our world now, it is not easy to be healthy. In part, that is because we have taken the joy out of this. We want to put the joy back in”, she said. “We are empowering people to take control of their own lives. Of course, what brings you joy may be different than what brings me joy—each person and each group has to find their own way.”

“As government it is our role to help make the healthy choices the easy and affordable choices”, the Surgeon General explained. “To let people know that health is in everything we do and every place we are. It is not just for the doctor's office and the hospital. Health is where we live, where we learn, where we work, where we drive, where we play, where we pray.”

The country starts from a baseline where a huge health-care effort has not achieved a commensurate level of benefit. “The United States still has a considerable way to go just to be average among developed nations in the area of life expectancy”, said Steven Teutsch, Chief Science Officer of the Los Angeles County Department of Public Health and Vice Chair of the committee that wrote the 2012 Institute of Medicine's (IOM) report For the Public's Health: Investing in a Healthier Future.

“The leading causes of death and illness—physical inactivity, unhealthy eating, tobacco use, and motor-vehicle injuries—may not yield to any great degree to pills and procedures but there is evidence that well targeted investment in the community can positively impact these factors”, points out David Fleming, Director and Health Officer for Public Health—Seattle & King County, a large metropolitan health department.

“Much literature teaches us that the most powerful determinants of the health of populations are mediated far upstream from what happens when an individual goes to see a physician”, states Marthe Gold, Professor and Chair of the Department of Community Health and Social Medicine at City College in New York City and chair of the IOM report writing committee.

Fleming lauded the action plan for funding such programmes as Community Transformation Grants “to spur investment in safer walking routes to schools, healthy corner stores, healthy homes, and clean indoor air. Such innovations will produce better health and cost savings for years to come. Unfortunately, critical funding for these efforts is under attack in Congress.”

“The national prevention strategy's power lies in its ability to bring together a wide range of sectors—housing, education, defense—to improve health”, explained Thomas Frieden, Director of the US Centers for Disease Control and Prevention (CDC). And Gold also found “particularly praiseworthy” this intersectoral approach involving 17 federal agencies, which “parallels work begun many years ago in Europe where this notion of considering the impact upon public health in all government policies is taken seriously and explored”.

“Because the approach to attenuating risks to population health may vary based on political philosophy, as administrations change there are likely to be different views on how to create a country that is healthier and more productive”, Gold said. “The IOM committee believes that the health of Americans need not be a partisan issue. My hope is that a standing prevention council at the highest level of federal government will do its work in a manner that crosses traditional political boundaries.”

“The big difference between the European action plans and the US plans is that for the most part Europe tends to emphasise more than does the US the social, economic, and political determinants of health”, said Vincent Navarro, Professor of Health and Public Policy, Bloomberg School of Public Health, Johns Hopkins University, MD, USA, and Editor-in-Chief of the International Journal of Health Services. The Europeans tend to pay attention “to public policies carried out by the central, regional, and municipal authorities and their implications on health and quality of life”, he explained.

One of the strengths of the action plan is that it reflects an extensive and determined “commitment to using evidence-based interventions to reduce tobacco use, improve nutrition, and make progress” in numerous health domains, Frieden pointed out.

An additional strength is how the action plan has been structured to catalyse local and regional action plans, said Andrew Rein, Associate Director for Policy at the CDC: “It's not a federal prevention strategy but a national prevention strategy, and it really has the greatest impact when people across the country pick it up in their own work.” As Teutsch explained, “What is really important is that the changes being made at the federal level sift through, so they work locally in all our communities.”

Another strength is that it requires government agencies to “start to do the things they can actually do, working with ongoing programmes”, said Teutsch. For example, the Department of Housing and Urban Development and the Department of Transportation have “taken this concept really to heart”, understanding that “the quality of our housing and our communities are vitally important for health. What we want to see is that in the future new policies are framed with the health of people and communities in mind.”

However, some experts point to weaknesses in the plan. “The Obama Administration tends to be less conservative than the previous administration, but still far more cautious than the reality the country calls for”, Navarro stated.

“The plan needs an integrated approach and a specific focus on the life course, development, and experiences of children and youth”, Martin José Sepúlveda, Vice President, Health Research at IBM, explained. “While it contains a good number of interventions for this subpopulation, the approach does not appear coordinated or continuous. Primary care and medical homes for children and youth, social-services enrichment, interventions for families, behavioural health and some children-specific, risk-factor interventions, such as injury prevention (apart from the Department of Transportation child restraint initiative), are not apparent in the plan. Given the significant impact of education for everything from life perspective and risk tolerance to employment, income, housing, recreation, health literacy, and health status, more aggressive and innovative interventions in schools are also needed.” As Gold commented, “Poor education tracks with poor health outcomes.”

How will this national prevention effort work out in the long run? Only time, and the November election result, will tell. On the one side are powerful forces that want current steps scaled back, including people in Congress opposed to the current strategy. On the other side are experts who see a crying need for more to be done to prevent ill health in America.

For the 2011 National Prevention Strategy see http://www.healthcare.gov/prevention/nphpphc/index.html

For the 2012 National Prevention Council Action Plan see http://www.healthcare.gov/prevention/nphpphc/2012-npc-action-plan.pdf

For the 2012 Institute of Medicine report on public health see http://www.iom.edu/Reports/2012/For-the-Publics-Health-Investing-in-a-Healthier-Future.aspx