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IRA FLATOW, host:

This hour we're going to be talking about an interesting statistic that's sort of disturbing. It's a look at the declining life expectancy for certain segments of the American population. Researchers reporting in the journal, Public Library of Science Medicine, say that in some counties in the U.S., the death rate, especially for woman, that has been going down in - for years has suddenly started to increase, and it's mostly due to diseases related to smoking, high blood pressure and obesity.

And while most of the country has an increase in life expectancy - people are living longer in general - life expectancy has stagnated, or even reversed, for a significant part of the American population. Joining me now to talk about the study and why these trends might be happening is my guest. Majid Ezzati is associate professor of public health at the Harvard School of Public Health, and he joins us from Boston. Welcome to the program, Majid.

Dr. MAJID EZZATI (Professor, International Health, Harvard School of Public Health): Good to be on NPR.

FLATOW: Majid, well, tell us about this - what segment of the population are we talking about here?

Dr. EZZATI: We are talking about primarily women who have had stagnation or decline in life expectancy. And this are women in countries that are primarily in Appalachia, along the Mississippi River, in the Delta, then getting a little bit into the Deep South and into some parts of Texas.

FLATOW: Mm hm. Are this places that were unexpected?

Dr. EZZATI: Well, the decline in life expectancy is actually an unexpected thing. So, we were not expecting to see that - this phenomenon at all, regardless of the location. Life expectancy in high-income countries has cut off for extreme - for very long periods.

If there has been declines, it has lasted maybe for one year or two years, and by small amounts. So, to see a 20 years, almost 20-year trend, downward trend or a stagnation, is something that we are just not used to seeing in rich part of the world.

FLATOW: If you'd like to talk to Majid Ezzati on Science Friday, give us a call. Our number is 1-800-989-8255. Talking with Dr. Ezzati about this troublesome - I guess you would describe them as troubling trends.

Dr. EZZATI: It is very troubling. Again, when we think about decreasing life expectancy over long periods and by large amounts, we think of a large epidemic. We think of a destruction of the social and health system, the sort of things that happened in Eastern Europe, the things that happened after the HIV/AIDS epidemic in parts of the world. So, this is not something that we associate, again, with the well-functioning health system in a high-income country.

FLATOW: But for these people, they're not in the high-income neighborhood, are they?

Dr. EZZATI: No, they are not. The counties that had the largest decline tended to be, in general, poorer than the counties that were going up. So that's a factor, but we are talking about income levels orders of magnitude higher than the level you seen in parts of Africa.

So, by any international standard, this is a rich place. And whatever sort of the distribution of income is probably a part of it, but there has to be other reasons besides the fact that these are the poorest parts of the country.

FLATOW: Mm hm. Are there some - could they be life choices? Can they not choice not to smoke, for example?

Mr. EZZATI: Well, we don't think it's a random thing that people are smoking in one part of the country more than others or there is higher blood pressure. There is certainly an aspect of individual choice, but the belief of the public-health system that - is that, it is a role of public health through known interventions for things like tobacco, like blood pressure, to actually lower these things.

We have done it very successfully in many parts of the country. We have done it well over time. So, it's probably a sign of the fact that things that we know extremely well how to do are not reaching the people who need it the most, which is probably, you know, associated with every other thing that might be not going as well there, making the places somewhat lower-income.

FLATOW: Mm hm. So, they're not getting the services, or the advice, or the medical care, things like that, that they might be getting?

Mr. EZZATI: Exactly. The services that - it may be financial access to healthcare. It may be physical access to healthcare. Their employment may not provide them the opportunity to go there. It may be too far. It maybe the quality of care that they are receiving. Are they being tested regularly for having hypertension? Are they being given advice about diet and smoking? Or do they have the financial opportunity to implement that advice when they leave the doctor's or the nurse's office?

FLATOW: And are these folks limited to a certain area of the country?

Dr. EZZATI: Well, they are primarily in the sort of middle and south of the country, starting from Appalachia. Those counties are more there, so the decline and the stagnation is relatively geographically-focused.

FLATOW: But these have been very poor counties for a long time, have they not?

Dr. EZZATI: They have been, and they are lowering from counties, and again, I think - we believe that there are two really sets of strategies to deal with these. One is fundamental social policies that improve the social conditions, and then the other one, as that's happening, is proven, effective, health and public-health strategies that can improve health as social conditions are getting better.

In the same way that when we deal with surviving children from dying when they have malaria, we actually deliver drugs to them, even if they are poor children in parts of the world, the question of delivering good healthcare and good health services.

FLATOW: Well, that's interesting that you bring that up, because some people would say that we give better care to - you know, sending more care out of the country than we do for the poor people in this country.

Dr. EZZATI: That's probably not the case. I don't have the statistics with me, but I think people would say that the amount of care that we send outside the country is actually quite small, compared to what other countries send.

But I think that is clearly a very unequal distribution of care inside the country itself, too, given that the sort of things that are causing the diseases affecting the populations that are not doing very well are, again, things that we have addressed very well in other parts of the country.

FLATOW: Mm hm. 1-800-989-8255. Let's see if we can go to the phone calls, take a call or two. Let's go to Rudy in James County. Hi, Rudy.

RUDY (Caller); Hi. I must have listened (unintelligible). I think a lot of these disparity is related the lack of affordable healthcare and lack of health insurance, or having poor-quality health insurance, and I was just wondering what his opinions were on that.

FLATOW: OK.

Dr. EZZATI: I mean, I think health insurance is certainly a part of this picture, and what we tend to emphasize is that it is likely that giving purely insurance will not solve all the problems. There should be additional things, such as increased physical access and better quality of care.

So if we take health and healthcare in its broad term of having financial access, which is dealt with by insurance, and having high quality care, having health providers that actually do the primary care that they need to do provide the dietary, smoking, lifestyle advice, and follow up with it.

Test for hypertension and giving the anti-hypertensives when they are needed, then it certainly would improve the condition of all. But giving health insurance is good for a whole lot of other reasons also, and it's certain it should be a priority and it would be a step to our solving this issue also.

FLATOW: Give me some idea of the difference. How much it has declined?

Dr. EZZATI: Well, the life expectancy, in the counties that declined, declined an average by about 1.3 years, over the period of nearly two decades. Just to put that in perspective, the nation as a whole gained, for men, about seven years over a 40-year period, for women, about six years. So, taking - again, a country is going up by six or seven years every four decades, taking a segment of it and reducing life expectancy by well over one year is a relatively large number.

FLATOW: Michael in Sarasota. Hi. Welcome to Science Friday.

MICHAEL (Caller): Hello.

FLATOW: Hi there.

MICHAEL: Thank you for taking my call. I'm always curious about the long-lived people that come from like rural Oklahoma, and you never hear of anybody from like New York City and I -have you looked statistically at the level of pollution? We know smoking is a big factor in longevity, but what about breathing polluted air? Have you looked at that at all?

FLATOW: Good question. Could there be environmental factors?

Dr. EZZATI: There certainly could be. I mean, we have looked at the diseases that are causing this decline, and diseases like lung cancer, like diabetes, like chronic lung disease, and these are primarily associated with things like smoking and blood pressure and obesity, which are also consistent with where those factors are.

That doesn't mean, at least not yet, until one does more analysis, that other factors, including environmental factors, are not a part of this picture, and we and other researchers are starting to look at that. Air pollution is actually one that's a good example, one, at least for cities, can look at the role of air pollution in this, certainly worthwhile to look at that because it affects a lot of the same diseases.

FLATOW: So what are you suggesting, in specific?

Dr. EZZATI: Well, I mean, I think there are two things. I mean, I think a part of this should be a question that, as society, we should be asking ourselves, that can we live with inequalities? And then most people in public health think that we shouldn't.

And above and beyond that, even if some people thought that they could live with some inequalities, can we live with the situation that the worst off are actually getting even worse? So the tide is not only not raising everybody, but some people are sinking in this situation. So there is a set of social-policy questions that, certainly as a civic society, we should debate and consider.

But there is also set of health-system issues here, again, things that we know extremely well how to do. Blood pressure, that's been down for decades in this country before it started to go up for women again in the 1990s. Why are those interventions not reaching? What is the role of health system?

Anything from having insurance to having a good primary care system that gets people tested, to one that changes the pricing of food so that better diets could be affordable for the people who need them, to one that bands tobacco advertising which we have done very successfully in many parts of the country. So the two, probably, would have to go hand in hand, the health-system intervention and the social sort of policy issues that would affect this.

FLATOW: What do you say to people who say, well, you know, these people, they have a right of choice to not smoke, to eat better, to see the doctor if they'd like to, they have those choices that they can make if they wished to avail themselves of?

Dr. EZZATI: I think that argument probably would hold, if people were randomly distributed in across the country and the conditions that we're facing were similar. The fact that it's geographically concentrated means that there is something above and beyond individual choice that is happening.

And we have seen this over and over, that through effective interventions, we have managed to shift the tide without forcing anybody to change their choices, in terms of things like smoking. There was time in this country that 60 or 70 percent of men where smokers, and it now down to less than 30 percent. So, why is it that the same things are not happening in parts of the country that need them? Why is it that people are - do not have access to healthier food at the right prices?

FLATOW: This is Talk of the Nation Science Friday from NPR News. I'm Ira Flatow, talking with Majid Ezzati, who is an associate professor of public health at the Harvard School of Public Health. He's joining us from Boston. Our number, 1-800-989-8255. Let's see if we can get a phone call or two. Let's go to Larry in Jacksonville. Hi, Larry.

LARRY (Caller): Yes, how are you?

FLATOW: Hi there.

LARRY: I'm a 64-year-old man who happens to believe that my healthcare from my physician was much better 20 years ago that it is today, simply from the fact that they used to do a routine things like x-rays, and put you on the treadmill after certain age, and certain other tests that they would do for you.

And now, because the insurance companies are really running what the doctors can and can't do, my healthcare is not as good, and doctors don't spend anywhere near the time on you - they can't afford to - that they used to spend. And I think my overall health service is not near as efficient than it was 20 years ago.

FLATOW: So, you're thinking that that's what might be the problem here?

LARRY: I think that that certainly contributes to it, along with the fact that we've got 50 million people with no health insurance. Yeah, I think that contributes a lot it.

FLATOW: Yeah. Dr. Ezzati?

Dr. EZZATI: I mean, Larry pointed out something quite important, which is that having simply health insurance is a part of this picture. But the other part of it is the care that one gets when one health insurance, when one sees either the primary provider or a specialist.

So, regular testing, regular checkups, preventive services, whether it's through lifestyle, whether it's through things like anti-hypertensives. All of those should be a part of these picture that, again, we can, broadly, together, call it "quality of care," somewhat. And Larry pointed those out and they are definitely a part of this, above and beyond just simply having insurance.

FLATOW: Mm hm. Thanks a lot, Larry.

LARRY: Yes, sir.

FLATOW: So, do you think these people need an ombudsperson?

Dr. EZZATI: Well, I mean, I think that, certainly, one of the things that we need to do is have a system of reporting and accountability that focuses not just of the nation as a whole, but on what's happening to different parts of the country, different groups of people. So, the fact that we are noticing 20 years later, more than 20 years later, after this phenomenon started, that's it's happening, it's actually a rather bad find...

FLATOW: Yeah.

Dr. EZZATI: That it took so long to catch it. So, I think a very good starting point would be to actually have regular and public reporting of how the statistics for different parts of the country and to change our focus from just reporting one average number to reporting the number for various groups of America.

FLATOW: Thank you, Dr. Ezzati, for taking time to join us today.

Dr. EZZATI: Thanks.

FLATOW: Majid Ezzati is an associate professor of public health at the Harvard School of Public Health. He joined us from Boston.

A program note, if you're going to be in Milwaukee on May 16th, we're going to be there on Science Friday doing a live broadcast from Science Friday. And if you'd like to join us in Milwaukee for our broadcast, it's sponsored by WHAD and Wisconsin Public Radio, you can go to our website for ticket information about the event and we'd be very happy to talk about you, with you, in Milwaukee.

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And if you'd like to send us mail, you can send us mail to Science Friday, at 4 West 43rd Street, Room 306, New York, New York 10036. Also, you can surf over to our website at sciencefriday.com where we're podcasting and blogging and we've got new videos. We've got new videos up there, if you'd like to look at the videos we post.

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Have a great weekend. We'll see you next week. I'm Ira Flatow in New York.

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