Dr. Rich Carmona was the keynote speaker at Xerox’s Midas+ Annual Symposium in Tucson in May 2016. He shared his observations about the powerful role health and economic disparities play not only in determining outcomes in the US, but also globally. His experiences with health diplomacy in Indonesia demonstrate that health can bring hope to communities in times of great need. This is the second of a two-part story. You can read Part One here.
The Surgeon General is charged with protecting, promoting, and advancing the health security of the United States. Every Surgeon General crafts a portfolio of activities that they want to advance during their tenure. This portfolio must not only be sound from a scientific point of view, but it must also be in sync with the policies and programs of the administration they served under.
When Rich Carmona became Surgeon General in 2002, he decided to concentrate on five areas: prevention, preparedness, health disparities, health literacy, and global health (including health diplomacy). His entire program was built on the premise that inequality in our society is a public health menace and harbingers of poor public health (i.e., widespread obesity) are a national security threat. His experiences as a warrior taught him the horror and futility of war. You can’t help but feel that his whole life story has found expression in his action plan.
He was certain that Job One needed to be prevention. His understanding of the importance of prevention—and not just treating disease—was based on his experiences growing up poor in Harlem. And, it was reinforced by the many different jobs he has held since then: Army medic, paramedic, nurse, physician’s assistant, teacher, surgeon, professor, police officer, swat team member, and CEO.
The enormous amount of money the U.S. spends on sick care has not made us healthier. Drivers of disease, such as tobacco use, are rampant. Yet, even though tobacco was already known to cause or contribute to a huge burden of disease (e.g., lung and other cancers, cardiovascular disease, chronic lung disease, etc.), public policies were in place at the time Rich was Surgeon General that directly countered efforts to improve health. One egregious example of the time was that politicians continued to vote to subsidize tobacco farmers in the face of the well-documented economic burden tobacco-related illnesses placed on society. This is, Rich says, “the morbidity and mortality of politics.”
He also identified obesity as another huge contributor to the disease burden in this country. He correctly points out that it is an accelerator of many different chronic diseases, such as type II diabetes, and it also impacts the psychological health of the population (think of the adolescent who is ostracized by his classmates because of obesity).
Rich’s next priority was national preparedness. Recall that his tenure was under the shadow of the Afghanistan and Iraq wars. The press and the public were focused on body counts and were not really interested in his agenda to reduce preventable illness by addressing tobacco use and obesity.
One day at a press conference, he was asked, what is the biggest problem that you are facing as Surgeon General. Without hesitation, he answered, “Obesity.” It is “the terror within.” After a year of trying to sell science to the press, he knew they would come back and ask him what he meant by that statement. When they did, he gave them the metrics of obesity and talked about how it is not just “the terror within,” but also a significant national security issue. With 40% of the Armed Forces downrange, in combat, he worried that there were not enough responders at home in case of an emergency, such as Hurricane Katrina.
He wondered whether this would be a serious workforce issue 10 years in the future when the cohort of children now experiencing a high rate of obesity, type II diabetes, hypertension, and cardiovascular disease grew up. Would they be physically fit enough to serve in the military?
According to the World Health Organization, social determinants of health (SDH) are
“…conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. The social determinants of health are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries.”
Rich used the disaster of Hurricane Katrina to illustrate the importance of these factors. He pointed out that many of the people whose homes were lost to Katrina were poor and not well-educated. When they were rescued and taken to the makeshift care facilities, they could not give a coherent history of their health status. And there were no electronic health records available to fill in the gaps. The healthcare infrastructure was in complete disarray. So when people were asked what medications they were taking or what conditions they were being treated for, the answers were often vague.
“I take a blue pill and a red one.”
“I get a shot. I think it’s for sugar diabetes.”
Katrina demonstrated how social determinants of health can place a drag on the nation’s ability to respond appropriately to a major disaster. And, it clearly illustrated the connection between poverty and outcome. Rich explains,
“Our nation is divided by our health metrics…If you are African American, Hispanic American, Native America, or poor, the data clearly shows you will have less access to healthcare, you will get there later, you will have more complications, you will die sooner, and you will cost society much more money.”
A related priority is health literacy. Rich points out that we are living in a time of some of the most complex science and advanced healthcare we’ve ever had. How do you package this information so that it is accessible to everyone? How do you tell people to eat this, but don’t eat that, to get enough exercise, to stop smoking, drinking, hitting your wife, and shooting at each other. It is a huge challenge, but one that must be addressed if we are to effect sustainable behavior change and improve the overall health of the public. “The diversity that gives our nation its strength,” he says, “paradoxically also divides us” when it comes to health.
Global health and health diplomacy
Rich’s final priority was global health. He notes that the world is flat and that we are all interconnected. If our allies aren’t prepared, then their problems will likely show up on our doorstep. We need to help them protect their communities so that our communities can be safe as well.
That raises the issue of health diplomacy. How can we use healthcare to not only help other countries be healthy, but also help them achieve economic security? He wondered,
“Maybe bombing countries doesn’t work or forcing them to be in a democracy. What if we showed them hope instead? That’s what health diplomacy is all about.”
Rich used the example of the 2005 Indonesian tsunami to illustrate how health diplomacy works. We sent personnel to help with recovery. They included sanitary engineers, doctors, nurses, and nutrition experts. They built field hospitals and engaged with the communities they served. This allowed the villagers to see firsthand what America was all about. This, he said, is soft projection, not force projection. It is how health diplomacy brings hope to people in desperate circumstances.
To wrap up, Rich reminded the healthcare executives in the room,
“if we don’t engage the public in all of these issues, we will just be managing the costs of a sick population better. We must engage people in their own health and welfare and help to drive the disease burden down.”
Rich Carmona’s life experiences and bold vision have provided a road map to better health outcomes both domestically and internationally. The question is whether we can put aside partisan politics and self-serving personal agendas in the interest of the public’s health.
As a part of their commitment to providing thought leadership to their customers, Xerox Healthcare’s Midas+ organization hosts an annual Midas+ Symposium in Tucson, Arizona. Rich Carmona, MD, the 17th Surgeon General of the United States was this year’s keynote speaker. This post was sponsored by Xerox Healthcare.