Wisconsin Public Television University Place  Population Heath Sciences Patrick Remington  November 7, 2012 UP796   cc >> Welcome, everyone, to Wednesday Nite at the Lab. I'm Tom Zinnen. I work here at the University of Wisconsin-Madison Biotechnology Center. I also work for UW Extension Cooperative Extension, and on behalf of those folks and our other sponsors, Wisconsin Public Television, the Wisconsin Alumni Association, and the UW Madison Science Alliance, thanks again for coming to Wednesday Nite at the Lab. We do this every Wednesday night, 50 times a year. A few years ago, I had to give a speech at very short notice for a member of congress who just moved from the House to the Senate, but she will go unnamed. [LAUGHTER] And it was to a group of public health people. I'm a plant pathologist by training, and we don't have individual health. You just cut the tree down. [LAUGHTER] And it was really interesting to get to give a speech at short notice to people in public health because they were so appreciative to hear somebody who said, you know, you guys save more lives than all the docs and all the nurses, you just don't know the names and faces. 

They clapped. Now, you guys have been hearing me talk a long time, and you never clap for me. [LAUGHTER] [APPLAUSE] Oh, yes. Thank you. I don't know if that was sarcasm or sardony. [LAUGHTER] We'll look that up. I still think one of the amazing things about public health is that they're the Rodney Dangerfields. They just don't get no respect. And, yet, many of us who are alive today, we don't even know what parts of public health kept us alive. And that's the great thing about the demography. 

We know more people are alive today than in previous centuries. We just don't know which ones of us have been saved. So, tonight it's going to be really great to hear from Patrick Remington, who's here to talk about tracking the health of Wisconsin. Dr. Remington is Associate Dean for Public Health and professor of Population Health Sciences here at the School of Medicine and Public Health at UW Madison. His research focuses on developing methods to measure the health of communities and to communicate this information to the public and to policymakers. He is currently co-directing the Robert Wood Johnson-funded County Health Rankings project, and this project ranks the health of the counties in all 50 states and examines strategies to improve population health. I don't know how many counties there are in the United States. There's 72 in Wisconsin, and that's plenty to try to keep track of. Dr. Remington worked as an epidemiologist at the Centers for Disease Control from 1982 to 1988 and then with the Wisconsin Division of Public Health from '88 to '97. He later directed the UW Population Health Institute, and since joining the UW in 1997, he served as Associate Director of the Carbone Cancer Center and was the founding director of the Master of Public Health Program. 

He earned his bachelor's degree in molecular biology and an MD here at UW Madison. He completed an Internal Medicine Internship at the Virginia Mason Hospital in Seattle. And he also worked at the Epidemic Intelligence Service and the Preventive Medicine Residency at the CDC. And he also earned an MPH in 1986 from the University of Minnesota. [LAUGHTER] He has authored or co-authored over 300 publications, and he teaches courses on public health practice to undergraduate, medical, and public health students. I think it's a great thing to be able to track the health of Wisconsin. You've got to know where you're going to know where you're going, and it's great to know where you've been. And it's going to be very interesting to see all the different approaches that are available now to see how we're doing and where we're heading. Please join me in welcoming Patrick Remington to Wednesday Nite at the Lab. [APPLAUSE]  >> Thank you. 

Can you hear this all right? Okay, great. Well, it's a pleasure to be here. And I do enjoy talking about public health. I did start my undergraduate... [INAUDIBLE]  >> Your microphone is not on. >> Sorry? >> Your mic is not on. >> The mic is not on. So I will turn it on. Yeah, that's a little better. Okay, sorry about that. 

I did an undergraduate major in molecular biology, but discovering that really didn't prepare me for any gainful employment, I then went to medical school. And it was really a year into my medical internship when I discovered that my curiosity about why people got sick quickly overtook my interest in treating sick people. And so I decided to take a little bit of a step away from clinical medicine and I went to CDC to learn epidemiology, and the rest is history. I became trained as an epidemiologist and then specialized in preventive medicine. So my parents think it was a wasted four years in medical school, but I think of it as really providing me with the training necessary to be a good public health physician. I also wanted to say that I'm born and raised in Madison. My father came out here as an undergraduate to go to college and stayed on in law school and then was on the faculty in the law school for, I think, 45 years or so. So I grew up, really, in the shadow of the university. And, in fact, I've got a picture here of my third grade class. [LAUGHTER] And you can see me, the handsome guy in the top row, third from the left. 

And, actually, two to my left is Sandy Roder, who's a regular attendee here. So Sandy and I have known ourselves, I won't tell you how long ago third grade was. But this is Shorewood Hills School just up the hill. And I actually still see quite a few of those people. So Madison's a great town. My wife and I were gone for almost 10 years, and it was really great for me to come back and to be able to work both at the State Health Department and at the university. So, I'm sorry that Tom said that there would be no exams tonight because I like to begin with a quiz question. But, realizing that it is Wednesday night, I'll pose it as a double jeopardy and give you the answer. Fulfilling society's interest and assuring conditions in which people can be healthy. So you would say the question, what is...? [INAUDIBLE] Public health. 

But I'm actually going to make it easy because I'm not going to show you the answer. [LAUGHTER] I'm just going to give you a hint. And I'm going to come back to this slide at the end and see how well you did. But there are several assumptions, I think, that we need to make when you work in public health. First, this seems rather obvious, but I think it needs to be stated. That the overarching goal is that we strive for long and healthy lives for all. And you can actually measure this goal by looking at the length of life, life expectancy or death rates. You can also look at measures of the quality of life. People can report, self-reported health, mental or physical health. And you can also look at differences in health in different sub-populations to look for disparities. 

So, it's good, I think, to have a goal, but my view is that we, as scientists in particular as public health practitioners, need to pay attention to periodically measuring how we're doing at achieving this goal. I also think, again this is pretty self-evident, that prevention, when possible, is better than cure. We certainly haven't designed the healthcare system to really address this goal because we pay people more for the more care provided. So it's, in effect, the perverse incentive that we lose money when prevention is effective or lose potential revenue. And so what we think of in public health as cost saving and health promoting, actually, my colleagues in the hospital look at it potentially as lost revenue or lost business. And we're now starting to talk about this conundrum. That the system we've designed is actually not designed to reward public health. And also, it's easier to be healthy when you live in a healthy place. I don't have to tell you that. If you live in Madison, Madison is incredibly blessed to have such a healthy environment. 

Places to go to recreate. Restaurants. Walking paths. Parks and libraries. It's much easier to live a healthy lifestyle when the community and the environment in which you live is designed appropriately. As I mentioned, the traditional medical approach focuses on patients. We learn to diagnose and treat patients. But the public health approach really focuses on populations. And I think about populations as the denominator. A demographer would think about the patient as a numerator, the person afflicted by a condition or an illness, but I spend time thinking about the denominator, everybody at risk to become a patient. 

We also focus on disease prevention as opposed to diagnosis and treatment. I also like to simplify public health. It took me a long time, by the way, maybe 20 years, to finally figure out what public health is. And I now am teaching an undergraduate course. First time was, let's see, two years ago in the fall, and then I taught it for the second time in the spring last year. And we went from about 50 students who signed up. Now we have 300 students interested in last spring, and we may exceed that next spring. So there's renewed interest on campus in what public health is and how it works. And I think about it as really four fundamental steps. The first job in public health is to define the problems, measure the burden. 

What is the nature and extent of the problem in the population. A clinician would do this by coming in and asking the patient about how he or she feels. The second issue, which takes a lot of time, is to think about the causes of the problem. And we use epidemiology as the science, primarily to look at the causes. The third step, once we identify the causes, is to think about solutions. We also call this intervention research. So it's not sufficient to find out, for example, that smoking causes lung cancer. That would be done through epidemiology. But then to use that information to design interventions, either at the individual level, helping individuals quit smoking, or preferably, at the population level, finding ways to make smoking less normative like clean indoor air policies, more expensive through cigarette excise taxes, or maybe target it towards kids to make it less sociably desirable through mass media or school-based programs. And the final, and I think most vexing, step or part of public health is to close the gap between what we know and what we do. 

And that involves policy and politics. So, little did I know when I began my work in public health focusing on epidemiology, I thought that would be the end of my training in public health that once I had epidemiology understood and I could identify the causes of problems through epidemiologic research, that information would be sufficient to simply have the problems go away. Then I spent many years working, for example, in tobacco control trying to get Madison to have a clean indoor air ordinance. In fact, I began with Shorewood Hills where I live. We were the first community in the state to ban smoking in our restaurants. Turned out, we only had one at the time. [LAUGHTER] They felt very picked on. We were also the first community in the state to ban smoking in all places of employment. And that was not also very hard to do in Shorewood. There aren't that many places of employment. 

The interesting thing is the country club was a bit concerned because they do employ people there, and they, at the time, allowed smoking, and they thought that they were protected by federal law and that our ordinance would not apply. We convinced them that that, in fact, was not the case, that there is no federal protection for smoking. But, at that time, they decided to implement a policy banning smoking. So those are ways to really not only implement solutions but to close the gap between what we know and what we actually do. And we do this in clinical medicine through a work-up of the patient. We have this acronym we use called SOAP where you SOAP the patient. Not literally, obviously. But you do an subjective assessment, use objective tools, then sit back and assess what you've learned, and finally, develop a plan. Well, we, in our program, take the same approach and do an assessment of the population. We work up the population. 

So here's an example. You can see the state of Wisconsin with its 72 counties, and we now go around the state and talk to communities and find out what people think about within their community. What are the leading public health concerns? What are the major problems that people perceive? We also look at objective measures, and I'll talk about that in a bit. What are the ways of, in effect, doing an examination on the community but thinking about the population? We then assess the problems, oftentimes in community-based groups, and then develop plans to address those. So, how do you measure the health of a community? Well, Dr. David Kindig and I got together and developed this model to develop actual measures of what we call the health outcomes of a community. And we can measure the death rate, mortality rate, or the morbidity rate, and that is the quality of life, things that affect health. And when you combine death and disease rates in a population, you have a very good measure of the current health of that population. In effect, how long and how well are the people living in that community. But we know that there are factors that contribute to the health of populations and of individuals. So, we also developed our model to consider the health factors, those health behaviors, and you can see on the right side of the health factors that box there. 

Below that we know that clinical care can also be important in the health of a community. Having access to good quality healthcare is important. We also know that social and economic factors contribute to the health of individuals and populations. And, finally, how the environment is designed and also the physical environment. And the sizes of those boxes, the largest being socioeconomic, means that we give those measures the greatest weight in the overall summary assessment. We think health behaviors are almost as important, about 30% of the weight. Clinical care we give about 20%, and the physical environment about 10%. And then the final step, obviously, is how do you improve the health of communities? And we know through research and public health intervention research that there are certain programs and policies, things you do in communities that can influence the health factors that then lead to better health outcomes. So, let me just use this model and try and answer the question, how's the patient doing? The patient, obviously, being the state of Wisconsin. How does Wisconsin compare to other states? Sometimes when we try and figure out how healthy we are, it's not really how healthy we are, it's whether we can ride our bicycle faster than our friend or how healthy we might compare to people our same age or in our own family. 

Second question is, in addition to the overall health, we'd like to know are there any health disparities, any differences in health? By race, for example, or education or, actually, where you live within the state, by county. And then the third question is what are the trends in overall health? Are we moving in the right direction or the wrong direction? So, we have actually, in the Population Health Institute, developed three different what we call checkups. The first is this report Opportunities to Make Wisconsin the Healthiest State. We had a grant from our medical school, our Wisconsin Partnership Program, to look at ways that we could actually achieve that number one ranking in the nation and Wisconsin could become the healthiest state in the nation. The second report is called The Health of Wisconsin. It's really our report card on how we're doing overall and for disparities. And the final report that we produced is a trends report. We put this out in 2011. How are we progressing in overall population health? Well, how are we doing overall compared to the rest of the nation? America's Health Ranking actually does a study every year. It comes out in November. 

They've been doing it for 21 or 22 years now. And this year, I believe last year, this is 2011, should be, Wisconsin was the 13th healthiest state in the nation. It's interesting because the report first came out in 1990 when I was working at the State Health Department, and we were fourth healthiest in the nation. And, in fact, Minnesota was ranked number one. And the media would call and ask why Minnesota is number one and we're only number four. It's interesting that the ranking, really over the last 20 years, has declined. We've really moved from the top five to the top 10 and now at 13, really in the top 15. So we appear to be slowly losing our ranking. Doesn't mean we're getting worse, but it appears that other states are getting better faster than we are. And that can be shown here. 

You can see the ranking, again, in the top 10 back in 1990. Right around 10 in the late '90s, and now this is actually just the 2010 data, or actually 2011 over there, we're in the 10 to 15 range. So, clearly evidence that our health is slipping a bit. So, how would you say the patient's doing? How do we compare to other states? We're better than average, but we seem to be losing ground. The second question then is, how healthy are we overall, and are there any disparities? So to answer that question, we can look at the report card. And you can see for different age groups. Infants on the top row, children, working age adults, and older adults 65 and older, we give an overall health grade for the average population. And then we also give a health disparity grade for the differences within sub-populations. And, if you look at the bottom, overall Wisconsin gets a B-minus compared to the rest of the country, but we're not as equal. We're not as fair in distributing health as other states. 

So for that we get a C-minus. In fact, D grades for children and older adults. And this is slide that a graduate student made. I think it is one of the best things about working in a university is the opportunity to work with bright and talented students. In fact, when I was entertaining taking the job at the university, I asked my dad if he thought it was a good idea, and his one bit of advice was make sure you have access to smart graduate students. And I didn't really appreciate what he meant at the time, but I now understand that faculty do very little work themselves. We simply take credit for the work of our graduate students and acknowledge their contributions. This is Angie Kempf Rohan's work where we had the data and she decided to create a graphic that showed how Wisconsin compared to the other states and then how the health was distributed within Wisconsin. So if you look at the bottom, Massachusetts is the healthiest state for infant mortality. This is just one age group. 

The rate of infant deaths, and this is the number of infants who died before their first birthday, born alive but they don't make it to their first birthday. And in Massachusetts only five infants died per thousand live births. Wisconsin is 6.4. Mississippi is the worst in the country at 10.6. So you can see where we are. We're a little better than average. We're certainly not the best, not as good as Massachusetts, but if you look above that bottom line, the graphic up here, you can see the distribution. Within Wisconsin, African Americans are way over here on the right with an infant death rate of 17.2. And we consider anything down here in the bottom tier to be failing. Milwaukee, as a county, is at 10 deaths per hundred thousand. 

Native Americans and people with only a high school degree or less are around eight. Males, 6.8. And now we're moving up to better than the state, Hispanics, people living in non-urban, suburban communities, rural communities, those who have some college, whites. And then really good, better than the healthiest state are people who live in suburbs or college grads. As low as 3.9 deaths per thousand. It's very hard to completely eliminate infant deaths, but a rate of 3.9 in a population of people with college degrees is excellent. And you could split that flag even further and say I want to take white female college grads, for example. And you would split it even further. And this is an example of the child health mortality. Again, Wisconsin, this is deaths per hundred thousand now. 

Massachusetts is the best for children. Wisconsin and here's Louisiana Notice Native Americans and African Americans in our state. Much worse than average. Rural health. Males and Milwaukee County, way up to females. Females age 1 to 24 have a very low risk of dying in that age group. Working age adults, again, the best state is now Minnesota. Wisconsin's a little bit further behind, and Mississippi is way down here at 530 deaths. Again, though, within Wisconsin when we take this light green flag and spread it out into the subgroups, you can see African Americans and Native Americans are worse than the worst state in the nation. Those with only high school and in Milwaukee County. 

Men have a poor mortality experience. Way up at the top here, the best, lowest mortality rates are among Asians, college grads, Hispanics, those with some college, women, and those living in suburban areas. And finally, older death rates, those over 65 years of age. Again, the best state: Hawaii, very low mortality rate in this age group. Wisconsin and the worst state is West Virginia. Again, this same pattern. Those with less education and ethnic minorities, like Native Americans, worse health than Hispanics, Asians, those with some college, women, and college grads. So, very clear differences across the life span within the state of Wisconsin. It is interesting, this is not a political map of voting results, but it is very interesting now on the day following the election. This is not the counties that voted for Obama and for Romney. 

The red counties are counties with premature death rates worse than the national average, and the blue counties are those counties with premature death rates better than the national average. And, actually, I've not thought about this question that why is it that this does seem to look like a political map where these counties tend to vote democratic in presidential elections and these counties tend to vote republican? Any suggestions as to why? >> Social and economic. >> It could be social and economic factors. These are places that have higher rates of poverty and less education. >> Rural areas. >> Rural areas and also higher minority populations. >> Why are there so many counties for which you don't have the data? >> Well, they're missing because this is, I don't know what year this is, but some of these counties are so sparsely populated that there aren't people to die in the county. There aren't that many people that are actually living in these counties, so you might have one or two deaths in any year. So these rates are not stable. If you average a number of years, these counties have some of the highest. 

They're very sparsely populated rural counties. But you can see, by and large, the more populated counties have enough to make a rate. Well, we decided to take this approach by looking at health as it distributes not by age or race or gender or education but by where people live. And in 2003 we produced a report called the Wisconsin County Health Rankings, and then we decided to publish that report each year from 2004 all the way up to 2008. And this what the map of Wisconsin looks like. And these are health outcomes. Early death, this is death and disease rates, and you can see a distinct pattern. The northern tier counties here along the top are, dark green is higher mortality rates, shorter lives. You can see the southeast part of the state, Milwaukee, Racine, and Kenosha, along with Rock County. And these counties, what we might refer to as the central sand counties of Wisconsin, from Jackson to Juneau, Adams, Marquette are some of the least healthy. 

The flip side is where are the healthiest places. St. Croix County, Pierce County, really suburbs of East St. Paul. The central part of the state. Wood County and Portage County and then Dane County and some of the Fox River Valley all the way up from Waukesha, Washington, Ozaukee, up to Door County. So there's a difference in the health outcomes in Wisconsin. It's not surprising when you look at the health factors, the social and economic factors, the healthcare factors, behavior, and environment that you basically see a similar pattern. Again, poor health factors and risk factors in the northern counties, more clustering right here in the central sand counties and the southeast, including Rock County, and better health outcomes in the what I call the Minneapolis greater metropolitan area. You can see Wood, Marathon, and Portage County and then Dane County some of the healthiest health factors. >> Do we know what those factors are? >> Well, the question is, do we know what those factors are? And I will show you an example, but all of this information is online and you can drill down, in effect, within each county. So I will show you a snapshot for a county and show you exactly what those factors are. 

It's a good question. When we published this information and we rank places from the healthiest to the least healthy, it's not surprising that we get newspapers to pay attention. The media are very interested in rankings, in places that are best or worst, teams that are either state champions or having a long losing streak. Well, when we did this, this is an example of a ranking. So, the year we published this report, I think it was 2006, Florence County, a small rural county, happened to lead the state. It was the healthiest place. Waukesha, Ozaukee, suburban communities in Milwaukee, Eau Claire, and Portage fared the best. But at the bottom of the list, small rural counties with low employment rates, low social and economic status, Forest, Adams, Milwaukee County, Menominee County, which is an Indian Reservation in northeast Wisconsin, and Juneau county was situated right at the bottom of the list. Dead last in the state that year. And, in fact, that year the local paper put out a story with this very sad face. 

And the graphic really tells it all. You don't have to read the story. The headline is "County is State's Unhealthiest, Researcher: Results of Study are a Call to Action for the Community." And this is another good example of the benefit of graduate students. Peter Vila was my graduate student and a researcher with our Population Health Institute, and he actually got to talk to the reporter and was quoted in the paper that year. I don't think this is going to work. Media not found because it's not. I didn't copy it over. But I'll, let's see... Yes, if I was on my own computer here, I saved a phone call from a physician that I got who lived in that community. And let's just say she wasn't very happy with the work that we were doing here in Madison, telling the people in Juneau County that they had problems. 

She said, we know we have problems. And she really took offense with the fact that my graduate student, as she called him, made some rather uninformed statements about what it's like to live and work in Juneau County. And she wanted an answer from me or else she was going to notify the senators and the governor and everybody who I reported to. One of the advantages of being a tenured professor is that I might not have an office but at least I still have a job. [LAUGHTER] If she wanted to make trouble. Well, it turns out that as a result of this phone call, the community really got mobilized. In fact, they invited me up to Juneau County. I got a call from the public health nurse, and she said-- I worked with her for years when I was at the State Health Department, and she invited me to come up to Juneau County to a meeting. And she wondered if I was willing to come. And I said sure. 

And she paused and said, really? She said, people are really upset here. And so I said, sure, I wouldn't mind at all coming up. So she invited me up, and she said the health department's in the courthouse so come to the courthouse. I took a couple of graduate students with me. We drove up to Juneau County, to Mauston, the county seat, and when I got up there, it turns out the meeting was actually in the courthouse in the courtroom. And the courtroom was packed. There wasn't any place to sit. The only available seat was right here in the witness stand. [LAUGHTER] Where I was invited to take my seat. [LAUGHTER] And the graduate students stood in the back. 

I don't get nervous very often, but this was really, for me, a trial by fire. And I was prepared. I even brought a PowerPoint presentation in case I needed to overwhelm them with PowerPoint. But, as I stood in the witness stand, actually the county health officer was sitting in the judge's chair and she leaned over and she said, in my 25 years here, I've never been in this chair. [LAUGHTER] So, we seemed to cause trouble, but in a way, we elevated public health to a higher level in this small community. And as I prepared for the questions about the rankings and the data and what the factors were, a gentleman stood up and said, look, Dr. Remington, we're not here to question the data. We know we have a problem here in Juneau County. We have unemployment. My company went out of business. The jobs got sent overseas. 

We have kids having kids. We have people without health insurance. We don't need somebody to come here and tell us we have a problem. What we'd like is help from you to do something about it. And I was completely unprepared for that question. I was going to tell them more about the problem. And as physicians, you know physicians sometimes are good at diagnosing problems and not always so good at treating problems. And now, as a public health physician, I'd spent most of my time thinking about how to diagnose a problem and not so much time thinking about how to solve the problem. But I did learn something in medical school which is when someone, actually I learned this more from my father who never answered a question that I asked, but he simply asked a question back. So I did that. 

I said, well, I think the people in this room know about the solutions. I think we should begin a conversation about what we can do. And it was a very exciting exchange from the head of the school board to a legislator to a businessman. And it started a dialog about what could be done in Juneau County. And so, they formed a coalition of partners, a healthcare segment. By the way, that physician who made the phone call and wrote me a five-page letter was sitting in the room, and she had already said her peace, and she was now an active part of the coalition and part of the solution. They got a grant from a statewide foundation, they did a community needs assessment, and they began to look for programs that could address some of these partners. And, in fact, they developed a plan called the Juneau County Community Needs Assessment, and they started developing three different programs. One was they provided universal healthcare to everybody in the county. The health clinic stood up and said nobody will be denied care for inability to pay. 

We'll have a sliding scale. If you don't have any money, you can get care and you won't have to pay. They also had a program where pediatricians handed out books to kids called Reach Out And Read, an evidence-based program that gets physicians involved in literacy, and it turns out kids who see their pediatrician focus on reading are more likely to read at home. And finally, they've started, this has been a hard program to get off the ground, a program to help young parents learn about parenting. And, in fact, it was nice that in their plan they shamelessly copied our model for population health. They asked permission, actually. We said of course. That's the best form of flattery, really, for us is to have our model adopted for your community to think about how you measure and then improve the health of your population. And this is Barb Theis, the health officer's comment, I feel it was the media that did public health a big favor and was a key ingredient to making people take notice. Having worked in public health, media normally are the enemy. 

They call because they want to make a problem. They want to stir up a problem, and the typical response in public health has been not to return phone calls or to hope that the issue dies down. The food borne outbreak or the environmental or toxic chemical spill. And she actually said this was actually something good. The media stirred up the problem, and we got together and started doing something about it. Well, the interesting thing was, as we were doing this for six years in Wisconsin, we went to talk about it at a conference in New Orleans and somebody from the Robert Wood Johnson Foundation was there and saw our presentation, saw the six county health rankings, and actually heard me tell the story and play the tape recording of this physician. And he thought that this was something that could catch on in other states. So we had a call and ask whether we would do that for every other state in the nation, and I paused and I said I could do it for four more states and maybe someday we'd roll up to 10 and maybe 15. And he said, no, I'd like to do all 50 states next year. [LAUGHTER] Seriously. 

I said I have to call you back. So I sat down with my research team and our graduate student and I said, what do you think? And it's actually pretty easy to scale it up because the methods were hard, developing the model was hard, but once you get the template, it wasn't that hard. So we said, let's ask for a ridiculous amount of money and see if they're serious. So we said, how about $5 million? And they said, okay. [LAUGHTER] So we got a $5 million grant, and within, this was 2008, in the spring of 2010 we published the first National County Health Rankings. And you can actually see it on the web. It's CountyHealthRankings.org. And we've done this now in 2010, 2011, and 2012, and we're getting ready for 2013. This is now an annual nationwide checkup of all 3,000-plus counties in the nation. And guess what? We weren't, Wisconsin was not the exception. 

It turned out that the whole nation is interested in this. So when we put this out in 2010, there was lots of national media coverage, print, wire, online stories. This year there were 700 stories and counting. And, in fact, it's really set the standard for Robert Wood Johnson Foundation for what they would call media touches, their name out in the media. So, clearly, we've shown, through this and other work, that there are differences in health based on where people live, certainly by county within Wisconsin and throughout the nation, but there are also important disparities by race and education. So, this is really remarkable, I think, when you think about, I think the best picture of that is the picture of the rainbow of the health of Wisconsin. Of the dramatic two, three, four times higher rates in some groups in the state versus others. Well then, let me just go to the last question which is, if health is getting better slowly but our health compared to the rest of the country is declining and we have a lot of disparities, are there any good news results? Well, if we think about premature death rates under 75 years of age, like taxes, I hate to report death is the one thing you can count on. So we don't look at all ages mortality rate. That will never go away. 

But if you look at under 75, you should be able to see that's an average life expectancy. I consider any death prior to life expectancy to be premature, to be avoidable in large part. And if you look at the last 10 years, you can see we're making slow progress in reducing premature death rates. About 1% per year. And nationally, a 10% decline in a decade is considered to be meeting a target, a federal target. So I'd say this is a green line. We're on track. We're making progress in reducing death rates, and that's good news. We're not making progress, though, in how we feel, self-reported health in disease, disability, and morbidity rates. That's going up about .6% per year. 

In fact, the last year, you see that red dot in the upper right? It's even higher than we would have projected. So, the bad news is we might be living longer but we may not be living better. We're probably living more with chronic illness. The treatments that medicine provides don't often cure disease. They control it and so people's quality of life may not be improving. How are we doing in health factors like smoking? This is an amazing rate of progress. Even since 2000 we're seeing progress. Down 2.7% per year. The last year may be a little worse than we expected, but that seems like a very continuous and progressive improvement. But if you look at the other major risk factor for poor health, obesity, we're going up over 3.5% per year, rates of obesity. 

Although, you look at the last year, it seems to be a little better than expected. This is a major public health problem, the obesity epidemic affecting kids, young adults, older adults, men and women, people of all races and social and economic backgrounds. We're also going in the wrong direction in high school dropouts. Going up about 2% per year. We don't often talk about this, but our educational outcomes are not improving. Rates of poverty, this is, again, for Wisconsin, increasing from about 10%. The last year is up to about 17%. So this is clearly going in the wrong direction. These are children living in poverty. How about people living without health insurance. 

Now, again, the last year of data there, I think, is 2009, but we were going up about 5% per year. So from about 5% of the population to approaching 10%. The hope is once we get the data on the Affordable Care Act that this number will not only level off but turn around. So, how are we doing in trends in health? In health outcomes we're living longer but probably with more chronic illness. So not necessarily better. How are we doing in behaviors? There's less smoking, actually teen births are going down, but there's more obesity and higher rates of STDs. How are we doing in clinical care? There's evidence that the quality of clinical care is improving but there remain a high number of uninsured. Again, particularly with the results of the election, it appears that the Affordable Care Act will likely remain law and will, as it's implemented, continue to insure more and more people. How about social and economic factors? We're seeing progress in reductions in violent crime with slightly more high school graduation, but there's more unemployment and children living in poverty. And our environment, the air quality seems to be improving but we have evidence that there's increasingly less places where people can get healthy foods and places to exercise. 

So, in summary, how are we doing in the health of Wisconsin? Clearly, we're having longer lives. I don't think we're necessarily having better lives. And we're clearly failing in the goal of having long, healthy lives for all. The health distribution in this state is not equal. Not equal by where you live, not equal by your race or your social or economic background. So let me return, then, to the double jeopardy question, and this is for all the money. We put all the money on this question. And somebody, anybody know what the question is? [INAUDIBLE] Look very closely. And it's late so you may not pay attention. I'm going to take that away. 

[LAUGHTER] Now I'm going to put that back. Watch very closely. And the point of this is that-- I'll do that again. Some people don't believe that that's not public health, but it turns out when you pull away, and the reason I show this is I think each of us thinks about public health in a different way. And when you are asked what is public health and how does it work, each of us has our own vision and image of it. So it think when you peel away the screen here or your preconceptions, you find out that public health is really more than just what happens at a local health department or might be related to safe water and safe food. It's a complicated field. It's one where people are working all the time to create conditions in which people can be healthy, but it's not always as easy as it might at first seem. The other issue is that we have gaps. Remember I talked about epidemiology and important part of public health is not only knowing what the problems are but knowing the causes? We don't know causes of important health problems like autism or Alzheimer's disease. 

We also have gaps in evidence about what works. For example, in disability services, even obesity prevention, we're not really sure about how to tackle some of these important problems. And we, most importantly, I think we have gaps in translating what we already know into effective programs, policies, and services. So, this is the latest rendition of our model, and if you think about the health outcomes that are influenced by health factors and health policies, you can sort of look at our model here. On the right we have length in mortality/morbidity and the different health factors and the different components. And this gets to your questions which is, do we know the components? Do we know why certain areas are less healthy? Well, we can tease that in. When you go to the CountyHealthRankings.org, you can look at smoking rates, obesity rates, alcohol rates, measures of unsafe sex, access in quality of healthcare, all these social and economic variables as well as the environment. So this is the type of information now that communities have at their fingertips to delve into understanding why their county might rank toward the bottom of their state. And finally, most importantly, we know that there are things that can be done in communities that addresses each of these issues. Things like taxes and clean indoor air policies. 

And I see somebody here from the Madison City Council who was a partner, I was going to say in crime, but actually it was legal what we were doing in enacting the smoke-free policy in Wisconsin, in the city of Madison, sorry. We know that worked, and it would be really hard to imaging turning back to a time when people would be smoking in this lecture hall or smoking in restaurants. Menu labeling. Actually, few people know that menu labeling is part of the Affordable Care Act. It will be implemented in 2014 requiring all fast food restaurants, large chains to put calories on the menus and on boards. School food policies, the Affordable Care Act is enforcing healthier school food options. And policies that relate to healthcare, social and economic policies, and in the built environment. So I think it's good to focus on the health problems when making a diagnosis and it's good to use epidemiology to understand the causes, but I think the real challenge is putting these evidence-based programs and policies, things like early childhood education, minimum wage programs, zoning for mixed use developments, reducing bus emissions, pedestrian cycling master plans, this is really the richness of a public health approach. All these programs that we know work need to be implemented to their full extent. So what would I prescribe if I was sort of the doctor in charge of the state? First and foremost, we need to focus on the conditions in which we live, work, and play, our offices, schools, and communities. 

Design them right so that they're healthy in the first place so that the healthy choice becomes the easy choice and not the hard choice. The second thing is it's amazing we don't invest more in our children, especially early childhood education. Every study in public health that's looked at major problems often begin in early childhood, and effective early childhood education programs save money in the long run. For every dollar invested in early childhood education, you save five to seven dollars downstream in societal costs. And I think, also, as a society, these disparities that we see are really unacceptable. We don't see them very often. They're invisible. The differences in health between places and between populations in the state. And finally, if we don't reform the healthcare system and actually start calling it a sickness care industry, we'll never achieve better health for all. We'll simply what I call is feed the beast because sickness is actually good for business in our current healthcare, sickness care industry. 

And until we reform that, no matter what we do, we'll be challenging one of the biggest industries in this city and in the state in the nation and not achieve our overall health outcomes. So, thank you for your attention. [APPLAUSE]