Health metrics, life expectancy, and obesity in the US

The last Lancet Voice of the year delves into the latest findings from the Institute for Health Metrics and Evaluation (IHME) from our recently released US Special Issue. Ali Mokdad and Emmanuela Gakidou join Miriam Sabin and Gavin Cleaver to explore the comprehensive analysis of the Global Burden of Disease, the alarming trends in obesity and life expectancy, and the critical need for policy changes to improve public health in the United States.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Miriam: Hello and welcome to The Lancet Voice. I'm Miriam Sabin, The Lancet's North American editor based in New York City. 

Gavin: And I'm Gavin Cleaver based in London. 

Miriam: We are delighted to bring you today the last in a series of podcasts that have been focusing on public health in the us. All the folks you have heard in this series are authors in our recently published US special issue, a presidential briefing book.

The Briefing book we hope will provide part of the basis for the next administration for policy advisors. And for civil society. So today, we are talking with Dr. Emanuela Gacadou, who is a co founder of the Institute for Health Metrics and Evaluation, or IHME. She is the Associate Chair for Academic Programs at the Department of Health Metrics Sciences and Senior Director of Organizational Development and Training at IHME.

She also leads two research teams and started the Gender Equality Research Team to investigate, quantify, and highlight the key drivers in disparities by gender to help promote and achieve pathways to gender equality and the elimination of hidden biases embedded in population health data collection.

analyses and results. And we also have with us Professor Ali Mokdad, who is a Professor of Health Metric Sciences and Chief Strategy Officer for Population Health at the University of Washington. Prior to joining IHME, Ali worked at the Centers for Disease Control and Prevention, where he was Chief of Behavioral Surveillance, at the CDC's National Center for Chronic Diseases Prevention and Health Promotion.

Thank you very much for joining us today to talk about IHME's work on the U. S. Special Issue, the Presidential Briefing Book that came out recently from the Lancet. You had a lot of really interesting content in there, providing the background and the background. bone for the research and the evidence on health in the U.

S. today. And so we thought it would be nice to be able to talk to you and to hear your thoughts on this work. We first thought it would be useful for our listeners to understand a little bit about what your organization, IHME, is. What the global burden of diseases is, and for you to just tell us really about your mission also as it pertains specifically to the U.

S. 

Ali: So IHME has been established here at the University of Washington in 2007, and we do three main activities. That's what we are focusing on. What's the burden of disease or what's the health problem in a location? What What society is doing to address these problems. And the last one, which is the most important one, is how could we maximize our input and get the most output out of it by doing this comparison across the world.

We do several projects at IHME. One of them is the global burden of disease that I will talk more in details about it. But it's very important for us to say that we also do other projects here at IHME. Equally important, we do small area estimates, and we've done that even at the local burden of disease, five by five kilometers, we use statistical techniques to get at a lower geographic unit, a prevalence or an incidence of a disease, diarrhea, five by five kilometers, which is very important, stunting.

And we publish those, the key diseases. We do this for every country. We monitor all the health related sustainable development goals for the UN. We do for every location that we work in health access and quality of medical care, which is very important. We monitor all the health resources, physician, what the facilities, what their capacity are in every country in the world where we have data and access to.

We do forecasting to the future. You look at. A burden of disease in 2050 and the idea here is not to come to a country and say what diabetes will be in 2050 and we'll talk more about this issue, but also to provide scenario if you do a what will happen to your burden, which is very important for everybody.

And we do all of this work with something we call socio demographic index, where basically every country in the world is different, and we measure their development, and we use fertility under age 25, GDP where we lag it in the past, and education above age 50. 

Miriam: Thank you. That's interesting. So it sounds like a lot of what you do is really important for people who work in policy areas or for programmatic planning, because that granular data that you've talked about getting down, it's such a small, Level helps people to understand where the problems are.

This is an interesting point for the U. S., of course, because the U. S. is a big country and there are a lot of differences between states and even within states and among populations. Your work is able to provide that kind of detail. I wonder if you might have an example of that from the papers that, that you wrote for the U.

S. Special Issue and how you're hoping that it might be taken up by the next administration and the next policy advisors. 

Ali: Definitely, but before I start, it's very important to talk about the global burden of disease and what's new here for the U. S. and what we are doing, and what's really new and innovative in this issue.

If you follow what's happening in the United States, people here monitor mortality, life expectancy, prevalence, and incidence. But we at IHME, part of the global burden of disease, we do disability. So basically, there are many conditions globally, and especially in the U. S., where back pain, neck pain, mental health, which is a big problem in the U.

S. If you don't take into account disability, you're basically missing the burden of disease. And we are the only unit here in the United States that does disability at a comprehensive level for all diseases or risk factors. And when you look at the disability in a country and the mortality, basically you're taking the pulse of a nation.

So what's ailing and what's skinning the population. And the way at IHME we do mortality, we do years of life loss. So basically we take the highest life expectancy in the world and then we say, everybody should live to that. So somebody dying at age one will lose more years of life expectancy, years of life lost.

And when you look at that measure, you're not only counting that people, but you're including in it how early these people are dying and you're adding the disability as well. And that's what's new was in the global burden of disease. What's unique in this issue here, what we have been doing in this issue.

And what's really even striking for us, Christopher Murray, our director, who's been working on the U. S. for a long time, and one of the manuscripts here is an update of a work, innovative and really great, trailblazing work, was 8 America, now it's 10 Americas. And when we look at it in the United States, and we see the decline.

Of our ranking compared to everybody in the world. And that has been striking to us because it's much more than we expected. One, two, even if we take our best performing state, it's falling behind our competitors out there. And then even if we apply our best state in terms of smoking, obesity, et cetera, we're still falling behind and we're not, we're losing our back.

What we wanted to do in this issue is not to say very importantly, it's not only your health as a nation. It will impact your economical development and we are at a stage in this country where we will lose our edge in a competitive way in terms of our economic input and taking care of our elderly population.

And it's very important to remind everybody in the United States that we're spending a lot of money on health and we're not getting the return on investment. We're a rich country. We should spend more money on health. But we're not getting the return on investment. And what we wanted from this issue, and working with Lancet, is basically to say it's time for a reset in this country.

And we're hoping that the new administration will look at all these publications and the great commentary that came with them from high level people in the U. S. It's not only IHME talking. You have an IH director. There is a CDC director piece coming out. Basically, everybody in the United States is saying, look at this data, and then we need to act on it.

And we need to act yesterday, not today. 

Miriam: Thank you. Thank you very much for that. And it strikes me that one of, one of the key issues that you talked about, you mentioned obesity, and that was one of the papers, you had one paper that was specific. To obesity in the U. S., it did get a fair amount of press here pointing to that there's most obesity that we've had among adults and children.

And so I wondered you led on that paper, and I wondered if you could tell us a little bit about how you came to the conclusions you came to in the paper. It would be helpful for our listeners to understand how you do the work, but also what it was like for you personally to see the results of that study, which were so striking.

Emmanuela: Yes, you're right, Miriam. The situation with average weight for heights of obesity and overweight in the U. S., it's not necessarily the. We're the first ones or the only ones to call attention to this issue, but what we did in this paper was bring together the trends for young children all the way through adolescence to adulthood and into the elderly from 1990 to the present.

And we also have produced forecasts of if the current trends continue, what we might expect to see in the next 30 years up until 2050. And since you asked, I have to say that I personally get very depressed every time I look at these numbers. So currently if we look Adolescents, roughly defined up until age 25, so 10 to 25, 15 to 25, at present about one in four is obese and about half are overweight or obese.

And that only gets worse between now and 2050. So over the next 25 years, we anticipate that among adolescents, about one in three will be obese. This is something that is very, has very severe consequences for the health of these individuals for the rest of their lives. We're already seeing high rates of hypertension and type two diabetes.

At young ages, which is unprecedented, and so for these kids as they're growing up for society, for the health system, the news is pretty bleak. It's also very bad for adults, it's not just adolescents that are suffering. It's even worse, currently in the U. S. about 4 out of 10 adults are obese, and we're forecasting that if current trends continue, this will be about 6 out of 10 in the next 25 years.

So we're facing a really severe prevalence of obesity in the U. S. And as Elie and you mentioned, there are disparities across the country and within the country. But with rates so high, it really is the overall trend and the average that we should be looking at and not focusing so much on which state might have a slightly higher rate than another, because across the board, obesity is rising, and it's particularly worrisome for the younger populations.

Gavin: What role does food policy and the industry have to play in these obesity numbers? 

Emmanuela: Yeah, that is not something that we have specifically addressed in the paper is the determinants of it, but the availability and affordability of food, specifically high calorie and not very nutritious food in the United States is something that has been the subject of a lot of discussion.

If you look around grocery stores, gas stations everywhere. We are surrounded by food in this country that is not very nutritious. It is more affordable to purchase food that is high in calories and lower in nutritional value, and we promote heavy consumption from the younger ages. There is absolutely a need for some severe shift.

Not just in policy, but also in societal acceptability and promotion of a food, of high food consumption. 

Gavin: What are some of the kind of knock on health effects that you alluded to in your first answer? What makes the obesity crisis a crisis? 

Emmanuela: The current situation is pretty bad because of the high rates of obesity among adults.

And if we look at the health effects associated with obesity, they range from anywhere from heart disease and stroke all the way to low back pain and Other musculoskeletal conditions, if you look at health expenditure in the U. S., musculoskeletal conditions and specifically low back pain is one of the leading expenditures for the healthcare system.

And then if you look obesity now starting at younger and younger ages with each generation, these problems are only going to be amplified in the future. So we're going to see more type two diabetes, more heart disease, more musculoskeletal conditions at younger ages. And both for the individuals, but also for the health system, the implications of having more than half of the population being obese are very severe.

Gavin: How does this compare to the rest of the world? Obviously, that's got the scope of your paper, but where does the U. S. sit on a wider global scale with obesity? 

Emmanuela: And obesity is a global crisis. It's not just confined to the U. S. Rates of obesity are rising. Pretty much everywhere in the world, we do not have a single example of a success story of a country that has succeeded in lowering obesity rates.

That said, the current rates of obesity in the U. S. are among the highest. There are other countries that are also facing pretty severe obese epidemics. Mexico, our neighbors to the south, also have very high rates of obesity, as well as a lot of the small island nations in the Pacific Ocean and the Middle East and North Africa.

Those are some parts of the world that have similar rates of obesity. Projected increases in obesity are not unique to the United States either. The United States And its policies and actions do have an influence on the rest of the world. So both for the sake of the population within the United States, but also for the rest of the world.

If we take action now to prevent obesity in the future generations, it probably will have positive implications for the rest of the world as well. 

Miriam: I think It's important to mention also that, as Gavin was alluding, these issues are very complicated. And the way that you framed it in the paper, I think, and also our leaders of the CDC and the NIH, who also wrote in the special issue, raising the point that these are really population based issues.

Level effects that are complicated. It is not just the, an issue with individuals not making the right choices, which unfortunately was very often how it was framed, which is not helpful, of course, but really as a nation, how we can be healthier and have the most productive long lives. And actually on that point, I wanted to ask about the human development index.

paper, Ali, in the special issue, which really looks at life expectancy and where the U. S. is compared to other countries. I wonder if you could just tell us a little bit about how you determine that and what do you think we can do about it? 

Ali: Thanks. I want to talk I'm sorry, but I want to talk briefly about the society issue when it comes to obesity.

It is purely apparent in the United States. After a long day at work and you come to feed your family and it's 7 p. m. The corner store has hot dogs and buns, very cheap, for you to get in a car and go and pick healthy fruits and vegetables, if they are available. We have deserts here. We have food deserts in the United States.

Even if you decide sometimes in the United States to live healthy. And to do the right things, the system around you doesn't support you. And of course, there is some personal responsibility involved. But in the whole issue, and Amr did a very good job here talking about these issues that we really need to take care of.

Chris and I wrote a piece about what we need to do. So I just wanted to make that comment. For the Human Development Index, that's a baby of our director, Christopher Murray. So Chris wanted to. Basically, to come at the United States and identify who are at a disadvantage and where they are, which is very important.

This has not been done before. And instead of creating a new index from us, we decided to take the UNDP human development index, and then we applied it in the U. S. What was innovative about it in the U. S., and again, credit goes to Chris Murray here, is we did it at the individual level. We took the American Community Survey, which is about a million a year.

And then, so we have an individual, we have their education, we have their income. And basically we use education and income, and we linked it to our work that is funded by NIH, the U. S. Health Disparities. So we have, at the local level, we have your life expectancy, depending on your age. So it's not life expectancy, it's depending on your age, if you are 25, life expectancy at 25, for you in that location.

And we put these three together. And what has shown in the United States, a huge disparity in HDI. But there are so many striking remarks in it, in that paper. One of it is, we are a dynamic country, where people are changing and improving. Some people are left behind and going backward. Give you a specific example.

Asian, an Asian community here, are extremely improving. And when you rank HDI, the size, the top, the size. Asian are increasing rapidly, whereas for white male, for example, in the older generation, it used to be about 50 percent on the top and the side. Now it's about 5 percent in those who are under 25.

What we are seeing in the United States, not only where they are, and we have a great visualization and I urge everybody to look at it. You see exactly where they are. Big cities is doing very well. East of Washington is not. You could see that very clearly, who they are and where they are. But what's showing us is Native Americans are left behind.

African Americans are left behind. Women are doing much better than males, and we need to do something about it. And of course, it's linked to our economical development, our economical input, and we need to pay attention to this. The 

Gavin: question that strikes me is because we're looking through all the graphs, especially when you look at the life expectancy one, it's going slowly up, and then it hits the pandemic, obviously, which life expectancy generally fell across the board in the U.

S. How far back did the pandemic put progress on life expectancy in the U. S.? I guess if we had our time again, or God forbid another pandemic turns up, what could be done differently to assuage some of the issues that the U. S. faced and obviously has suffered with? 

Ali: The graph that you are looking at has so many stories and it's very important to take it piece by piece.

One of it is for Native Americans, all that period, life expectancy declined. So in the United States, you have a group of people that their life expectancy throughout the follow up declined. The other news, African American and one group of African American was below Native American early on, but they improved and bypassed them.

But what in the United States that's really important is That improvement slowed down in 2010. So you could see a stagnation in 20 decline before covid. So stopping at 2019, you could see that stagnation and that decline for African American, native American are always falling behind and even a slow down for white, many white people in the United States.

And it's at a time in the United States. Puzzling for us, and we looked at it very carefully here at IHME, because in 2010 here, if you follow the politics of the U. S., is when ACA came, when insurance increased, and many people got health insurance. And it makes you wonder, Yeah, it makes you wonder if we didn't have this, what would have happened?

That's one. This third part is the one that you're talking about is the rapid decline because of COVID 19. But in the United States, that decline wasn't the same across all race groups. So Native American, Hispanics, Black suffered the most, more than white people here, in their decline. And in fact, What we do at IHME, the highest decline of life expectancy from COVID 19 is in Navajo Nation here in the United States, about nine years.

Second one is Mexico City. In Mexico City, when we looked at it, it was different because many people came to Mexico City and died in Mexico City. So even the pandemic itself impacted more people, more minorities in the U. S. than white people. What should we have done differently in the U. S. And we at IHME, if you followed what we did, we monitored the pandemic.

We gave scenarios. What if you wear a mask? What will happen if you take the vaccine? What will happen? And we've been actively working on it. And Chris has been briefing everybody global. What we could do. Honestly, what we could do differently is and it's a sad story. And I'll tell you briefly, Yeah. We didn't protect our essential workers early on.

We really failed miserably in this country, protecting our essential workers. And that's why you see African American, Hispanics, and Native American were more impacted, because I could work from home. Many of them could not. They have to go and work. In the United States, which is sad here, and I know we're doing this, and we've been taped.

The attention was paid to workers here and their safety when one of our meat processing shut down because of the infection among employees. We went all over the news and people were talking to us, what should we do in the United States as if this wasn't happening before until you can get your steak in the U.

S. Now we started paying attention. Oh, we need to keep those workers so we can still eat. We have failed to protect our essential workers in the United States. That's the main problem, that you see the decline among minority more than the white population and the African population in the U. S. 

Miriam: Daniela, I'm curious for your thoughts on this as well, based on your work, you haven't, we've talked about obesity today, but you've worked across many issues as well.

You were very involved in what happened during COVID 19 and what the effects of that are still today. Wondered if you had any thoughts. 

Emmanuela: Yeah, related to trends in the U. S., to add to it, Ali has just been talking about some of the reversals we saw during the pandemic. For those of us that were better off to begin with, the reversal was maybe a decade or two in terms of life expectancy, but like Ali was saying, for some of the populations in America, 10, 8, and 9, the reversals we saw were several decades back.

And this is more generally about the US and some of the drivers that. we see impacting the trends. We talked a little bit about the Human Development Index. One of the components is education. So if we look at, take a step even back in terms of the causal chain and look at the social determinants of health and other ways in which we could influence future trajectories, education is one of the biggest drivers of health, is one of.

The most important, not the biggest social determinant of health and what we see within the U. S. is huge disparities in educational attainment, both in terms of just how much schooling individuals receive, but also the quality of education, the learning that happens across the various communities. And Ali mentioned briefly how males are falling behind in some of the health trends.

We also see that in education. And so if you look at trends. and educational attainment in the U. S. It is the boys that are falling behind. Of course, there are other dimensions of disparities across race, ethnicity groups, and across geographies, but probably the biggest change that has happened in the last couple of decades is the increasing disparity in schooling between girls and boys.

And if you combine that with other social determinants of health, but also more behavioral issues that are happening. Ali mentioned mental health, there is also a lot of cause for concern about the health and being in future directions among particularly young males in this country. 

Miriam: Is that across all races and ethnicities, all males, or are there particular groups where that's more of an issue?

We're 

Emmanuela: seeing that across the board within the U. S., across states, across race, ethnicity groups. Some of the gaps are more pronounced in certain populations than others, but it is a trend that we're seeing across the board. 

Ali: For all males, if you look at our HDI, you see a decline in male performance, and it comes from different things.

So remember, our index says education, income, and health. So Parts in the U. S. because of the drug epidemic. In fact, it made more than females, so they got that. But in general, and we, by the way, that's not a U. S. trend that make less likely to go to college right now. It's everywhere. In fact, in Norway, we work with Norway and does more than I do.

There is a commission how we can get male to come back to college and attend colleges. And in our manuscript, when we look at it, and Chris was very keen to say it, it's not only The issue of free education, because even in countries where there is a free education in Europe, for example, male are less likely now to go to college.

Even we see it in our own university, in our own campus right now, we have way more percentage, more females than males coming to the university across the border, the United States. 

Emmanuela: Yeah, and the impact of the pandemic, at least on the mortality side, was much more severe for males. If you tried to look at all the drivers of some of these disparities, there's immediate impacts such as the pandemic, and there's long term social determinants of health such as education that are influencing it.

And the end result is we're seeing males falling farther behind, and particularly young boys compared to girls and women. 

Gavin: I guess I wanted to finish up by asking, and Ali, this is probably a question for you. In your paper, of course, you have the 10 Americas, which is a change from the eight Americas in the paper previously.

But it just strikes me how hard it must be to draw those boundaries, especially with the information available to you. You could have 380 million Americas really, couldn't you? Everyone's slightly different to each other. So what are some of the challenges that went into kind of coming up with those 10 Americas?

Ali: So let me tell you that then America is, again, this is Chris Murray work 20 years ago where he published Eight Americas. I knew, by the way, he was funded by CDC to do it and it got a lot of attention, that manuscript. If you look at the United States, we have 3, 100 counties. And we have five racial groups, now we're adding more new OMB regulation, we'll have more racial groups in the U.

S. So if you take 3, 100 and you start doing it by all the racial groups and you start to describe to the policy makers just how much disparity we have, it becomes very complicated. And Chris, being Chris Murray and how smart and innovative he is, he decided, let me simplify it in order to put it in front of policy makers.

And he did the eight Americas where he could see, based on his division, different performance when it comes to health. It was clear, rural area, urban area, white man in Appalachia, Native American. But at that time, he couldn't do Hispanics because we didn't have the data to connect mortality data. to the race, Hispanic race.

At that time, was it available? That data is that became available right now. So when we did redid it again, Chris Murray and it's 10 America, we added two Hispanic groups in the United States in order to capture the beauty of the 10 America. It's very simple. The fact that you say that our 10 Americas was in Your country that's in itself is a big point.

That's what the second one It makes it so simplified in a way for people to see. Oh, I understand white man or white people in Appalachia Are different than the other white people here in the US African american living in like suburban area is different than American living in like high density population or ruler African Americans.

It gave that indication. The challenge for us was for many, like Native Americans, we have them in the Midwest. We didn't have enough data for, sorry, Native Americans elsewhere in order to create a group for Native American elsewhere. The challenge of data in the U. S. is a huge one. And two, in the United States, we have to talk about it, is there is a delay in sharing data or releasing data.

For us to be able to do what we need to do at IHME at the local level and understanding the disparities, for example, right now, we don't have mortality for 2023 by race, ethnicity at the county level, and we're almost in 2025. So these challenges we have to deal with at IHME and at IHME. We have expertise in working with messy data, and we have an expertise in looking at a comprehensive picture even with the limited deck of cards that you have.

I 

Miriam: wanted to know quickly where you see you can go in the next year from all this work that you've done in the five papers for the U. S. Special Issue. Since 

Emmanuela: we were just talking about data, I also just wanted to make one additional point how the US compares to other countries. 'cause this is one of the outcomes that we hope this special issue will have is to increase the attention that is paid to monitoring and tracking of health within the United States.

For a country at this level of development and with the amount of spending that we do on health, we really should have more timely and accurate data. We have, like Ali was mentioning, we have data from other countries, even for 2024, earlier this year, that gets released. The delays in having data available for the U.

S. are really not helping policy makers track what is happening, but there's also big gaps in data, for example, in terms of how we measure things like hypertension and obesity and high cholesterol and high fasting plasma glucose. There are a lot better examples out there in terms of tracking that at population level than the U.

S. The U. S. has also fallen behind in monitoring and keeping up with the. various subgroups of the populace. For example, for the 10 Americas that we're talking about, we really should have much more timely and reliable monitoring of some of the key drivers of health than we do in the U. S. And we hope that by raising attention to these health issues, it will also lead to improved monitoring.

Of course, what we're also hoping is that the incoming administration will consider the findings of this special issue as they're formulating the health policy for the next four years and seeing some of the biggest challenges that we're facing and emphasizing prevention as well as adequate and appropriate treatment for some of the issues, particularly for the populations that are more disadvantaged.

Ali, over to you for your thoughts on this as well. 

Ali: Miriam, I first want to thank you for working with us on this special issue, and for Lancet to allow us to put these papers together. I know it was a tough review process, and I, we enjoy your reviewers and how they give us a hard time. But it makes our paper much, our papers much stronger.

And I appreciate Miriam what you have done by having different people in the U. S. leadership position. We mentioned CDC, NIH, National Academy of Medicine, and others to speak about the value of the work and what needs to come up. What we are hoping to come after this is basically for the United States to address the risk factors in the U.

S. These preventable risk factors could lead to improving health and the minorities will benefit from them the most because unfortunately, they're the most likely to be obese. Although obesity is an epidemic in the U. S., but they're more likely to be smokers, more likely to have diabetes, less likely to have access to medical care.

That's one. The second one we are hoping from this issue is for universal health care in the U. S., with the only rich country that doesn't have universal health care. And even if we believe that it's not the answer, you have to do the socio economic and you have to address the risk factors. But in the United States, many of the problems that we have, especially mental health problems, is because of the stress.

You could lose everything you have if you get sick and you don't have money here. That safety is very important for us in the U. S. in order for us to enjoy life and spend money and feel like we are, this country is taking care of us. And the third one, which is the most important part, and we talk about it in the viewpoint, Chris Murray and I.

It's about education and early education in the U. S. M said it very well. There are disparities in education. And M, by the way, did a paper before, not only years of schooling, but also learning, where we took national tests. And she showed in the U. S. that there You know, high school graduate in one place in this country, or even in the state, is different than a high school graduate somewhere else.

So there is a gap in learning, especially early learning, where we need to prepare our kids to go to school. And once they are at their school, prepare them to go to high school. And when they are in high school, to prepare them to go to college. That work is very important. And the last point, because The special issue came in a perfect time during a transition and administration.

We need to do our part to put it in front of everybody who's working on health and education. And we are doing this at IHME. We're reaching out to governors. We're reaching out to politicians to make sure they're aware of this issue. But what we really need to do, both of us, is To send a reminder to everybody, sometimes four, five months from now, I'm not asking for more work, but I think we have to, when people take their position, and then we have new data from IHME, come GBD 2023, to remind everybody about these key points, and we are still in front of the news, in front of them, in order to tell them these are issues that you need to deal with.

And the fact that we did, then, Americas and HDI, and we have this geography, we know what the People are. We wanted not only to give to policymakers what the issues in this country, but we needed to empower the population itself to know I have a problem. What are you doing about it as my representative?

And why I am in this part of the state and why is Seattle doing better than me and I am and. Clallam County and you are in King County. We wanted even to empower the people to ask for what they deserve and say, I deserve better here. And then we need to keep reminding everybody that you have the data to act upon it.

And it's time for action. In the U. S. we talk about health more than anybody else. We debated more than anybody else and look at our outcomes. Enough talking. Let's roll our sleeve. What we are doing is not working. We need to change, and we hope this issue will set us straight. 

Miriam: What a perfect call to action to end with, don't you think, Gavin?

Gavin: I completely agree. It's been a really fascinating chat. Thank you both so much, Ali and Emanuela, for joining us on The Lancet Voice.

Thanks so much for listening to this episode of The Lancet Voice. And thanks for listening to the Lancer Voice throughout 2024. We'll be back in 2025 with some new episodes, but until then, take care and we'll see you soon.