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The Surgeon General's Call to Action to Control Hypertension

The US Surgeon General’s office has released a report emphasizing the importance of making hypertension control a national public health priority. Vice Admiral Jerome Adams, MD, MPH, the 20th US Surgeon General, discusses the report's background and recommendations. Recorded October 7, 2020.

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>> Hello and welcome to Conversations with Dr. Bauchner. It is Howard Bauchner, editor in chief of JAMA. And what a delight today to be joined by Admiral Jerome M. Adams. Jerome is the 20th Surgeon General of the United States. Jerome, before we get started and we're going to talk about a new initiative from your office and I am incredibly excited about it, in part because of a paper we published just two months ago. But, Jerome, before we get focused on the Viewpoint, what's it like to be Surgeon General?

>> Well, if you'd asked me that question before 2020 I would have given you an incredibly different answer. But what I will tell you is that I come from a family who have worked in public service. Several of my uncles have been in the uniformed services and it has always been my dream to be able to give back. My kids keep saying, "Dad, how come you keep taking more and more important jobs that pay less and less money?" Started in private practice, went into academia, ran the Indiana State Department of Health and now Surgeon General. So the most honest thing I can tell you is that as challenging as it has been, it's the honor of my life and I really do believe you're put in certain positions for a reason. And, so, I'm just trying to do the best I can with the opportunity I have and the voice that I have in my place at the table to try to move things a little bit in the right direction. And to the topic of today, that's really what it's all about, it's realizing that a very few of us have the ability to change the world in one fell swoop. We all just have to do a little bit with the levers that we have in front of us, the opportunities we have in front of us. And I just want to thank you and the viewers and listeners for giving me the opportunity to serve.

>> Jerome, we're going to talk about the Viewpoint, which is just being released simultaneously with this conversation, it's entitled, "A National Commitment to Improve the Care of Patients with Hypertension in the United States. And it's timed with the release of the Surgeon General's call to action to control hypertension. So before we get focused on the Viewpoint, could you just say something about your co-author, Janet Right? Well, Dr. Right works in my office, Dr. Janet Right, she used to run the Million Hearts initiative, which really looked at the different things that we could do to try to save lives from the number one killer in our country and that is cardiovascular disease. And I want to remind people of that, because a lot of people are saying to themselves even right now, why are you worried about high blood pressure, hypertension in the middle of a pandemic? I would remind folks that any life lost is a tragedy and we need to remain focused on doing everything we can to slow the spread of Covid, because we've lost 200,000 lives. But we can't lose sight of a fact that we lose over 600,000 lives to cardiovascular disease every year. We lose about 100,000 lives due to stroke every year. And we're finding more and more about the interplay between uncontrolled high blood pressure and dementia, maternal mortality, sexual and reproductive health. The time is now for us to prioritize what is an epidemic, an epidemic of uncontrolled blood pressure in this country. One in two adults in the United States approximately have high blood pressure.

>> Well, you've summarized the data, which was going to be my next question. More than 600,000 deaths from cardiovascular disease, it's about 500,000 deaths from cancer, we'll see what happens at the end of the year in terms of Covid related and Covid excess deaths. But the other consequences, stroke, kidney disease, dementia, all related, associated with hypertension. Why, why now, Jerome?

>> Well, I think it's important for people to understand that what we're seeing in terms of Covid really shouldn't surprise us. many of the people who are at risk of dying from Covid, of getting Covid, are the same people who are at risk from getting and dying from cancer or cardiovascular disease or stroke or any of the other causes of death in the United States. Covid and high blood pressure disproportionately impact black and brown communities. 80%, 80% of Hispanic Americans and Black Americans who have high blood pressure do not have it under control. So, again, these numbers mirror what's happening in Covid and there's the magnitude factor, again, 500,000 people will die with hypertension listed as a primary or secondary cause of death on their death certificate this year. That's direct, direct link to hypertension. And many other diseases impacted or exacerbated by hypertension, so just from a sheer magnitude point of view, we need to consider this as important as we consider other things like Covid. But we're also seeing rates of control hypertension go down. The decade before 2010 we actually saw an increase in hypertension control, but as you all talk about in the article that you put out a few weeks ago, we've seen rates of control decrease over the last decade. So we have a pandemic, which has shown a light on disparities, we've seen it really pray on people who are at higher risk due to high blood pressure or high blood pressure exacerbated diseases. And I really feel like we have more tools than ever before. I know not everyone can see on the podcast, we're doing video and audio, but I'm holding up my own automated blood pressure cuff right now. I have high blood pressure. My family's been impacted by it, all four of my grandparents died from diseases related to high blood pressure. My grandfather on my mother's side died of a stroke, my paternal grandfather died of a heart attack and both of my grandmothers died from dementia, which again can be exacerbated by high blood pressure and it's why we all need to prioritize getting it under control. We cannot wait another second to make this a national priority. And, again, tools, such as automated blood pressure cuffs, teen based care and we'll talk about some of these other things, I hope, in a bit, but we've never had more tools, more opportunity to really deal with an epidemic that is impacting as many and arguably more people than Covid.

>> Yeah, the Paul Motner [assumed spelling] that we published almost a month ago and then Janet had called me and I found out about the Surgeon General's call -- call to arms. I found the Motner article almost an indictment of the American healthcare system. That control had declined over the last decade I found so disturbing. We can actually diagnose hypertension and treatment isn't that expensive. It's not like a lot of other things that we do, where getting from diagnoses to treatment can be very difficult and expensive. So I think there's a way forward. Jerome, when you think about it, how do we get the 45 or 50% of people who have it appropriately recognized, diagnosed and treated and controlled, how do we get the 50% to 75%?

>> Well, that's a great question. And I just -- I appreciate you bringing up that it is an indictment of our system, that we have gone backwards in terms of control. W Edwards Demming [assumed spelling] said, "Every system is perfectly designed to get exactly the results that it gets." We need to understand that our systems, in many cases, are fundamentally flawed, broken. We pay for people to do things to you and check a box, but we don't pay for outcomes. Your doctor or nurse or healthcare system will get paid for bringing you in for a visit, checking your blood pressure and then sending you back out, but they don't necessarily get paid for following up to see whether or not you're doing the things you were told to do. For checking another blood pressure outside of clinic to make sure that you didn't either have white coat hot hypertension or high blood pressure or that your blood pressure wasn't artificially low or that we didn't just catch you at a time of day when you weren't particularly stressed or had other things going on in your life that normally would raise your blood pressure up. We need to make sure we're focused on the evidence based practices out there that have allowed practices across the country, rural and urban, black communities, white communities, rich, poor. Large, small practices have been able to achieve 80 plus percent hypertension control through the -- and are recognized through the Million Hearts Champions initiative. So I would encourage people to go to millionhearts.hhs.gov and find out about some of those champions, because a lot of people have said, "Well, I can't do this, I'm just one doc or I'm just a small practice or I'm in a bad community." No. Anyone can get this under control. And to answer your question, again, very simply, I think we need to have the courage to acknowledge that our systems are fundamentally broken. But one more thing I just want to add in really quickly, Howard, because it perhaps is the most important aspect of this. This isn't all about taking a pill. We know that two of the top things that you can do to get your blood pressure under control are eating a healthy diet and being more active. And we also know that not everyone has an equitable opportunity to eat a healthy diet and to be more active. This is what we call the social determinates of health. So we talk about medical preexisting conditions, but we don't talk enough about social preexisting conditions, transportation, childcare, a job that pays a good wage, the environment, the neighborhood you live in and whether or not it's safe to go out and be active. And I think that reflects in our failure to be able to control high blood pressure or control Covid and I hope one of the things that comes out of Covid-19 is that is that we really all recognize the disproportionate impact that diseases can have on certain communities. But we also realize that if any of us is unhealthy it can have a spillover impact on all of us and our viability.

>> Jerome, how do you think -- part of it is hypertension is kind of silent, if it's not extreme. You know, you'll have a blood pressure of 135 or to 140 over 90 and you may not feel it, you know, say it's diagnosed, how do you think around preventive care that we know has such long term important implications we can get people to think about it differently?

>> Well, you're exactly right. One of the challenges we've always had was non-communicable diseases in general, but high blood pressure specifically is they're not acute, they're not sexy. They are silent killers. Whether it's diabetes or high blood pressure or a cancer that grows insidiously until it becomes metastatic. So one of the things we need to do is help people understand all the ways that it can impact their lives. And, again, a lot of people understand the link between high blood pressure and cardiovascular disease. But what a lot of them don't realize is that having uncontrolled high blood pressure will increase your chances of neurocognitive decline, of dementia, of having to go into a nursing home, of being dependent on other people. We'll go out and talk about and spend $100 for a little blue pill, but we don't recognize that every single day you walk around with uncontrolled blood pressure is a day that your arteries that are feeding your reproductive and sexual organs are being assaulted by this high blood pressure and that we could do so much more with a really cheap prescription given at the right time and some simple intervention, versus relying on a little blue pill 20 or 30 years down the road. So we need to make it real for people, we need to help them to understand. But the other thing again is we need to make the healthy choice the easy choice. And in my call to action and you can check it out at Surgeongeneral.gov, we don't just talk about the individual and we don't just talk about doctors, we talk about healthcare systems, we talk about communities, we talk about employers. Howard, one of the things that I emphasize in here is that uncontrolled hypertension causes $300 of expense per employee per year in the United States to employers. Most people spend about a third of their day, most of their waking hours at work when you're an adult in the United States. And, so, if we want to tackle some of these difficult problems we've got to create an environment at work that is conducive to health. Blood pressure cuffs, more screenings available at work. Making sure you have opportunities for exercise, whether it's the labeling the stairs or having walking paths outside. Looking at healthy vending machine policies and what you're serving in the cafeteria and making sure the fries cost more than what the salad does, which unfortunately I still have a hard time finding a cafeteria where the fries are actually more expensive than the salad and where the healthy choice is the easy choice in that regard. These are all things that I list in my call to action. Measures that we can take to help move the needle on this disease that seems intractable, but actually can be really impacted upon with some pretty simple measures.

>> Jerome, you know, we're in the midst of a pandemic, we're in the midst of a presidential election, how do you make sure this doesn't get lost? I can say that JAMA will work hard to make sure that hypertension stays on the front page, but how do we make sure it doesn't get lost as an important national priority?

>> Well, we have to link it to things that people care about. So, while people are talking about Covid, we've got to help them understand, if you care about Covid and complications from Covid, you need to care about high blood pressure. It's women's health month in October and just as a -- I'll give you a sneak peak, I'm putting out the second call to action during my 10 year as Surgeon General in a little bit and that will be on maternal health, highlighting the fact that hundreds of women die, thousands of women are harmed every single year around the time of childbirth, but 60% of those deaths are preventable. But guess what, about -- a significant proportion of them are related to uncontrolled and sometimes unrecognized high blood pressure. I'm also putting out a report on community health and economic prosperity helping businesses understand the impact. And it seems odd for a Surgeon General to report, but highlighted in this is really an entire section for employers talking about the economic impact. $10 billion. As we look to recover from what has been an unprecedented economic insult on our nation, we need to help people understand that, look, simple measures to control your employee's blood pressure will help provide more income, more money, more resiliency for your workplace.

>> one of the findings in the Mutner paper, besides the differences by race and socioeconomic status and it's confounded, individuals who did not have a regular source of care, their control rate for hypertension was about 10%. It was remarkably low. How do we get to ensure that every single person in the United States has a regular source of care? How do we get there? We're now at about 35 million people who lack health insurance, that number may grow, it depends upon what happens with Medicaid, but how do we insure that everyone has a regular source of care?

>> Well, you know as well as I do that no other system in the world is set up like the United States where such a high proportion of people have their healthcare coverage and access tied to their place of employment or their status of employment. I think one of the things we need to do is really take a fundamental look at that system and figure out how we can provide supports for people that are available regardless of where you're working or whom you're working for. And I think we need to help people understand that that will in turn tie to our ability to be economically competitive as a country. What I call the US health disadvantage is the fact that the US spends more money on healthcare than any other country, but gets some pretty abysmal results relative to many of our peers. Most people think that, okay, well, that's a personal problem, that's an individual problem. No, it's not, because the number two expense for Fortune 500 companies out there and for most businesses is healthcare, workforce, productivity, absenteeism, all impacted. And, so, we need to help people understand that coverage, access to high quality affordable care, regardless of the vehicle you choose is important, but there's some few other key things. I want people to know that there are federally qualified health centers.

>> Yes.

>> some of our best kept secrets out there, but also some of the best actors in terms of controlling high blood pressure and high risk communities. Just because you don't have a job or you don't currently have coverage doesn't mean that you should ignore your blood pressure. Go to your state or local department of health website and use them as a connector to find out where the resources are in your community for free care or low cost care.

>> Yeah, before I came to Chicago for JAMA I was in Boston and for many years I worked at the Dorchester House, which was a community health center. And it changed, when I first started a lot of the people were from Ireland. Then there was a large influx of people from -- who were African American. And then as I was leaving it had become much more dominated by people who from Vietnam and Cambodia. It was just striking to see, but it was a community health center. Do you think we need to be more creative in trying to use unrecognized places where people who are at high risk go, churches, you know, there's kind of an interesting barber shops paper last year, bodegas, to try to get -- to mobilize individuals to get diagnosed or to talk about hypertension? Do you think we need to raise the conversation about it in different communities?

>> We absolutely do and here's something that you I know have talked about before too. We need to help people understand how and when and where and why to know their numbers and understand what those numbers mean. Current cutoff we're using are a systolic of 130 and a diastolic of 80. But that is just the first step. If you don't connect people to care after they get a reading of hypertension, then it's for naught and we call this the health fair paradox. Lots of people go to health fairs and they get a screening, but if it's not connected to a follow-up action, then they'll go every single year to that same health fair, they'll get their screening and they'll continue to know that they had high blood pressure and continue to not have it actually improved upon. So we need to create those opportunities in the community, but then connect people to care. And as you mentioned, bodegas, barber shops, CVS and Walgreens and pharmacies and grocery stores, these are all interventions we can use. We can use promontories and community health workers and one of the things I highlight in here is that hypertension control needs to be a team based, community based effort. It's not all in the physician, because again you're just getting a snapshot at a single point in time. But there are many other touch points in the community where we can reinforce positive behaviors, again like healthy eating and activity where we can help people know their numbers and understand their numbers and educate them. But then we need to make sure there's that transition to a care provider, so that if people actually need blood pressure medications, that they can get them prescribed and someone can follow up on them.

>> Last question, I know you have other groups to talk with. Do you have partners in this initiative? It's always hard to go it alone, but do you have other partners, professional societies, professional groups, other people that will champion this over the long run?

>> Well I absolutely do, Howard and one of those partners, I consider a partner, is you and JAMA.

>> Thank you.

>> You all have done some great work in this space and I just want to applaud you for lifting this up in the midst of a pandemic, because, again, that urgency, that urgency is what we've been lacking. But people need to understand the magnitude of the problem and institutions like JAMA can help spread the word that, hey, this is just a big of a killer as Covid. But we're also working with the American Heart Association, the American Medical Association, the National Medical Association, which is a group of black doctors and an association of black cardiologists.

>> Right, right.

>> These are great partners out there. One more I want to mention is the APHA, and ASTO, because we need to take a public health approach and get upstream, we're not going to treat our way out of this without recognizing that there are upstream factors and community factors that come to play. But also churches, as you mentioned, and employers. Again, this is a team effort, but together we've got this. And I want people to go to surgeongenral.gov, check out my call to action, but there are links to other resources and make knowing your own personal numbers a priority, because that's the start. One in two adults have high blood pressure, so look around you the next time you're in a room, if there's two people in the room, one of the two of you all likely has high blood pressure. If there's four people, two of you have high blood pressure. Start by knowing your numbers and using it as an opportunity to have a conversation with your health provider and everyone else around you about how we can move our nation towards health and away from this epidemic of uncontrolled blood pressure.

>> I hope I can have you back following Paul Mutner's update of his data in five years and that number of 45% would be 75% or 80%. As I said, to me the Mutner piece represented just a dramatic failure of the US healthcare system over something we can diagnose and we can treat and has just a remarkably long-term consequences for human health.

>> Well, you change outcomes for individuals one person at a time, but you change trends, you change systems by working on a broader level. And that's what this call to action is about, giving the individuals the tool they need, because I don't want any individual person to suffer from preventable complications due to high blood pressure, but it also talks about the systemic changes that need to happen if we really want to change the narrative here. But I'm optimistic, I'm convinced we can, we have the tools, we have the partners, we have the opportunity and the wind in our sails that Covid has presented with everyone talking about some of these complex issues, we just need to have the will to make it happen. And I appreciate you giving me the time to talk a little bit about this. you can hear the passion in my voice, because this has impacted my family and I feel that, again, if we can move it even -- I know you say to get it up to 75, 80% and that's my goal too, but if we can even move it 1 to 2, 3 to 4% in the next couple of months or even years, that's thousands, that's thousands. Tens of thousands of lives saved. So just do what you can. Read my call to action, look at the sector guides, do what you can and, again, that will save lives.

>> This is Howard Bauchner, editor and chief of JAMA. This has been conversations with Dr. Bauchner and I've been joined by the 20th Surgeon General of the United States, Vice Admiral Jerome Adams who, along with Janet Right, has written a Viewpoint that's being released simultaneously with this discussion entitled, The National Commitment to Improve the Care of Patients with Hypertension in the United States. Jerome, thank you so much for joining me and please stay healthy.

>> Thank you. Any time, Howard.

>> Be well.


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