The Surgeon General's Call to Action to Control Hypertension

Aug 24, 2023

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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Topics discussed in this interview:
0:00 Introduction
0:26 What is it like to be Surgeon General?
1:52 Background on Janet Wright, MD (report co-author)
3:36 Why should we focus on hypertension now?
6:47 How do we increase blood pressure control in the US?
10:43 Preventive care
14:08 Ensuring that hypertension remains a national priority
15:55 Access to health services
18:22 Engaging communities
21:14 Partners in this initiative
23:10 Changing the trend
25:02 Closing remarks
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#JAMALive #HighBloodPressure #Hypertension

Content

0.426 -> >> Hello and welcome to Conversations with Dr. Bauchner. It is Howard Bauchner, editor in chief

4.88 -> of JAMA. And what a delight today to be joined by Admiral Jerome M. Adams. Jerome is the 20th

12.96 -> Surgeon General of the United States. Jerome, before we get started and we're going to talk

17.68 -> about a new initiative from your office and I am incredibly excited about it, in part because of a

24.16 -> paper we published just two months ago. But, Jerome, before we get focused on the Viewpoint,

30.56 -> what's it like to be Surgeon General? >> Well, if you'd asked me that question

37.04 -> before 2020 I would have given you an incredibly different answer. But what I will tell you is that

43.36 -> I come from a family who have worked in public service. Several of my uncles have been in the

50.16 -> uniformed services and it has always been my dream to be able to give back. My kids keep saying,

56.48 -> "Dad, how come you keep taking more and more important jobs that pay less and less money?"

60.72 -> Started in private practice, went into academia, ran the Indiana State Department of Health and now

66.08 -> Surgeon General. So the most honest thing I can tell you is that as challenging as it has been,

71.44 -> it's the honor of my life and I really do believe you're put in certain positions for a reason.

77.76 -> And, so, I'm just trying to do the best I can with the opportunity I have and the voice that

83.28 -> I have in my place at the table to try to move things a little bit in the right direction.

88.72 -> And to the topic of today, that's really what it's all about, it's realizing that a

94.64 -> very few of us have the ability to change the world in one fell swoop.

99.12 -> We all just have to do a little bit with the levers that we have in front of us, the

104 -> opportunities we have in front of us. And I just want to thank you and the viewers and listeners

108.56 -> for giving me the opportunity to serve. >> Jerome, we're going to talk about the

112.88 -> Viewpoint, which is just being released simultaneously with this conversation,

117.6 -> it's entitled, "A National Commitment to Improve the Care of Patients with Hypertension in the

123.36 -> United States. And it's timed with the release of the Surgeon General's call to action to control

129.68 -> hypertension. So before we get focused on the Viewpoint, could you just say something about

135.36 -> your co-author, Janet Right? Well, Dr. Right works in my office, Dr. Janet Right, she used to

142.16 -> run the Million Hearts initiative, which really looked at the different things that we could do

148 -> to try to save lives from the number one killer in our country and that is cardiovascular disease.

153.68 -> And I want to remind people of that, because a lot of people are saying to themselves even right now,

160.4 -> why are you worried about high blood pressure, hypertension in the middle of a pandemic? I

165.52 -> would remind folks that any life lost is a tragedy and we need to remain focused on doing everything

172.64 -> we can to slow the spread of Covid, because we've lost 200,000 lives. But we can't lose

177.84 -> sight of a fact that we lose over 600,000 lives to cardiovascular disease every year.

184.56 -> We lose about 100,000 lives due to stroke every year. And we're finding more and more about the

191.6 -> interplay between uncontrolled high blood pressure and dementia, maternal mortality,

197.68 -> sexual and reproductive health. The time is now for us to prioritize what is an epidemic,

204.72 -> an epidemic of uncontrolled blood pressure in this country. One in two adults in the United States

211.12 -> approximately have high blood pressure. >> Well, you've summarized the data,

216.4 -> which was going to be my next question.

219.04 -> More than 600,000 deaths from cardiovascular disease, it's about 500,000 deaths from cancer,

225.28 -> we'll see what happens at the end of the year in terms of Covid related and Covid excess deaths.

230.32 -> But the other consequences, stroke, kidney disease, dementia, all related, associated

237.68 -> with hypertension. Why, why now, Jerome? >> Well, I think it's important for people

244.08 -> to understand that what we're seeing in terms of Covid really shouldn't surprise us. many of

252.08 -> the people who are at risk of dying from Covid, of getting Covid, are the same people who are at risk

258 -> from getting and dying from cancer or cardiovascular disease or stroke or any

263.2 -> of the other causes of death in the United States. Covid and high blood pressure disproportionately

270.72 -> impact black and brown communities. 80%, 80% of Hispanic Americans and Black Americans who have

278.32 -> high blood pressure do not have it under control. So, again, these numbers mirror what's happening

285.28 -> in Covid and there's the magnitude factor, again, 500,000 people will die with hypertension listed

294.4 -> as a primary or secondary cause of death on their death certificate this year. That's direct,

299.76 -> direct link to hypertension. And many other diseases impacted or exacerbated by hypertension,

305.36 -> so just from a sheer magnitude point of view, we need to consider this as important as we

310.48 -> consider other things like Covid. But we're also seeing rates of control hypertension go down. The

318.08 -> decade before 2010 we actually saw an increase in hypertension control, but as you all talk about

324 -> in the article that you put out a few weeks ago, we've seen rates of control

328.88 -> decrease over the last decade. So we have a pandemic, which has shown a light on disparities,

335.6 -> we've seen it really pray on people who are at higher risk due to high blood pressure or high

341.6 -> blood pressure exacerbated diseases. And I really feel like we have more tools than ever before.

350.16 -> I know not everyone can see on the podcast, we're doing video and audio, but I'm holding up my own

355.84 -> automated blood pressure cuff right now. I have high blood pressure. My family's been impacted by

361.2 -> it, all four of my grandparents died from diseases related to high blood pressure. My grandfather on

367.2 -> my mother's side died of a stroke, my paternal grandfather died of a heart attack and both of

372.4 -> my grandmothers died from dementia, which again can be exacerbated by high blood pressure and

377.68 -> it's why we all need to prioritize getting it under control. We cannot wait another second

384.56 -> to make this a national priority. And, again, tools, such as automated blood pressure cuffs,

390 -> teen based care and we'll talk about some of these other things, I hope, in a bit,

394.16 -> but we've never had more tools, more opportunity to really deal with an epidemic that is impacting

403.04 -> as many and arguably more people than Covid. >> Yeah, the Paul Motner [assumed spelling]

409.44 -> that we published almost a month ago and then Janet had called me and I found

413.36 -> out about the Surgeon General's call -- call to arms. I found the Motner article almost an

419.92 -> indictment of the American healthcare system. That control had declined over the last decade

425.52 -> I found so disturbing. We can actually diagnose hypertension and treatment isn't that expensive.

430.88 -> It's not like a lot of other things that we do, where getting from diagnoses to treatment can be

436.16 -> very difficult and expensive. So I think there's a way forward. Jerome, when you think about it,

442.72 -> how do we get the 45 or 50% of people who have it appropriately recognized, diagnosed and treated

449.04 -> and controlled, how do we get the 50% to 75%? >> Well, that's a great question. And I just -- I

456 -> appreciate you bringing up that it is an indictment of our system,

459.68 -> that we have gone backwards in terms of control. W Edwards Demming [assumed spelling] said,

464.96 -> "Every system is perfectly designed to get exactly the results that it gets." We need to understand

471.36 -> that our systems, in many cases, are fundamentally flawed, broken. We pay for

477.68 -> people to do things to you and check a box, but we don't pay for outcomes. Your doctor or nurse

485.04 -> or healthcare system will get paid for bringing you in for a visit, checking your blood pressure

490 -> and then sending you back out, but they don't necessarily get paid for following up to see

494.8 -> whether or not you're doing the things you were told to do. For checking another blood pressure

499.12 -> outside of clinic to make sure that you didn't either have white coat hot hypertension or high

504 -> blood pressure or that your blood pressure wasn't artificially low or that we didn't just catch you

509.2 -> at a time of day when you weren't particularly stressed or had other things going on in your life

514.16 -> that normally would raise your blood pressure up. We need to make sure we're focused on the evidence

521.2 -> based practices out there that have allowed practices across the country, rural and urban,

527.68 -> black communities, white communities, rich, poor. Large, small practices have been able

532.56 -> to achieve 80 plus percent hypertension control through the -- and are recognized through the

539.04 -> Million Hearts Champions initiative. So I would encourage people to go to millionhearts.hhs.gov

546.08 -> and find out about some of those champions, because a lot of people have said, "Well,

549.92 -> 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.

556.96 -> Anyone can get this under control. And to answer your question, again, very simply,

562.32 -> I think we need to have the courage to acknowledge that our systems are fundamentally broken. But one

569.36 -> more thing I just want to add in really quickly, Howard, because it perhaps is the most important

574 -> aspect of this. This isn't all about taking a pill. We know that two of the top things that you

582.64 -> can do to get your blood pressure under control are eating a healthy diet and being more active.

589.68 -> And we also know that not everyone has an equitable opportunity

594.56 -> to eat a healthy diet and to be more active. This is what we call the social determinates of health.

600.08 -> So we talk about medical preexisting conditions, but we don't talk enough about social preexisting

605.2 -> conditions, transportation, childcare, a job that pays a good wage, the environment,

611.04 -> the neighborhood you live in and whether or not it's safe to go out and be active. And

615.6 -> I think that reflects in our failure to be able to control high blood pressure or control Covid

622 -> and I hope one of the things that comes out of Covid-19 is that is that we really all recognize

629.76 -> the disproportionate impact that diseases can have on certain communities. But we also realize that

635.76 -> if any of us is unhealthy it can have a spillover impact on all of us and our viability.

641.76 -> >> Jerome, how do you think -- part of it is hypertension is kind of silent, if it's not

649.2 -> extreme. You know, you'll have a blood pressure of 135 or to 140 over 90 and you may not feel it,

657.6 -> you know, say it's diagnosed, how do you think around preventive care that we know has such

664.32 -> long term important implications we can get people to think about it differently?

669.36 -> >> Well, you're exactly right. One of the challenges we've always had was

676 -> non-communicable diseases in general, but high blood pressure specifically is they're not acute,

682.64 -> they're not sexy. They are silent killers. Whether it's diabetes or high blood pressure or a cancer

690.24 -> that grows insidiously until it becomes metastatic. So one of the things we need

695.36 -> to do is help people understand all the ways that it can impact their lives. And,

700.72 -> again, a lot of people understand the link between high blood pressure and cardiovascular disease.

706.16 -> But what a lot of them don't realize is that having uncontrolled high blood pressure will

710.64 -> increase your chances of neurocognitive decline, of dementia, of having to go into a nursing home,

718.32 -> of being dependent on other people. We'll go out and talk about and spend $100 for a little blue

724.72 -> pill, but we don't recognize that every single day you walk around with uncontrolled blood pressure

730.72 -> is a day that your arteries that are feeding your reproductive and sexual organs are being assaulted

739.36 -> by this high blood pressure and that we could do so much more with a really cheap prescription

745.52 -> given at the right time and some simple intervention, versus relying on a little blue pill

751.68 -> 20 or 30 years down the road. So we need to make it real for people, we need to help

755.68 -> them to understand. But the other thing again is we need to make the healthy choice the easy

759.52 -> choice. And in my call to action and you can check it out at Surgeongeneral.gov, we don't just talk

765.12 -> about the individual and we don't just talk about doctors, we talk about healthcare systems, we

770.08 -> talk about communities, we talk about employers. Howard, one of the things that I emphasize in here

776.32 -> is that uncontrolled hypertension causes $300 of expense per employee per year in the United

785.2 -> States to employers. Most people spend about a third of their day, most of their waking hours

791.92 -> at work when you're an adult in the United States. And, so, if we want to tackle some

796.64 -> of these difficult problems we've got to create an environment at work that is conducive to health.

801.44 -> Blood pressure cuffs, more screenings available at work. Making sure you have opportunities for

806.8 -> exercise, whether it's the labeling the stairs or having walking paths outside. Looking at healthy

812.64 -> vending machine policies and what you're serving in the cafeteria and making sure the fries cost

818.24 -> more than what the salad does, which unfortunately I still have a hard time finding a cafeteria

824.16 -> where the fries are actually more expensive than the salad and where the healthy choice is the

828.8 -> easy choice in that regard. These are all things that I list in my call to action. Measures that we

834.48 -> can take to help move the needle on this disease that seems intractable, but actually can be really

842.8 -> impacted upon with some pretty simple measures. >> Jerome, you know, we're in the midst of a

848.56 -> pandemic, we're in the midst of a presidential election,

854.72 -> how do you make sure this doesn't get lost? I can say that JAMA will work hard to make sure

861.76 -> that hypertension stays on the front page, but how do we make sure it doesn't

866.48 -> get lost as an important national priority? >> Well, we have to link it to things that people

874.64 -> care about. So, while people are talking about Covid, we've got to help them understand,

879.92 -> if you care about Covid and complications from Covid, you need to care about high blood

884.88 -> pressure. It's women's health month in October and just as a -- I'll give you a sneak peak,

891.2 -> I'm putting out the second call to action during my 10 year as Surgeon General in a

896.32 -> little bit and that will be on maternal health, highlighting the fact that hundreds of women die,

901.2 -> thousands of women are harmed every single year around the time of childbirth, but 60% of those

909.84 -> deaths are preventable. But guess what, about -- a significant proportion of them are related to

917.36 -> uncontrolled and sometimes unrecognized high blood pressure. I'm also putting out a report

922.64 -> on community health and economic prosperity helping businesses understand the impact. And

927.28 -> it seems odd for a Surgeon General to report, but highlighted in this is really an entire section

933.84 -> for employers talking about the economic impact. $10 billion. As we look to recover from what has

940.96 -> been an unprecedented economic insult on our nation, we need to help people understand that,

945.6 -> look, simple measures to control your employee's blood pressure will help provide more income,

951.44 -> more money, more resiliency for your workplace. >> one of the findings in the Mutner paper,

958.4 -> besides the differences by race and socioeconomic status and it's confounded,

964.32 -> individuals who did not have a regular source of care,

968.08 -> their control rate for hypertension was about 10%. It was remarkably low.

974.56 -> How do we get to ensure that every single person in the United States has a regular source of care?

981.68 -> How do we get there? We're now at about 35 million people who lack health insurance,

987.36 -> that number may grow, it depends upon what happens with Medicaid, but how do we insure

991.76 -> that everyone has a regular source of care? >> Well, you know as well as I do that no other

998.48 -> system in the world is set up like the United States where such a high proportion of people

1003.12 -> have their healthcare coverage and access tied to their place of employment or their status

1010.16 -> of employment. I think one of the things we need to do is really take a fundamental look

1016.96 -> at that system and figure out how we can provide supports for people that are available regardless

1023.44 -> of where you're working or whom you're working for. And I think we need to help people understand

1029.04 -> that that will in turn tie to our ability to be economically competitive as a country.

1035.92 -> What I call the US health disadvantage is the fact that the US spends more money on healthcare

1040.8 -> than any other country, but gets some pretty abysmal results relative to many of our peers.

1046.24 -> Most people think that, okay, well, that's a personal problem, that's an individual problem.

1050.24 -> No, it's not, because the number two expense for Fortune 500 companies

1053.68 -> out there and for most businesses is healthcare, workforce, productivity,

1059.12 -> absenteeism, all impacted. And, so, we need to help people understand that coverage, access to

1065.52 -> high quality affordable care, regardless of the vehicle you choose is important, but there's some

1070.88 -> few other key things. I want people to know that there are federally qualified health centers.

1074.76 -> >> Yes. >> some of our best kept secrets

1077.2 -> out there, but also some of the best actors in terms of controlling high blood pressure and

1083.44 -> high risk communities. Just because you don't have a job or you don't currently have coverage

1088.32 -> doesn't mean that you should ignore your blood pressure. Go to your state or local department

1092.48 -> of health website and use them as a connector to find out where the resources are in your

1097.92 -> community for free care or low cost care. >> Yeah, before I came to Chicago for JAMA I

1107.68 -> was in Boston and for many years I worked at the Dorchester House, which was a community health

1113.68 -> center. And it changed, when I first started a lot of the people were from Ireland. Then there

1121.84 -> was a large influx of people from -- who were African American. And then as I was leaving it

1128.72 -> had become much more dominated by people who from Vietnam and Cambodia. It was just striking to see,

1135.28 -> but it was a community health center. Do you think we need to be more creative

1140.32 -> in trying to use unrecognized places where people who are at high risk go, churches, you know,

1149.2 -> there's kind of an interesting barber shops paper last year, bodegas, to try to get -- to mobilize

1158 -> individuals to get diagnosed or to talk about hypertension? Do you think we need to raise the

1163.44 -> conversation about it in different communities? >> We absolutely do and here's something that you

1170.96 -> I know have talked about before too. We need to help people understand how and when and where and

1178 -> why to know their numbers and understand what those numbers mean. Current cutoff we're using

1183.52 -> are a systolic of 130 and a diastolic of 80. But that is just the first step. If you don't

1190.8 -> connect people to care after they get a reading of hypertension, then it's for naught and we call

1199.52 -> this the health fair paradox. Lots of people go to health fairs and they get a screening, but if it's

1206.32 -> not connected to a follow-up action, then they'll go every single year to that same health fair,

1211.92 -> they'll get their screening and they'll continue to know that they had high blood pressure and

1216.4 -> continue to not have it actually improved upon. So we need to create those opportunities in the

1223.36 -> community, but then connect people to care. And as you mentioned, bodegas, barber shops,

1230.08 -> CVS and Walgreens and pharmacies and grocery stores, these are all interventions we can use.

1235.76 -> We can use promontories and community health workers and one of the things I highlight in

1241.28 -> here is that hypertension control needs to be a team based, community based effort. It's not

1246.24 -> all in the physician, because again you're just getting a snapshot at a single point in time. But

1250.96 -> there are many other touch points in the community where we can reinforce positive behaviors,

1255.12 -> again like healthy eating and activity where we can help people know their numbers and understand

1260.72 -> their numbers and educate them. But then we need to make sure there's that transition to

1265.6 -> a care provider, so that if people actually need blood pressure medications, that they can get them

1270.88 -> prescribed and someone can follow up on them. >> Last question, I know you have other groups

1277.12 -> to talk with. Do you have partners in this initiative? It's always hard to go it alone,

1282.96 -> but do you have other partners, professional societies, professional groups, other people

1288.64 -> that will champion this over the long run? >> Well I absolutely do, Howard and one of

1294.08 -> those partners, I consider a partner, is you and JAMA.

1297.84 -> >> Thank you. >> You all have done some great work in this space

1300.64 -> and I just want to applaud you for lifting this up in the midst of a pandemic, because, again,

1306.08 -> that urgency, that urgency is what we've been lacking. But people need to understand

1311.04 -> the magnitude of the problem and institutions like JAMA can help spread the word that, hey,

1318.8 -> this is just a big of a killer as Covid. But we're also working with the American Heart Association,

1323.92 -> the American Medical Association, the National Medical Association,

1327.44 -> which is a group of black doctors and an association of black cardiologists.

1330.72 -> >> Right, right. >> These are great partners out there.

1332.96 -> One more I want to mention is the APHA, and ASTO, because we need to take a public health approach

1338.16 -> and get upstream, we're not going to treat our way out of this without recognizing that there

1343.2 -> are upstream factors and community factors that come to play. But also churches, as you mentioned,

1348.4 -> and employers. Again, this is a team effort, but together we've got this. And I want people

1353.92 -> to go to surgeongenral.gov, check out my call to action, but there are links to other resources and

1360.96 -> make knowing your own personal numbers a priority, because that's the start. One in two adults have

1366.56 -> high blood pressure, so look around you the next time you're in a room, if there's two people in

1371.12 -> the room, one of the two of you all likely has high blood pressure. If there's four people, two

1375.28 -> of you have high blood pressure. Start by knowing your numbers and using it as an opportunity to

1380.24 -> have a conversation with your health provider and everyone else around you about how we can

1385.68 -> move our nation towards health and away from this epidemic of uncontrolled blood pressure.

1390 -> >> I hope I can have you back following Paul Mutner's update of his data in five years

1398.16 -> and that number of 45% would be 75% or 80%. As I said, to me the Mutner piece represented just

1408.88 -> a dramatic failure of the US healthcare system over something we can diagnose and we can treat

1414.8 -> and has just a remarkably long-term consequences for human health.

1419.28 -> >> Well, you change outcomes for individuals one person at a time, but you change trends,

1426.72 -> you change systems by working on a broader level. And that's what this call to action is about,

1432.32 -> giving the individuals the tool they need, because I don't want any individual person to suffer from

1437.92 -> preventable complications due to high blood pressure, but it also talks about the systemic

1442.32 -> changes that need to happen if we really want to change the narrative here. But I'm optimistic,

1448.16 -> I'm convinced we can, we have the tools, we have the partners, we have the opportunity

1454.56 -> and the wind in our sails that Covid has presented with everyone talking about some of these complex

1460.4 -> issues, we just need to have the will to make it happen. And I appreciate you giving me the time to

1466.08 -> talk a little bit about this. you can hear the passion in my voice, because this has impacted

1470.88 -> my family and I feel that, again, if we can move it even -- I know you say to get it up to 75, 80%

1477.44 -> 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

1485.44 -> or even years, that's thousands, that's thousands. Tens of thousands of lives saved. So

1492 -> just do what you can. Read my call to action, look at the sector guides, do what you can and,

1499.04 -> again, that will save lives. >> This is Howard Bauchner,

1502.64 -> editor and chief of JAMA. This has been conversations with Dr. Bauchner and I've

1506.4 -> been joined by the 20th Surgeon General of the United States, Vice Admiral Jerome Adams who,

1512.08 -> along with Janet Right, has written a Viewpoint that's being released simultaneously with this

1518.32 -> discussion entitled, The National Commitment to Improve the Care of Patients with Hypertension in

1523.52 -> the United States. Jerome, thank you so much for joining me and please stay healthy.

1527.84 -> >> Thank you. Any time, Howard. >> Be well.

Source: https://www.youtube.com/watch?v=zQI4J370iuA