OUR OWN WORST HEALTH ENEMIES

By John Skow

If the U.S., as skirmishers in our health-insurance wars like to boast, has the best medical care in the world, what is the actual state of our health?

A thoughtful public-health expert tells us what we don't want to hear: the nation's health is fairly good but should be better, and the failings are mostly not medical. Public health depends more on private behavior--boring, heard-it-before considerations of how much we eat, drink, smoke and exercise-- than on whether somebody in a lab coat squints at a test tube and sees microbes turning up their toes. ``We need to realize,'' says Dr. Alfred Sommer, dean of the Johns Hopkins School of Public Health, ``that `medical care' by itself still accounts for only a small proportion of actual lives saved.''

Unfortunately for a populace that tends to equate health with crisis intervention--surgery and antibiotics--what counts more is moderation and common sense, the dreary behavioral equivalent of tofu. We say we jog and eat low-grease chips and may convince ourselves that this is true, or will be true next week when we shape up. But the fact is that as a population, we are fatter and more couchbound than ever.

Even positive trends are seldom entirely reassuring. Smoking is down among adults, though lung-cancer deaths continue to rise rapidly among women because they began smoking in large numbers less than 50 years ago. But teenagers, with their genius for perversity, are smoking more than in recent years. Should adult society shrug and blame Joe Camel, or hit the kids over the head with market forces in the form of a $2-a-pack tax?

Mortality rates in urban young--and misery rates too, if anyone keeps such figures--will be affected for years to come by cocaine, heroin and casual gunfire, and by teen pregnancy. Medicine now has to deal with crack babies and AIDS babies and, increasingly, premature babies born to single teens who had no prenatal care.

Strictly medical problems, like dealing with cancer, are tough enough. Should women under 50 have mammograms, when tests may be inconclusive in younger women? And if prostate cancer often progresses so slowly that most aging men who incur it will die of something else, should a 70-year-old have surgery, with its risk of incontinence and impotence? Should his managed-care gatekeeper okay payment?

Advances on some fronts are marred by setbacks on others. Lower cholesterol levels and better emergency care have cut death rates from heart disease and stroke. But scourges thought conquered, such as tuberculosis and whooping cough, are showing new virulence as microbes outwit antibiotics. And we are almost powerless against new killers like the AIDS virus.

Potent psychoactive drugs have enabled people once paralyzed by schizophrenia and depression to lead productive lives. Even so, pills have not vanquished mental anguish. While the rate of suicide is falling in the population as a whole, it is rising alarmingly among people ages 15 to 24 and among those over 75.

When all the pluses and minuses are added up, average life expectancy at birth is still increasing and now tops 75 years. None of us is ``average,'' however. Girl babies are expected to live 6.8 years more than boys, a difference that may or may not be mostly genetic. And newborn blacks are expected to live an average of seven years less than whites. That could stem from environmental factors, including access to medical care, since the gap was only six years as recently as 1985. But even the world's best medicine makes no difference in the end. A surprising truth, which may suggest that geriatrics is still an infant science, is that for people already 65, life expectancy in the U.S. is hardly greater than it is in the Third World.

---By John Skow

With reporting by DAVID BJERKLIE AND SHARON E. EPPERSON/NEW YORK, ANN BLACKMAN/WASHINGTON AND RICHARD WOODBURY/DENVER. CHARTS RESEARCHED BY DEBORAH L. WELLS, KATHLEEN ADAMS, ELIZABETH L. BLAND, RATU KAMLANI AND RICHARD RUBIN