Of Mills’ many efforts in her 10 years as Maine’s “Top Doctor,” her best-known efforts include the Partnership for a Tobacco-Free Maine and her work on programs to reduce obesity. A graduate of the University of Vermont College of Medicine, Children’s Hospital of Los Angeles Pediatric Residency Program, and the Harvard School of Public Health, Mills has practiced medicine in Tanzania, East Africa, Los Angeles, California, and Farmington, Maine. She spoke to Bangor Metro recently, between committee hearings, about her views on the health of her 1.3 million patients—the people of Maine.
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How healthy are we Mainers?
We’ve seen great successes in public health the past few years in Maine, especially the comprehensive and coordinated efforts to reduce teen smoking. That’s down 60% from 1997 to 2005. Maine’s rate of teen pregnancies went from one of the highest in the country in the 1980s to the third lowest. I think the lessons learned from both efforts—smoking and teen pregnancy—are that when we lead with a comprehensive approach that involves many private and public partners (state agencies, families, schools, healthcare systems, businesses, policy makers, etc.), we can effect change that provides opportunities for Maine people to live longer and healthier lives. Our infant mortality rate is also among the lowest in the country. But there are other places where we face a lot of challenges.
Is that because we’re older, on average, than many other states?
I think some of the biggest challenges we face in the next several years are driven both by demographics and by our chronic disease burden. For example, the baby boomers are now turning 60, and we’ve got especially heavy burdens of chronic diseases, such as heart disease, stroke, cancer, chronic lung disease, and diabetes.
Generally speaking, the population of northern and eastern Maine is older than in southern and western Maine. Since the instance of these diseases is higher in older populations, the burden of chronic disease is bigger in northern and eastern Maine. There’s also a correlation between lower income and the burden of chronic disease, so I think in the next several years we need to pay special attention to northern and eastern Maine.
A recent study showed that northern and eastern Maine also have high hospitalization rates for asthma. Are age and income factors here, too?
Asthma is the only chronic disease that affects more children than adults. About 100,000 people in Maine have asthma, and most of them are children. Maine’s hospitalization rates for asthma are higher than the national average for three basic reasons. First, we’re at the tailpipe of the jet stream; a lot of the pollutants from smokestacks in the Midwest often precipitate in colder climates like ours, or come out on very hot days in the summertime. Second, asthma rates are higher in colder climates because people spend a lot more of the year inside; indoor tobacco and wood smoke and other indoor air issues tend to push those rates up. Third, there is an association across the country between low income and high asthma rates, and Maine is around number 37 in per capita income. So, given we’re in a relatively cold climate, we’re at the tailpipe of the jet stream, and we have relatively low income, it’s not surprising that our asthma rates are high.
What should we do about it?
I think the Baldacci administration, the Maine DEP, and the state’s congressional delegation have done a great job of advocating for pollution controls across the country. Cleaning up indoor air is also important, and we’ve made great strides ridding public indoor areas of tobacco smoke. And we need to make sure we’re treating asthma effectively and offering preventive care. I think our physicians and other healthcare providers are doing a great job in treating asthma proactively and early. But I think there’s always room for improvement.
How are such improvements reflected in the governor’s most recent Maine State Health Plan?
I think what the state health plan gives us is a road map to become the healthiest state in the nation. I think it’s a great vision, and I think it’s one that’s attainable. There is a focus on chronic diseases, specifically the three Cs and a D: cardiovascular disease, chronic lung disease, cancer, and diabetes. There is also a focus on mental health, specifically depression, because of the positive impact that early treatment has and the high prevalence of depression. The third focus is on substance abuse, again, because of the prevalence and the success of early treatment and prevention. So, I think if we focus on those three areas, we can certainly become the healthiest state in the country.
Is the main goal of the health plan, then, to make services more widely available?
I think it’s a matter of everyone having a focus on direct services, but also a focus on prevention, which may not involve direct services. For instance, the successes we’ve had curbing youth smoking are a result, not only of direct services, but also of a statewide multimedia campaign, education and intervention in schools and communities, policies that have driven indoor public places to be entirely smoke-free in Maine. They’re the result of a comprehensive approach that involves policies and prevention, as well as direct services. We have one of the most successful tobacco “quit lines” in the country, for example. I think that the comprehensive approach we use against tobacco can be applied to these other issues.
Another example: I remember growing up in Maine in the 1970s. We had one of the highest infant mortality rates in the country. We also had one of the highest teenage pregnancy rates in the country. Both have plummeted, and now both are among the lowest rates in the country. That’s because of the concerted efforts of many people across the state. We need to take that same concerted approach, that same focus, and apply it to these three other areas: chronic disease, mental health, and substance abuse.
So would you say that education is the key ingredient to success?
Certainly, we want to stay evidencebased and look at the science and the research and get that information out there. But it’s a lot more than education. Look at tobacco, before the recent successes. If you took a survey in the 1990s, you’d find virtually 100% of people knew smoking was bad for them. If you look at surveys now, of all types of people, asking what’s healthier, salad or junk food, they’re going to tell you salad is healthier. If it were easy for us to make healthy choices in our society, we would all be healthy. But what if you don’t have much money, you’re hungry, and you walk into a fast food restaurant: Are you going to buy one $4 salad, or four $1 hamburgers? We tell everyone to eat lots of fresh fruits and vegetables, but for many, buying broccoli and pears in the winter is too expensive. A package of hot dogs and rolls is more affordable.
This is just one example of how we have built poor health—in this case, obesity—into the fabric of our society. Generally speaking, four dollars buys a lot more soda than it does milk. If you’re poor and you’re thirsty, which one are you going to buy? So, I think we have to look at retooling our entire society, so that we rebuild health into the fabric of the society. That involves education, but it also involves policies and other interventions that make it a lot easier for all of us to make healthy choices.
Are the monies from the tobacco settlement helping fund some of these efforts?
The tobacco settlement is one of the best success stories in Maine. The governor and the legislature several years ago had many choices in ways to spend that money, and they made a wise investment in the health of Maine people. The settlement ranges from $45 million to $50 million a year. That funds expansions of Medicaid insurance and drugs for the elderly; about $14 million a year goes to tobacco prevention and control, as well as physical activity issues; some of it goes to child care, substance abuse treatment, home visits for parents of newborns, and dental clinics. So, the money goes to a wide variety of programs that have a lasting impact on the health of Maine people.
In your view, how much should government do to promote public health, and how much is an individual’s responsibility?
It’s a balancing act. The responsibility of the health status of a population is split among individuals, government, and other organizations, such as the healthcare system. When you look at the underlying factors
affecting health, it’s overwhelming how much of it is due to the broader environment that we live in. For instance, two of the biggest determining factors of one’s health in this country are a color and a number. The color is the color of your skin, and the number is the number on your paycheck. Race and income are major drivers of our health status.
Everything is connected. In any society, when you look at health, the physical environment, education system, even the infrastructure— water, roads, electricity, and the economy—all of those are connected. But
what we know from studies is that a lot of those other factors have a big impact on our health. Your access to transportation, a good job, and a good education have a tremendous effect on your health. So, yes, we need to take personal responsibility to take better care of ourselves; but it is also true that many people face barriers to making healthy choices, barriers which often they themselves cannot bring down. We as society can reduce those barriers to make it easier for all of us to make healthy choices.
Do you think we should be headed for universal health care?
Yes. It is absolutely shameful that we are the richest country in the world, and we spend far more per capita on health care, yet health status—what we get for that money—is a very poor outcome. There are about 25 countries with much better health status and longer life expectancy than we have. In those countries, there is some basic set of healthcare services available to all, and they have a strong public health infrastructure. I think across this country we need to strengthen our health infrastructure. We also need to make health services—including some kind of health insurance—available to all.
Does that mean I believe in a singlepayer system or universal coverage for everything at all costs? Not necessarily. It’s simply shameful that many people in this country are fearful that they may get into an accident and get a healthcare bill that could devastate their families. It’s shameful that so many families have to wait out a screaming child, burning up with fever, because they can’t afford to go in and be seen. I think the state of Maine can be extremely proud of the progress we’ve made on these issues. But across the country, we need a wakeup call to see that everybody has some assurances of getting some kind of care when they face an emergency, at the very least.
As Maine’s public health director, you oversee many of the state’s health and safety programs, including emergency preparedness. Recent world events, from Hurricane Katrina to the avian flu, have left many Mainers wondering—how prepared are we for emergencies in Maine?
We are much better prepared than we were five years ago. But, do we have a ways to go? Absolutely. The federal emergency preparedness funds have gone a long way in helping us prepare. For example, during the ice storm in January 1998, we did not even have a “blast fax” machine at the Bureau of Health to send a message out to all hospitals. We had to use the state police “blast fax” machine, and even then we only had the numbers of hospital administrations, which, of course, were closed nights and weekends.
With the public health emergency preparedness funds, we were able to build a full health alert network in Maine, which allows us to contact people through faxing, paging, phone calling, email, Web services, to notify them of a health advisory or alert. That’s just one use of those funds. We have a comprehensive, multimodal communication system with healthcare providers around the state, which we are still strengthening. But it’s a far cry from the lone fax machine in January 1998 when we could fax only one recipient at a time.
As a woman, do you bring something unique to your position?
We all bring our personal experiences to our jobs. I’ve had this job since the summer of 1996, and in those 10 years I’ve also gotten married and had two children. I put on a lot of weight after I had my children. Having two infants at home and working fulltime, there was absolutely no time for me to get out and exercise. Eating on the run was putting it mildly, too. I think I particularly empathize with the uphill swim it is to get to and maintain a healthy weight, particularly as a woman juggling a job and two children. But I also think about how challenging that struggle is for many other women. I’m more committed, I guess, to making sure that our policies are helping all people in Maine, especially those with low incomes.
A litmus test for me is this: If a policy helps low income women, it probably helps to lift our entire population. Low income women traditionally are some of the most vulnerable people in our society. My own experiences as a woman have helped me realize that, and to realize if I’m challenged, how much more challenging it is for many other women.
How do you keep all your responsibilities in perspective?
My mother, who’s 89 and very healthy, grew up on a potato farm in Aroostook County. I’m extremely proud of my County roots. When I tell her how busy I am, she’ll say, “Honey, if you are fortunate enough to live long, you will retire, your children will move away, your phone will stop ringing, people will stop calling and writing, and you will be lonesome for those busy, busy days.” So, I try not to complain
