Chronic disease strikes earlier, more frequently, prompting review of public health policies

February 13, 2019

Stroke and heart disease are no longer markers of a long life, hard-lived. High blood pressure and cholesterol no longer wait for middle-age.

Frank Franklin, Ph.D., principal epidemiologist for Multnomah County, sharing data on chronic illness, alongside Public Health Director Rachael Banks, left, and Deputy Health Officer Dr. Jennifer Vines, right.

“Chronic disease is happening younger. It’s driving down our life expectancy,” Multnomah County’s Public Health Director Rachael Banks said Tuesday while briefing the Board of Commissioners on leading causes of death in Multnomah County.

Nearly 60 percent of adults in the United States have a chronic illness — most commonly cancer, heart disease, and stroke. They are also largely preventable.

The Centers for Disease Control and Prevention estimate that four risk factors — a poor diet, inactivity, smoking, and obesity — are responsible for 80 percent of cases of heart disease and stroke, and 40 percent of cases of cancer. Yet nationally, only 3 percent of healthcare dollars go to measures such as increasing access to healthy foods and tobacco cessation.

“We know money is an issue, and we don’t have the dollars we would like to invest,” Banks told the Board of County Commissioners. “We want to have better health care at a lower cost, with better outcomes. We can not get there without addressing chronic disease.”

Tuesday’s briefing on chronic disease deaths builds on a November 2018 presentation to the Board of Health on the leading causes of death in Multnomah County and prepares commissioners for next month’s presentation by the Public Health Advisory Board, which will deliver policy proposals

The Board of County Commissioners, acting as the Board of Health, operates under Oregon law as the Local Public Health Authority. It has the power to pass local ordinances on issues affecting people’s health and has pledged to take a more active role in creating supporting policies that promote healthy options for low-income people and people of color.  

“The burden of chronic disease is beginning to increase into younger ages,” Frank Franklin, Ph.D., principal epidemiologist for Multnomah County, said Tuesday. “It’s not just the burden of those 65 and older.”

But those increases aren’t evenly distributed, he said. African Americans die from chronic diseases at a higher rate than any other demographic group. In fact, Franklin explained, the combined cost of health inequalities in Multnomah County runs about $442 million per year, including $332 million from premature death and more than $100 million in direct medical costs.

Multnomah County Deputy Health Officer Dr. Jennifer Vines focuses on four contributors to chronic disease: Diet, exercise, alcohol and tobacco

Multnomah County Deputy Health Officer Dr. Jennifer Vines focused Tuesday on the big four contributors to chronic diseases, where commissioners might consider focusing future policy.

“I come from family medicine and I have a real respect for what happens at health care clinics,” said Vines, who started her career at a county clinic. “But I realized pretty quickly that most days people don’t need a doctor. Most days they need health in their environment.”

Chronic disease is expensive. It’s common. And there are cheaper interventions than medicine.

“There’s a lot we can do outside the clinic walls,” Vines said, just by focusing on the four big risks outlined by the CDC:


About 14 percent of Multnomah County residents report they get no exercise outside of work. Only 10.5 percent of residents walk or bike to work.

Health guidelines suggest a modest 30 minutes of walking a day, and a couple of light sessions of endurance exercise a week. Bike commuting or walking to work would cover that for most residents. But it’s not always an option. Some neighborhoods have no sidewalks, or those sidewalks run along clogged throughways with poor lighting.

Many can’t afford a gym membership as an alternative to the daily commute, and they might have a social circle more interested in watching a match on TV than taking a hike in Forest Park.

“If physical exercise were a pill, we would all want it. It helps you sleep better. It helps your mood. It staves off many of the common diseases you can think of,” Vines said.


Fewer than a quarter of county residents eat the recommended five servings of fruit and vegetables a day, while one-in-10 consume at least one soda per day. More than 10 percent of teens are obese, yet one-in-five children don’t get enough nutrients in the food they do consume.

In the span of her career, Vines said, doctors have had to learn to manage weight-related chronic diseases such as high blood pressure and type-2 diabetes in children.

And now, obesity is nearly on par with tobacco in influencing how long people live.

“We have a collective interest in supporting healthy food, making sure it is widely available and affordable,” Vines said. “Whether human compassion or the cost savings compels you, this is something we are ethically obligated to look at.”


Seventeen percent of residents use tobacco, leading to 1,200 preventable deaths a year and costing more than $300 million in medical bills. The vast majority of smokers started as young people.

“When these products are cheap and they’re flavored, kids tend to use them,” Vines said. Research hasn’t concluded that the use of e-cigarettes leads to later use of tobacco, she said, “but I don’t think anyone wins when we're recruiting a new generation of people addicted to nicotine.”


Multnomah County residents report higher rates of heavy drinking and binge drinking than Oregon as a whole, with one-in-five residents reporting having binged on alcohol in the past month and one-in-10 reporting heavy drinking (eight or more drinks a week for women and 15 or more drinks for men).

Abusing alcohol is directly linked to a host of chronic diseases, including high blood pressure, stroke, scarring of the liver, and cancers of the mouth, throat, liver, and breast.

“This is somewhat difficult to talk about in a town that prides itself on microbrews and in a state that prides itself on its wines,” said Vines. “But it’s a carcinogen. A known cancer-causing agent. Used steadily or heavily, it causes quite a bit of damage.”