“Why is USA in the worst shape as patient among industrialized nations?”
That’s the question I just got on Twitter. Indeed, the United States ranks 37th out of 191 countries in average life expectancy.
My quick answer back: “Off top of head, uneven access & expense of health care, inequality, diet & levels of activity, early adverse experiences, smoking.”
Some of the stuff I thought about as I crafted that answer:
Steven Schroeder’s 2007 paper in the New England Journal of Medicine, We Can Do Better — Improving the Health of the American People. It opens with exactly that question: “The United States spends more on health care than any other nation in the world, yet it ranks poorly on nearly every measure of health status. How can this be? What explains this apparent paradox?”
Shroeder’s answer starts by saying “poor health care” isn’t really the answer. “Poor health” comes first, driven by poverty and inequality and by individual behavior in social contexts (e.g., smoking and obesity). Once people are sick or vulnerable to poor health, then care matters, and here the United States “even in those instances in which health care is important, too many Americans do not receive it, receive it too late, or receive poor-quality care.”
Richard Wilkinson and Kate Pickett’s work that shows that societal inequality – the differences in status and income within a country – can drive poorer health for the entire society (including the rich folk!). They outline the evidence and what might be done about it in their book The Spirit Level: Why Greater Equality Makes Societies Stronger. Wilkinson and Pickett also have a 2009 paper in the Annual Review of Sociology, Income Inequality and Social Dysfunction. Here they lay out their argument for why inequality within a society can drive poor health, focusing on how status and experience shape human life.
In a recent chapter, this is how my co-authors and I described this research:
Wilkinson & Pickett (2009) have demonstrated how the breadth of social inequality matters to health outcomes: the scale of income disparities between Western nations, as well as between regions within a country, is linked to the scale of social problems and health differentials. This association is not solely the result of an individual’s socioeconomic position, but linked to unequal distribution at the societal level. This unequal distribution of income affects all members of society, not just the poorest members, and is manifested in greater behavioral and mental health problems like alcoholism, violence, mental illness, suicide, homicide, and obesity. Wilkinson and Pickett (2009) propose social stress, status anxiety, social competition and lack of trust as plausible mechanisms linking inequality to health. Another plausible mechanism is a lack of cultural consonance, where individuals who are unable to match their lived experiences to valued cultural goals suffer greater behavioral and mental health problems (Dressler et al. 2007).
In answering the “Why Americans have poorer health” question, I also thought of the role that Adverse Child Experiences (stress and trauma during childhood) play in life-long health, including how maternal health during pregnancy can impact the developing child (the developmental origins of health and disease). In 1998 Vincent Felitti and colleagues published their massive study on abuse and household dysfunction during childhood, and showed how these experiences were powerfully linked to later adult health. They recently backed up that initial study with a hefty 2009 paper Adverse Childhood Experiences and the Risk of Premature Mortality (pdf), and outlined the overall research and its implications for health care in this book chapter.
Taking a developmental approach – like Felitti and his colleagues do – means we need to extend our thinking to include how maternal health and the development of the child in utero can also impact health over the lifespan. This work – known as the Developmental Origins of Health and Disease – began by recognizing how much being born at low-birth weight was linked to problems in adult health and premature mortality. Today, the lens has broadened beyond nutrition to include maternal stress, exposure to toxins, and patterning of risk (e.g., feast and famine) all contribute to health, demonstrated most clearly through cardiovascular health. Chris Kuzawa and Elizabeth Quinn lay out the biological reasons why we might see this pattern, where early insult leads to life-long costs, in their review paper, Developmental Origins of Adult Function and Health: Evolutionary Hypotheses.
A crucial factor to address is the role that behavioral and mental health play in preventable disease today. Smoking, diet and activity, violence, suicide, alcohol and drug use – all of these are major drivers of differences in health over the lifespan, and particularly from adolescence on. The paper “Personal Decisions are the Leading Cause of Death” demonstrates this case empirically in the United States. Behavior can also make a positive difference when growing up in difficult situations, where children who can find strong personal relationships and persist in pursuing a future (or have hope) (“shift-and-persist”), can be resilient in the face of adversity. Or one can look at the leading causes of death in the United States. Heart disease is #1, and cancer is #2, accidents at #4, and suicide at #10 – what we do, from activity to eating to driving, and how we feel, from depression to stress to feeling less equal, play a major role in how our health in industrial settings plays out.
Finally, let me come back to health care. The United States system has a dual nature – hugely expensive, driven by technology, covering every angle at the top end, and with a lack of preventive health care and primary care, and over-reliance on the emergency room, at the low end. Medical errors and over-diagnosis and over-treatment can actually drive health problems within the health care system itself. And outside it? This study shows that, even when controlling for many of the factors already mentioned above, a lack of health insurance in the United States is directly associated with higher rates of mortality in the United States.
So here is my more long winded answer: (1) Societal inequality that helps drive social determinants of health, (2) A worse developmental context for some children from conception on, (3) How behavioral and mental health shape adolescent and adult life and contribute heavily to early mortality, and (4) A contradictory health care system that burdens some through error and over-treatment and does not reach those who really need the preventive and primary care that would help address factors 1, 2, and 3.
Update January 2013: The Institute of Medicine in the US has just released the report U.S. Health in International Perspective: Shorter Lives, Poorer Health. A sobering read. Here’s part of the introduction:
No single factor can fully explain the U.S. health disadvantage. It likely has multiple causes and involves some combination of inadequate health care, unhealthy behaviors, adverse economic and social conditions, and environmental factors, as well as public policies and social values that shape those conditions. Without action to reverse current trends, the health of Americans will probably continue to fall behind that of people in other high-income countries. The tragedy is not that the U.S. is losing a contest with other countries, but that Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary.