Why Does the United States Rank So Badly in Health?

“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.

Related Posts Plugin for WordPress, Blogger...
This entry was posted in Development, Health, Inequality, Society, Stress. Bookmark the permalink.

19 Responses to Why Does the United States Rank So Badly in Health?

  1. There is also the strong role played by the food industry which should not be discounted. They have a vested interest in moving their product which, in a significant way, is essentially harmful to health. It’s cheap, filled with sugar, oil, and salt. This leads to excessive weight which itself is a major major contributor to poor health.

    Often framed as an individual choice matter, the reality (I think) is that the food industry spends billions advertising and lobbying to ensure that it has essentially unfettered ability to dupe people into eating stuff that isn’t food and that causes harm.

  2. A.D. Sevigny says:

    A perceived paradox is typically a symptom of a lack of understanding of a situation. I find that the pervasive influence of a profit-based health industry explains quite well the high cost and poor quality of U.S. health care.

    • Bless you. I get sick of hearing and reading disclaimers and foot notes about how something hasn’t been evaluated be the food and drug administration. It implies that they are the undisputed authority on global food and drug matters. Same difference when be are told to first consult a doctor before using herbal remedies. I not suggesting anyone be reckless with their health, but I have a problem with these god concepts of excepting the fox that’s guarding the hen house as the over riding authority. We are being told not to think and reason. The World is full of knowledge that we can benefit from, but if those special interest groups have their way we will get to believe very little of it. They have perfected making us slaves to their authority, and laughing all the way to the bank.

  3. Becky Zarger says:

    Very thought provoking piece. I agree with Charles Menzies’s comment. When you take into account the ways social inequalities (manifested in the biocultural developmental evidence you present here Daniel) intersect with our present “industrial food system complex,” it is no surprise that the US ranks so poorly in overall health. At a very basic level, fresh vegetables and fruit cost 3x what highly refined, preserved, sugary, salty, fatty foods cost. That is not even taking into account additional debates about the real health impacts of pesticides, herbicides, BPA lined cans, etc. on our long term health. In addition to marketing, access to more healthy food “choices” is often the most limited to families under the most stress. This is just one thread in a complex crazy quilt of influences of course, but an important element to consider. Thanks as always for getting an interesting dialog going!

  4. Pingback: Anthropology Update - 11 August 2012 | Anthropology Report

  5. Access to health care is one of the causes of America’s poor health statistics, so are diet, sedentary lifestyle and smoking but the causes of the causes – poverty, inequality and powerlessness are far more important overall. You mention Wilkinson and Pickett, but not Marmot or the Commission on the Social Determinants – access to resources and to power were identified by the WHO Commission.

    The illusion of choice blinds people to the reality – that activity is built out of many Americans’ lives, that food choices are limited by agribusiness. Yet in Chicago, the work of the Assets Based Community Development Institute is not only lauded by President Obama, it is world leading in a view of health which focuses not on deficits, but on assets, while the work of people like Robert Putnam, Kenneth McLeroy and Ichiro Kawachi have been really vital in understanding inequalities in health and the social ecological model.

  6. daniel.lende says:

    Just came across a fascinating paper that backs up many of the points made in the post as well as the comments, Elizabeth Bradley et al. (2011), Health and social services expenditures: associations with health outcomes.

    Here’s the description provided by Bradley et al.’s work in this Andrew Boozary post:

    A recent paper by Elizabeth Bradley underscored the shortcomings of fractioning health care from the total umbrella of social spending. Her team found that industrialized countries with the best health outcomes didn’t spend the most on the health care sector per se. Rather, they had higher levels of aggregate public spending.

    Quite neatly, she distilled it down to a ratio. The societies that spent more on other social services (such as education, housing and old age support) in relation to conventional health care had their citizens live longer and performed better on a bunch of other outcomes.

    For me, this research highlights why basic social services matter – they address those problems of inequality, early development, and lifelong health in a general way, buffering against poverty, early insults, and risky habits. In other words, they are an investment in healthy development over the lifespan.

    Elizabeth Bradley and Lauren Taylor describe their research and its policy relevance at greater length in this NYT article, To Fix Health, Help the Poor.

    Our study found that countries with high health care spending relative to social spending had lower life expectancy and higher infant mortality than countries that favored social spending…

    It’s time to think more broadly about where to find leverage for achieving a healthier society. One way would be to invest more heavily in social services…

    [R]ecognizing the health effects of our disdain for comprehensive safety nets may well be the key to unraveling the “spend more, get less” paradox. Before we spend even more money, we should consider allocating it differently.

  7. Bob says:

    Isn’t life expectancy a rather suspect statistic for health care outcomes? I mean, it’s subject to a number of factors outside of the health care arena. For example, Japan recently lost the “life expectancy” top ranking not due to an increase in price of health care or lack of access but due to the Tsunami and Earthquake last year. Iraq experienced drops in life expectancy over the past few years due to the civil war. The US scores infant mortality a bit different than many other countries as well, which can affect the numbers as well. Some commentators have also pointed to studies that show when you do some regression on the numbers for things like murder and suicide, the US actually scores quite a bit higher.


    Please don’t think I’m taking issue with the many valid points you make and the need to increase the overall health of Americans. I’m just wondering if life expectancy is really the best or most accurate measure out there for this.

  8. Ray Lewis says:

    Another basis is an economic system where a bottom line which can be counted is more quantifiable, compared to the estimated value of health and happiness of the population. Health promotion and disease prevention have largely been a market failure if capital invested elsewhere can have a better return on investment.

    We are now in a position where the US has to spend money promoting health in order to reduce future medical costs – or wait until the rising tide of people with hronic conditions overwhelmes the medical care system. thanks for the article and comments.

  9. T H Shelby says:

    A welcome and incisive discussion on the topic. Some years ago Barbara closed a special on comparison of health & life expectancy between Japan and the US with the astute observation that she was comparing a homogeneous society to a heterogeneous society. Insurance has been a prime producer of cost by extirpating responsibility. Yet, it does not deliver health care much less health. For example, my diabetic friend, who pursues an unhealthy lifestyle, has discovered that with regular medical and drugs the blood sugar tests are normal without correcting the underlying condition. and you pay for it all. Regretfully, our culture does not support the strategies outlined above.

  10. Alex says:

    The most stupid and greedy health care system in the world , The poor can not get any health care , may be die and one ask about him / her. The private sector controls everything, the government has nothing, and Most Europe health care is free, except US.

  11. Pingback: Social Position Drives Gene Regulation of the Immune System | Neuroanthropology

  12. George Miranda says:

    1. medical businesses more interested in profit than care of patients.
    2. a system where the haves get good care and the have nots don’t.
    3. system is based on treating, rather than preventing, illness.
    4. Too focused on high-cost, individualized, late-term care, rather than public health, prevention and wellness.
    5. Medical community dominated by individualist practitioners who don’t really believe in evidence-based practice, although they will claim to be scientists.

  13. Isla D. Belle says:

    Great article. The problem in the US is rooted in economics. The “Haves” in promoting their big business is good brand of social engineering have managed, by funding our legislators’ campaigns, to entrench their for-profit-above-all philosophy. This agenda pervades medical and insurance related business, food production and energy production. At the extreme, people are merely consumers of some product that generates a profit.

    Medical insurance should be a non-profit industry, which would shift the focus onto the preventative rather than dealing with the end result of years of poor health management.

    Food production should focus more on quality and impact on the earth and our health, rather than making cheaper, higher calorie, higher sugar processed products.

    Energy – politicians talk about the US decreasing its reliance on foreign sources, but the impact of this plan is never addressed. The reality is that decreasing dependence on foreign oil means increasing dependence on new oil drilling in the US and in places that we have previously deemed protected from the harmful impact of drilling, it also means an increase in coal mining, fracking and other action harmful to our environment and to people’s health.

    Education efforts in these areas are often attacked and labeled as some radical agenda, but if we really want our grandchildren and great grandchildren to have better quality lives than ours, we had better re-think our approaches.

  14. Chris T Bene says:

    Build a system – where everyone gets healthcare – and you will achieve amazingly improved results on almost every measure – 30-40% of our system-wide waste is associated with non-value added activities from a customer care perspective. There are already many, many different Countries, which have incredibly productive and excellent health care programs. Having lived in Austria, Germany, and Japan – I noticed first-hand top notch healthcare with a centralized system ensuring excellent care for all. We need to stop allowing the profit-at-any-cost providers in our system to continue dictating “scare” tactics to protect their very profitable yet wasteful programs.

    Variation is the root of all evil in any operational system or program and there is no system that has more variation than the US system by design.

  15. Cody says:

    I wish my doctor would have just told me ‘how to eat right’, I think that is a problem.

    22 now and I just figured out our ‘diet’ in united states is BAD.

    I don’t even know how so many people can live in such ignorance it makes me sad to think about it.

  16. Pingback: United States health care issues | ABCINFOPAGES.COM

  17. Pingback: Oops, We’re Not So Exceptional – 10 Disturbing Facts About America |

  18. Ahmed Sofyan says:

    It is interesting to observe, there are many factors that cause this to happen. one of which is a condition that is too pluralistic society. certainly not a major factor. but see the different conditions in each society, causing services and health insurance policies are not easy to implement. nice post.

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>