The US Health Disadvantage

 Mobilization of an unprecedented kind is now necessary in the United States. It requires a campaign to remove the public veil of ignorance about the evidence.

So states the public health Policy Forum in the Aug 30 issue of Science ("Confronting the Sorry State of U.S. Health," Bayer et al.*), which raises some important questions about health and sickness in the United States.  The authors are commenting on a recent report published by the U.S. National Research Council and Institute of Medicine, "US Health in International Perspective: Shorter Lives, Poorer Health," (Jan, 2013) which asks why the US is among the richest nations in the world, and yet the health of its people is far down the list.  The report is the outcome of 18 months of work by a panel charged with exploring the problem and identifying causes and solutions.

The panel compared health outcomes of Americans with those of 16 other wealthy countries.  They found that Americans have had a shorter life expectancy than people in the comparable countries for many years, and that the differential is growing, especially for women.  The health disadvantage affects everyone up to age 75, it's worse among poorer Americans but exists even in the wealthy, and includes multiple diseases, risk factors and injuries. 

It's worth quoting the panel's findings in detail.

1. Adverse birth outcomes: For decades, the United States has experienced the highest infant mortality rate of high-income countries and also ranks poorly on other birth outcomes, such as low birth weight. American children are less likely to live to age 5 than children in other high-income countries.

2. Injuries and homicides: Deaths from motor vehicle crashes, nontransportation-
related injuries, and violence occur at much higher rates in the United States than in other countries and are a leading cause of death in children, adolescents, and young adults. Since the 1950s, U.S. adolescents and young adults have died at higher rates
from traffic accidents and homicide than their counterparts in other countries.

3. Adolescent pregnancy and sexually transmitted infections: Since the 1990s, among high-income countries, U.S. adolescents have had the highest rate of pregnancies and are more likely to acquire sexually transmitted infections.

4. HIV and AIDS: The United States has the second highest prevalence of HIV infection among the 17 peer countries and the highest incidence of AIDS.

5. Drug-related mortality: Americans lose more years of life to alcohol and other drugs than people in peer countries, even when deaths from drunk driving are excluded.

6. Obesity and diabetes: For decades, the United States has had the highest obesity rate among high-income countries. High prevalence rates for obesity are seen in U.S. children and in every age group thereafter. From age 20 onward, U.S. adults have among the highest prevalence rates of diabetes (and high plasma glucose levels) among peer countries.

7. Heart disease: The U.S. death rate from ischemic heart disease is the second highest among the 17 peer countries. Americans reach age 50 with a less favorable cardiovascular risk profile than their peers in Europe, and adults over age 50 are more likely to develop and die from cardiovascular disease than are older adults in other
high-income countries.

8. Chronic lung disease: Lung disease is more prevalent and associated with higher mortality in the United States than in the United Kingdom and other European countries.

9. Disability: Older U.S. adults report a higher prevalence of arthritis and activity limitations than their counterparts in the United Kingdom, other European countries, and Japan.

It's not all bad -- if an American reaches 75, s/he has a higher survival rate thereafter; the US has higher cancer screening and survival rates, blood pressure and cholesterol are better controlled, we're more likely to survive a stroke, we smoke less and our average household income is higher, suicide rates aren't higher than comparison countries (faint praise, that), and the health of recent immigrants is better than that of people born here. Otherwise, and even though health care spending per capita is much higher in the US than the comparison countries, health outcomes here are significantly worse. Though, of course, we're ahead of the curve in some respects, obesity rates e.g., with other countries fast catching up.  

So, why the dismal picture in the US?  The panel considered this at great length (it's a 400 page document).  You'd think it might be because we have more people without access to health care than other countries, but the disadvantage holds even for those with access to care.  We smoke and drink less, but eat more.  We have more accidents and have more guns.  Our educational attainment is lower than other countries, and poverty rates and income inequality higher. and social mobility lower.  And, the panel also points out, a less effective social safety net.  But, even those of us with "healthy behaviors" are more likely to get sick, and have accidents, than our counterparts in other wealthy countries.

So, understanding what's behind the sorry state of health in this country is not straightforward.  Indeed, the panel seemed sorely tempted to describe unhealthy social and environmental conditions in the US, and ascribe our health conditions to the whole sorry mess.

Potential explanations for the U.S. health disadvantage range from those factors that are commonly understood to influence health (e.g., such health behaviors as diet, physical inactivity, and smoking, or inadequate access to physicians and high-quality medical care) to more “upstream” social and environmental influences on health (e.g., income, education, and the conditions in which people live and work). All of these factors, in turn, may be shaped by broader national contexts and public policies that might affect health and the determinants of health, and therefore might explain why one advanced country enjoys better health than another.

That's of course not very helpful in policy terms because public health measures must be directed at something specific, like cleaning dirty water or vaccinating against disease. The situation reminds us of too many attempts to explain complex disease with simple, enumerable factors -- for example, we dream of simple genetic causes, but in fact it's multiple gene and environment interactions.  Here, the Affordable Care Act won't be the answer, nor would gun control be, nor enforcing seat belt laws, nor banning supersize drinks or increasing the availability of fresh fruits and vegetables in poor neighborhoods.  It's complicated.  And surely a combination of many factors, social and environmental.
 
The panel recommends, though, more data collection, more refined analytic methods and study design, and more research.  They recommend focusing on children and adolescents, because early life experiences and habits can affect the whole life span. They also recommend that research should be on the entire life course rather than more localized cause and effect.    But the study urges that the situation is so critical that action must be taken while research is ongoing, and they provide a long list of actions they believe should be taken, from increasing the use of motorcycle helmets to increasing the availability of public transport to improving air and water quality and increasing the proportion of adolescents who don't use illegal drugs.  More generally, they recommend:

(1) intensify efforts to pursue existing national health objectives that already target the specific areas in which the United States is lagging behind other high-income countries, (2) alert the public about the problem and stimulate a national discussion about inherent
tradeoffs in a range of actions to begin to match the achievements of other high-income nations, and (3) undertake analyses of policy options by studying the policies used by other high-income countries with better health outcomes and their adaptability to the United States.

But what kind of issue is this?  A public health issue?  Public policy?  Economic, educational?  Here we come to a fundamental question of causation. What, we might ask, causes AIDS? Is it HIV?  Needle sharing?  Poverty?  A confluence of factors at all levels?  Epidemiology has long struggled to take multi-level causation into account, acknowledging the role of many different kinds of factors including biological and social determinants (see Nancy Krieger's old but seminal and still good 1994 paper on this, "Epidemiology and the web of causation: has anyone seen the spider?"), but once the web extends into social causes, the field of public health is pretty much stymied when it comes to fixing things.  And throwing this into the political arena is a sure recipe for a lot of grandstanding but not much else.

Is more research really needed into why Americans are sicker than our counterparts in other wealthy countries?  No doubt it is a serious problem, and very costly in both human and monetary terms.  But of course the request will be for more mega-scale, long-duration highly technological studies--more grant money.  You'd expect us to say that.  But is the plea for more funding a reflex or is it really the answer? 

It does not seem obviously so, except for the many small factors that would be found.  We know enough to know that the answer is going to be complicated, and causal factors changeable.  Indeed, we surely will be found to be leading the pack in some measures, and other countries will catch up.  And, whether the fix is deemed to be personal behavior or political, or a mix of many approaches, once we go beyond requiring vaccines or seat belts, we are the master of none of them. And they're always changing.  Perhaps research money should be going into things like how to improve health education (that is, how to get people to do things they'd rather not do, like exercise or eat less fat). 

If history is any guide, we're betting that when another such study is done in the future, we'll be better than we are now in some measures and worse in others.  And we won't know why.  And we'll say that 'more research is needed'.  Cardiovascular disease rates have risen and fallen over the past 60 years or so, and we still don't know why -- and that's just one disease.  A serious question is how to deal with phenomena that are so changing, and so subtly complex, that we have to keep surveying to understand them.  Could there be some better way, a different approach?
 

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*Thanks to Bob Ferrell for bringing this to our attention.