by Kim Krisberg
When it comes to good health, America is far from top dog.
Yes, we may spend the most, we may have some of the most advanced medical technologies and we may produce some of the best doctors. But when it comes to the ultimate measure of a health care system's success — the health of people and populations — it seems we are losing a winnable battle.
"There's hardly anything more consequential than Americans dying earlier and being sicker," Dr. Steven Woolf, chair of the Institute of Medicine's and National Research Council's Panel on Understanding Cross-National Health Differences Among High-Income Countries, told me. "That our children are going to die an earlier death than children in other (comparable) countries — I think this is a pretty serious situation. ...On all accounts, humanitarian and economic, this is serious."
Woolf and his colleagues on the panel recently released a report finding that although the nation has experienced dramatic improvements in life expectancy and survival in the last century, we're falling behind our counterparts in other high-income countries. The report, which compared U.S. health outcomes to those in 16 comparable nations, such as Australia, Canada, Germany, Japan and the United Kingdom, found a "pervasive pattern of higher mortality and inferior health in the United States, beginning at birth." In fact, the U.S. health disadvantage can be seen in all age groups up to age 75 and is observed for multiple diseases, injuries, and biological and behavioral risk factors. Woolf noted that the report provides the most comprehensive analysis of the topic to date.
The report found that the nation fares worse in nine health domains:
- The U.S. is home to the highest infant mortality rate among high-income countries, and American children are less likely to live to age 5 than children in comparable nations.
- Deaths related to motor vehicle crashes and violence happen at much higher rates in the U.S. and are a leading cause of death for children, adolescents and young adults.
- U.S. adolescents experience the highest rate of pregnancies and are more likely to become infected with a sexually transmitted disease.
- The U.S. has the second-highest HIV infection prevalence among the nations studied and the second highest mortality rate linked to HIV/AIDS after Portugal. The U.S. is also home to the highest incidence of AIDS.
- U.S. residents lose more life years to alcohol and other drugs than people in peer nations.
- The U.S. has the highest obesity rate among high-income countries. Also, beginning at age 20, American adults have the highest prevalence rate of diabetes.
- The U.S. is home the second-highest death rate from ischemic heart disease after Finland among the nations studied.
- When compared to European countries, lung disease is more prevalent and tied to a higher mortality rate in the U.S.
- Older U.S. adults experience a higher prevalence of arthritis and activity limitations than their peers in Europe and Japan.
Researchers surprised by pervasiveness of problem
Woolf, who is also a family medicine professor and director of the Center on Human Needs at Virginia Commonwealth University, said that since the U.S. health disadvantage has been discussed previously in the literature, especially the disadvantage among older Americans, "we had some sense that we might find other bad news, but we were not prepared for the scale of what we found." Woolf said he and his colleagues were most surprised at the sheer pervasiveness of the problems.
For example, he said that while researchers knew violence was a big issue in the U.S., they didn't realize that American children younger than 5 experienced the highest rate of violence when compared to their counterparts in other high-income nations. Similarly, he said the health status of American teens was quite surprising — they have a higher risk of dying in their teen years and experience a higher prevalence of disease and risk factors.
"American teens are in a really bad place compared to teens in other countries," Woolf said. "It's a stunning pattern."
During our conversation, Woolf took care to note that while some might be inclined to conclude that the U.S. average is being drawn down due to the nation's racial, ethnic and socioeconomic diversity and the health disparities documented in many minority and low-income communities, that's not the case.
"When we analyzed data for advantaged Americans, there's still a disadvantage," he said. "We still find the same patterns — that Americans are dying earlier, even if you're a rich American. So to dismiss this as someone else's concern is a mistake. We're all in this together."
However, the news wasn't all bad. The report did find that Americans older than 75 live longer. Also, Americans experience lower death rates from stroke and cancer, better control over cholesterol and blood pressure levels, and lower rates of smoking compared to many of their counterparts in other wealthy nations. Woolf said it's critical to better understand how those success stories came to be. For example, he said, researchers aren't sure if lower stroke mortality rates are a reflection of better blood pressure control, better diet or the success of the medical sector in treating stroke — "we haven't unpacked that enough to know what's going on there," he said.
While there are many probable explanations for the U.S. health problems, such as a large uninsured population, high calorie consumption, more access to firearms, and higher rates of poverty and income inequality, the report stated that "no single factor fully explains the U.S. health disadvantage." The authors wrote:
Might certain aspects of life in modern America — including some of the choices that American society is making (knowingly or not) — be part of the explanation for the U.S. health disadvantage? There are no definitive studies on this subject, but the public health literature certainly documents the health benefits of strengthening systems for health and social services, education, and employment; promoting healthy lifestyles; and designing healthier environments. ... In countries with the most favorable health outcomes, resource investments and infrastructure often reflect a strong societal commitment to the health and welfare of the entire population.
On the other hand, the report also notes that in some cases, it "may simply be that the United States is at the leading edge of global trends that other high-income countries will follow."
Woolf noted that the Affordable Care Act and its expanded access to affordable insurance could address some of the issues highlighted in the report. But he called the law's investments in public health and prevention "crucial," adding that "talks to cut back on (public health funding) are scary because they will likely only exacerbate the U.S. health disadvantage." He added that while some policymakers claim that the current fiscal environment demands cuts to discretionary public health spending, he doesn't believe that's an accurate assessment of the situation. It's not that the money isn't there, Woolf said, it's how we're spending it.
"If you look at the ratio of health care spending to social spending, the U.S. is an outlier...countries with better (health) outcomes are spending more on social programs and less on health care," he said. "We need to start thinking about whether spending on public health and social programs may give us better value for our dollar."
For a copy of the new report, "U.S. Health in International Perspective: Shorter Lives, Poorer Health," visit www.nap.edu. Also, click here to use an interactive graph to see how the U.S. compares to its 16 peer countries. And below is a video interview with Steven Woolf discussing the new report. (Video courtesy the National Academies)
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for the last decade.
You forgot guns. It's thought gun homicide is a very powerful contributor to US mortality, especially because the mean age at death for gun homicide is so low. Worse, 80% of gun homicides in the top OECD countries occur in the US. We're way out in front on that one.
What about the size of the United States? The US has approx. 315 million people living within its borders (not counting those who live here unknown). The population of the US is 2.5 times bigger than Japan (who is the bext highest pop. next to the US in your list). Lets view the first bullet dealing with Infant Mortality Rate (IMR). Japan for instance has a IMR of 2.21/ 1000 deaths( or .00221 deaths per birth). The US has 6.00/ 1000 deaths (.006 deaths per birth). The US is much higher but when you multiple Japans IMR by 2.5 (how much bigger the US is than Japan) you can see that japan is within .000475 deaths per birth(.475 deaths per 1000 births). My question is this, Is the population taken into account in these studies?
Thanks for your comment. The researchers involved in this study used a diversity of data sources when examining this question of the U.S. health disadvantage. They note in the study that their research is, in part, drawn from "analysis of data on mortality, morbidity, and disease determinants in high-income countries, drawn from databases (e.g., the Human Mortality Database) from the World Health Organization (WHO), the OECD, and other major data repositories. All of these analyses compared the health of the U.S. population with those in a peer group of comparable affluent countries, and some had a special focus on social factors (based on life-cycle events and living conditions) that might explain health differentials."
So as not to let population size distort their findings, they focused on prevalence, severity and mortality rates among the nations --- not total numbers. While the U.S. is indeed much larger than Japan, the goal was to study health outcome differences that persist despite similar wealth and resources. It may be true that when dealing with a much larger population/resource dynamic, Japan might do worse on infant mortality. However, the different social determinants in Japan, such as the presence of a universal health care system, might act as a buffer even as the population grows. Much of the report was not only looking at statistical differences, but at the social/policy roots that shape such differences, which are not necessarily tied to population size.