How Could the United States Have a "Health Disadvantage"?

By David A. Kindig, MD, PhD

This was the question that I couldn’t keep out of my mind while reading the superb new report from the National Research Council and Institute of Medicine titled “U.S. Health in International Perspective: Shorter Lives, Poorer Health.”

Before I get to my title question, let me briefly summarize the ambitious effort that this distinguished panel, chaired by Population Health expert Steve Woolf from Virginia Commonwealth University, has produced for both scholars and policy makers. In the opening summary the authors assert, “The United States is among the wealthiest nations in the world, but it is far from the healthiest…Americans live shorter lives and experience more injuries and illnesses than people in other high income countries….The US health disadvantage cannot be attributed solely to the adverse health status of racial or ethnic minorities or poor people, since recent studies suggest that even highly advantaged Americans may be in worse health than their counterparts in other countries.”

The report takes on the very challenging task of explaining what underlies this poor performance of the United States.  Two initial chapters deal with the evidence on mortality and morbidity, while five more deal with current evidence for the explanatory factors, such as public health and health care systems, individual behaviors, social factors, and physical and social environmental factors. It is beyond the scope of this blog post to try to summarize this vast content, but suffice it to say it is an extremely comprehensive treatment of what we know about the multiple factors producing health. The report can and should be used as an evidence guide for policymakers and a population health textbook for the academic community.

 Concluding that no single factor can fully explain the differences in health outcomes identified in the report, the authors considered the possibility of an unidentified root cause. In a provocative chapter on “Policy and Social Values“ they question the possible role of “characteristics of life in America that create material interests in certain behaviors or business models,” and discuss the roles of “five iconic American beliefs” such as individual freedom, free enterprise, self-reliance, religious values, and Federalism. While the committee acknowledges that no empirical evidence exists to link these factors to the poor performance they document, this chapter should certainly be the basis for much discussion and future research.

The report closes with six recommendations. Three call for major new research and data efforts aimed at “better elucidating the complex causal pathways that might explain the cross national differences in health” they document. Three are in the policy area, including calling for redoubled efforts to achieve established national health objectives and the development of a comprehensive media and outreach campaign to “stimulate a national discussion” about the findings and their implication for the nation.

The report does have some limitations worth mentioning, including its exclusive focus on  aggregate health status of the US and other high income countries. The authors acknowledge that addressing disparities within countries, which can be as great as those between, was beyond the scope of the investigation. This is certainly understandable given the massive effort the report represents. But they also assert that addressing disparities is a “paramount national priority” that is worthy of equally rigorous study. As useful as cross national analysis can be, it is possible for some to dismiss the implications because of fundamental differences in national cultures and policies. This limitation is significantly less when exploring similar differences within national boundaries of even such a large and diverse country as ours. Secondly, with regard to monitoring improvement even for the nation in aggregate, the report relies primarily on a list of Healthy People 2020 objectives which are relevant to the cross national differences they highlight. This might have been an opportunity to at least discuss the potential and challenges of setting higher level goals such as life expectancy reduction targets suggested by another IOM committee last year.

So are we disadvantaged? In a footnote the report defines the term health disadvantage as “a condition of relative inferiority, reflecting the unfavorable health outcomes in the United States compared with those in other high-income countries…the term is not meant to imply that the United States, among the wealthiest countries in the world, is disadvantaged in the dictionary sense of ,‘lacking in the basic resources or conditions (as standard housing, medical and educational facilities, and civil rights) believed to be necessary for an equal position in society.’”

But in reading one of the references in the provocative social value chapter I found this definition of American disadvantage: “a unique weakness of its social safety nets, the magnitude of social inequalities, and the harshness of its poverty (1)”. Thought of this way, disadvantage is certainly a compelling hypothesis deserving serious and urgent attention of population health scholars and policy makers.

1. Avendano M, Kawachi, I. (2011). The search for explanations of the American health disadvantage relative to the English. Am. J. Epidemiology, 173 (8), 866-869.

David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health. Follow him on twitter: @DAKindig.

Comments

[Brad F]

David
I did not read the report due to length and access. However, I scanned all the press and blog coverage and have a good feel for the findings.

Observation and question:
On mortality <50yo, report conveys that 2/3 of attributable risk due to public health issues like guns, accidents, etc.

Given rates of death in younger demographic contribute to overall life expectancy, as cited, significant wake up call for public health investment. We emphasize obesity and other modifiable risks, but surprisingly, the difference between US and OECD stems from things we know about, but overlook. The collective sum of all the poisonings, shootings, car crashes add up. I was surprised much of the disparity rested in those issues.

(I cite overall life expectancy due to its use as "gold standard" for HC quality between countries, even if misapplied as a metric.)

Given the absolute levels of death from CVD, cancer, etc. (large), as compared to non-medical occurrences of "youth," (small), does the delta between USA vs other actually stem from non-clinical issues? Does the cure reside there and have we directed our efforts in the wrong places?

Of course, by posting here, a bias presents, but I think you get the crux of my question. I am very interested in the answer.
Thanks
Brad
NY, NY

[Ralph]

The difference between the US and the other countries studied is the presence of a cohesive "health system". They have one, we do not. The simple solution is to get a national health system -- is this really so difficult? I suspect the author of this blog or many other individuals could outline a great system in an afternoon.

[David Kindig]

Brad and Ralph: Thanks for reading and for your comments. Brad: I know that the Committee was also surprised at how much of the differences were from non-clinical causes like injuries. Ralph: I think we do need a more systematic approach to improvement, but I can't design it in an afternoon. I hope you aren't referring only to national health CARE systems which have many advantages but alone are not adequate. I suspect that a greater level of social spending to health care spending may be partly responsible, which could be considered a HEALTH system. But even if we knew exactly what the right investment balance would be (stay tuned for Wednesday's blog) finding common ground to make it happen will probably take a generation of afternoons. Let's hope the report is a wake up call to get us moving on a serious population health improvement strategy.