“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 More Equal Societies Almost Always Do Better. 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).