Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 91
Part II:
Explaining the U.S. Health Disadvantage
I
n Part I of this report, the panel reviewed the available evidence regard-
ing cross-national differences in health and concluded that the United
States has experienced dramatic improvements in health over the past
century but still appears to have a major health disadvantage compared
with other high-income countries. The research literature shows that this
disadvantage has actually existed for many decades and appears to be grow-
ing, especially for women. On almost every measure of life expectancy, the
United States ranks at or near the bottom compared to other high-income
countries. Each year, other high-income countries are improving their health
at a much faster rate than the United States, and the United States currently
ranks lowest on a variety of health measures.
The evidence reviewed in Part I also makes clear that this disadvantage
is pervasive: the United States ranks at or near the bottom on multiple mea-
sures of mortality and morbidity, in all age groups up to age 75, in males
and females alike, and in virtually all other subgroups of the population.
Furthermore, the disadvantage does not appear to be simply a reflection of
lower levels of health among Americans who are uninsured and/or poor, as
important as these are. Even advantaged Americans seem to be less healthy
than their peers in other high-income countries. This pervasiveness also sug-
gests the need to not only look at specific health conditions such as heart
disease or other causes of morbidity and mortality, such as injuries, but also
to pursue overarching, multisystemic explanatory factors at play. It is these
potential explanations that are the focus of this second part of the report.
Our approach to this task was informed by our charge, which was to
“propose alternative explanations or potential causes of the reported health
91
OCR for page 92
92 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
disadvantage, going beyond previously tested explanations.” We began
by adopting a social-ecological and life-course perspective to frame the
question (Chapter 3), which led to our decision to systematically consider
a broad range of factors that might influence individual- and population-
level health: public health and medical care systems (Chapter 4), individual
behaviors (Chapter 5), social factors, such as education and income (Chap-
ter 6), environmental factors (Chapter 7), and policies and social values
(Chapter 8).
Dividing these topics by chapter is an editorial device: the reality is that
these influences are deeply interconnected. Rarely do these factors influence
health in isolation, and a reductionist approach can miss interrelationships
that affect health outcomes. For example, a U.S. health disadvantage with
respect to diabetes might result partly from inadequate medical care (Chap-
ter 4), but also from the obesity epidemic, a product of unhealthy diets and
sedentary behavior (Chapter 5), and an obesogenic environment (Chapter
7). The latter disproportionately affects households that face financial stress
(Chapter 6), because assistance programs to buffer the impact of this stress
are limited (Chapter 8).
The editorial device of separating these topics into distinct chapters
should therefore not obscure the complex, dynamic interrelationships
between these factors and the different roles they play over the life course
as health disadvantages evolve over time. While all of these disparate fac-
tors may play a role, it would be a mistake to assume that the topics in each
chapter can be decomposed into independent risk categories that “add up”
to the U.S. health disadvantage. The dynamic and synergistic interactions
between causal factors, only some of which are fully understood, are central
to the many issues we review in Part II.
Out of necessity, the panel was selective and systematic in its approach
to these complex and comingled influences. In each of the chapters in Part
II, the panel focused on three key questions to understand the U.S. health
disadvantage:
1. Does the set of factors matter to health?
2. Does the set of factors have greater prevalence or health effects in
the United States than in other high-income countries?
3. Could this difference between the United States and other countries
contribute to the U.S. health disadvantage?
Large bodies of research, at various stages of evolution and quality,
have been devoted to the first question in this three-stage logical sequence
and have been ably reviewed elsewhere. Rather than presenting this research
in great detail, and because this was not the panel’s primary focus, the panel
OCR for page 93
PART II
93
provides a concise summary of this evidence and refers readers to compre-
hensive research reviews and landmark studies.
The chapters that follow focus instead on the second and third ques-
tions. For example, the second question entails not only demonstrating
whether particular risk factors are more common in the United States than
elsewhere, but also whether they have different effects on health outcomes.
Countries with the same levels of hypertension (in untreated populations)
or the same levels of poverty may experience different health outcomes if,
respectively, one country performs better in controlling blood pressure or
has a stronger safety net to help poor people avoid health complications.
Although we did not systematically examine these differential effects, we
did consider them when we knew there was some evidence available. For
example, Chapter 6 reviews evidence that the lack of a college degree may
have greater health consequences in the United States than elsewhere.
OCR for page 94
