The National Research Council’s report, U.S. Health in International Perspective: Shorter Lives, Poorer Health (2013) compares data on U.S. life expectancy and health indicators with data from 16 “peer countries”, i.e., other high income democracies in Western Europe, Canada, Australia and Japan. The report asserts that “For many years, Americans have been dying at younger ages than people in almost all other high-income countries. The disadvantage has been getting worse for three decades, especially among women.” The U.S. ranks seventeenth in life expectancy for males at 75.64 years and sixteenth in life expectancy for females at 80.78 years compared to Switzerland (first in life expectancy for males at 79.33 years and third for females at 84.09), Japan (third for males at 79.20 and first for women at 85.98) and Australia (second for males at 79.27 and sixth for females at 83.78). U.S. males on average live almost four fewer years than males in Switzerland, Australia and Japan, and U.S. females live an average of more than five fewer years than females in Japan and three fewer years than females in France, Switzerland, Italy, Spain and Australia.
The National Research Council (NRC) also finds that “Americans also have a longstanding pattern of poorer health that is strikingly consistent and pervasive over the life course – at birth, during childhood and adolescence, for young and middle – aged adults, and for older adults.” According to this report, “the U.S. health disadvantage spans many types of illness and injury,” including:
- infant mortality and low birth weight
- injuries and homicides
- adolescent pregnancy and sexually transmitted infections
- HIV and AIDS
- drug-related deaths
- obesity and diabetes
- heart disease
- chronic lung disease
The NRC report asserts that “The U.S. health disadvantage cannot be fully explained by the health disparities that exist among people who are uninsured or poor, as important as these issues are. Several studies are now suggesting that even advantaged Americans – those who are white, insured, college-educated, or upper income – are in worse health than similar individuals in other countries.” For example, a 2009 study comparing several thousand non-Hispanic white U.S. residents, 55-64, with residents of England in the same age bracket matched for income and education (Banks, Marmot, et al) found that low income persons in England have about the same rates of good health and poor health as high income groups in the United States. U.S. residents in this study had twice the rate of diabetes, and much higher rates of heart disease, hypertension and cancer than their English counterparts. These differences could not be explained by differential access to health care as higher income Americans with medical insurance had poorer health on average than higher income English residents in the sample. The authors assert that about one-fifth of the differences in health between U.S. residents and the English were due to higher rates of obesity among U.S. residents.
The NRC report identifies multiple likely explanations for the U.S. health disadvantage, including the relatively large number of medically uninsured persons in the U.S., high calorie diets and higher rates of drug abuse, higher rates of traffic accidents that involve alcohol, more gun violence, higher rates of child poverty and a greater degree of income inequality than other “peer countries.”
Michael Marmot’s The Status Syndrome: How Social Standing Affects Our Health and Mortality (2004) contains one of the liveliest and best informed discussions of national differences in health and mortality and differences among social groups in the United States. Marmot’s theme is the social gradient in health, i.e., “Where you stand in the social hierarchy is intimately related to your chances of getting ill, and your length of life.” According to Marmot, these differences in health and mortality result in part from income differences but also from autonomy, i.e., “how much control you have over your life,” and opportunities for “full social engagement and participation.” Marmot asserts that “Degrees of control and participation underlie the status syndrome,” and the relationships he describes between status and health.
In a memorable passage, Marmot writes: “Travel from the southeast of downtown Washington to Montgomery County, Maryland. For each mile traveled, life expectancy rises about a year and a half. There is a twenty-year gap between poor blacks at one end of the journey and rich whites at the other.” Marmot’s interest is in the effects of status and income differences on all social/economic groups, not just the poor. He argues that “We must look at the health impact of how different societies organize themselves;” given that the social causes of illness and early death (Marmot asserts) affect all social classes to a greater or lesser degree.
Marmot maintains that no more than a third of the social gradient in health is explained by differences among social classes in diet, rates of smoking, use of dangerous drugs and other life style choices. These are important factors, but, according to Marmot, they do not explain health differences among relatively privileged groups with more than enough resources to meet their basic needs, and who have access to medical care, high rates of educational achievement and employment. Status in organizational settings and related income differences “affect the degree of autonomy and control individuals have and their opportunities for full social engagement,” according to Marmot.
Marmot argues that in work environments, status and rank influence individuals’ ability to cope with stress. For example, “people whose jobs are characterized by high demands and low control have a higher risk of developing coronary heart disease than others in jobs with more control.” Furthermore, “low control in the home is particularly salient for women, even women who are employed outside the home,” Marmot states.
Marmot discusses evidence that positive social relationships are protective of health, in part because “supportive social relationships will reduce the body’s stress reactions.” Societies that have higher levels of income inequality are likely to be less socially cohesive and to have higher levels of interpersonal tensions in a wide variety of social situations, Marmot argues. By hypothesis, the degree of hostility among and between individuals and social groups affects the sense of security of persons in all social classes; these daily tensions are exacerbated in highly unequal societies, Marmot asserts.
In The Spirit Level: Why Greater Equality Makes Societies Stronger (2010) Richard Wilkinson and Kate Pickett present evidence that conflict between children (i.e., fighting, bullying and finding peers not kind and helpful) is greater in countries such as the U.S. with higher levels of income inequality. Wilkinson and Pickett argue that “… violence is most often a response to disrespect, humiliation and loss of face, and is usually a male response to these triggers.” Violence triggered by “dissing”, i.e., flagrantly disrespectful behavior, occurs more frequently in highly unequal societies, Wilkinson and Pickett maintain, because more people lack the protections and buffers accorded by status, education and income. “Shame and humiliation become more sensitive issues in more hierarchal societies,” they assert.
Marmot argues that a main reason the Japanese have better health and live four years longer than Americans (on average) is that Japanese culture is socially cohesive to a far greater degree than American culture . Arguably, crime rates are an indicator of social cohesion. Marmot presents data comparing crime rates in Japan and the U.S. indicating that the Japanese murder rate is one seventh that of the U.S., its rate of aggravated assault is one eightieth (yes, 1/80, not 1/8), its rate of rape one twenty-fifth, and its rate of robbery less than one-hundredth of the U.S. rate.
The NRC report and Marmot’s The Status Syndrome present a bleak picture of U.S. health in which factors such as dietary habits, drug/alcohol abuse and misuse and gun violence, combined with factors such as income inequality and low levels of social cohesion whose effects on health and mortality are poorly understood, have led to a 4-5 year difference in life expectancy compared to developed countries at the top of the rankings of 17 affluent democracies. To help readers understand the magnitude of a 4 year difference in life expectancy, Marmot comments that the elimination of heart disease as a cause of death in the U.S. would lead to an average increase in life expectancy of 3-4 years!
A far more positive view of national trends in well-being is provided in the Foundation for Child Development’s (FDC) 2012 National Child and Well-Being Index (CWI), which is a composite of 28 key indicators. The FDC has issued a yearly report on these measures since 1975; the 2012 report focuses on changes in how American children fared during the past decade.
This report found that 2001-2011 was a decade of decline in families’ economic well-being that began several years before the Great Recession of 2008-10, and that this economic decline has included an increase in poverty, a reduction in median income and a fall in secure parental employment. The report comments that despite reductions in poverty in the 1990s, “all improvements made over the past 36 years in the economic well-being of families with children under the age of 18 have been lost.” The median income for families with children (in 2010 dollars) declined from $62,796 in 2001 to $55,918 in 2011. The secure parental employment rate declined from 79 percent in 2001 to 71 percent in 2011.
Nevertheless, the CWI “ceased to deteriorate in 2010 and 2011. Safety from violent crime and an increase in the Social and Emotional Well-Being Domain served to counterbalance the decline in the Family Economic Well-Being Domain.” The 2009 CWI was higher in 2011 than in 2009.
The most encouraging indicators in this composite index are the remarkable declines in crime victimization and crime offenders for youth 12-19. According to this report, “these numbers indicate that the violent crime victimization rate in 2011 for ages 12-19 … has declined to about 25 percent of the 1975 base year rate and 17 percent of its peak in 1994. Further, the violent crime offending rate for the corresponding age group in 2011 is about 20 percent of the 1975 base year rate and 12 percent of its peak in 1993.” The authors comment that “this is an unprecedented success story of social agencies – including parents, families, schools, communities, juvenile agencies and courts and, not least, the children and youth themselves – in increasing the physical safety of children and youth in American society.”
Interestingly, the decline of sexual abuse and physical abuse in NCANDS began about the same time (the mid-1990s) that the CWI indicators of improved youth safety began to improve.
The authors acknowledge that there is no consensus among experts regarding the causes of the decline in crime victimization and crime offending among American teens; but the report emphasizes the combined effects of changes in how families monitor and organize after-school activities as well as long term trends towards increasing community engagement “in the form of higher rates of participation in mainstream schooling and work institutions … as institutional engagements both reduce exposure to the risk of violent crime in non-programmed activities and promote social bonding.” Perhaps most importantly, the improvement in the safety of adolescents over the past couple of decades indicates what is possible when parents, schools and social service agencies are fully committed to the same goal and engage in persistent collective action to achieve results.
On a less positive note, the CWI found very small changes in averages of 9, 13 and 17 year olds’ reading and mathematics test scores in National Assessment of Educational Progress (NAEP) surveys despite the ambitious and costly educational initiatives of the past decade. The authors state that in 2001 “only 29 percent of children in the 4th grade were reading at grade level. By 2011, that number had grown modestly, to 34 percent. If this slow rate of improvement in reading scores continues, it would take more than three decades – 35 years – to reach the point where even 50 percent of our young children are reading proficiently,” the report states.
The authors emphasize the importance of halting the decline in the CWI in the third and fourth years of the Great Recession. In comparison, the CWI declined sharply from 1980-85 and steadily (though more slowly) from 1985-94 during and following the severe recession of the 1980s. Fortunately, American families appear to be coping with the effects of the Great Recession on family life better than the response to the 1980s recession.
This report presents a picture of a country in an economic decline which has placed an increasing number of American families under extreme pressures to make ends meet. Nevertheless, families, communities and social institutions have been able to achieve remarkable improvements in adolescent safety and well-being through increased levels of parental vigilance and increases in community engagement and participation in social institutions. These encouraging trends suggest the possibility that improvements in health and mental health of youth may require investments to increase social participation and positive social development for children and youth in all social classes rather than a narrow focus on children and youth’s diets and exercise habits.
Banks, James, Marmot, Michael, Oldfield, Zoe, & Smith, James, “Death and Disadvantage in the United States and in England,” Journal of the American Medical Association, Volume 295, No. 17, 2006.
Committee on Population at the National Research Council, “Report Brief: U.S. Health in International Perspective: Shorter Lives, Poorer Health,” National Institutes of Health, National Academies Press, http://www.nap.edu.
Marmot, Michael, The Status Syndrome: How Social Standing Affects Our Health and Longevity, 2004.
2012 National Child and Youth Well –Being Index (CWI), The Foundation for Child Development, www.fcd-us.org, 2013.
Wilkinson, Richard & Pickett, Kate, The Spirit Level: Why Greater Equality Makes Societies Stronger, 2009.