In a hard-hitting report, a panel of the US National Research Council and the Institutes of Medicine has addressed the question of why the United States, despite spending far more per person on health care than any other country in the world, is falling behind other high-income countries in health status. Readers familiar with Evans and Stoddart’s critique of the “thermostat model” will experience a strong sense of déjà vu.
The figures are striking. For example, relative to the 16 other high-income countries selected for comparison, the United States “had the highest rate of child deaths due to negligence, maltreatment, or physical assault.” It has the highest average body mass index (BMI) of the 17 countries among people aged 15-44. And the list goes on. In the words of the study: “The U.S. health disadvantage is pervasive: it affects all age groups up to age 75 and is observed for multiple diseases, biological and behavioral risk factors, and injuries. More specifically, when compared with the average for other high-income countries, the United States fares worse in nine health domains: adverse birth outcomes; injuries, accidents, and homicides; adolescent pregnancy and sexually transmitted infections; HIV and AIDS; drug-related mortality; obesity and diabetes; heart disease; chronic lung disease; and disability.”
The report’s focus on structural influences and on the life course perspective is notable, and a summary is wroth quoting at length. “[T]the absence of green space today may be the product of zoning decisions two decades ago. Such influences also extend over a person’s lifetime: that is, the upstream-downstream continuum can also be a temporal experience for an individual. An individual’s struggle through middle age with exertional angina from coronary artery disease may have originated in adolescence with the adoption of cigarette smoking, perhaps as a coping mechanism for a stressful childhood … or simply because the family lived in a poor neighborhood where smoking was the norm. In turn, the family’s move into that poor neighborhood may have resulted from financial setbacks that occurred before the child was born. Health trajectories unfold not only over a lifetime, but also across generations as people are subject to changing health influences stemming from family, neighborhood, and public policies. …. The key dynamic trajectories of health, risk factors, socioeconomic circumstances, and physical and institutional environments are all integrally linked and cannot be decomposed in a reductionist fashion.”
Pointing out that the United States has the highest relative poverty rates of the 17 countries, the report notes the accumulation of social disadvantages and their health consequences over an individual’s lifetime and across generations. Other, more domain-specific explorations include an intriguing comparison between approaches to road traffic safety in the United States and elsewhere in the high-income world and the topical observation that rates of death by homicide involving firearms are an order of magnitude higher than in other OECD countries. (The accompanying picture, taken at the entrance to a Houston, Texas emergency room, may suggest a partial explanation; the need for such a warning would be almost inconceivable elsewhere in the high-income world.)
There is no point in trying to provide a more extensive summary of a very long document here; suffice it to say that the report is essential reading for all those concerned with health equity. A wonderful commentary from the British think tank Chatham House correctly warned that: “Rather than indulge in self-congratulatory comparisons with America's dismal health record, other industrialized countries would be wise to ask themselves if … global trends may soon erode their own hard-earned health gains of past decades.” Perhaps predictably, the report’s recommendations emphasize the need for further research, and research syntheses. Nevertheless, there are important steps forward. On research methods, the report observes: “The premise that randomized controlled trials are the ‘gold standard’ for establishing causal relationships has put the accumulation of knowledge about the social determinants of health at a distinct disadvantage.” Numerous earlier papers, including one that colleagues and I published more than a decade ago, have made a similar point, but it has yet to be recognized. And a key recommendation for further research synthesis emphasizes comparative investigation of the influence of public policy “in one or more health domains.” Our own health funding agencies would do well to take note. Social determinants of health may not yet have become mainstream, but there is hope.