PLANETARY HEALTH WEEKLY

This blog presents data on health, as measured by mortality rates, for those in the United States to suggest that no one in America can claim the best health possible.

One of the most challenging concepts to get people to understand and accept is that their individual health is to a large part beyond an individual’s control. We believe we have free will and are responsible for what happens to us as we course through life. Consider that if someone told you in early 2019 that soon your life would be profoundly changed by a viral infection that likely did not exist then you would have discounted such nonsense. Yet consider what happened in those few years. While many feel that the COVID-19 pandemic is behind us, we may just be at the end of the beginning.

Last month’s blog on how early life conditions impact our adult health is a good example of how little autonomy we have to direct our lives.

We are always being given advice on how to be healthy. Given what I have covered so far in my blogs the tips for good health could be stated as:

Be born in a caring, sharing, and repairing society.

Nurture strong family and social ties.

Don’t be poor.Don’t have poor parents.

Don’t work in a stressful, low-paid and meaningless job.

Don’t live in a country with:

-high income or wealth inequality

-large health inequities

-lack of time and resources for parenting

-costly specialized inaccessible medical care.

Ridiculous as they sound, these are not choices we can make on our own. They represent the decisions made by societies through their political process. There are countless studies demonstrating this concept. One simple statement relates to Americans, no matter where they rank, being less healthy than similar groups in other nations. “Americans with healthy behaviors or those who are white, insured, college-educated, or in upper-income groups appear to be in worse health than similar groups in comparison countries.” This comes from a book appropriately titled: U.S. Health in International Perspective: Shorter Lives, Poorer Health.

Let’s begin with the tip to not be poor (or if you are poor, don’t be poor for long). We need to make comparisons of U.S. health with those in other countries. An important study by Schwandt and colleagues appeared in 2021 comparing U.S. mortality rates in various age ranges with those of six other nations: England, France, Germany, Netherlands, Norway and Spain. The graph (see above) for deaths among working adults, those aged 20-64, presents deaths per thousand in 2018 stratified by a measure called poverty ranking. The lower the ranking the higher the income. U.S. Blacks are the red triangles and White the blue filled circles. The open circles are the average of the six countries above. The fitted lines are the regression lines. The light grey lines are those for the individual non-U.S. countries.

To interpret, the poorest White (blue filled circle on the upper right), has a mortality in the middle range of the red triangles representing U.S. Blacks. The richest U.S. Blacks have higher mortality than the richest fifth of Whites. Mortality in the other six nations is essentially below that of any of the American ethnicities depicted. We can interpret this as demonstrating that everyone’s health (measured by mortality) in the USA is not as good as those living in the other six countries. 

This is just one study. We should never stake a claim on the basis of one research investigation. Another study, though, considered the most privileged U.S. White citizens (those living in the richest 1% or 5% of counties) and compared their health with those in twelve other rich countries. The comparative mortality and survival measures associated with healthcare interventions were: infant and maternal mortality, colon and breast cancer, childhood acute lymphocytic leukemia, and acute myocardial infarction. Instead of overall adult mortality, we are considering conditions amenable to medical care. The outcomes for our most privileged group were better than others in the U.S. but were typically behind the average of the outcomes in the 12 other nations. 

There are many other studies. None of them contradict the basic concept that people living in the U.S. have compromised health if the standard is comparing themselves to those in other nations. 

I find this the most difficult concept to get Americans to consider. Namely no matter what they believe will work to be healthy, being born in another nation would be more effective. Now for the bad news! In September the United Nations came out with its 2022 Human Development Report that presented 2021 life expectancies for UN nations. In my February blog (#2) the 2019 health Olympics depicted there had the U.S. as tied for 36th. For 2021 it now stands 44th (see chart below).

Part of the reason for this decline is the shameful American response to the COVID-19 pandemic which has so far taken almost 1.1 million lives. If the U.S. eradicated its three leading causes of death – heart disease, cancer and COVID-19 – it still wouldn’t be the longest lived country. 

Back when the U.S. ranking dropped to 25th (about 1999), I was sure the decline had stopped. How wrong I was. Today there is too much mud on the crystal ball to see what the future holds. 

The next blog (Nov. 17) will go back to early life and consider what being of low birthweight does to brain development, then look at adverse childhood experiences (ACEs) which are being increasingly recognized, and finally issues of parenting.