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Confronting the Sorry State of US Health

  • Texas A&M School of Public Health


President Obama should convene a National Commission on the Health of Americans to address the social causes that have put the U.S.A. last among comparable nations.
In January 2013, the U.S. National
Research Council (NRC) and Institute
of Medicine (IOM) issued U.S. Health
in International Perspective: Shorter Lives,
Poorer Health, a stunning depiction of how,
over the past four decades, the compara-
tive health status of Americans has declined
( 1). The report applied a term, commonly
used to describe the relative deprivation of
social groups, to the nation as a whole: the
“U.S. health disadvantage.” How can this be
explained and what is to be done?
Researchers have known about the role of
social inequality in this decline, yet the public
and policy-makers studiously avoid this chal-
lenge to Americans’ self-concept. The health
status of Americans is a social problem that
demands social solutions. Will this analy-
sis from two of the most prestigious science
advisory bodies in the United States become
a turning point or be consigned to the dustbin
of history, with other studies critical of U.S.
health and health care?
The report ranks the United States last
among peer nations in health status and com-
pares it unfavorably to 17 peer countries at
almost every stage of the life course. The
United States has higher rates of adverse
birth outcomes, heart disease, injuries from
motor vehicle accidents and violence, sexu-
ally acquired diseases, and chronic lung dis-
ease. Americans lose more years of life to
alcohol and other drugs. The United States
has the highest rate of infant mortality among
high-income countries and the second high-
est incidence of AIDS and ischemic heart dis-
ease, and it has, for decades, experienced the
highest rates of obesity in children and adults
and diabetes from age 20 onward. Only those
who survive to age 75 escape this pattern. The
report emphasizes socioeconomic causes—
the “drivers”—of these outcomes.
From its origins in the early 19th century,
the study of public health has been informed
by concerns about how sharp social class
differences produce serious health conse-
quences. Rudolph Virchow observed in 1848
that preserving health and preventing disease
required “full and unlimited democracy” ( 2).
For some, like Friedrich Engels, the relation
between health and wealth fueled a call for
revolutionary change.
In contrast to such socialist proposals, the
United States before the 1850s favored more
conservative measures that would unfetter
the market economy. Yet observers found
themselves bewildered by a new contradic-
tion: New York, the world’s richest city, also
was burdened by its most miserable health
statistics ( 3). The Citizen’s Association of
New York launched a sweeping social and
health survey ( 4). The findings provided
grounds to create new, permanent pub-
lic health institutions and sparked political
action, which, by the early 20th century, cul-
minated in the environmental, social, labor,
and political reform movements that defi ned
the Progressive Era in America ( 2).
By the eve of the First World War, however,
broad social reform and regulation would be
eclipsed by a narrower vision with twin tar-
gets: the germ and individual behavior. For
bacteriologists, who commanded the field,
education and therapeutic intervention were
appealing as less costly and disruptive ways
to change or prevent pathogenic behavior as
compared with sweeping, ambitious social
reforms that were seen as overreaching ( 5).
During the Cold War, in which any allusion
to left-wing thought was deemed “un-Amer-
ican,” questions about how social class and
income might disadvantage whole groups
risked being tarred as subversive and became
too charged to ask ( 6). John Knowles, in 1977,
captured the transformation: “Over 99 percent
of us are born healthy and suffer premature
death or disability only as a result of personal
misbehavior and environmental conditions.
The average American can either “change
his personal bad habits or stop complaining.
… Benefi cent Government cannot—indeed,
should not—do it for him …” ( 7).
As the individual-focused approach was
pursued in the United States, studies from
England gave new life to the more-than-
century-old understanding of the relation
between wealth and health. In a nation with
a much-praised universal health care system
that assured access to all who needed ser-
vices, the fi rst Whitehall study demonstrated
that rates of mortality were arrayed on a con-
tinuum—a social gradient of health—rather
than being discontinuous or clustered. Those
slightly better off socially were consistently
at a health advantage compared with those
of lower status. In 1980, England’s landmark
Black Report examining the social gradi-
ent concluded: “Thirty years of the Welfare
State and the National Health Service have
achieved little in reducing social inequalities
in health” ( 8, 9). This was not just the 19th-
century picture of privilege versus poverty.
It is surprising that it was not until 2006
that the fi rst epidemiological study compar-
ing England and the United States found
a social health gradient in both. What was
unanticipated was that America as a whole
was sicker than England ( 10). Even those at
the top of the U.S. social ladder, despite their
access to a vast and costly health-care sys-
tem, fared worse than their British counter-
parts. An extended analysis ( 11) compared
the United States to 11 European countries.
Americans face a health disadvantage” that
“is remarkably pervasive and affects even the
wealthy but is largest for the poor” ( 11).
To look deeper, the National Institute on
Aging, part of the U.S. National Institutes of
Health (NIH), requested that the NRC investi-
gate international trends in life expectancy for
those older than 50 years. The resultant 2011
study ( 12), noted that U.S. life expectancy at
birth was 68.9 years in 1950, ranking 12th in
the world. Despite an increase to 79.2 years,
America’s relative standing had dropped to
28th by 2009. But the report and attendant
press coverage focused on two explana-
Confronting the Sorry State
of U.S. Health
Ronald Bayer, * Amy L. Fairchild, Kim Hopper, Constance A. Nathanson
President Obama should convene a National
Commission on the Health of Americans to
address the social causes that have put the
U.S.A. last among comparable nations.
*Corresponding author.
Department of Sociomedical Sciences, Mailman School of
Public Health, Columbia University, New York, NY 10032
Published by AAAS
on September 25, 2014www.sciencemag.orgDownloaded from on September 25, 2014www.sciencemag.orgDownloaded from SCIENCE VOL 341 30 AUGUST 2013 963
tory risk factors: smoking and obesity; this
kept attention trained on individual health
The 2011 NRC report ( 12) set the stage
for the NIH Offi ce of Behavioral and Social
Science Research, despite internal resis-
tance, to commission a joint report from the
NRC and IOM to see whether the compar-
ative standing of the United States among
younger Americans had also declined. It
had. In explaining the patterns of morbid-
ity and mortality that distinguish the United
States from its peers, Shorter Lives ( 1) fi r s t
addressed obvious disparities in health care
provision. But it then pivoted to stress the
limits of that focus: “Even if health care
plays some role, decades of research have
documented that health is determined by far
more than health care” ( 1).
What then about health behaviors, which
had fi gured so prominently in the 2011 NRC
report on older Americans? Why were adverse
behaviors more common in the United States
than in other countries? Drawing upon a vast
literature in social epidemiology, there was,
argued Shorter Lives, a need to “look beyond
individual behaviors and choices” to “sys-
temic processes that may infl uence multiple
health outcomes” ( 1).
The report explored the possible relation
between the decline of the United States on
various health measures and the co-occur-
rence of the worsening of some economic and
social conditions since the 1970s. Although it
could not assert a defi nitive causal relation, it
argued that it was critical to examine the rise
in income inequality (which some economists
have described as being greater than at any
point in the past 100 years), poverty, single-
parent households, divorce, and incarcera-
tions ( 1). It also explored causes from the role
of individualism in American social ideology
to the structure of the welfare state and pat-
terns of gun ownership.
This bold shift to the social and struc-
tural and a sense of urgency sets the current
report apart from its 2011 companion. While
acknowledging the need for further research
into sources of the U.S. disadvantage and into
policy alternatives, its authors argued that
action not be delayed by investigations that
could well take years to complete. In so writ-
ing, the committee echoed a line from Goethe
that appears on the title page of every IOM
report: “Knowing is not enough; we must
apply. Willing is not enough; we must do.”
It is not surprising that NIH all but
ignored this report ( 13). This can, in part, be
explained by NIH’s research vision, which
Sandro Galea, former president, Society for
Epidemiological Research, has described as
“focused heavily on resolving ever narrower
molecular questions” ( 14). Nor is it startling
that the institutionally cautious IOM and
NRC exhibited little enthusiasm for spark-
ing national discussion. A delayed pub-
lic forum on the report in March 2013 did
not include a panel on policy implications
( 15). It was the dogged effort of the com-
mittee leaders that paid off in widespread
news coverage. “US Health is Lousy Com-
pared with Peer Nations,The Los Ange-
les Times reported ( 16). Other papers with
international circulations were just as blunt;
The Atlantic headlines described the United
States as “dead last” ( 17).
Given the austerity-driven political stale-
mate that characterizes Washington today,
combined with congressional attacks on
federal support for social science research
( 18), it is hard to imagine a less propitious
moment for confronting the profound chal-
lenge posed by Shorter Lives. In 1980, when
the Black Report underscored the depth of
class disparities in health, the newly elected
Thatcher government all but buried it. “The
term ‘inequalities’ could not be used,” wrote
Sir Liam Donaldson, who would become
England’s Chief Medical Offi cer ( 19). “Only
subsequently was the term ‘disparities’ per-
mitted” ( 19). Professional scrutiny and (later)
commercial publication ensured that the
Black Report became a critical turning point
in health-policy discussion. In the UK, the
Blair and Brown governments made serious
commitments to incorporating the lessons
of intervention research to address the social
determinants of health, reduce inequalities,
and improve overall health status ( 20).
Mobilization of an unprecedented kind is
now necessary in the United States. It requires
a campaign to remove the public veil of igno-
rance about the evidence. Notably, the NRC-
IOM committee, although it had the author-
ity to call for presidential leadership, felt con-
strained to assign this task to the philanthropic
and advocacy community. Although they
should have a role, given the stakes and the
specter of offi cial neglect, it is remarkable that
government was not charged with the respon-
sibility of spurring and sustaining a national
conversation about what needs to be done.
We believe the gravity of the situation
demands presidential action. In 1974, in
the face of mounting evidence that abuse of
human research subjects was commonplace,
the National Commission for the Protection of
Human Subjects and Biomedical and Behav-
ioral Research issued the Belmont Report,
which provided the principled basis for
sweeping change in research norms. A decade
later, the AIDS epidemic compelled President
Reagan to create the Presidential Commis-
sion on the Human Immunodefi ciency Virus
Epidemic. It successfully swam against pow-
erful conservative currents and marked the
beginning of action not only to fund research
and care but also to prohibit discrimination
against those with AIDS.
President Obama recently declared that
growing social inequalities are tearing at the
social fabric of the nation ( 21). He must now
create a National Commission on the Health
of Americans charged with holding public
hearings and determining vigorous steps that
must be taken to address, not simply the health
of those at the bottom, but the comparative
status of America as a whole. There is a strong
evidentiary basis for action beyond interven-
tions at the individual behavioral level ( 22
25). It is time to reverse a course of events at
least four decades in the making.
References and Notes
1. S. H. Woolf, L. Aron, Eds., U.S. Health in International
Perspective: Shorter Lives, Poorer Health (NRC and IOM,
National Academies Press, Washington, DC, 2013).
2. A. L. Fairchild, D. Rosner, J. Colgrove, R. Bayer, L. P.
Fried, Am. J. Public Health 100, 54–63 (2010).
3. E. Blackmar, in Hives of Sickness: Public Health and
Epidemics in New York City, D. Roser, Ed. (Rutgers Univ.
Press, New Brunswick, NJ, 1995), pp. 42–64.
4. Council of Hygiene and Public Health of the Citizens’ Asso-
ciation of New York, Sanitary Condition of the City: Report
of the Council of Hygiene and Public Health of the Citizens’
Association of New York (CHPHCANY, New York, 1865).
5. E. Fee, Disease and Discovery: A History of the Johns
Hopkins School of Hygiene and Public Health, 1916–
1939 (Johns Hopkins Univ. Press, Baltimore, 1987).
6. G. M. Oppenheimer, Int. J. Epidemiol. 35, 720–730
7. J. H. Knowles, Daedalus 106, 57–80 (1977).
8. The Black Report, cited (9), p. 337.
9. G. D. Smith, D. Dorling, M. Shaw, Poverty, Inequality, and
Health in Britain, 1800-2000: A Reader (The Policy Press,
Univ. of Bristol, Bristol, 2001), p. 337.
10. J. Banks et al., JAMA 295, 2037–2045 (2006).
11. M. Avendano, M. M. Glymour, J. Banks, J. P. Mackenbach,
Am. J. Public Health 99, 540–548 (2009).
12. E. M. Crimmins et al., Explaining Divergent Levels of
Longevity in High-Income Countries (NRC, National
Academies Press, Washington, DC, 2011).
13. R. Bayer, Interviews given under conditions of confi denti-
ality, May 2013.
14. S. Galea, personal communication, 9 May 2013.
15. Public Briefi ng, 18 March 2013; http://sites.national-
16. E. Brown, Los Angeles Times, 9 January 2013.
17. G. Rubenstein, Atlantic, 10 January 2013.
18. P. Krugman, New York Times, 11 February 2013, p. A19.
19. L. J. Donaldson, Public Health 127, 514–515 (2013).
20. D. M. Fox, Public Health 127, 503–513 (2013).
21. J. Calmes, M. D. Shear, New York Times, 27 July 2013,
p. A1.
22. For an example that considers a combination of access
to care, individual behavior interventions, and economic
measures, see ( 21).
23. D. Kindig et al., Public Health Rep. 125, 160–167 (2010).
24. For an example that underscores the impact of broad
policy change, see ( 23).
25. M. L. Hatzenbuehler et al., Am. J. Public Health 100,
452–459 (2010).
Published by AAAS
... Hypertension and diabetes are well-documented major risk factors for Cardio Vascular Disease (CVD), a leading cause of morbidity and mortality in the United States (US) and in the state of Wisconsin [1][2][3][4]. Approximately 655,000 Americans die every year from CVD, representing 1 out of every 4 deaths in the US and 1 in 5 (11,680 deaths/year) in Wisconsin [5]. Although there is an overall decline of CVD mortality in the US and in the state of Wisconsin over the last two decades, racial/ethnic disparities in the incidence of CVD morbidity and mortality have persisted in Milwaukee County, Wisconsin [6,5]. ...
... These communities are also faced with significant inequalities driven by behavioral risk factors including lack of healthy food choices, smoking, obesity, and physical inactivity [7]. The city of Milwaukee, Wisconsin, has well documented evidence of racial/ ethnic CVD outcomes disparities that are attributable to high prevalence of adverse SDOH, consistent with observations among similar underserved communities in the U.S [8,9,[11][12][13][14][15]. Despite overwhelming evidence of higher CVD comorbidity and mortality burden among African Americans and other racial/ethnic minorities in the US, there are limited published studies that have examined the impact of community engagement programs on sustaining long-term health access and healthful behaviors aimed at reducing CVD outcomes disparities in this population [12][13][14][15]. ...
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ABSTRACT Background: Health care disparities continue to exist in Milwaukee, Wisconsin, with underserved groups experiencing a higher incidence of cardiovascular disease, other chronic comorbidities, and associated risk factors. Pharmacists have the training and ability to perform physical assessment, conduct screening tests, and educate patients on the prevention and treatment of many disease states. The objective of the study was to develop a pharmacist-led, community-based health screening service to address health disparities through academic-community partnerships. Methods: A community engagement research approach was used to partner with the target communities, determine leading chronic diseases, and develop health screening and preventive services that would most benefit the community based on the community identified healthcare needs. Operational testing of the health screening services was conducted to refine the screening workflow, train students and faculty to ensure efficient delivery of the services. Results: Collaborations were developed with longstanding local community service organizations to strengthen and leverage resources within the study area. A point-of-care community health screening program for obesity, diabetes, hypercholesterolemia, and high blood pressure was established and launched in the target community. The services continue to be provided in the community by pharmacists and pharmacy students from the School of Pharmacy. Conclusion: A community-based research approach was successfully used to develop and implement a pharmacistled community health screening service intended to address health care disparities in an underserved community. This paper will describe the community-based research approach to the development and implementation of this service intended to address health care disparities. Keywords: Community health screening; Community engagement; Development; Implementation; Socioeconomic determinants of health; Underserved population; Health care access Abbrevations: CVD: Cardio Vascular Disease; US: United States; SDOH: Social Determinants of Health; HRSA: Health Research and Services Administration; SES: Socioeconomic Status; MCWSOP: Medical College of Wisconsin School of Pharmacy; IRB: Institutional Review Board; NDF: Next Door Fo
... C ardiovascular disease (CVD) remains the leading cause of death of men and women in the United States, with a continued rise in the prevalence and mortality of CVD (1). With the awareness that more than 80% of CVD is preventable, and given that the U.S. trajectory has contrasted with that of other high-income countries, there have been calls to address the social causes that have placed "the USA last among comparable nations" (2). CVD Table 1). ...
... The national pretax income of the middle 40% began to fall, along with US life expectancy. 6 Long-standing trends in immigration enforcement and control changed little with the election of President Barack Obama ( Figure 1). The priority for the administration was expansion of the welfare state, achieved in 2010 with the Patient Protection and Affordable Care Act (ACA). ...
... The American Heart Association recently published a statement to increase awareness of the influence of social factors on the incidence, treatment, and outcomes of CVD. They recommended further observational studies examine the complex interactions between social factors and ardiovascular health (Bayer, Fairchild, Hopper, & Nathanson, 2013). There is now consistent evidence showing that socioeconomic adversity in childhood (e.g. ...
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Studies assessing associations of childhood psychosocial adversity (e.g. sexual abuse, physical neglect, parental death), as opposed to socioeconomic adversity, with cardiovascular disease (CVD) risk factors in adulthood are scarce. The aim of this study is to assess associations of various types of psychosocial adversity and cumulative adversity in childhood, with multiple CVD risk factors in mid-life. At study enrolment, women from the Avon Longitudinal Study of Parents and Children (N=3612) retrospectively reported: lack of maternal care, maternal overprotection, parental mental illness, household dysfunction, sexual abuse, physical and emotional abuse, and neglect in childhood. Approximately 23 years later, body mass index (BMI), waist circumference, systolic and diastolic blood pressure, plasma glucose, insulin, triglycerides, low and high density lipoprotein cholesterol, C-reactive protein, carotid intima-media thickness (cIMT) and arterial distensibility were assessed (mean age 51 years). We examined associations of each specific type of psychosocial adversity and cumulative adversity with CVD risk factors. No specific type of psychosocial adversity was consistently associated with the CVD risk factors. There was evidence that a one standard deviation greater cumulative psychosocial adversity was associated with 0.51cm greater waist circumference (95% confidence interval [CI]: 0.02cm, 1.00cm, p=0.04) and a lower arterial distensibility, even after adjustment for age, ethnicity and childhood and adult socioeconomic position. We found no consistent evidence that any specific type of psychosocial adversity, or cumulative psychosocial adversity in childhood, is associated with CVD risk factors in adult women.
... 2,8,9 However, an approach that solely emphasizes behavioral differences is impoverished by ignoring the role of socioeconomic and environmental determinants. 10 A substantial body of research suggests that most behavioral risk factors are socially patterned; lower education or income are associated with a higher prevalence of smoking, excessive alcohol consumption, obesity, and poor dietary patterns. 11---19 In addition, European countries and the United States differ in many aspects of the physical and social environment that can affect population health and that are in turn socially patterned within each country. ...
Objectives: This study examined to what extent the higher mortality in the United States compared to many European countries is explained by larger social disparities within the United States. We estimated the expected US mortality if educational disparities in the United States were similar to those in 7 European countries. Methods: Poisson models were used to quantify the association between education and mortality for men and women aged 30 to 74 years in the United States, Belgium, Denmark, Finland, France, Norway, Sweden, and Switzerland for the period 1989 to 2003. US data came from the National Health Interview Survey linked to the National Death Index and the European data came from censuses linked to national mortality registries. Results: If people in the United States had the same distribution of education as their European counterparts, the US mortality disadvantage would be larger. However, if educational disparities in mortality within the United States equaled those within Europe, mortality differences between the United States and Europe would be reduced by 20% to 100%. Conclusions: Larger educational disparities in mortality in the United States than in Europe partly explain why US adults have higher mortality than their European counterparts. Policies to reduce mortality among the lower educated will be necessary to bridge the mortality gap between the United States and European countries.
The release of the American Heart Association’s 2030 Impact Goal and associated metrics for success underscores the importance of cardiovascular health and cardiovascular disease surveillance systems for the acquisition of information sufficient to support implementation and evaluation. The aim of this policy statement is to review and comment on existing recommendations for and current approaches to cardiovascular surveillance, identify gaps, and formulate policy implications and pragmatic recommendations for transforming surveillance of cardiovascular disease and cardiovascular health in the United States. The development of community platforms coupled with widespread use of digital technologies, electronic health records, and mobile health has created new opportunities that could greatly modernize surveillance if coordinated in a pragmatic matter. However, technology and public health and scientific mandates must be merged into action. We describe the action and components necessary to create the cardiovascular health and cardiovascular disease surveillance system of the future, steps in development, and challenges that federal, state, and local governments will need to address. Development of robust policies and commitment to collaboration among professional organizations, community partners, and policy makers are critical to ultimately reduce the burden of cardiovascular disease and improve cardiovascular health and to evaluate whether national health goals are achieved.
Sexual harassment, both implicit and overt, restricts the productivity, recognition, funding, advancement, earnings, retention, and continuation of women in their fields.¹⁻³ Sexual harassment contributes to declines in productivity and is associated with higher stress. The consequences for women who experience sexual harassment are not only professional. These women are also at risk for adverse health outcomes with health effects compounded for minorities, including sexual minorities.
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This volume of collected essays is a product of the 2015 Minority Health Disparities Initiative writing retreat at the University of Nebraska-Lincoln. The goal of UNL's MHDI is to disseminate and translate the research of affiliated university faculty to our community partners and organizations, as part of a larger goal to address the needs of minority and under-served populations throughout the Central Plains. These essays discuss ongoing research on discrimination and stress, obesity prevention in rural areas, human trafficking, Native American health promotion, the health impacts of bi- and multi-racial identity, and the emerging field of community health workers.
An Institute of Medicine report titled U.S. Health in International Perspective: Shorter Lives, Poorer Health documents the decline in the health status of Americans relative to people in other high-income countries, concluding that “Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary.”1 The report blames many factors, “adverse economic and social conditions” among them. In an editorial in Science discussing the findings of the Institute of Medicine report, Bayer et al2 call for a national commission on health “to address the social causes that have put the USA last among comparable nations.” Although mortality from cardiovascular disease (CVD) in the United States has been on a linear decline since the 1970s, the burden remains high. It accounted for 31.9% of deaths in 2010.3 There is general agreement that the decline is the result, in equal measure, of advances in prevention and advances in treatment. These advances in turn rest on dramatic successes in efforts to understand the biology of CVD that began in the late 1940s.4,5 It has been assumed that the steady downward trend in mortality will continue into the future as further breakthroughs in biological science lead to further advances in prevention and treatment. This view of the future may not be warranted. The prevalence of CVD in the United States is expected to rise 10% between 2010 and 2030.6 This change in the trajectory of cardiovascular burden is the result not only of an aging population but also of a dramatic rise over the past 25 years in obesity and the hypertension, diabetes mellitus, and physical inactivity that accompany weight gain. Although there is no consensus on the precise causes of the obesity epidemic, a dramatic change in the underlying biology of Americans is …
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We predicted the amount of health outcome improvement any state might achieve if it could reach the highest level of key health determinants any individual state has already achieved. Using secondary county-level data on modifiable and nonmodifiable health determinants from 1994 to 2003, we used regression analysis to predict state age-adjusted mortality rates in 2000 for those younger than age 75, under the scenario of each state's "ideal" predicted mortality if that state had the best observed level among all states of modifiable determinants. We found considerable variation in predicted improvement across the states. The state with the lowest baseline mortality, New Hampshire, was predicted to improve by 23% to a mortality rate of 250 per 100,000 population if New Hampshire had the most favorable profile of modifiable health determinants. However, West Virginia, with a much higher baseline, would be predicted to improve the most-by 46% to 254 per 100,000 population. Individual states varied in the pattern of specific modifiable variables associated with their predicted improvement. The results support the contention that health improvement requires investment in three major categories: health care, behavioral change, and socioeconomic factors. Different states will require different investment portfolios depending on their pattern of modifiable and nonmodifiable determinants.
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We examined the relation between living in states that instituted bans on same-sex marriage during the 2004 and 2005 elections and the prevalence of psychiatric morbidity among lesbian, gay, and bisexual (LGB) populations. We used data from wave 1 (2001-2002) and wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (N = 34,653), a longitudinal, nationally representative study of noninstitutionalized US adults. Psychiatric disorders defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, increased significantly between waves 1 and 2 among LGB respondents living in states that banned gay marriage for the following outcomes: any mood disorder (36.6% increase), generalized anxiety disorder (248.2% increase), any alcohol use disorder (41.9% increase), and psychiatric comorbidity (36.3% increase). These psychiatric disorders did not increase significantly among LGB respondents living in states without constitutional amendments. Additionally, we found no evidence for increases of the same magnitude among heterosexuals living in states with constitutional amendments. Living in states with discriminatory policies may have pernicious consequences for the mental health of LGB populations. These findings lend scientific support to recent efforts to overturn these policies.
Objective We predicted the amount of health outcome improvement any state might achieve if it could reach the highest level of key health determinants any individual state has already achieved. Methods Using secondary county-level data on modifiable and nonmodifiable health determinants from 1994 to 2003, we used regression analysis to predict state age-adjusted mortality rates in 2000 for those younger than age 75, under the scenario of each state's “ideal” predicted mortality if that state had the best observed level among all states of modifiable determinants. Results We found considerable variation in predicted improvement across the states. The state with the lowest baseline mortality, New Hampshire, was predicted to improve by 23% to a mortality rate of 250 per 100,000 population if New Hampshire had the most favorable profile of modifiable health determinants. However, West Virginia, with a much higher baseline, would be predicted to improve the most—by 46% to 254 per 100,000 population. Individual states varied in the pattern of specific modifiable variables associated with their predicted improvement. Conclusions The results support the contention that health improvement requires investment in three major categories: health care, behavioral change, and socioeconomic factors. Different states will require different investment portfolios depending on their pattern of modifiable and nonmodifiable determinants.
During the last 25 years, life expectancy at age 50 in the United States has been rising, but at a slower pace than in many other high-income countries, such as Japan and Australia. This difference is particularly notable given that the United States spends more on health care than any other nation. Concerned about this divergence, the National Institute on Aging asked the National Research Council to examine evidence on its possible causes. According to Explaining Divergent Levels of Longevity in High-Income Countries, the nation's history of heavy smoking is a major reason why lifespans in the United States fall short of those in many other high-income nations. Evidence suggests that current obesity levels play a substantial part as well. The book reports that lack of universal access to health care in the U.S. also has increased mortality and reduced life expectancy, though this is a less significant factor for those over age 65 because of Medicare access. For the main causes of death at older ages -- cancer and cardiovascular disease -- available indicators do not suggest that the U.S. health care system is failing to prevent deaths that would be averted elsewhere. In fact, cancer detection and survival appear to be better in the U.S. than in most other high-income nations, and survival rates following a heart attack also are favorable. Explaining Divergent Levels of Longevity in High-Income Countries identifies many gaps in research. For instance, while lung cancer deaths are a reliable marker of the damage from smoking, no clear-cut marker exists for obesity, physical inactivity, social integration, or other risks considered in this book. Moreover, evaluation of these risk factors is based on observational studies, which -- unlike randomized controlled trials -- are subject to many biases. © 2011 by the National Academy of Sciences. All rights reserved.
The United States is among the wealthiest nations in the world, but it is far from the healthiest. Although life expectancy and survival rates in the United States have improved dramatically over the past century, Americans live shorter lives and experience more injuries and illnesses than people in other high-income countries. The U.S. health disadvantage cannot be attributed solely to the adverse health status of racial or ethnic minorities or poor people: even highly advantaged Americans are in worse health than their counterparts in other, "peer" countries. In light of the new and growing evidence about the U.S. health disadvantage, the National Institutes of Health asked the National Research Council (NRC) and the Institute of Medicine (IOM) to convene a panel of experts to study the issue. The Panel on Understanding Cross-National Health Differences Among High-Income Countries examined whether the U.S. health disadvantage exists across the life span, considered potential explanations, and assessed the larger implications of the findings. U.S. Health in International Perspective presents detailed evidence on the issue, explores the possible explanations for the shorter and less healthy lives of Americans than those of people in comparable countries, and recommends actions by both government and nongovernment agencies and organizations to address the U.S. health disadvantage.
Since Scottish devolution in 1999, successive governments have accorded priority to reducing health inequality and increasing economic growth. The Scottish Nationalist Party Government elected in 2007 and re-elected in 2011 has accorded considerable attention and allocated substantial resources to addressing these priorities. This article describes why, how and with what results to date the participants in the governance of Scotland, broadly defined to include persons outside as well as within central government, have addressed the determinants of health in order to reduce inequality and, as a result, improve the health status of the population.