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30 AUGUST 2013 VOL 341 SCIENCE www.sciencemag.org
962
POLICYFORUM
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
PUBLIC 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.
CREDIT: JOE BELANGER/ISTOCKPHOTO
*Corresponding author. rb8@cumc.columbia.edu
Department of Sociomedical Sciences, Mailman School of
Public Health, Columbia University, New York, NY 10032
USA.
Published by AAAS
on September 25, 2014www.sciencemag.orgDownloaded from on September 25, 2014www.sciencemag.orgDownloaded from
www.sciencemag.org SCIENCE VOL 341 30 AUGUST 2013 963
POLICYFORUM
tory risk factors: smoking and obesity; this
kept attention trained on individual health
behavior.
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
(2006).
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-
academies.org/DBASSE/CPOP/DBASSE_081127#.UYz-
j4Ij6CI.
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).
10.1126/science.1241249
Published by AAAS
