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America's health: We're living longer, but not better

With a barrage of fresh research findings, published today in two leading medical journals, researchers at the University of Washington and the US Burden of Di
A failure of public health.   (Photo by Andrew Burton/Getty Images)
A failure of public health.

With a barrage of fresh research findings, published today in two leading medical journals, researchers at the University of Washington and the US Burden of Disease project have filled out the details of the mediocre state of America’s health. By scouring and analyzing two decades’ worth of health records from 34 developed countries—a subset of the 187 countries in their database—the researchers have determined “which diseases, injuries and risk factors are related to the greatest losses of health, and how these risk factors and health outcomes are changing over time.” And by plotting out these problems and opportunities, the researchers have laid a sturdy foundation for better public-health policymaking.

The new reports sound some familiar themes. Though Americans’ life expectancy increased by three years between 1990 and 2010 (from 75.2 years to 78.2 years), the researchers note that 27 out of 33 peer countries now out-rank us on mortality statistics such as life expectancy and premature death. “Citizens living in countries with a substantially lower gross domestic product and health expenditures per capita, such as Chile, Portugal, Slovenia, and South Korea, have lower mortality rates than those in the United States,” they write in an overview article appearing in this week’s JAMA.

But the studies go beyond overall death rates to examine the factors that underlie them. In separate articles, the researchers highlight the disparities between America’s most prosperous counties (where Americans live as long as the Swiss or Japanese) and its poorest ones (where we die as young as Algerians or Bangladeshis). They also gauge the shifting impact of different diseases and injuries. Here are some of the conditions that took the greatest toll on Americans’ health in 2010.

Leading causes of disability & death, 2010Change in impact, 1990-20101. Ischemic heart diseaseDown 19%2. Chronic obstructive pulmonary disease (COPD)Up 34%3. Low back painUp 25%4. Lung cancerUp 4%5. Major depressive disorderUp 43%6. Musculoskeletal painUp 34%7. StrokeNo change8. DiabetesUp 58%9. Road injuryDown 16%10. Drug abuseUp 85%11. Neck painUp 29%12. Alzheimer diseaseUp 159%13. Anxiety disordersUp 21%14. Self-harmUp 6%15. FallsUp 58%16. CirrhosisUp 38%17. Chronic kidney diseaseUp 69%18. Colorectal cancerUp 3%19. Alcohol abuseUp 26%20. Lower respiratory tract infectionsDown 13%21. Breast cancerDown 2%22. Interpersonal violenceDown 26%23. Preterm birth complicationsDown 25%24. AsthmaUp 14%25. OsteoarthritisUp 56%26. Non-ischemic cardiovascular diseasesUp 27%27. SchizophreniaUp 29%28. MigraineUp 19%29. Congenital anomaliesDown 26%30. CardiomyopathyUp 6%

Why would anyone list back pain and migraine alongside lung cancer and heart disease as the nation’s leading health challenges?

Because unlike most international comparisons, which treat mere survival as a surrogate for health, the Burden of Disease project strives to gauge people’s actual well-being. Besides tracking life expectancy and the number of life years lost to different diseases and injuries, the project also tracks the prevalence of conditions that cause chronic disability, meaning diminished function and poor quality of life. Its core measure is not life expectancy per se but rather healthy life expectancy—the number of years an average person can expect to live without chronic disability.

The United States scores slightly better on healthy life expectancy (26th out of 34 developed countries) than it does on longevity alone (27th or 28th, depending on the measure). But we’re becoming more disabled, not less. As the researchers explain in this week's JAMA article, the average American has seen “an increase in the number of years lived with disability” since 1990, and “chronic disability now accounts for nearly half of the health burden in the United States.” The leading causes—which include depression, anxiety and musculoskeletal pain—are largely distinct from the causes of premature death. As the researchers observe, the National Institutes of Health devote more research dollars to extending life than extending health.

But biomedical research won’t cure what now ails us. Our high rates of death and disability are driven by social, economic and environmental factors—not just biological ones—and the measures needed to address them go far beyond medical science. As the researchers conclude, “In many cases, the best investments improving population health would likely be public health programs and multisectoral action to address risks such as physical inactivity, diet, ambient particulate pollution, and alcohol and tobacco consumption.”

Where injuries are concerned, a simple regulation can often save more lives than an army of well-trained emergency physicians. Consider the example of road deaths. The toll, measured in lost life years, declined by a third from 1990 to 2010. Yet road deaths remain the second leading cause of lost life years among U.S. males, and 30 out of 33 peer nations have left us behind on this basic measure of public safety.

At the start of the 20-year study period, Spain and the United States suffered comparable losses from vehicular accidents. Since then, Spain has tightened enforcement of drunk-driving laws, underage-drinking laws and seat belt laws. It has also expanded the use of motorcycle helmets and introduced graduated driver licensing for teens. The payoff: twice the reduction in carnage that this country has seen. As the researchers note drily, “a more concerted intervention approach, drawing on lessons from other countries, would seem to be a key U.S. public health priority.”