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THE MEASURE OF A NATION
How to Regain America's Competitive Edge and Boost Our Global Standing
By HOWARD STEVEN FRIEDMAN
Copyright © 2012 Howard Steven Friedman
All right reserved.
Chapter One The Nation's Heartbeat: Health
Health is at the heart of human progress. It determines whether parents can work to support their families, children can attend school, women can survive childbirth, and infants can grow and thrive. Where health services are strong and accessible, families and communities flourish. Where health services are inaccessible, weak, or nonexistent, families suffer, adults die prematurely, and communities unravel. —from the US Government Global Health Initiative Strategy, available online at ghi.gov/resources/stragegies/.
Nothing else about our lives as Americans matters at all if we don't have a reasonable expectation of a healthy life. Basic safety, the enrichment of education, our entire democratic process, our own individual chance at social mobility: none of these things has any importance or interest if we cannot take advantage of them. And without health, we can't.
Maybe that's why our Declaration of Independence places life first in the list of "unalienable" rights with which we are naturally endowed. We all get just the one life, and living it in health and for as long as possible is basic to everything else that we do and everything else that affects us. So it makes sense that health should be the first comparison we look at, for it underlies all the other assessments this book explores.
But how do we measure health? So many factors determine and affect it. We have no control over many of them—gender, for example, or genes, or even the culture in which we grow up. The air we breathe, the water we drink, and other environmental realities affect our health, but these are realities we can only change immediately by moving our location. We have limited control over where we work and how much income we earn, our social status, and our education, yet all of these impact our health, as do lifestyle choices such as diet, exercise, and personal habits like smoking, use of alcohol and drugs, health practices, and coping mechanisms.
Health is a subject with which we seem to be obsessed. Wonder drugs, diet fads, and superfoods buzz around American pop culture and are regular topics on radio and television talk shows. Feats of medical practice that seem miraculous routinely lead the headlines. There isn't a newspaper or news broadcast that isn't staffed with a health columnist or physician interpreting the latest medical research results and advising us all on lifestyle choices. We thrill to the story of the child from a distant land, born with a rare ailment, who is flown here to undergo a special life-saving procedure available only in America. We read regularly about world leaders arriving in private jets for cutting-edge treatments developed by American researchers in American laboratories.
Essential to it all is our health system, the totality of medical and healthcare products, systems, services, people and resources, and physical facilities that affect us throughout our lifetime. In fact, the healthcare system starts to affect us even before our lifetime. From the moment our mothers initiate prenatal care to the debilitations of old age, and for every bruise, break, sickness, and stress in between, our healthcare system is where we go for a healthier life and more of it. So, how the system responds is central to measuring the health of our nation as a whole.
The cliché dutifully repeated by so many politicians, perhaps buoyed by the stories of those outstanding medical accomplishments, is that the United States enjoys "the best healthcare in the world." It's an oft-used phrase, its frequency of use matched only by its inaccuracy, as we will discover in separating the fiction from the facts about how the United States's healthcare stacks up against the competition.
The simplest and most compelling metric for assessing health and comparing health outcomes is life expectancy, the average number of years an individual can expect to live. On that measure, the United States does very badly indeed, registering the lowest life expectancy in our group. Stunningly, that low life expectancy includes both the highest infant mortality rate and maternal mortality ratio in the group. Moreover, we spend per person nearly twice as much as all the other nations in our competitor group and in some cases as much as four times more. More money for the worst outcome. You don't have to be on the board of directors to know a bad return on investment when you see one.
Bottom line: as a competitor in healthcare, the United States is clearly ailing—and we the people are not getting our money's worth.
Why? How is it we can spend so much more for healthcare than our competitor nations and yet have one of the lowest life expectancies in our sector? Why are we losing so many infants and mothers in childbirth when we are supposed to be the health market leader? How have we cut our smoking rate dramatically yet seen a striking increase in obesity, a major health risk factor? How, with our world-renowned hospitals and research centers, are the vital statistics on our national health so poor?
Let's look at the data.
WEALTH MAKES HEALTH?
The inherited factors of genes and gender as well as the influences of such things as where we live, the kind of work we do, and, of course, our own behavior all affect health and, therefore, life expectancy. A positive change in behavior—for example, improving diet or exercising more—will have a positive effect on our health and can extend our lifespan. And vice versa; negative behavior can have a negative effect.
Other factors also affect life expectancy: the rate of disease at a particular time in a particular place, an individual's mental health, even the rates of crime and safety. Advances in healthcare knowledge and technology, for example, from the development of the polio vaccine to breakthroughs in cancer treatment, can increase life expectancy, while the sudden arrival of new epidemics, like HIV/AIDS and the rampant use of crack cocaine in the 1980s, can cause it to plummet.
One of the more definitive factors affecting a nation's life expectancy is wealth. The numbers demonstrate that, globally, life expectancy generally increases as a function of a country's wealth—that is, up to a certain level of wealth. In fact, looking at life expectancy data is a little like taking the rough economic pulse of a country.
The reason is simple: In poorer countries, the chances of survival are dominated by the rates of infectious diseases, infant mortality, and malnutrition; and their healthcare systems struggle to provide safe drinking water, sanitary living conditions, adequate food supplies, and basic health services. Indeed, the poorest countries on the planet have life expectancies in some cases of less than fifty years, with few resources to fight infectious diseases like AIDS, malaria, tuberculosis, and measles.
In the developed world, however, where sanitation, sufficient food, and basic healthcare are givens, mortality is driven mostly by noncommunicable diseases such as heart disease and cancer, diseases affected by lifestyle, nutrition, environmental factors, and genetics. In these wealthier countries, there are no infectious diseases in the top eight causes of death, and life expectancy, which has increased dramatically in the past century, can average seventy-five years or more as the rates of infectious diseases and infant mortality have declined. In the United States, in fact, the average lifespan increased by more than thirty years in the twentieth century. 6 In some sense, therefore, comparing the health of today's wealthy nations to today's poor nations is like comparing the health of today's wealthy nations to the health of those same countries several generations ago, when they struggled to fight polio, smallpox, and other infectious diseases.
The relationship between health and wealth can be clearly seen in the global life expectancy curve. This graph includes all countries in the world for which data were available; each data point represents a country's life expectancy and GDP per capita. At the lower left-hand corner of the graph, the point at which GDP per capita is the lowest, life expectancy is also the lowest. Moving to the right, we see that life expectancies rise very sharply with wealth—until we reach around the $4,000 level. As the average wealth improves, so do health services, sanitation, and the supply and availability of safe drinking water. The provision of those basics produces a dramatic spike in people's health, and they live longer, thus raising average life expectancy. Above the $4,000-per-capita point, although life expectancy continues to rise, it does so at a slower rate. And when per-capita GDP exceeds $20,000, the life expectancy curve becomes an almost completely flat line. This flat-lining tells us that above a certain threshold of national wealth, the nation's finances are sufficient to meet its citizens' medical needs, and therefore other factors become more important in predicting life expectancy.
As often happens, the exceptions to this prove the rule. South Africa is a negative outlier: with one of the world's highest rates of HIV/AIDS, average life expectancy is some twenty years lower than in countries of similar wealth. By contrast, Vietnam and Nepal are positive outliers that enjoy life expectancies much higher than countries of similar wealth.
So, which countries are best at keeping their citizens alive? And where does the United States, the richest country on earth, stand in the rankings? Take a look:
As in our other competitive intelligence graphs, the Star appears on the left side of the graph and the Dog appears on the right. In our competitor set of countries, the United States is the clear market Dog in life expectancy, falling more than one year shorter than the next closest competitor, Portugal. The market segment Star, Japan, has the highest life expectancy, nearly five years longer than in the United States and more than one year longer than any of the other competitors. Other stronger performers like Australia, Italy, France, and Spain all have life expectancies that are more than three years longer than in the United States.
Perhaps equally striking, we've come down in the world. Back in 1987 only seven other countries had longer life expectancies. Today we're not even in the top twenty!
As with many other aspects of American society, life expectancy varies greatly from one population subgroup to another, reflecting fundamental disparities between ethnic groups, socioeconomic groups, and geographies. One striking example: there is a difference of about twenty years of lifespan between Asian American women and African American urban males. On a state level, the diverse set of states with the longest life expectancies (Hawaii at 81.5 years, Minnesota at 80.9 years, California at 80.4 years, and New York at 80.4 years) average at least five years longer than the states with the shortest life expectancies (Mississippi at 74.8 years, West Virginia at 75.2 years, Alabama at 75.2 years, and Louisiana at 75.4 years). It is important to observe that the eleven states with the lowest life expectancy are all in the South.
Nearly universally, women live longer than men. In the United States, both sexes do rather badly: both American men and American women have the lowest life expectancy in our competitor group, while Japan registers the longest life expectancy for both men and women.
The US-Japan life expectancy comparison is affected by vast genetic differences, but genetic differences are not sufficient to explain America's lagging performance versus competitor countries with more similar gene pools—among them Australia, Italy, France, and Spain. Other factors must be at work in affecting American life expectancy.
The infant mortality rate is defined as the number of deaths of infants one year or younger per one thousand live births. It is a critical measure because the death of a young child has a greater impact on a population's life expectancy than does a death from disease or injury in the middle or later stages of life. In the developing world, infant mortality tends to be a result of pneumonia, diarrhea, tetanus, and congenital malformation. In the developed world, it is typically associated with low birthweight or extremely premature births.
We don't usually think about infant mortality in the United States. We associate it with the developing world or with the distant past. During the Industrial Revolution, for example, the percentage of children born in London who died before the age of five decreased from 74.5 percent to 31.8 percent over a span of sixty years. The introduction of clean drinking water, sewage disposal, and greater attention to personal hygiene dramatically reduced death rates due to diarrhea, pneumonia, diphtheria, and typhoid fever during the early part of the twentieth century. The post-World War II era saw vaccines, antibiotics, and other life-saving interventions contributing to further declines. Globally, in just the brief period between 1960 and 2001, infant mortality declined from 126 infant deaths per one thousand live births to 57 per one thousand live births.
It is particularly stunning to note that today the United States has the highest rate of infant mortality of any of the competitors while Japan, the competitor with the longest life expectancy, has the lowest. In the United States, the most common causes of infant mortality are congenital malformations and disorders associated with low birthweight and short gestation.
The fact that the United States is the market Dog in infant mortality is not because of a lack of specialists or facilities for neonatal births; on the contrary, we have more neonatologists and neonatal-intensive-care beds per person than Australia, Canada, or the United Kingdom.
As with other health metrics, our relative performance is declining. In 1960, the United States had the twelfth-lowest infant mortality rate in the world. By 1990, we had dropped to twenty-third, and we sank to thirty-fourth in 2008. Our most recent decline in ranking has been accompanied by a relatively stagnant infant mortality rate, which remained virtually unchanged from 2000 to 2005 before declining slightly between 2005 and 2006. That stagnant mortality rate was accompanied by an increase in the percentage of very preterm births—that is, births happening at fewer than thirty-seven weeks of gestation, an occurrence cited by the Centers for Disease Control and Prevention (CDC) as a key risk factor for infant mortality. By 2005, the start of a slight decline in the infant mortality rate, preterm babies accounted for 69 percent of all infant deaths. Although data comparing the rate of preterm births are not readily available, the key contributing factor to our high rate of infant mortality appears to be our rate of low-birthweight newborns, which is one of the highest among our competitor nations.
Our high infant mortality rate evidences the economic, ethnic, and racial disparities referred to earlier. For example, in 2005, African American infants suffered a death rate of 13.63 per one thousand births, more than twice the national average. The CDC's 2004 world rankings indicate that an African American baby would have a better chance of survival if born in Russia or Bulgaria than in the United States. Low-birthweight incidence explains some of the racial inequality. Low-weight births, defined as newborns weighing less than 2,500 grams or approximately five pounds, are about twice as common among African Americans as among (non-Hispanic) Caucasian and Hispanic babies, occurring at a rate of 13 percent among the former and at a rate of only 6.5 percent among the latter. Among the factors contributing to these lopsided outcomes are disparities in prenatal care, nutritional supplementation for pregnant women, and inadequate social welfare. Yet even if we eliminate this racial disparity and compare only the infant mortality rate of the United States's Caucasian population, our ranking versus the competition is unaffected.
Could our relatively high infant mortality rate result from the fact that Americans are less likely to selectively abort? Whether motivated by religion, politics, or some other perspective, a choice not to abort an impaired pregnancy raises the percentage of births with congenital malformations, and some argue it is this choice that raises our infant mortality rate. It isn't at all obvious that this claim is supported by facts. We are able to compare the overall abortion rates across countries, but we lack insight into whether the decision to abort was driven by social reasons, economic pressures, or concerns about the health of the mother or fetus in each country. When we do examine the overall US abortion rate, defined as the number of abortions per one thousand women between the ages of fifteen and forty-four, we see that it is higher than in Canada, Belgium, the Netherlands, and the United Kingdom, all of which have lower infant mortality rates and higher life expectancy rates. The abortion ratio, defined as the number of abortions per one hundred known pregnancies, is higher for the combination of the United States and Canada than for northern Europe, western Europe, and western Asia. There is thus no evidence that American women show a disinclination to abortion, so selective abortion tendencies are not likely to be a valid explanation for America's high infant mortality rate.
Excerpted from THE MEASURE OF A NATION by HOWARD STEVEN FRIEDMAN Copyright © 2012 by Howard Steven Friedman. Excerpted by permission of Prometheus Books. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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