by Kirsten Hartil
The United States is the seventh-richest country in the world based on gross domestic product (GDP) per capita. It spends more money on health care than any other Organisation for Economic Co-operation and Development (OECD) country (17.6 percent of GDP, compared with the OECD median of 9.5 percent). Yet, according to an Institute of Medicine (IOM) report, Americans die sooner and experience more illness than residents in comparable high-income countries.
The report U.S. Health in International Perspective: Shorter Lives, Poorer Health draws on datasets from organizations including the OECD, WHO and UNICEF and commissioned studies. It compares mortality and health outcomes for the United States with 16 peer countries, (Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands and the United Kingdom.)
The report, while acknowledging limitations, including a lack of harmonization of datasets across countries, convincingly demonstrates that the United States is experiencing a significant health disadvantage. It describes the major causes of death that contribute to the years of life lost (YLL), an estimate of the average years a person would have lived if he or she had not died prematurely, and discusses behavioral, social, environmental and political factors that may contribute to this disadvantage.
The U.S. has the highest all cause rate of mortality
Total non-communicable diseases (NCDs) (including cancer, diabetes mellitus, cardiovascular disease (CVD), respiratory, neuropsychiatric conditions) were the greatest contributor to mortality in all peer countries. The U.S. ranked second in mortality from NCDs. For every 100,000 individuals 418 deaths were attributable to NCDs. CVD (including rheumatic, hypertensive, ischemic, cerebrovascular and inflammatory heart disease) was the largest contributor accounting for 155.726 deaths per 100,000. Malignant neoplasms (including lung, prostate, breast, colon, melanoma, pancreas and liver cancer) accounted for 123.97 deaths per 100,000. Mortality from neuropsychiatric conditions contributed less (39.23 deaths per 100,000), however the U.S. ranked first in mortality from PTSD (0.00455 deaths per 100,000) compared with second ranked Germany (0.001189 deaths per 100,000).
The U.S. ranked second in deaths from injuries (both intentional and unintentional) (52.80/100,000). Unintentional injuries (road traffic accidents, poisonings, falls, fires, drowning) accounted for 38.5/100,000 deaths and intentional injuries (self-inflicted injuries, violence and war) accounted for 17.3/100,000 deaths. The U.S. ranked first in death from road-traffic-accidents, violence and war. Homicide rates in the U.S. were 6.9 times higher than 23 other OECD countries and the rate of firearm homicides was 19.5 times higher.
The U.S. ranked fourth in deaths from communicable disease (infectious and parasitic diseases, respiratory infections) maternal, perinatal and nutritional conditions. It ranked second in deaths from HIV/AIDs and first in deaths from hepatitis C. The U.S. has the highest incidence of AIDs among all peer countries (about nine times higher than the OECD average) and is exceeded only by Estonia, Portugal, the Russian Federation, and South Africa in prevalence of HIV infection among 40 OECD countries. It is important to note that the case reporting definitions were expanded in the U.S. in 1993 and subsequently differ from the definition used across Europe and other OECD countries.
New cases of HIV, estimated to be about 50,000 per year, have remained relatively stable over recent years. The highest incidence of HIV infection in the U.S. was among individuals aged 25-34 (31%) followed by individuals aged 13-24 (26%). African Americans face the most severe burden of HIV with gay, bisexual and other men who have sex with men most seriously affected.
Shorter life expectancy
Men in the U.S. can expect to live to 75.64 years (3.7 years less than men in Switzerland). Women can expect to live to 80.78 years (5.2 years less than women in Japan.) As with many of the health disadvantages discussed in the report, across country differences in life expectancy are not as stark as within country disparities. In New Orleans for example, life expectancy in certain parts of the city is 54 yrs compared to 80 yrs in other parts.
Decreased life expectancy is accompanied by high rates of mortality across most age groups and the U.S. has the lowest probability of surviving to age 50. In females, death after age 50 contributed to 58 percent of YLL but only 32 percent in males, suggesting an increased risk of mortality in males before age 50. In males, NCDs and injuries (intentional and unintentional) contribute to the majority of YLL before age 50. Homicides, motor vehicle accidents and non-transportation-related injuries contributed to 53 percent of excess mortality among American males under age 50. In females NCDs, unintentional injuries and perinatal conditions are the major cause of YLL.
Child and Infant Mortality
The U.S. ranked first among the other peer countries in deaths from maternal conditions related to pregnancy and perinatal conditions. Out of 40 OECD countries only Brazil, Chile, China, India, Indonesia, Mexico, the Russian Federation, South Africa and Turkey have higher infant mortality (death before their first birthday) rates than the U.S. How countries register preterm births can account for cross country differences in infant mortality rates. The U.S. registers all preterm neonates (with low probabilities of survival) as live births, thereby increasing the mortality rate relative to countries that do not include preterm neonates among live births.
Adolescent pregnancy increases risk of low birth weight and infant mortality. The U.S. had the highest rate of adolescent pregnancy of all the peer countries. In the recent County Health Rankings, Bronx County ranked 62 out of 62 NY State Counties in health outcomes and socioeconomic factors. Rates of teenage pregnancy (45 per 1,000 female population, ages 15-19) in the Bronx are twice as high as the National Benchmark (21 per 1,000 female population, ages 15-19), infant mortality and the percent of live births that are low birthweight (< 2500 grams) are higher in the Bronx than the NY State average.
Infant mortality rates in the U.S are significantly higher among African Americans than Caucasians, even after accounting for factors such as poverty and education (Figure 2). African Americans have higher rates of preterm and low birthweight, sudden infant death syndrome (SIDS), and maternal complications that all contribute to high rates of infant mortality. However, U.S. infant mortality for non-Hispanic whites and among mothers with 16 or more years of education are still higher than other countries (Palloni and Yonker, 2012, Mathews and MacDorman, 2007).
Child (1-19 yrs) mortality rates are also higher in the U.S. compared to all other peer countries except Portugal. In 2006, the U.S. had the highest rates of child rates due to negligence, maltreatment, or physical assault among the peer countries. UNICEF, the United Nations Children’s Fund, ranked the U.S. last out of 21 countries based on statistics for birth weight, infant mortality, breastfeeding, vaccinations, physical activity, mortality and suicides. 11 percent of deaths under the age of 5 were from injuries, the second highest among the peer countries. Of the leading causes of death among children unintentional injury is the number one cause. Mortality from transportation-related injuries is higher in the U.S. than the mean for the 17 peer countries. Homicide is the third leading cause of death for children age 1-4, the fourth leading cause of death in children age 5-14 and the second leading cause of death among adolescents and young adults (15-24). U.S. male adolescents (age 15-19) are five times more likely to die from violence than those in other OECD countries.
The Good News
Mortality rates for certain cancers (cervical and colorectal) are lower than for most peer countries, which may be a result of increased screening and early detection. The U.S. has the third highest rate of mammography screening and the highest cervical cancer screening rate among all OECD countries (although, women who are uninsured, receiving Medicaid or have lower educational levels report lower use of mammography and Pap smears.) Rates of screening for colorectal and prostate cancer in adults age 50 and older are greater than in European countries. Although, evidence that the benefit of PSA screening for prostate cancer does not outweigh the harms resulted in a United States Preventative Services Task Force (USPSTF) recommendation to reduce prostate cancer screening. Another evidence-based recommendation by the USPSTF on the use of mammograms under the age of 50 for breast cancer screening was met with some controversy in 2009.
Finally, should you survive to 75 years of age, be reassured that you will have higher survival rates compared with other high income countries. This may be a result of the aggressive efforts to treat chronic and end of life diseases. Advances in pharmaceuticals and technology allow us to control our blood pressure and cholesterol levels and to extend and support the life of loved ones afflicted with chronic disease and multi-organ failure which was the topic of a Frontline documentary.