• The missing well-being

    Aaron has a post on the new JAMA article by Christopher Murray and a host of colleagues on “The State of US Health, 1990-2010.” Aaron is amazed by this study and I am too, in part because if anything the title understates the authors’ ambitions. Although the focus is on the US, they are actually describing health and its determinants throughout the developed world.

    The authors measured the health of 34 developed nations using age-standardized measures of death, morbidity, and disability. They then looked at how these measures and the rankings of the nations changed from 1990 to 2010.

    The good news is that the US made progress on most measures. For example,

    US life expectancy for both sexes combined increased from 75.2 years in 1990 to 78.2 years in 2010.

    However, as Harvey Fineberg summarizes

    the health of the US population has improved only gradually and has fallen behind the pace of progress in many other wealthy nations. In fact, by every measure including death rates, life expectancy, and diminished function and quality of life as assessed by the authors, the US standing compared with 34 OECD countries declined between 1990 and 2010.

    I have argued that absolute changes in health — where the US rose — are more important than comparative rankings — where the US fell. So is there a problem here?

    There is a tragic problem. Even though we have made progress, comparable countries did a lot better. We should have done as well as our peers did. Because we did not there was suffering we should have prevented and lives that we should have saved, but that were lost. Unrealized marginal improvements in health, accumulated over two decades and hundreds of millions of people, amount to many tens of millions of years of healthy life that Americans did not enjoy. Think of it as an invisible holocaust.

    Why we did not enjoy these millions of years of healthy living is an enormously complex question. It is in part because of the manifold deficiencies of our health care system. But only in part. Population health is much more than just the performance of the health care system. It is also how we live: obesity in West Virginia, homicide in Flint, methamphetamine in Hawaii, and suicides in the Mountain West.

    Land Use DetroitAnd a huge amount of stress everywhere. I’m reading George Packer’s The Unwinding: An Inner History of the New America. Atul Gawande exactly captured my feelings about this book.

    Packer documents the shredding of jobs, families, and communities across America. It has always been true that

    The mass of men lead lives of quiet desperation

    but now we confirm this desperation by sitting in idling cars at the fast food pick-up window.

    Americans are extraordinarily creative and productive. But we do not realize the well-being that we should be deriving from our incredible effort, talent, and physical capital. We need to stop accepting substandard and inefficient performance from our health care system. And we need to reflect on how we are living and what we are living for.


    • You should look further at the broader picture to figure out why so many people are poor. The rich have gamed the system and are getting a bigger and bigger slice of the pie; almost the whole pie in fact. SEE: . 50 percent of Americans have one percent of the nation’s wealth. SEE: . Twenty percent of the population owns a staggering 89 percent fo the wealth in this country; with the top one percent owning 35 percent. SEE: . Equal opportunity is a myth. SEE: http://opinionator.blogs.nytimes.com/

      The fact is that we are fast becoming an oligarchy run by monied special interests (if we aren’t yet).SEE: .

      One can rightfully argue that the meager payments made to the poor are payments made to stave off civil unrest. No society that has had such uneven income distribution has survived. What is more surprising is that the poor and middle class have not rioted for their fair share.

      You want a good laugh/cry: watch this video about wealth produced circa 1955 by Benson, a noted anti-communist and this video: . Then watch today’s world:http://www.youtube.com/watch?v=QPKKQn

      Our country will not end well unless we change this.

    • I have this week’s Frontline on my DVR but need to prepare myself for it, having seen the promos and Charlie Rose’s interview with Bill Moyers. “Two American Families: Bill Moyers chronicles two ordinary families – one black and one white – for two decades.” http://www.pbs.org/wgbh/pages/frontline/two-american-families/

      (The promo I saw had one of the families with a $30,000 medical bill that wiped out their savings and the hope of paying off their mortgage.)

    • That gets at probably my biggest non-health pet peeve: our dependence on the car has led us to create suburbs upon suburbs upon far flung suburbs. You cannot reasonably cycle or walk to a nearby shop in many of these suburbs, as traffic is too heavy and/or there are too few viable pedestrian crossings. You have to drive everywhere.

      Cars are expensive, which reduces families’ economic resources. Furthermore, auto travel is not that safe. Humans are not equipped with the attention span to juggle all the tasks we try to juggle in the car.

      Further, long commutes are positively correlated with mortality. The first wave of White folks to flee to the suburbs got lucky. They were reasonably close to jobs in the cities. But then more and more people got the same idea, and suburbs turned to sprawl.

      As suburbanites’ spending power left inner cities, the number of jobs in those cities that a working person could do declined. Furthermore, more and more they had to remake the cities for cars, not pedestrians. All over it was the same: you had to drive to work the grocery store or take a long bus ride. It became less and less hospitable to walk places. I bet there is something to be said about exposure to auto emissions in cities as well.

      It is physically harder to deliver health care to a more sparsely populated area. Patients’ travel times go up, and if they don’t have reliable transportation, this is a further barrier. You may have to maintain more than one office.

      I could go on, but my point is this: Sprawl makes America weak. One of the reasons we are not able to reap the full benefits of our effort, talent and physical capital is sprawl.

      • Are you sure European cities are less sprawling? Many of them have height restrictions US cities don’t have, which means you are even less likely to be able to afford to live near your work. Just to offer one example comparison: London and NYC are similar in population (about 8.3 million). London’s population density is 13,689 people per square mile, while NYC is 27,550 per square mile. On a list of US cities arranged by density, London wouldn’t even crack top 30.

    • Packer documents the shredding of jobs

      It is interesting that he includes jobs, because that is an area where the USA does relatively well. The USA generally has lower unemployment than do the other developed countries.

      I really think that we need to look deeper for the causes of the USA’s lower level of health.

      I may be biased but I believe that is it healthier overall to have more people working at lower compensation than to have more compensation but more involuntary un-employment.

      This whole subject fascinates me. Here is a story that (How Cubans’ Health Improved When Their Economy Collapsed) , that implies that lower wealth can in sometimes improve health. It shows how complex this subject can be so I really think the broad indicators should only cause to ask why and lead us to drill down to look at the causes.