May 29, 2006

 Sick America

A heavyweight study published in JAMA ("Disease and Disadvantage in the United States and in England", Michael Marmot et al.) has found that

"Americans are much sicker than the English."
It covered large samples of white middle-aged people enrolled in longitudinal studies in both countries. For once, England is the exact term; unhealthy Scotland and healthy Wales now run their own parts of the NHS. The design makes the USA look better than it is; the omission of the Scots is outweighed by that of African-Americans.

I've turned the key findings into charts.

This one (from Marmot's table 1) shows the self-reported incidence of the major diseases:


There's little inter-country difference between men and women. In both countries, disease rates fall with income and education, more steeply in the US as you would expect.

To cover for subjective biases in the self-reporting, Marmot also looked at various objective clinical indicators for diabetes and heart disease; this is from his Table 4. The USA only does well on cholesterol:


Disregard the usual "balanced" newspaper reporting that gives equal weight to a major piece of research and off-the-cuff objections that it has already anticipated. You have to take this as fact. So why, when Americans spend twice as much on health care?

Surprisingly, the authors discount access to health insurance, as the gap with England still holds for well-off and presumably fully insured Americans. (This is not an argument against universal insurance, which is essentially a question of justice within the USA.) They find the risk factors of alcohol and tobacco are roughly equal, and greater American obesity doesn't account for much of the difference in disease.

Explanations that are still possible: childhood experience - English children of my postwar generation had a fairly spartan upbringing, walked to school, etc; other lifestyle factors like exercise and Coke; more competent or less compliant doctors; it's a purely temporary advantage as the English have also become fatties swilling junk food and sodas in front of the telly or computer.

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