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May 02, 2006

Why So Unhealthy?

By Ezra

Man, I hate to make a point cutting against universal health care, but this study Kevin's citing in favor of the British system doesn't seem to show what he thinks it shows. The paper, to be published next week, basically found that once you control for factors like race, age, and income, Americans remain significantly less health than the British. We have more diabetes, more heart disease, more cancer, more hypertension. But the researchers themselves admit that "Britain's universal health-care system shouldn't get credit for better health," save for at the lowest income brackets.

One of the little-mentioned truths is that health care is given far more credit for health outcomes than it actually deserves, particularly once you hit a base level of access. So while it may be that beyond the British level of care you get diminishing returns, that's not really conclusive from this particular study. The question raised here is why Americans are so much sicker than others, and this gets trickier. A few hypotheses:

• Inequality and occupational stress are heavily correlated with poor health. There have been tons of studies finding that your placement within an organization's hierarchy is an excellent determinant of your heart's health, with greater autonomy leading to better outcomes. America is markedly unequal, and we place an impressive amount of emphasis on occupational achievement and success.

• Stress could do it as well. I don't have data on this, but I'd guess that Americans, for a variety of reasons, are simply more anxious than the English, or Europeans in general. Stress is heavily connected to all the illnesses being mentioned, so if someone could dig up a cross-national comparison of anxiety, it would be worth looking into.

• Diet, in particular high fructose corn syrup. The latter, which is heavily used in the US due to our corn subsidies, is very tough on the body, and quite a pal of diabetes (and thus heart disease, hypertension, etc). Given its near-ubiquity in our diet, it could play a surprisingly large role.

• Exercise. We're simply more auto based than most European countries, leading to less walking, and thus, worse health outcomes. This would operate independently of weight, and thus might not appear in simple comparisons of obesity rates.

Anyway, that's what I can come up with on the spot. Add to my list in comments.

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Comments

Sounds like many of the variables are the responsibility of the individual. No on eforces you to be a chouch potato or to smoke.

Posted by: Fred Jones | May 2, 2006 3:47:05 PM

What Fred says is true, up to a point. But as Ezra mentions, there are a lot of aspects of American society that are mostly/completely out of individuals' control and are bad for health outcomes. They also tend to link together: Lower-income people have little or no insurance, and they also engage in more unhealthy behaviors, largely because they have fewer alternatives; for example, fresh fruits and vegetables are notoriously unavailable in low-income neighborhoods, as are safe/cheap/accessible places to exercise. Access to prenatal and well-baby care tend to be very poor for low-income people, and our infant mortality rates reflect this. And stress is much higher for low-income people; chronic stress releases hormones that over time wreak havoc on the body and the brain. I've often thought that our relatively poor health outcomes are at least as much due to our greater inequality (compared to the rest of the industrialized world) as to our chaotic health care "system".

Posted by: Rebecca Allen, PhD, ARNP | May 2, 2006 4:21:22 PM

Whether it's class mobility or public health, Fred seems deeply committed these days to the proposition that Americans as a group are fundamentally lazier than Europeans. Why do you hate America?

Posted by: djw | May 2, 2006 4:22:14 PM

I can't think of any other class of factors (than those you mentioned) that would account for the Brits being healthier the the Americans, except for two things:

- the age bracket chosen for study (55-64) may reflect a near-working-lifetime of different healthcare access opportunities - inferior in the US. Maybe earlier-in-life neglect of health issues in the US makes us less healthy as we approach retirement (which means that Medicare will be burdened more than it would be with a better working-age health system)

- problems in the study itself. The numbers of people included in the study are not reported, and it seems clear that they manipulated the data extensively to get comparable populations. After so many medical research studies point in one direction of some issue and then have later studies come to other conclusions (confusing everybody - estrogen supplements for post-menopausal women, for example), it wouldn't be surprising if something was out of tilt in this study that might change the outcomes.

That said, I guess I agree (in my heart, like G.W. Bush on his trust of Putin) that our dog-eat-dog society does put a huge stress on everybody. The climb is hard and long, and the fall is all too easy and obvious.

Or perhaps it is just the stress of living with our national myth that hard work and playing by the rules will get you success, when it so obviously doesn't work that way for many people.

I'd still bet our health at 60 years old would be far better if we had universal availability of health care paid by a single payer with a fair distribution of costs among the recipients.

Posted by: JimPortlandOR | May 2, 2006 4:24:16 PM

I'd still bet our health at 60 years old would be far better if we had universal availability of health care paid by a single payer with a fair distribution of costs among the recipients.

I imagine so, both functionally, and because that would be one less damn thing to worry about.

Posted by: paperwight | May 2, 2006 4:36:06 PM

There have been tons of studies finding that your placement within an organization's hierarchy is an excellent determinant of your heart's health, with greater autonomy leading to better outcomes.

Tons of studies? Are you sure there aren't just a handful? Plus, what are you saying: That America somehow has fewer "organizations" proportionally, such that a greater percentage of the population sits in a lower position in organizational hierarchies? How would you measure something like that?

fresh fruits and vegetables are notoriously unavailable in low-income neighborhoods

Says who? Most low-income neighborhoods are in urban settings, right? Don't cities have grocery stores, Super Wal-Marts, etc., any more? It seems much more plausible to me that *rural* areas have more of a problem here -- if you're 30 miles from a grocery store, and the local crop is corn, you're going to have a hard time getting a lot of fresh produce.

Posted by: Thurmond | May 2, 2006 4:42:40 PM

1) Nope, I'm sure there are a ton. The relevance is that poor occupational position is bad for your health. Poor occupational position in a society even more intent on occupational success is worse.

2) Do some googling for the relevant studies. Large supermarkets and Wal-marts don't tend to enter areas of extreme poverty. Such pockets generally have to rely on convenience stores and other inadequate fill-ins for the shopping choices we take for granted. There's also interesting research on the relationship between the cost of produce (relative to income) and the weight of children.

Posted by: Ezra | May 2, 2006 4:51:04 PM

I've got some information on grocery stores and impoverished areas here.

Also, as regards stress levels, Mr. Shakes (recent British immigrant) comments on this with regularity. The comparative lack of vacation time is a big concern (it's much harder for him to get home and see his family and friends, for a start, than it would be for me if we had moved there), the limitation on paid sick leave is another (he goes into work ill here when he never would have in Britain, and gets sick more often because co-workers do the same), and then there's the stress of knowing that affordable healthcare is predicated on having a job--a worry he never had in Britain.

Posted by: Shakespeare's Sister | May 2, 2006 5:01:52 PM

Look, supermarkets respond to demand. I work in East Baltimore, which is one of the poorest urban areas in the US

There are no Walmarts or supermarket chains, but there are tons of mom/pop grocery stores.

These mom/pop stores operate on the same premise of capitalism that WalMart operates on. They stock what the public demands. If all the people in the rich white suburbs decided that they hated health food and only wanted to eat junk food, then Walmart would quickly cater to that demand.

So the reason that these stores dont stock good food is because the PUBLIC DOES NOT BUY GOOD FOOD. If they did, they would modify their food selection.

Posted by: joe blow | May 2, 2006 9:36:56 PM

The demand for fresh produce in poorer urban areas would have to be astronomical to make it worth grocers' while to both establish good sources for it and to absorb the costs of merchandising it (produce takes up a lot of square footage) and the inventory loss due to spoilage. Even in upscale urban markets, produce prices are astronomical IME compared to conventional suburban grocers'- it just costs more to bring it in, display it, throw it away at the appropriate time, etc., and obviously that's a riskier proposition for owners in poor neighborhoods than it is for, say, a Safeway manager. Plus, inventory control is a huge pain when not relying on bar codes on boxes.

Anyway, there are plenty of factors that contribute to a lack of fresh produce in certain urban neighborhoods other than demand. The demand problem also exists-- hell, I went out with a middle-class guy in college who could not remember ever eating a vegetable that hadn't come from a can-- but it's far from the only consideration in this economic equation. I'm middle class myself and balked at paying $3.89 a pound for grapes at an urban neighborhood market a few months ago... granted, it was winter, but it's not like grapes are generally in short supply in California at any time of the year. I could afford it in that instance, but it would definitely hurt if I had to pay that all of the time.

Posted by: latts | May 2, 2006 10:38:18 PM

Well, you can eat plenty of perfectly good vegetables and fruits that are either 1) canned or 2) frozen. It's ridiculous to suggest that because poor people in impoverished urban areas have problems finding fresh cilantro and heirloom tomatoes, therefore their only other options are to subsist on deep-fried Twinkies or something. The only reason that anyone in America eats junk food is because they choose to do so, not because healthy food is completely unavailable.


I'm sure there are a ton. The relevance is that poor occupational position is bad for your health. Poor occupational position in a society even more intent on occupational success is worse.

Cites, then? Or even a link to someone who is aware of the cites? I've heard of one (1) study to that effect from Britain. If there are "tons," I'd like to know about them.

Posted by: Thurmond | May 3, 2006 10:56:40 AM

Do some googleing around pyschological journals. The literature on the negative health benefits of inequality and lack of autonomy is voluminous.

And yeah, the problem with Kwik-e-marts is that they lack heirloom tomoatoes. YOu're not trying to be a parody here, are you?

Posted by: Ezra | May 3, 2006 11:02:44 AM

Do you honestly think there are very many people in America who have to shop for groceries at Kwik-e-marts? I.e., they are completely unable get to any sort of store that stocks canned spinach, applesauce, etc. OK, maybe you can come with a handful of crippled elderly people without cars, who live in poor neighborhoods, and who have no friends or relatives who can give them a ride to a grocery store, and therefore the best that they can do is hobble to the Kwik-e-mart once a month to get a few cans of Spaghetti-Os. But that's supposed to be the reason that Americans in general are less healthy than the British?

Posted by: Thurmond | May 3, 2006 11:20:54 AM

By the way, Ezra, are you aware of this paper?

Posted by: Thurmond | May 3, 2006 12:07:46 PM

"Stress could do it as well. I don't have data on this, but I'd guess that Americans, for a variety of reasons, are simply more anxious than the English, or Europeans in general. Stress is heavily connected to all the illnesses being mentioned, so if someone could dig up a cross-national comparison of anxiety, it would be worth looking into."

For what it is worth: from an immigrant's perspective who worked in his native Switzerland for 10 years before making the "jump" across the ocean: work culture is much more competitive here. In Europe you are supposed to be GOOD ENOUGH TO DO YOUR JOB PROPERLY. Here in the US you have to be BETTER THAN THE OTHER PERSON (which is much more important than the "good enough" part of the equation). Competition is certainly stress inducing (it also leads to resume embellishing and constant posturing).

P.S.: Somebody got angry at perceived suggestions that Americans are lazier than Europeans. They are not. But they are less productive (counting work habits and disregarding gizmos): we spend an awful lot of time in most US workplaces sitting in meetings talking about the work rather than just getting it done.

Posted by: zumbrunndbla | May 3, 2006 1:51:44 PM

No on eforces you to be a chouch potato or to smoke.

No-one enforces you to be a fuckwit, either.

I'd say that the British are as beholden to large supermarkets as Americans: indeed, Tesco's clout is one reason why Wal-Mart's takeover of Asda hasn't gone as planned. That said, Tesco and its competitors have also invested in smaller 'local' outlets with a decent range of produce. Food is more expensive in the UK, but fresh fruit and vegetables are comparatively cheaper, whereas the bargain aisles in American grocery stores are often for highly-processed goods.

I personally suspect that the sheer presence of the NHS has an impact in the UK, regardless of actual use. That's difficult to quantify, but it's remarkable how bad for one's health simply dealing with the American system can be. As Shakespeare's Sister says, you can take sick days in Britain without fear of termination, and can often take long leave of absence for treatment without having the additional worry of losing your job (and thus your health coverage).

Posted by: nick s | May 3, 2006 2:07:52 PM

"Do you honestly think there are very many people in America who have to shop for groceries at Kwik-e-marts?"

Well, yes. I attended a conference at USDA a couple of years ago where this was discussed. There are two factors at work; First, the chains stay out of poor neighborhoods and they have economies of scale that allow them to charge lower prices. Here's what one report says, "Small stores offer fewer food choices at higher prices than supermarkets. Reasons for differences in price, quality, and selection are varied, and are often tied to "economies of scale." For example, smaller stores cannot buy in volume, have limited access to large-scale wholesale produce, and often do not have the space or equipment needed to offer fresh produce on a daily basis. Studies have shown that prices at neighborhood markets can exceed those at chain supermarkets by as much as 76 percent."
SUPERMARKET ACCESS IN LOW-INCOME COMMUNITIES

Not only do poor people have less access to fresh fruits and vegetables, they have to pay more than higher-income people for whatever is available. It's not simply a matter of demand, upscale markets carry radicchio because higher-income people want and CAN AFFORD to pay for it. But even on fresh broccoli vs frozen, small grocers charge more because they have to and poor people buy what they can afford.

Second, yes, many people have to shop locally. I load my car with groceries and drive it home. Lots of people don't have cars and would either have to take a cab (very expensive) or haul large amounts of groceries long distances on public transportation very frequently.

Posted by: SteveH | May 3, 2006 3:44:48 PM

Lots of people don't have cars and would either have to take a cab (very expensive) or haul large amounts of groceries long distances on public transportation very frequently.

Indeed, and it's often not the highest priority of transit planners to route buses from neighborhoods of extreme poverty to upscale grocery stores.

Posted by: djw | May 4, 2006 9:39:56 AM

Lots of people don't have cars and would either have to take a cab (very expensive) or haul large amounts of groceries long distances on public transportation very frequently.

Indeed, and it's often not the highest priority of transit planners to route buses from neighborhoods of extreme poverty to upscale grocery stores.

Posted by: djw | May 4, 2006 9:39:58 AM

The web is full of information.You can get whatever you want and it is easy to learn online than to find that information in some book.

Posted by: steven davies | Aug 16, 2007 2:07:23 PM

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