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    Wednesday, May 03, 2006

    Healthier Than Thou: A study in today's JAMA says that the British are healthier than Americans:

    Middle-aged, white Americans are much sicker than their counterparts in England, startling new research shows, despite U.S. health care spending per person that's more than double what England spends.

    A higher rate of Americans tested positive for diabetes and heart disease than the English. Americans also self-reported more diabetes, heart attacks, strokes, lung disease and cancer.

    The gap between the countries holds true for educated and uneducated, rich and poor.

    "At every point in the social hierarchy there is more illness in the United States than in England and the differences are really dramatic," said study co-author Dr. Michael Marmot, an epidemiologist at University College London in England.

    The study limited itself to non-Hispanic white Americans and non-Asian white Englishmen. The disparity does not seem to be due to access to care:

    But richer Americans' health status resembled the health of the low-income British.

    And in fact, in their paper, the authors say that access to insurance seemed to have little impact on the differences.

    However, there is a difference between the two populations that is being overlooked - white people are not ethnically homogenous. Most white people in England might share the same ethnicity, but white people in America can not be assumed to share it. Not with Englishman, and not with each other.

    White people in America are not all Anglo-Saxons. Even those named Smith or Kerry have a varied genetic background. We really are a melting pot of races. There are a lot of families in this country who may look white, but who carry a hodge-podge of different ethnic populations in their genes.

    posted by Sydney on 5/03/2006 08:57:00 AM 15 comments


    Could the difference be one of perception? I would have preferred a study using objective criteria rather than personal opinions.

    By Anonymous EM, at 1:05 PM  

    I would agree with EM. Many doctors diagnose patients with a medical condition in order to create the need for continued visits and testing. We are also a country where we are all special and every personal problem must be blamed on someone or something other than ourselves. Combine this with a desire to be perfect and a medical system where there is no relationship between cost and fees paid and I think the outcome of this study is not that surprising.

    Steve Lucas

    By Anonymous Anonymous, at 1:39 PM  

    I think there is a little denial going on here--I have heard reason after reasuon on study after study which indicated that we as a nation are not as healthy as those with National Health Plans, particularly the NHS--of course the NHS is flawed but......As some one who spends substantial time in the UK I will assert this--their primary and preventive care is better than ours (access, patient education, nursing support, access to medications, home visits etc.) Their specialty care is inferior. Take a hard look at this study, though perhaps flawed. And then take a hard look at the health of our citizens. Go to the UK, people walk more, portions are smaller, primary care is more accessible. Thanks Frank

    By Anonymous Anonymous, at 9:47 PM  

    uhh . . . methodological weakness? at least from the article, this study is based on SELF_REPORTED illness. Maybe the Brits are just more reticent about their illnesses.

    By Anonymous Anonymous, at 10:15 PM  

    English (the study was of England, not all of the UK) are more reticent than Americans so that might explain some of the difference in self-described health status. And what about the childhood experiences of the two groups. There was a vast difference in living standards between England and the US in the 1950s. Perhaps English kids in the 1950s walked more and ate less than American kids at the same time. Perhaps these childhood experiences shaped subsequent personal habits. I also wonder about climate. In most of the US climate is much more extreme, hotter and colder, wetter and drier, than in England. Could there be some subtle impact on the health of the population?

    By Blogger cokaygne, at 6:33 AM  

    I don't think pointing to genetic diversity is a reason to bring up poorer health. In genetics classes one learns that crosses exhibit greater growth and better health due to the heterozgocity (forgive my spelling can't remember exact spelling) and hybrid vigor. Amercans being a mixture of backgrounds should be healthier as a people not less so. Environmentally we are erasing the advantages of being so diverse.

    By Anonymous Dara, at 10:40 AM  

    Oh for heavens sake--I have read blog after blog and response after response on this issue. I have looked at WHO stats, stats by other independent groups, infant mortality, morbidity, life span, deaths by different diseases, missed worked days etc. Data, whether objective or subjective consistently suggests those living in Europe (including the UK and England) are usually healthier than we are. And I have heard almost every reason to explain that away--different ways of measuring/counting data, diversity of the US population, cutural and life syle issues. While all of that may be partially acurate is it not possible that our way of funding (ignoring) public health, providing employment based insurance, limiting medicaid services/benefits, providing limited access to preventive care and education, etc. is a problem. I will always acknowledge that most specialty care is much better here. But try and appreciate the very real differences in access and payment for primary care. It is possible that somethings we just do not do as well as others. England is not a medical Shangri la but neither is it hell hole of rationed and mismanged care. In the primary care trusts in which I have spent tme there is an incredible emphasis on patient involvment, personal relationships, extensive nursing and educational support and a warmth that you just do not see in some of our corporate practices and ERs. And just imagine what a relief it is for folks to not worry about every test ordered, the cost of medicine, the cost of the next follow up and if they lose their job the insulin , lipitor, lexapro and bloodpressure medicine does not become a major medical and financial crisis. OK, I am done Thanks if you read all the way through this

    By Anonymous Frank, at 12:13 AM  

    I noticed this in the article:
    "A higher rate of Americans tested positive for diabetes and heart disease than the English. Americans also self-reported more diabetes, heart attacks, strokes, lung disease and cancer."

    Self reporting bias is a typical error that trips up many studies.

    There's also the classic problem of early diagnosis seeming to help outcomes, but the reality is that discovering a disease 2 years earlier because of advanced testing falsely makes a big difference to 5-year survival rates.

    I'd much prefer a study of outcomes, i.e. age adjusted cancer deaths.

    By Blogger Frank Borger, at 9:18 AM  

    These two links lay out age adjusted cancer deaths in many different countries. No matter how you cut it the US does not come out particularly well--obviously many are realted to cultural differences, rate of smoking, diet etc. In the ones I looked at the UK has a better profile than the US.


    By Anonymous Frank A, at 12:07 PM  

    BTW, The second link is better -scroll down and you will find links to various tables--I believe 11.2 and 11.3 are summary of international data

    By Anonymous frank A, at 12:10 PM  

    There's also the classic problem of early diagnosis seeming to help outcomes, but the reality is that discovering a disease 2 years earlier because of advanced testing falsely makes a big difference to 5-year survival rates.
    Not only that, but it also inflates incidence of the desease since the incidence increases with age, so for example a screened 40 year old has as much chance of being diagnosed as a non-screened 42 year old. Actually higher chance because a) tumors grow with different speed, you may detect some more than 2 years earlier b) there is overdiagnosis. So screening results in higher number of people diagnosed the desease, but significantly higher survival percentage (even if some of these survivers would've never been diagnosed without screening). All of the advertising on TV seldom mention that if you get screened you have a much higher chance of being diagnosed with the desease in the first place.

    Back to the subject, why do so many think that the difference between British and Americans has all to do with healthcare. From what I understand even rich Americans that have access to the best health care fared worth than the poorest British.

    So maybe it is our lifestyle? Like the fact that Europeans work less hours and have 5+ weeks vacation? Our whole lifestyle is much more stressful. They also walk more and eat less. I know they considered obesity, but there are thin people who sit at home and watch TV and thin people who walk.

    By Anonymous diora, at 8:30 PM  

    diora, excllent points--I had never really considered the mpact of early dx.etc. In my heart I think life style and cultural factors are very significant in explaining the differences. Given the amount of time I spend in the UK there clearly is a difference in such thinks as walking, holidays, size of food portions, access for all people to alternative health practices (not advocating them except as they promote relaxation, nutrition and self confidence). I don't think you can underestimte the sense of security that the NHS provides since it is not tied to employment--let's face it for (10s)millions of americans there is a chronic or acute sesne of desperation re: access to care and medication.
    What much of this does not address is whether the differential in spending really raises the quality of life for most people. I would posit that it does not but I have no idea how to prove it. Thanks for your response

    By Anonymous Frank A, at 11:36 AM  

    Frank, thanks.
    To be honest much of what I told about the impact of early detection on incidence I learned from "Should I be tested for cancer? Maybe not and here is why." by Gilbert Welch, MD - a really excellent book. I had known about overdiagnosis before, but most of the remaining stuff I learned from this book.
    You are right about the sense of security. I have pretty high salary, but I am still worried about medical care if I loose my job or when I get older and retire (not that I plan to do it while they want to keep me - specifically because of medical). Sure I have savings, but they can easily be wiped out with one serious illness. Of course, there are other reasons I don't want to loose my job, but the fear of loosing medical is one of the major reasons.
    I'd imagine that for lower income family, the level of stress is much higher.

    By Anonymous diora, at 5:59 PM  

    I do think some of this disparity does have to do with the general overattention we as a country pay to health, or rather, disease. So, the self-reporting is bound to make a difference. However, as an American visiting the UK, I found the main difference seems to be lifestyle. We don't walk anywhere- the Brits seem to walk everywhere. They have compact cities and great public transportation- we have a giant continent and cars. I'd say compare England to Boston in terms of health and see what the results are. Food is also extremely cheap here. I think the health care systems have very little to do with it. They're both adequate to provide the vast majority of preventable deaths. I think Frank is right on his assessment of the NHS. Though I really do think the hospitals are pretty bad, compared to the average community hospital here. And I'm sure my little "tour" group got to see the very best. Of course, since the NHS is trying to privatize some of the care there, I guess they must think we're not doing such a terrible job, either...

    By Anonymous Dani, at 10:08 PM  

    Great typo! I meant that both systems could AVERT the vast majority of preventable deaths! Really, though, ever since I got back from the UK, whenever I sit through another Leapfrog presentation I always think what a field day they could have there. Which makes one wonder, of course, how valid these concepts of quality are, since people are not dropping like flies in England, whereas healthcare in the US, as everyone knows, actually kills 100,000 people a year, right? I have a hard time reconciling all of these facts. Just last week I attended a talk where someone from the Leapfrog Group admitted they couldn't show yet any improvement in morbidity and mortality in institutions that had adopted their recommendations. Great, just great- but that's a topic for another day.

    By Anonymous Dani, at 10:24 PM  

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