This post was written by Maggie Mahar and Niko Karvounis

Life expectancy is a pretty simple concept: it’s an estimation of how long the average person lives. Anyone can understand that. So how is this for a compelling data point: if you look at life expectancy in nations around the globe, you’ll find that over the past 20 years, the U.S. has sunk from ranking  No. 11 to  ranking No. 42. In other words, a baby born in 2004 in any one of 41 other countries can expect to live longer than his or her American counterpart.

This may come as a surprise. Sure, we all know the health care system in the U.S. is broken, but life expectancy isn’t just tied to medicine—it’s also related to quality of life in a larger sense. (I can live in a nation with the best health care system in the world, but if it’s in the throes of civil war, my life expectancy will be short). As we all know, the American standard of living is the envy of the world.  After all, we’re the richest country on the globe. So what gives?

While some of us are rich, the average American is not.  And while the rich are living longer, the poor are living shorter.  Factor in the profit motive that drives U.S. healthcare, and you will begin to understand why American medicine has done little to heal the gap between rich and poor.  Over the past twenty-five years, we have poured money into healthcare, but have paid relatively little attention to public health.

This may seem a bold claim, but last month the Congressional Budget Office (CBO) issued a report that provides the numbers:  “In 1980,” the CBO found that “life expectancy at birth was 2.8 years more for the highest socioeconomic group than for the lowest. By 2000, that gap had risen to 4.5 years.”

The report notes that “the 1.7-year increase in the gap” between socioeconomic groups “amounts to more than half of the increase in overall average life expectancy at birth between 1980 and 2000.” In other words, even though the average life expectancy has increased in the U.S., it has grown more slowly because of widening socioeconomic disparities.

Citizens of countries that don’t tolerate as much inequality enjoy
longer lives. According to numbers from the Census Bureau and the
National Center for Health Statistics, a baby born in the United States
in 2004 will live an average of 77.9 years. In the U.K., an ’04 baby
can expect to live 78.7 years; in Germany, 79 years; in Norway, 79.7
years; in Canada, 80.3 years; in Australia, Sweden, and Switzerland,
80.6 years; and in Japan, a newborn can expect to live 81. 4 years.

Somehow or other, when they hear these figures, most Americans just
shrug. Indeed, “it is remarkable how complacent the public and the
medical profession are in their acceptance of” our low ranking when it
comes to life expectancy, “especially in light of trends in national
spending on health, ” Dr. Steven Schroeder, a professor in the
Department of Medicine at the University of California, San Francisco wrote in the New England Journal of Medicine last year.

“One reason for the complacency may be the rationalization that the
United States is more ethnically heterogeneous than the nations at the
top of the rankings, such as Japan, Switzerland, and Iceland. But,”
Schroeder pointed out, “even when comparisons are limited to white
Americans, our performance is dismal (see table below) And even if the
health status of white Americans matched that in the leading nations,
it would still be incumbent on us to improve the health of the entire
nation.”

In the OECD countries that outrank us, the gaps between rich and
poor are not as great and, not coincidentally, all have universal
health insurance. (As Maggie wrote in an earlier post
on Health Beat, in countries that are mainly middle-class, there tends
to be more social solidarity. People identify with each other, and are
more willing to pool their resources to pay for healthcare for
everyone.)

But having access to health care is only a small part of health.
Schroeder identifies five factors that determine health and longevity:
“social circumstances, genetics, environmental exposures, behavioral
patterns and health care.”  Of these five, when “it comes to reducing
early deaths,” he points out, “medical care has a relatively minor
role.”  Indeed, “inadequate health care accounts for only 10% of
premature deaths, yet it receives by far the greatest share of
resources and attention.”

Socioeconomic status is the strongest predictor of health, above and
beyond access to health care. This is because socioeconomic status
includes access to health care and a variety of other factors. Even if
when the poor have insurance, they are less likely to have access to
cutting-edge medical discoveries; they’re more likely to smoke, more
likely to be obese, more likely to live in unsafe or unhealthy
environments. They also tend to be less educated, meaning that they are
less able to manage chronic diseases.

These facts are reflected in life expectancy. African-Americans are
more likely to live in poverty than other Americans: as a result, black
men can expect to live six years less than white men, and black women
four years less than white women.  Education, another critical
component of socioeconomic status, also contributes to the story. The
CBO reports that “the gap in life expectancy at age 25 between
individuals with a high school education or less and individuals with
any college education increased by about 30 percent” from 1990 to 2000.
“The gap widened because of increases in life expectancy for the better
educated group,” the report notes. “Life expectancy for those with less
education did not increase over that period.”

This trend is clear: since 1980, affluent members of society have made
gains while the have-nots have, at best, run in place, and, at worst,
lost ground. Another recent study published in the PLoS Medicine
takes a broader look at the problem by going all the way back to 1960
to see at how life expectancies have differed in U.S. counties.
(Counties were used because they are the smallest geographic units for
which death rates are collected, thus allowing for a precise comparison
of subgroups). The authors, who hail from Harvard, UCSF, and the
University of Washington, discovered that “beginning in the early 1980s
and continuing through 1999, those who were already disadvantaged did
not benefit from the gains in life expectancy experienced by the
advantaged, and some became even worse off.”

1980 was a watershed year. Indeed, the study reports that from 1960 to
1980, life expectancy increased everywhere. But “beginning in the early
1980s the differences in death rates among/across different counties
began to increase. The worst-off counties no longer experienced a fall
in death rates, and in a substantial number of counties, mortality
actually increased, especially for women…”

So what was so special—or rather, harmful—about the 1980s?

1980 was the year that a conservative agenda firmly replaced the “War
on Poverty” that LBJ had begun in the 1960s. For the next 28 years, the
trend would continue as corporate welfare and tax cuts for the wealthy
replaced programs for the poor and middle-class.

As the authors of a 2006 PLoS Medicine
study note, “in the 1980s there was a general cutting back of welfare
state provisions in America, which included cuts to public health and
antipoverty programs, tax relief for the wealthy, and worsening
inequity in the access to and quality of health care.” By contrast, in
the 1960s, “civil rights legislation and the establishment of Medicare
set out to reduce socioeconomic and racial/ethnic inequalities and
improve access to health care.”

But after 1980, the ’06 PLoS Medicine study shows that rates of
premature mortality across socioeconomic groups began to diverge,
helping to roll back the gains of the 1960s and 1970s. In a stunning
conclusion, the study’s authors reported that “if all people in the US
population experienced the same health gains as the most advantaged
[i.e. whites in the highest income group] without the problems of the
1980s,  “14 percent of the premature deaths among whites and 30 percent
of the premature deaths among people of color would have been
prevented.”

In sum, the stronger social safety net of the 1960s helped to increase
longevity for all Americans; its erosion in the 1980s created a
discrepancy between the haves and the have-nots. Indeed, given that
socioeconomic status is the strongest predictor of health, it’s
noteworthy that the lowest quintile of earners in the U.S. saw its
income fall by 15 percent between 1979 and 1993, while the highest 20
percent saw their income grow by 18 percent over this same period. The
poverty rate in the U.S. was cut nearly in half tin the 1960s; from
1980 to 1989, it inched down by just one percentage point.

Clearly, the decline of American longevity is related to an increase in
American inequality. But it would be short-sighted to stop our analysis
here. It’s also worth asking, where have we been spending our health
care dollars?

“To the extent that the United States has a health strategy, its focus
is on the development of new medical technologies and support for basic
biomedical research,” Schroeder observes. “We already lead the world in
the per capita use of most diagnostic and therapeutic medical
technologies, and we have recently doubled the budget for the National
Institutes of Health. But these popular achievements are unlikely to
improve our relative performance” when it comes to longevity.

If we want to cut the number of premature deaths, we might put more
emphasis on smoking cessation clinics. “Smoking causes 440,000 deaths a
year in the United States,” notes Schroeder,
who directs the Smoking Cessation Leadership Center at UCSF. “Smoking
shortens smokers’ lives by 10 to 15 years, and those last few years can
be a miserable combination of severe breathlessness and pain.”  44.5
million Americans still smoke.  “Smoking among pregnant women is a
major contributor to premature births and infant mortality. Smoking is
increasingly concentrated in the lower socioeconomic classes and among
those with mental illness or problems with substance abuse,” Schroeder
explains.  “Understanding why they smoke and how to help them quit
should be a key national research priority. Given the effects of
smoking on health, the relative inattention to tobacco by those federal
and state agencies charged with protecting the public health is
baffling and disappointing.”

Kaiser Permanente of northern California has shown that it can be done.
When Kaiser implemented a multisystem approach to help smokers quit,
Schroeder reports that “the smoking rate dropped from 12.2% to 9.2% in
just 3 years. Of the current 44.5 million smokers, 70% claim they would
like to quit. Assuming that one half of those 31 million potential
nonsmokers will die because of smoking, that translates into 15.5
million potentially preventable premature deaths. Merely increasing the
baseline quit rate from the current 2.5% of smokers to 10% — a rate
seen in placebo groups in most published trials of the new cessation
drugs — would prevent 1,170,000 premature deaths. No other medical or
public health intervention approaches this degree of impact. And we
already have the tools to accomplish it.”

The poor also are more likely to be obese, “in part because of
inadequate local food choices and recreational opportunities,” says
Schroeder.  Fattening foods are cheaper than fresh fruit, vegetables
and fish, particularly if you are shopping in inner cities. Gyms are
too expensive for low-income families; exercising outdoors can be
dangerous, and in inner cities, public schools often lack playgrounds
and gymnasiums.

“Psychosocial stress” also leads poorer Americans to engage in “other
behaviors that reduce life expectancy such as drug use and alcoholism,”
Schroeder notes. And even when they avoid these behaviors, “ people in
lower classes are less healthy and die earlier than others.” A polluted
environment, combined with uncertainty and worry, takes a toll.

Rather than focusing solely on medicine and medical care, Schroeder is
committed to strategies that would improve public health. In the U.S.
there is a sharp division between the two, with public health always
the poor relation.

“It’s harder, because there’s stigma attached to it,” Schroeder explains.
“There’s a sense among some that if a large portion of the nation’s
population is obese or sedentary, drinks or smokes too much, or uses
illegal drugs, that’s their own fault or their own business.”

“We often get a double-standard question,”  he continues.  “Critics who
object to investing more in programs that could help drug addicts and
alcoholics, ask: Well, don’t many of these people relapse?

“Yes, of course,” Schroeder responds. “But is it worth treating
pancreatic cancer, which has a 5 percent survival rate, at most? Yes.
So the odds of successfully treating drug abuse or alcoholism are
actually better than in many of the serious illnesses that society,
without question, wants us to treat.”

Schroeder is right: When allocating health care dollars, we eagerly
spend far more on cutting-edge drugs that might give a cancer patient
an extra five months than on drug rehab clinics that could make the
difference between dying at 28 and living to 68.

Again, 1980 marks a turning point, notes Marcia Angell, a Senior Lecturer at Harvard Medical School and the former editor-in-chief of NEJM.
“Between 1960 and 1980, “prescription drug sales were fairly static as
a percent of US gross domestic product, but from 1980 to 2000, they
tripled.”

This wasn’t just happenstance, says Angell. A major catalyst of the
pharma boom was the Bayh-Dole Act of 1980, a law that “enabled
universities and small businesses to patent discoveries emanating from
research sponsored by the National Institutes of Health, the major
distributor of tax dollars for medical research, and then to grant
exclusive licenses to drug companies.” In other words, the Bayh-Dole
Act commoditized medical research.

Before 1980, “taxpayer-financed discoveries were in the public domain,
available to any company that wanted to use them,” says Angell. As a
result, long-term, collaborative tinkering could help to create new and
effective medications. But Bayh-Dole made research proprietary and
profitable.

After Bayh-Dole, drug research seemed to be less about making real
medical progress, and more about doing the bare minimum to create a
patentable product. And so began the age of me-too drugs, which do
little to promote health and instead exist to increase market share. In
a Boston Globe op-ed
last year, Angell observed that, “according to FDA classifications,
fully 80 percent of drugs that entered the market during this decade
are unlikely to be better than existing ones for the same condition.”

Why are we willing to devote 13 or 14 percent of our $2.2 trillion
health care budget to prescription drugs, while refusing to help the quarter of the population that still smokes?

“It is arguable that the status quo is an accurate expression of the national political will — a relentless search for better health among the middle and upper classes,” Schroeder acknowledges.
[our emphasis]  “This pursuit is also evident in how we consistently
outspend all other countries in the use of alternative medicines and
cosmetic surgeries and in how frequently health ‘cures’ and ‘scares’
are featured in the popular media. The result is that only when the
middle class feels threatened by external menaces (e.g., secondhand
tobacco smoke, bioterrorism, and airplane exposure to
multidrug-resistant tuberculosis) will it embrace public health
measures. In contrast, our investment in improving population health —
whether judged on the basis of support for research, insurance
coverage, or government-sponsored public health activities — is
anemic.”

We’re hopeful that this will change. In going to medical conferences
over the past year, Maggie has met an impressive number of very, very
bright 20-somethings who are devoting their careers to public health.
And they understand that “medicine” and “public health” are not
separate disciplines.