hi all,
i guess i was surprized at these results, though i should not have been..
part of the reason i started the us/uk dialogue on achieving health equity in post deindustrial regions was the sense i had that the uk had much healthier health/social policies..
has anyone ever looked at comparing canadians and americans on health status? do you all in canada do anything like the behavioral risk factor survey we do in the US?
ken thompson
pittsburgh
-----Original Message-----
From: Social Determinants of Health on behalf of Dennis Raphael
Sent: Mon 5/15/2006 4:25 PM
To: [log in to unmask]
Subject: [SDOH] Slate Magazine...
Jolly Rogers
Why are British men healthier than American ones?
By Sydney Spiesel
Posted Monday, May 15, 2006, at 12:03 PM ET
Earlier this month, a study in the Journal of the American Medical
Association compared the health of a group of men in the United States
with that of a very similar group of men in England. The researchers found
a striking difference in the quality of health of the two populations?the
Americans were sicker and died younger than their British counterparts.
The results are anxiety-provoking because they can't easily be accounted
for?and because one of the study's authors, Dr. Michael Marmot of
University College, London, is a giant in the field.
Marmot's new study compared two populations, one in England and one in the
United States, totaling about 8,000 in all, with many similar
characteristics. All were male, non-Latino whites between the ages of 55
and 64. The researchers curbed diversity in this way in order to weed out
extraneous factors. But in each group, the men ranged widely in terms of
income and educational attainment. Thus, though the study primarily
compared the health consequences of living in the United States or living
in England, the researchers also looked at the degree to which
socioeconomic status contributed to the health differences they found.
Marmot and his co-authors?James Banks, Zoe Oldfield, and James P.
Smith?asked the research subjects to self-report rates of diabetes, high
blood pressure, heart disease, lung disease, stroke, and cancer. The
researchers found that American men were far sicker with these chronic
diseases than British men similar in age, ethnicity, and socioeconomic
status. When these two groups were compared, the American men were worse
off with respect to every disease the study included. Often, the
differences were striking: 12.5 percent of the American men reported that
they were diabetic, compared to 6.1 percent of the British men; the men in
the United States were 1.25 times as likely to report high blood pressure,
more than 1.5 times as likely to report heart disease, and 1.7 times as
likely to report cancer.
Could the difference have been one of interpretation?do American and
British men respectively exaggerate or underplay illness? To rule out this
possible weakness of self-reporting, Marmot's team considered studies that
examined lab test results, so they could objectively corroborate the
reports of the patients in their own study. The team found that, in
general, for both groups the level of self-reported illness and the
laboratory findings closely matched. (For instance, in England,
self-reporting of diabetes was 8 percent higher than diabetes confirmed by
laboratory testing, while in the United States, the self-reported rate was
11 percent higher.) So, both self-reporting and lab results suggest the
same thing: British men appear to be significantly less likely to suffer
from chronic disease than similar Americans.
There are many ways in which these results are not at all what one would
expect. For instance, the United States spends a great deal more on health
care than England does?2.4 times as much per capita. And other differences
like the terrible state of British dentistry also ought to weigh in
Americans' favor. It's long been suspected that dental and oral infections
play a role in promoting heart disease and possibly stroke. Tooth loss can
lead to poor nutrition and social isolation among the elderly, which
increase the risk for illness and early death.
So, how do we account for the apparent better health of Englishmen? This
study shows that the answer doesn't relate to race or ethnicity. The
researchers also showed that neither smoking (Brits and Americans smoke in
about equal numbers) nor overeating (Americans do this more than Brits)
nor heavy drinking (here the Brits have the edge) could account for the
difference. So what, then?
Perhaps the answer comes from Marmot's previous research. As a social
epidemiologist, Marmot's life's work has been seeking to understand the
social determinants of health?for example, the extent to which poverty and
inequality in the provision of health services leads to poor health and
lower life expectancy. (Answer: a lot. For example, just under one in
three children living in Sierra Leone will die before age 5, compared with
three in 1,000 children in Iceland. The difference is a hundredfold.)
Marmot's greatest contribution is probably the "social gradient"?the
notion that in any culture the rates of illness and mortality are strongly
affected by one's socioeconomic status. At any given age, the higher you
are on the social totem pole, the lower your likelihood of illness and the
longer you are likely to live. This prediction?that higher socioeconomic
status means better health and longer life?is equally true in cultures of
plenitude and cultures of material deprivation.
In 1967, Marmot began the first of his two Whitehall studies?
epidemiological research involving a total of about 28,000 British civil
servants. Again, the group was selected to weed out diversity: The
subjects were all male in one of the two studies, virtually all white, and
none had physically demanding or dangerous jobs. But they ranged in
employment grade from messengers and doorkeepers to the highest-level
administrators. Marmot and his team examined the relationship between
their employment levels and their rate of death from heart disease (in the
first Whitehall study) and from other kinds of chronic illness (in the
second study). The team found that men in the lowest civil-service
grade?doorkeepers, for example?were three times more likely to die of
heart trouble than, for example, administrators in the highest grade.
About a third of the difference in death rate could be attributed to
differences in risk: Lower-status workers were more likely to be obese,
smoke, and spend less leisure time on physical activity. But other factors
were clearly at work.
The factor that Marmot found played the greatest role was the lack of
control that people in lower status occupations felt over their jobs. This
factor was an important predictor for risk of heart disease and
depression. It was most acute when employees faced situations of high
stress but had little autonomy in dealing with them. Women who felt they
had little control over their lives at home also had an increased risk of
depression and of heart disease. The factors that correlated with good
health were a sense of being happy much of the time or of working in a
situation where the supervisor was perceived as acting in a fair or just
manner. High levels of both appeared to protect against heart disease.
Marmot's work counters the strong bias among physicians and public health
planners to understand the roots of illness and mortality in
straightforward biological and mechanical ways. The professionals often
want to blame dirty water, lack of calories, smoking, overeating, and poor
access to modern diagnostic and treatment methods. No doubt all these
problems contribute to illness and early death. But social factors also
directly affect health, and not just through the obvious pathway from
poverty to limited access to food or clean water or good medical care.
Among British white-collar workers, good health and high status are
intimately related, even in a health-care system that gives everyone
access to good medical care. The same relationship holds true in America
and in most of the rest of the world.
We don't know yet precisely how a sense of low status or lack of control
activates the biological mechanisms that cause heart trouble or other
chronic disease, but there is clearly some powerful interplay. The
critical point may simply be that unrelieved stress and anxiety are
intrinsically bad for your health. Which forces us to ask the question: Is
life more stressful in the United States than it is in England? Perhaps
Marmot's next study will venture an answer.
Related in Slate
--------------------------------------------------------------------------------
While Brits may be healthier than Americans, fat Americans may actually
help increase the size of the American economy. In 2001, Steven E.
Landsburg tried to find economic reasons driving America's burgeoning
weight problem. The title of the best-selling book aside, French women do
get fat, Kate Taylor found in 2005.
Sydney Spiesel is a pediatrician in Woodbridge, Conn., and associate
clinical professor of pediatrics at Yale University's School of Medicine.
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