Cover Story

How long can you expect to keep blowing out the candles on your birthday cake? American men and women enjoy a life expectancy at birth of almost 76 and 81 years, respectively. That's not bad, globally speaking, but not as impressive as the life expectancy for Swiss men, at more than 79 years, or Japanese women, at almost 86.

In fact, U.S. life expectancy ranks 16th for women and dead last for men among the 17 "peer countries" evaluated in a National Academies report released this year by the National Research Council and the Institute of Medicine, called U.S. Health in International Perspective: Shorter Lives, Poorer Health.

Americans not only die sooner, but also suffer higher rates of injury and disease than their peers in other high-income countries, the report found.

The reasons for America's grim prognosis are many and complex, experts say. It's clear, though, that social and economic inequality is an important factor. And all Americans, rich and poor, are suffering the consequences.

"We knew that Americans had poorer health than people in other countries, but the surprise for us was how bad the problem is," says Steven H. Woolf, MD, a professor of family medicine at Virginia Commonwealth University and chair of the panel that produced the report. "The problem has been going on for many years and has been getting worse."

Richer, poorer

The United States is among the richest nations in the world. That prosperity doesn't translate to better health, however. Where the U.S. health disadvantage is concerned, few segments of the population are spared. The Shorter Lives, Poorer Health report found that just about all Americans — from birth to age 75, with low incomes and high, with or without health insurance, with or without college educations — are worse off than people in other wealthy countries, including Australia, Canada, Japan and most of Western Europe.

Specifically, Woolf and his colleagues on the report panel found that U.S. health falls short in nine broad areas: adverse birth outcomes (including infant mortality and low birth weight); injuries and homicides (including deaths from car crashes); sexually transmitted diseases; HIV and AIDS; drug- and alcohol-related deaths; obesity and diabetes; heart disease; lung disease; and disability from arthritis and other physical limitations.

"While some [Americans] might be aware that our health-care system has some issues, they probably think their health is still very good. Our findings are the exact opposite," says Woolf. He and his co-authors note that compared with other high-income countries, the U.S. health-care system is more fragmented, and more Americans are uninsured, often finding health care to be inaccessible or unaffordable.

But health care is only one piece of the puzzle. "Health care is estimated to account for about 10 percent of premature mortality," says Nancy Adler, PhD, director of the Center for Health and Community at the University of California, San Francisco. "Health care matters, but it's a very small part of what's going on."

Individual behaviors are also a cause of concern, the report notes. Compared with our peers elsewhere in the world, Americans consume more calories, experience more violent deaths, misuse more prescription and illicit drugs, and have more alcohol-related traffic accidents.

We also have higher rates of poverty and income inequality than most other wealthy countries, which undermines our health in a multitude of ways. Among the 17 countries evaluated in the Shorter Lives, Poorer Health report, the United States had the highest rates of poverty and child poverty, according to the Organisation for Economic Co-operation and Development (OECD). More than one in five American children live below the federal poverty level, making them more likely to suffer from asthma and obesity and have poorer nutrition, less access to health care and lower vaccination rates.

Adults with lower socioeconomic status are more likely to experience high blood pressure, obesity, heart disease, infectious diseases and mental illness, according to a report by Adler and colleagues for the John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health. For people just scraping by with paying the rent or finding a ride to work, taking a trip to the gym or to the doctor for a check-up can seem like a luxury, says Linda Gallo, PhD, a psychologist at the Institute for Behavioral and Community Health at San Diego State University.

"With life's competing crises, those demands take precedence over health behaviors," she says.

When considering the American health disadvantage, the picture changes dramatically depending on whom you look at, says Hector González, PhD, a behavioral health psychologist at Wayne State University. In 2012, homicide was the leading cause of death for young African-Americans and the second-leading cause for young Latinos, the CDC reports. "Violent deaths seem to be something that is part of the black experience, and part of the Latino experience, too," he says.

If we're concerned about America's position in the global health rankings, González says, these are the groups we need to help most. "If we could do something about these terrible disadvantages, our life expectancy would go up," he says.

The power of stress

People living at the low end of the socioeconomic spectrum may be most affected by health inequalities, but poorer health doesn't exist only among the poor. "Just having money in your pockets doesn't make you healthier," says Adler.

The National Academies report noted that even Americans who are insured, college-educated, with higher incomes and healthy behaviors are worse off than similar groups in other countries.

What accounts for this difference? Richard Wilkinson, PhD, a social epidemiologist at the University of Nottingham Medical School, says it's the inequality itself. In decades of research, Wilkinson has shown that societies with greater inequality suffer more health and social problems. People in more egalitarian societies live longer, experience less violence, have lower rates of obesity and teen pregnancy, are less likely to use illicit drugs and enjoy better mental health than their counterparts in countries with a wide divide between rich and poor, he and his colleagues have found. And children in more equal societies score higher on the UNICEF Index of Child Wellbeing, which includes factors such as immunization rates, deaths from accidents, alcohol and tobacco use and educational success.

In America, the gap between the haves and have-nots is wide and getting wider. Since the 1970s, inequality has risen sharply. The richest 1 percent of Americans made 9 percent of the total pre-tax income in 1970, compared with 19.8 percent in 2011. "The U.S. is one of the most unequal of the rich, developed countries, and it suffers so many of the consequences," Wilkinson says.

Inequality seems to do its dirty work through the biology of chronic stress, says Wilkinson. Acute stress evolved for good reason — a racing heart and heightened alertness came in handy when our savannah ancestors wanted to avoid being eaten by a lion. But when the fight-or-flight feeling persists for hours or days, the immune system is down-regulated, tissue repair and growth slow down, and reproductive functions are put on hold. "All those things don't matter in an emergency, but you pay the cost if you go on feeling stressed for weeks and months and years," he says.

In unequal societies, he says, competition is fierce and we worry about our place in the pecking order. Often that translates to a constant, low-level anxiety. "We all become more twitchy about how we are seen and judged," he says, and social contact becomes increasingly trying. "People trust each other less and community life weakens. Inequality affects the whole social fabric."

Unfortunately, Americans are plenty familiar with stress, as APA's annual Stress in America survey shows. Last year, 20 percent of those surveyed reported experiencing extreme stress, and 35 percent of respondents said their stress increased in the past year. Just 37 percent of Americans feel they're doing a very good job managing their stress levels.

Closing the gap

What can be done to shrink America's health disadvantage? Top-down policy changes are an obvious way to enact broad change. "We got to this situation of inequality because of economic and social policies," Adler says. "So policies that could reduce inequality would in fact promote health."

Wilkinson believes such policies should aim to close the gap between the rich and the poor. "We've become more unequal because top incomes have run away from the rest of us," he says. One way to address the disparity is by increasing taxes for top incomes, but that's not the only way to do it, he adds. He also supports other measures that keep runaway incomes in check, such as establishing employee-owned companies and requiring employee representatives to sit on company boards. The latter practice is common in many European companies, he says, and helps close the salary gap between the people in the corner offices and those in the cubicles below.

Of course, the status quo is notoriously difficult to change. Many entrenched U.S. policies are in fact at odds with our well-being, Gallo says. Influential interest groups fight sex education in schools, block efforts at gun-control legislation and give the food industry power to market unhealthy foods. "In the U.S., there's strong political will to maintain an environment that will perpetuate these unhealthy behaviors," she says.

Put another way, says Adler, "If we wait for [broad public-policy change], we're going to have a lot of unnecessary suffering."

In the meantime, psychologists are well positioned to help individuals and communities get healthier. Notably, behavior plays a major role in nearly all of the nine health domains singled out by the National Academies report. "These are behavioral factors related to health, and these are things that can be changed," notes González.

One of the best places to focus efforts, many experts say, is early childhood. "Putting our resources on early life is probably the most important thing we can do because it has ramifications across the whole life course," says Adler, who's studying an intervention that involves stress management and mindfulness for low-income, overweight pregnant women. "Babies who are born to low-socioeconomic-status moms, from the moment of birth, are on more adverse trajectories," says Adler. Exposure to stress in utero seems to make them more reactive to stressors in older age. "Often you don't see the diseases until later in life, but the seeds may have been planted in childhood," she says.

Early education is another good target. Kids from families with fewer resources often start school a step behind, setting them on a negative path throughout their lives. Universal preschool may help them start out on a level playing field, Adler says.

Preschool is just a start. Our entire education system should improve, too, says Gallo. In general, people with better educations exhibit healthier behaviors and have better access to health care. But the United States is falling behind in the classroom. Compared with those in other nations, graduating U.S. students in 2011 ranked 17th for reading proficiency and 32nd for math (Globally Challenged: Are U.S. Students Ready to Compete? 2011). "We haven't kept pace," Gallo says.

Changes to the health-care system could also raise the grade on our national health report card. The U.S. health-care system is excellent for the elderly, Adler says. The report, Shorter Lives, Poorer Health, found that Americans have higher survival after age 75 than their contemporaries in other wealthy countries. The United States also has lower mortality from stroke and cancer, illnesses that disproportionately affect the elderly. But for younger Americans, the system is fragmented and not particularly focused on preventive care.

"We've put so much of our resources into high-tech, dramatic, end-of-life care, and less on primary care, prevention and early life," says Adler.

Raising awareness

Woolf says he and his colleagues on the National Academies panel went into the project with a goal of making recommendations for researchers. But they came away feeling a need to educate the general public as well. "Our sense was that most Americans are not aware of this problem," he says.

Gradually, though, people are getting the message. The financial crisis and the Occupy Movement, for example, demonstrate that "a growing minority of people is angered by these issues," Wilkinson says. "That's a start, but it will take a long time to put right."

Ultimately, Woolf and his colleagues hope their report will stimulate a national discussion about the state of our country's vigor.

"A lot of the problems that are responsible for the health disadvantage are difficult to address without some difficult choices," he says. "We need to make a decision about whether we want to just accept the health disadvantage, or to make some compromises so that our kids can live longer lives."

Kirsten Weir is a writer in Minneapolis.