Sick America

Middle-aged Americans are sicker than English ones

A heavyweight study published in JAMA (“Disease and Disadvantage in the United States and in England”, Michael Marmot et al.) has found that

“Americans are much sicker than the English.”

It covered large samples of white middle-aged people enrolled in longitudinal studies in both countries. For once, England is the exact term; unhealthy Scotland and healthy Wales now run their own parts of the NHS. The design makes the USA look better than it is; the omission of the Scots is outweighed by that of African-Americans.

I’ve turned the key findings into charts.

This one (from Marmot’s table 1) shows the self-reported incidence of the major diseases:


There’s little inter-country difference between men and women. In both countries, disease rates fall with income and education, more steeply in the US as you would expect.

To cover for subjective biases in the self-reporting, Marmot also looked at various objective clinical indicators for diabetes and heart disease; this is from his Table 4. The USA only does well on cholesterol:


Disregard the usual “balanced” newspaper reporting that gives equal weight to a major piece of research and off-the-cuff objections that it has already anticipated. You have to take this as fact. So why, when Americans spend twice as much on health care?

Surprisingly, the authors discount access to health insurance, as the gap with England still holds for well-off and presumably fully insured Americans. (This is not an argument against universal insurance, which is essentially a question of justice within the USA.) They find the risk factor of tobacco is roughly equal, and greater American obesity and English drinking do not account for much of the difference in disease. (Update: following a comment, I corrected a mistake here on alcohol.)

Explanations that are still possible: childhood experience – English children of my postwar generation had a fairly spartan upbringing, walked to school, etc; other lifestyle factors like exercise and Coke; more competent or less compliant doctors; it’s a purely temporary advantage as the English have also become fatties swilling junk food and sodas in front of the telly or computer.

Author: James Wimberley

James Wimberley (b. 1946, an Englishman raised in the Channel Islands. three adult children) is a former career international bureaucrat with the Council of Europe in Strasbourg. His main achievements there were the Lisbon Convention on recognition of qualifications and the Kosovo law on school education. He retired in 2006 to a little white house in Andalucia, His first wife Patricia Morris died in 2009 after a long illness. He remarried in 2011. to the former Brazilian TV actress Lu Mendonça. The cat overlords are now three. I suppose I've been invited to join real scholars on the list because my skills, acquired in a decade of technical assistance work in eastern Europe, include being able to ask faux-naïf questions like the exotic Persians and Chinese of eighteenth-century philosophical fiction. So I'm quite comfortable in the role of country-cousin blogger with a European perspective. The other specialised skill I learnt was making toasts with a moral in the course of drunken Caucasian banquets. I'm open to expenses-paid offers to retell Noah the great Armenian and Columbus, the orange, and university reform in Georgia. James Wimberley's occasional publications on the web

11 thoughts on “Sick America”

  1. Can we control for geography? Maybe it's the latitude, or the London fog. How do those living a traditional English lifestyle fare in the States, and vice versa?

  2. I am as ready as anyone to believe that the U.S. is comparatively unhealthy, but this study sure doesn't help one analyze how or why.
    If I understand what they said correctly, an American is significantly more likely to be diagnosed with cancer, because we are crazy with early screening, but an Englishman is more likely to die from cancer. (I welcome correction, if I misunderstood.) That odd factoid from the study certainly gave me pause.

  3. Marmot is unquestionably the gold standard in these things, but it's also true that the only figure that really counts – the only thing that can't be due to cultural norms of what constitutes disease – is the all causes death rate. Which is also, of course, a bad comparison for Americans, but perhaps not as markedly.

  4. This part of the JAMA article makes me wonder if some of the illness here could be due to stress, finanacial stress that is:
    "Thus, British households are more isolated from any financial impacts of out-of-pocket medical expenses. A similar argument applies to earnings and job losses, for which the more generous UK income maintenance system should mitigate any effects of health changes on income and wealth there compared with what is available in the United States."

  5. Bruce: If you cite Marmot's concession that differences in reported cancer may reflect greater screening, you should also note his counterargument that the differences show up at all income levels. Poor US whites presumably don't get nearly as much screening as the rich. It's a pity that there aren't yet any simple biological indicators iof risk to screen for.
    Margot: I didn't cite this explanation of Marmot's because I can only understand it as dealing with the greater SES gradients in the USA, not the overall gap in prevalence; he'd already ruled out insurance as an explanation for that. Can you cite any medical evidence that stress contributes to disease? It makes people unhappy, but the longitudinal studies don't seem to have asked this question. Maybe they should.

  6. Living in the UK, having parents in their late 70s, my take is:
    – this is an artefact of the long period of postwar privation and the relatively low disposable incomes of Brits prior to the 1980s.
    I has only been since the 1980s that the British lifestyle has really caught up to the American:
    – long hours at work – hardest working people in Europe
    – sedentary – drive everywhere, drive to shops, drive to work. Housing subdivisions without sidewalks, kids no longer walk or cycle to school (less than 10% of schoolchildren walk or cycle to school). Only 3 TV channels, now over 30 etc.
    – fast food – fat and salt laden, eat out a lot more
    The next generation will not be any healthier. In Scotland, it probably is not, already.
    We also drink a lot more, and drink more in binges, than Americans.

  7. Valuethinker: I misrepresented Marmot on booze – he does find the English drink more, but like the excess American obesity, he doesn't think it explains much. I'll correct.

  8. My computer won't pull up the full article. Did they control for genetics and ethnic make-up? Certain ethnic groups have higher incidince of particular diseases (which could either be genetics or socio-economics). If that group is a higher percentage of the population in one country, that could give an increase.

  9. James
    I think the study is almost entirely a result of time lags.
    British social trends remain resolutely 10-15 years behind American ones. In the 25 years I have been paying attention to this, this remains true.
    Our fondness for alcohol and binge drinking has exploded in the last 10 years, expect to see the impact on personal health in the next 20*.
    So obesity, sedentary lifestyle etc. are only now catching up to where the US was in the late 80s/ early 90s. Our health statistics will catch you up.
    Also our GDP/head is only 60% of yours, so we get the same diseases of affluence when our income level reaches the one you reached 20 years earlier.
    I am not an optimist on this one, that somehow British people will escape the consequences of bad diet, sedentary lifestyle and (uniquely British problem) extreme alcohol abuse. Many of the capitals of Europe are despoiled each weekend (Prague, Talinn etc.) by crowds of shatteringly drunk English men and/or women on 'stag' or 'hen' weekends, etc. We are known now as the inebriates of Europe.
    When our 29 year olds are 45, they are going to look as shocking as yours do. I track the (working class) kids outside my kitchen window– you already see far more seriously overweight 10 year olds than even 10 years ago.
    * interestingly, cultural trends the reverse seems to be true. We lead you on any measure of secularisation, modernisation (of attitudes be it to unmarried couples, gay couples etc.) and are noticeably ahead in various areas like urban fashion, etc.

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