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unusually deleterious. This could be the case in the United States, which had the highest level of cigarette consumption per capita in the developed world over a 40-year period ending in the mid-1980s (Forey et al., 2002). Smoking in early life has left an imprint on mortality patterns that remains visible as cohorts age (Haldorsen and Grimsrud, 1999; Preston and Wang, 2006). One recent study estimated that, if deaths attributable to smoking were eliminated, the ranking of U.S. men and women in life expectancy at age 50 among 21 countries of the Organisation for Economic Co-operation and Development (OECD) would improve sharply (Preston, Glei, and Wilmoth, Chapter 4, in this volume). Recent trends in obesity are also more adverse in the United States than in other developed countries (Cutler, Glaeser, and Shapiro, 2003; Organisation for Economic Co-operation and Development, 2008).

This chapter begins with a review of previous international studies of the comparative performance of health care systems in disease identification and treatment. The review is focused on the major diseases of adulthood, cancer and cardiovascular disease, in the belief that disease-level analyses are more likely to reveal the forces at work than more highly aggregated studies (Garber, 2003). In 2005, cancer and major cardiovascular diseases were responsible for 61.0 percent of deaths in the United States at ages 45+ (National Center for Health Statistics, 2008). Because our concern is with mortality per se, the criterion we employ is effectiveness at preventing death, rather than cost-effectiveness or efficiency of resource deployment. These latter criteria have been used in several other recent comparative studies describing features of the U.S. health care system that appear inefficient by international standards (Garber and Skinner, 2008; McKinsey Global Institute, 2008). A comprehensive evaluation of the U.S. health care system would need to consider patient physical and emotional welfare, a much broader concept than survival, which is the sole focus of this chapter.

Health care systems can prevent death from a particular disease either by preventing it from developing or by effectively treating it once it has developed. A key element in effective treatment is accurate diagnosis. However, almost no internationally comparable data exist on the actual incidence of various diseases, which is the appropriate measure of the success of prevention. While cancer appears to be an exception because “incidence” data are published for various cancer registry sites (e.g., at the website of the International Agency for Research on Cancer), the data refer not to the origin of a disease but to its detection, a process that combines actual patterns of incidence with the mechanics of identification. And even if pure measures of it were available, actual disease incidence reflects not only features of a health care system but also many other factors of behavioral, social, and genetic origin.

Disease prevalence—the proportion of the population that has been diagnosed with a disease—is even more difficult to interpret. The United



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