1

Shorter Lives

Do Americans live as long as people in other high-income countries? This chapter reviews one of the most reliable sources of information about cross-national health differences, vital statistics on deaths. Unlike measures obtained from survey data, these data pertain to an unambiguous indicator of health. High-quality vital statistics are available for nearly all deaths in high-income countries. Their continuous coverage permits the construction of accurate time series, and the data can be converted into meaningful popular indicators, such as life expectancy at birth, which is an intuitively appealing summary measure that is often used as the basis for evaluating overall health status. Data on mortality by cause of death can also provide important clues about the social and epidemiologic pathways that affect population health.

This chapter examines mortality from multiple perspectives to present a comprehensive picture of the evidence: we examine mortality rates (the number of deaths from particular causes per 100,000 persons), life expectancy at various ages, the probability of living to age 50, and years of life lost from particular causes. We present both the data and the United States’ ranking on these data relative to other high-income countries.1 In

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1We report rankings to simplify comparisons across countries, but it is important to recognize that this is an ordinal measure that does not reflect the size of the difference between one rank and the next. Rankings can change when small differences in rates shift a country’s rank.



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1 Shorter Lives D o Americans live as long as people in other high-income countries? This chapter reviews one of the most reliable sources of information about cross-national health differences, vital statistics on deaths. Unlike measures obtained from survey data, these data pertain to an unam- biguous indicator of health. High-quality vital statistics are available for nearly all deaths in high-income countries. Their continuous coverage per- mits the construction of accurate time series, and the data can be converted into meaningful popular indicators, such as life expectancy at birth, which is an intuitively appealing summary measure that is often used as the basis for evaluating overall health status. Data on mortality by cause of death can also provide important clues about the social and epidemiologic pathways that affect population health. This chapter examines mortality from multiple perspectives to pre­ sent a comprehensive picture of the evidence: we examine mortality rates (the number of deaths from particular causes per 100,000 persons), life expectancy at various ages, the probability of living to age 50, and years of life lost from particular causes. We present both the data and the United States’ ranking on these data relative to other high-income countries.1 In 1  We report rankings to simplify comparisons across countries, but it is important to rec- ognize that this is an ordinal measure that does not reflect the size of the difference between one rank and the next. Rankings can change when small differences in rates shift a country’s rank. 25

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26 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE this chapter we focus on 17 high-income countries:2 Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Por- tugal, Spain, Sweden, Switzerland, the Netherlands, the United Kingdom, and the United States. MORTALITY RATES For many years, global health statistics compiled by the OECD3 and the World Health Organization (WHO) have documented higher mortality rates in the United States relative to other high-income countries. Among the 17 peer countries examined by the panel, Americans faced the second highest risk of dying from noncommunicable diseases in 2008 (418 per 100,000 persons) and the fourth highest risk of dying from communicable (infectious) diseases in 2008 (World Health Organization, 2011a) (see Figures 1-1 and 1-2). Death rates from noncommunicable diseases, notably cardiovascular diseases, have declined everywhere but less so in the United States. As of 2009, ischemic heart disease mortality among males in the United States was 129 per 100,000, higher than the other 16 peer countries except Finland (OECD, 2011b).4 Table 1-1 provides cause-specific mortality rates 2  The panel selected these 17 as “peer countries” because they are most comparable to the United States. We set three criteria for designating peer countries: (1) high levels of develop- ment for a long period of time, (2) sufficient population size to ensure stability of estimates, and (3) data from the Human Mortality Database (2012) of suitable quality and availability for the time period used in our analysis, 2006-2008. Excluded countries did not meet one or more of these criteria. For example, data quality has been a problem in Belgium, and its latest year of available data was 2005; Greece and Korea were not included in the Human Mortality Database at the time of our analysis; and several other high-income countries are former Soviet satellites with atypical mortality experiences. For consistency, this report’s documentation of the U.S. health disadvantage is based on comparisons with these 16 peer countries. The panel uses a more general term, “high-income countries,” to refer to other groups of high-income countries. On occasion, we make comparisons with these other high-income countries and even emerging economies (e.g., Mexico, Russia) because data were available for this larger comparison group, because we cited studies that included these countries, and because for certain conditions (e.g., mortality rates, child poverty) comparisons with emerging economies underscore the United States’ relative position. 3  The OECD is a membership organization of 34 member countries that share a commit- ment to democratic government and the market economy. Well known for its publications and statistics, the work of the OECD covers both economic and social issues, including macroeconomics, trade, employment, education, health, and social welfare. The organization was established in 1961 when the United States and Canada joined the 18 former members of the Organization for European Economic Cooperation (established in 1947 for postwar reconstruction) to work together on shared economic development. The OECD’s 34 members now include countries from North and South America, Europe, and the Asia-Pacific region, and it includes not only most advanced economies, but also such emerging economies as Chile, Mexico, and Turkey. 4  U.S. mortality rates from ischemic heart disease are even higher than those of some emerg- ing economies, such as Mexico and Slovenia (OECD, 2011b).

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SHORTER LIVES 27 Japan 273 Switzerland 323 Australia 330 France 336 Italy 342 Canada 346 Spain 351 Sweden 358 Norway 363 Austria 373 Netherlands 377 Finland 377 Portugal 394 Germany 394 United Kingdom 401 United States 418 Denmark 440 0 50 100 150 200 250 300 350 400 450 500 Age-Standardized Deaths per 100,000 People FIGURE 1-1  Mortality from noncommunicable diseases in 17 peer countries, 2008. SOURCE: Data from World Health Organization (2011a, Table 3). Fig1-1.eps Finland 11 Austria 14 Italy 16 Switzerland 17 Australia 18 Sweden 20 Germany 21 France 23 Canada 23 Spain 24 Norway 27 Denmark 27 Netherlands 28 United States 34 United Kingdom 36 Japan 40 Portugal 46 0 5 10 15 20 25 30 35 40 45 50 Age-Standardized Deaths per 100,000 People FIGURE 1-2  Mortality from communicable diseases in 17 peer countries, 2008. Fig1-2.eps SOURCE: Data from World Health Organization (2011a, Table 3).

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28 TABLE 1-1  Mortality Rates in 17 Peer Countries, 2008 Australia Austria Canada Denmark Finland France Germany Italy Japan Netherlands Norway Portugal Spain Sweden Switzerland U.K. U.S. ALL CAUSES 378.0 420.5 401.2 500.8 446.6 397.7 440.6 383.0 349.3 427.3 425.3 467.7 397.7 409.8 371.2 462.1 504.9 Specific causes Noncommuni- 329.9 372.5 345.8 440.4 377.0 336.4 393.9 342.1 273.0 376.8 363.1 393.9 351.0 357.6 323.3 400.5 418.4 cable diseases Cardiovascular 117.2 154.4 118.6 144.6 163.6 99.2 174.9 132.3 97.4 122.4 132.9 148.2 115.7 150.8 123.1 141.7 155.7 diseasesa Malignant 118.8 123.6 125.8 157.7 106.5 138.4 127.5 124.2 115.1 147.1 130.3 134.3 122.0 116.4 112.7 137.0 123.8 neoplasmsb Other neoplasms 2.9 3.5 2.4 3.6 2.1 5.2 2.8 5.3 3.3 3.6 2.5 2.9 3.7 3.2 2.8 2.9 2.9 Neuropsychiatric 26.2 19.6 28.2 38.8 48.4 34.0 19.5 18.8 7.2 32.7 32.7 16.1 28.2 34.2 33.5 31.7 39.2 conditionsc Respiratory 21.6 15.5 22.4 31.2 12.7 13.3 17.3 17.3 15.8 23.9 25.4 25.6 31.1 15.5 13.4 34.4 34.3 diseases •    Chronic 12.8 12.9 15.4 26.8 9.1 5.4 11.9 11.5 4.0 19.0 20.8 10.5 12.6 11.7 9.9 21.5 24.3 obstructive pulmonary disease •    Asthma 1.2 0.9 0.5 0.8 0.8 0.8 1.0 0.4 0.7 0.3 1.2 0.6 0.8 0.6 0.5 1.1 0.9 Digestive 13.0 19.4 15.5 29.5 27.2 20.4 25.7 16.4 14.5 17.4 13.7 25.6 21.3 15.1 15.9 26.7 19.8 diseasesd Diabetes mellitus 9.9 17.4 13.4 12.3 5.5 8.1 11.1 12.4 4.5 10.1 7.4 19.3 9.4 9.2 8.2 5.0 15.2

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Genitourinary 8.2 5.4 7.6 8.1 3.0 5.7 7.1 5.7 8.0 9.3 7.7 12.2 9.2 4.6 4.0 9.1 12.3 diseasese Endocrine 5.2 8.1 5.1 6.5 1.6 5.8 3.5 4.3 2.6 3.5 3.8 5.3 3.4 3.2 2.7 3.1 7.1 disorders Congenital 3.2 3.9 3.7 4.0 3.6 2.8 2.8 2.8 2.6 3.3 3.4 2.7 2.9 2.7 3.8 3.7 4.3 anomalies Musculoskeletal 2.8 1.5 2.4 3.4 2.3 2.5 1.2 2.0 1.7 2.4 2.6 1.4 3.0 2.1 2.8 3.5 2.9 diseasesf Skin diseases 0.8 0.3 0.5 0.6 0.3 0.9 0.3 0.5 0.3 1.1 0.7 0.1 1.0 0.5 0.5 1.5 0.8 Oral conditions 0.1 0.0 0.0 0.1 0.1 0.0 0.0 0.0 0.0 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.0 Injuries 30.0 33.6 32.1 33.1 58.5 38.2 25.2 24.6 36.3 22.1 35.6 28.3 23.2 32.2 30.5 25.5 52.8 Unintentional 21.0 21.2 20.6 22.3 38.6 23.3 15.4 19.0 16.1 13.7 25.2 19.3 16.7 19.7 17.2 17.4 35.5 injuries •    Road traffic 6.8 6.9 7.8 5.4 5.7 6.6 5.7 8.4 3.8 4.0 5.2 10.0 6.1 4.1 3.8 4.8 13.9 accidents •    Poisonings 3.0 0.2 2.1 3.8 13.9 1.6 0.9 0.7 0.6 0.9 6.8 0.2 1.0 3.2 1.9 2.8 8.9 •    Falls 3.1 5.3 3.7 2.8 10.1 4.0 4.6 2.2 2.5 4.0 3.7 2.5 2.2 4.1 7.5 3.5 4.4 •    Fires 0.3 0.3 0.6 0.9 1.2 0.6 0.3 0.2 0.7 0.3 1.0 0.5 0.3 0.7 0.1 0.5 0.9 •    Drowning 0.9 0.8 0.8 0.8 1.8 1.3 0.5 0.6 2.4 0.4 0.8 0.7 0.9 0.9 0.6 0.4 1.2 •    Other 6.9 7.8 5.6 8.6 6.0 9.3 3.3 7.0 6.2 4.1 7.7 5.4 6.1 6.7 3.3 5.5 6.2 Intentional 9.0 12.3 11.5 10.8 19.9 14.8 9.9 5.6 20.2 8.4 10.4 9.0 6.5 12.6 13.3 8.0 17.3 injuries •    Self-inflicted 7.8 11.8 9.9 10.1 17.7 13.6 9.1 4.5 19.8 7.4 9.7 7.5 5.6 11.7 12.6 6.9 10.3 injuries 29 continued

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TABLE 1-1 Continued 30 Australia Austria Canada Denmark Finland France Germany Italy Japan Netherlands Norway Portugal Spain Sweden Switzerland U.K. U.S. •    Violence 1.3 0.5 1.6 0.8 2.2 1.3 0.7 1.1 0.4 0.9 0.6 1.5 0.9 0.9 0.7 1.1 6.5 •    War — — — — — 0.0 — — — 0.1 0.0 0.0 — — — — 0.4 Communi- 18.1 14.4 23.3 27.3 11.1 23.1 21.5 16.3 40.0 28.4 26.6 45.5 23.6 20.0 17.3 36.1 33.7 cable, maternal, perinatal, and nutritional conditions Respiratory infectionsg 7.0 5.7 9.0 13.9 4.0 8.4 10.1 4.7 29.7 16.8 13.8 23.6 9.3 8.9 7.4 23.8 9.7 Infectious and parasitic diseasesh 5.9 4.7 7.6 7.6 4.4 9.0 7.4 6.8 8.1 6.9 9.2 17.5 9.8 7.8 4.7 6.7 15.4 Maternal conditions 0.1 0.0 0.1 0.2 0.1 0.1 0.1 0.0 0.1 0.1 0.1 0.1 0.1 0.1 0.0 0.1 0.4 Perinatal conditions 4.6 3.8 5.9 4.4 2.5 3.6 3.6 3.8 1.3 3.6 3.1 3.4 3.7 2.4 4.8 5.2 7.1 •    Prematurity and low birth weight 1.2 1.9 2.0 2.7 0.9 0.6 2.0 1.5 0.4 0.8 0.4 0.9 0.9 0.4 1.4 3.4 3.2 •    Birth asphyxia and birth trauma 0.6 0.5 1.1 0.6 0.4 0.8 0.5 1.1 0.4 0.7 0.5 0.8 0.7 0.5 0.7 0.6 0.9

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•    Neonatal infections and other conditions 2.8 1.4 2.7 1.1 1.2 2.2 1.1 1.1 0.5 2.0 2.1 1.7 2.1 1.4 2.7 1.2 3.0 Nutritional deficienciesi 0.5 0.2 0.7 1.2 0.1 2.0 0.4 1.0 0.8 1.0 0.4 0.9 0.7 0.9 0.4 0.3 1.0 NOTES: Age-adjusted mortality rates in the 17 peer countries show similar relationships when the age-adjusted data are examined separately by sex. However, for some conditions, cross-national patterns change slightly. For example, although the mortality rate for overall injuries (and unintentional injuries) is higher in aggregate in Finland than in the United States, among females only the United States has a higher rate. Similarly, among females, the U.S. mortality rate for infectious and parasitic diseases is higher than that of Portugal, the mortality rate for respiratory diseases is higher than that of the United Kingdom, and the mortality rate for musculoskeletal diseases is higher than that of Spain. Austrian females have a higher mortality rate for cardiovascular diseases, and Swedish and Swiss females have higher rates of mortality for intentional injuries. Among males, the U.S. mortality rate for communicable diseases is higher than that of the United Kingdom; Portugal has a higher mortality rate for noncommunicable diseases in general and genitourinary diseases in particular; Denmark has a higher mortality rate for neuropyshicatric disorders; both Denmark and Austria have higher mortality rates for congenital anomalies; Sweden has a slightly higher mortality rate for cardiovascular diseases; Spain has a higher mortality rate for respiratory diseases; and France and Switzerland have higher mortality rates for musculoskeletal diseases. Not listed here are conditions with relatively low mortal- ity rates (e.g., less than 2 per 100,000), for which the standing of the United States compared with peer countries may differ more substantially by sex. aPrimarily includes ischemic heart disease but also includes higher death rates from hypertensive and inflammatory heart disease. U.S. death rates from cerebrovascular disease and rheumatic heart disease are at or below average. bIncludes cancers of the mouth and oropharynx, esophagus, stomach, colon and rectum, liver, pancreas, trachea, bronchus, lung, skin, breast, cervix uteri, corpus uteri, ovary, prostate, and bladder; lymphomas; multiple myeloma; and leukemia. cIncludes Alzheimer and other dementias, Parkinson disease, multiple sclerosis, and drug use disorders, for which the United States has above-average mortality rates, and the following neuropsychiatric disorders for which the United States has average or below-average mortality rates: unipolar depres- sive disorder, bipolar disorder, schizophrenia, epilepsy, alcohol use disorder, posttraumatic stress disorder, obsessive-compulsive disorder, panic disorder, insomnia, and migraine. dIncludes peptic ulcer disease, cirrhosis of the liver, and appendicitis. ePrimarily nephritis and nephrosis. U.S. death rates from benign prostatic hypertrophy are at or below average. fIncludes rheumatoid arthritis and osteoarthritis, but U.S. death rates from the latter are at or below average. gIncludes upper and lower respiratory infections and otitis media. hIncludes HIV/AIDS and other sexually transmitted infections, tuberculosis, diarrheal diseases, childhood-cluster diseases (e.g., pertussis, poliomyelitis), meningitis, hepatitis B and C, malaria, tropical-cluster diseases (e.g., schistosomiasis, leishmaniasis), leprosy, dengue, Japanese encephalitis, trachoma, and intestinal nematode infections. iIncludes protein-energy malnutrition, iodine deficiency, Vitamin A deficiency, and iron-deficiency anemia. 31 SOURCE: Adapted from World Health Organization (2011a, Table 3).

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32 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE for the 17 peer countries and shows that the United States also experiences relatively high mortality rates for neuropsychiatric conditions, respiratory diseases, diabetes and other endocrine disorders, genitourinary disease, congenital anomalies, infectious diseases, and perinatal conditions. This pattern differs little when the data are examined separately by sex (see NOTES in Table 1-1). An interactive graph, which allows a more thorough examination of the data in Table 1-1, is located at http://nationalacademies. org/IntlMortalityRates. Figure 1-3 shows that in 2008 the United States had the second highest death rate from injuries among the 17 peer countries, exceeded only by Fin- land (World Health Organization, 2011a, Table 3). Unintentional injuries are the leading cause of death among Americans, from ages 1-44 (National Center for Health Statistics, 2012). An important contributor has been deaths related to transportation. In 2009, the United States had the highest death rate from transportation- related accidents among the 17 peer countries (and the third highest in the OECD, exceeded only by Mexico and the Russian Federation). The death rate from transportation-related accidents decreased by 42 percent in OECD countries between 1995 and 2009, but by only 11 percent in the United States (OECD, 2011b). Although there are more motorists and miles driven in the United States, calculations of fatality rates per vehicle-kilometer, which correct for this confounding variable, also show that the United States Netherlands 22 Spain 23 Italy 25 Germany 25 United Kingdom 25 Portugal 28 Australia 30 Switzerland 30 Canada 32 Sweden 32 Denmark 33 Austria 34 Norway 36 Japan 36 France 38 United States 53 Finland 58 0 10 20 30 40 50 60 70 Age-Standardized Deaths per 100,000 People FIGURE 1-3  Mortality from injuries in 17 peer countries, 2008. SOURCE: Data from World Health Organization (2011a, Table 3). Fig1-3.eps

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SHORTER LIVES 33 5 4.5 4 3.5 fatalities/100M vkmt 3 2.5 2 1.5 1 0.5 0 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 year fatalities/100M vkmt, 15 countries fatalities/100M vkmt, US FIGURE 1-4  Motor vehicle fatalities in the United States and 15 other high-income countries, 1975-2008. NOTE: The comparison set of countries in this analysis are Australia, Austria, Bel- gium, Denmark, Finland, France, Germany, Great Britain, Israel, Japan, the Nether- lands, Norway, Slovenia, Sweden, and Switzerland. SOURCE: Transportation Research Board (2011, Figure 2-2c). has lost the advantage it once held over other countries. Figure 1-4 shows the trend over three decades. As the Transportation Research Board (2011, p. 40) explains: Fatality rates per vehicle kilometer have declined greatly in every high- income country in the past several decades, and the absolute disparity of rates among countries has lessened. A comparison of the U.S. experience with that of 15 other high-income countries for which 1975–2008 data are available shows that the U.S. fatality rate was less than half the aggregate rate in the other countries in 1975 but has been higher since 2005. Con- sequently, total annual traffic deaths in the 15 countries fell by 66 percent in the period, while U.S. deaths fell by only 16 percent. The U.S. fatality rate was among the best before 1990 but has been below the median rate of the group every year since 2001. The United States also has dramatically higher rates of death from vio- lent injuries, especially from firearms. In a study that compared 23 OECD

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34 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE countries in 2003, the U.S. homicide rate was 6.9 times higher than the other high-income countries and the rate of firearm homicides was 19.5 times higher. Although overall suicide rates were lower in the United States than in those countries, firearm suicide rates were 5.8 times higher than in other countries. Across the 23 countries in the study, 80 percent of all firearm deaths occurred in the United States (Richardson and Hemenway, 2011). This pattern is not new; data from the early 1990s showed similar results (Krug et al., 1998). Although the incidence of AIDS has fallen since the early 1990s, the United States still has the highest incidence of AIDS among the 17 peer coun- tries (and the third highest in the OECD, exceeded only by Brazil and South Africa) (OECD, 2011b). The incidence of AIDS in the United States (122 per million) is almost nine times the OECD average (14 per million).5 High mortality rates in the United States relative to other rich nations have been the subject of numerous research studies. A 2005 study reported that U.S. adults aged 15-59 had higher mortality rates than those in nine economically comparable nations: “Compared with other nations in the WHO’s mortality database, in the United States 15-year-old girls rank 38th and 15-year-old boys rank 34th in their likelihood of reaching age 60” (­enkins and Runyan, 2005, p. 291). These researchers noted that J the higher mortality was true for both sexes and throughout the first five decades of life (Jenkins and Runyan, 2005). The U.S. health disadvantage is not limited to death rates; the United States also has relatively high prevalence rates for disease and disability. Chapter 2 details this morbidity disadvantage by age group, but in Box 1-1 we briefly note the key findings that apply across the entire U.S. population. The United States does enjoy some health advantages compared with other countries. In 2009, the United States had the third lowest mortality rate from stroke among the 17 peer countries (OECD, 2011b), despite its above-average mortality for ischemic heart disease.6 As of 2009, the U.S. suicide rate (10.5 per 100,000 persons) was also below the average of the 16 peer countries (OECD, 2011b). Finally, although the U.S. incidence rate for cancer is the fourth highest of the 17 peer countries (OECD, 2011b),7 mortality rates for certain cancers (e.g., cervical and colorectal cancer) are lower than most peer countries (World Health Organization, 2011a). 5  The United States has the fifth highest prevalence of HIV infection among 40 OECD coun- tries, exceeded only by Portugal, the Russian Federation, Estonia, and South Africa (OECD, 2011b), and the highest prevalence of HIV infection (for ages 15-49) among the 17 peer countries (World Health Organization, 2010). 6  The reasons for this differential pattern are not entirely clear, but they may relate to cross- national differences in risk factors and treatment for cerebrovascular disease. 7  The incidence of cancer may be skewed by the intensity of screening programs in the United States and may not accurately reflect the prevalence of the disease.

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SHORTER LIVES 35 Table 1-2 lists other conditions for which the U.S. mortality rate is at or below the average of the 16 other peer countries. CROSS-NATIONAL DIFFERENCES IN LIFE EXPECTANCY Not surprisingly, higher mortality rates affect life expectancy in the United States. Perhaps the single most impressive achievement of the past century is the striking increase in longevity in nearly all parts of the world. At the turn of the 20th century, North American and Western European countries experienced life expectancies at birth of 40-50 years (Preston and Haines, 1991): 100 years later (in 2007), no country in these regions had a life expectancy of less than 75 years, and most had levels of more than 80 years (Human Mortality Database, 2012). However, as shown in Table 1-3, there remain large differences in life expectancy at birth among high-income peer countries. In 2007, men in Switzerland and women in Japan enjoyed the longest life expectancies for their sexes. In contrast, the United States ranked last among males and next to last among females.8 These differences with the top-performing countries amount to approximately 3.7 years for males and 5.2 years for females (Ho and Preston, 2011).9 We emphasize that these large cross-national differences are often eclipsed by even larger within-country disparities in life expectancy. As discussed in Box 1-2, such disparities are substantial in the United States (Agency for Healthcare Research and Quality, 2011; Bleich et al., 2012; Braveman et al., 2011a; Satcher et al., 2005; Woolf et al., 2004), and they may be part of the reason that the United States compares so unfavorably with its peers. The U.S. disadvantage in life expectancy relative to other high-income countries is not a recent phenomenon (although the gap has grown over time), nor is this the first report to call attention to the problem. Jenkins and Runyan (2005) reported that U.S. survival rates for each of the five decades 8  The life expectancy of females was lower in Denmark than in the United States in 2007. Life expectancy in aggregate (for males and females) has historically been lower in Denmark than in the United States, but not since 2005. These findings are from the Human Mortality Database (2012), which provides regularly updated detailed mortality and population data to researchers, students, and others interested in the history of human longevity. It is available at http://www.mortality.org. 9  Ho and Preston’s analysis for this panel is modeled on a similar analysis of mortality above age 50 that they conducted for the National Research Council (2011) panel and also pub- lished in Ho and Preston (2010). The current analysis draws on data from three sources: the Human Mortality Database, the WHO Mortality Database, and Statistics Canada. The data were downloaded July 2011, and, for each country, the latest year of data available between 2006 and 2008 was extracted. Dana Glei of Georgetown University provided the panel with a focused mid-project technical review of this analysis.

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46 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE 99% 97% Probability of Survival to Age 50 95% 93% 91% 89% 87% 85% 1980 1985 1990 1995 2000 2005 Year FIGURE 1-7  Probability of survival to age 50 for males in 21 high-income coun- tries, 1980-2006. Fig1-7.eps NOTES: Red circles show the probability a newborn male in the United States will live to age 50. Grey circles show the probability of survival to age 50 in Australia, Austria, Belgium, Canada, Denmark, Finland, France, Iceland, Ireland, Italy, Japan, Luxembourg, the Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, the United Kingdom, and West Germany. SOURCE: National Research Council (2011, Figure 1-5). than in other countries with a similar overall life expectancy (Shkolnikov et al., 2003). As a result, Americans lose more years of life than do those in other high-income countries (Shkolnikov et al., 2011), a topic we address in the next section. YEARS OF LIFE LOST BEFORE AGE 50 At the turn of the 20th century, an individual born in Western Europe or North America could expect to live no more than 34 years between birth and age 50 (Keyfitz and Flieger, 1990), a loss of 16 years of life. In many countries today, a newborn can expect to live more than 49 of the first 50 years of life.13 These remarkable gains are the result of major reductions in infectious diseases among infants and young children, as well as declines 13  Data are from the Human Mortality Database (2012).

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SHORTER LIVES 47 100% 98% Probability of Survival to Age 50 96% 94% 92% 1980 1985 1990 1995 2000 2005 Year FIGURE 1-8  Probability of survival to age 50 for females in 21 high-income coun- tries, 1980-2006. Fig1-8.eps NOTES: Red circles show the probability a newborn female in the United States will live to age 50. Grey circles show the probability of survival to age 50 in Australia, Austria, Belgium, Canada, Denmark, Finland, France, Iceland, Ireland, Italy, Japan, Luxembourg, the Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, the United Kingdom, and West Germany. SOURCE: National Research Council (2011, Figure 1-6). in maternal mortality, the virtual elimination of infectious diseases among adolescents and middle-aged adults (particularly respiratory tuberculosis), and more recently, lower death rates from cardiovascular diseases from age 35 onward (Cutler and Miller, 2004; Riley, 2001). Although the United States has shared in these improvements, it still forfeits the most years of potential life before age 50. Figures 1-11 and 1-12 show the number of years lost before age 50 by males and females, respectively, in the 17 peer countries. U.S. male and female newborns can expect to lose about 1.4 years and 0.8 years of life, respectively, before age 50. In the best performing country, Sweden, the corresponding losses are only 0.7 and 0.4 years, respectively. This mortality gap has also grown significantly over time. In 1990, U.S. females and males lost approximately 35 percent more years of life before age 50 than did those in other high-

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48 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE Males Females 1 3 5 7 Rank 9 11 13 15 17 1 4 9 4 9 4 9 4 9 4 9 4 9 4 9 4 9 4 9 4 9 0- 1- 5- -1 -1 -2 -2 -3 -3 -4 -4 -5 -5 -6 -6 -7 -7 -8 -8 -9 -9 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 Age FIGURE 1-9  Ranking of U.S. mortality rates, by age group, among 17 peer coun- tries, 2006-2008. Fig1-9.eps NOTES: The top rank is number 1, indicating the lowest death rate, and the bot- tom rank is number 17, indicating the highest death rate. Rankings are based on all-cause mortality rates for 2006-2008. Data for this figure were drawn from (1) the Human Mortality Database, 2011, University of California, Berkeley (USA), and Max Planck Institute for Demographic Research (Germany), available at http:// www.mortality.org or http://www.humanmortality.de (data downloaded July 18, 2011) and (2) Arias, Elizabeth, 2011, United States Life Tables, 2007. National Vi- tal Statistics Reports, 59(9), Hyattsville, MD: National Center for Health Statistics. SOURCE: Adapted from Ho and Preston (2011, Figure 1). income countries, but by 2009 this figure had grown to nearly 75 percent (Palloni and Yonker, 2012). CAUSES OF PREMATURE DEATH What causes of death are responsible for this excess loss of life in the United States? Because deaths in high-income countries are assigned to various causes of death by medical certifiers using internationally accepted criteria, it is possible to examine how life expectancy varies cross-nationally by cause. In this section, the panel presents an analysis of years of life

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SHORTER LIVES 49 Males Females 1 3 5 7 Rank 9 11 13 15 17 1 9 9 9 9 9 9 9 9 9 9 0- 5- -1 -2 -3 -4 -5 -6 -7 -8 -9 15 25 35 45 55 65 75 85 95 Age FIGURE 1-10  Ranking of U.S mortality rates for non-Hispanic whites only, by age group, among 17 peer countries, 2006-2008. NOTES: The top rank is number 1, indicating the lowest death rate, and the bot- Fig1-10.eps tom rank is number 17, indicating the highest death rate. Rankings are based on all-cause mortality rates for 2006-2008. Data for this figure were drawn from (1) the Human Mortality Database, 2011, University of California, Berkeley (USA), and Max Planck Institute for Demographic Research (Germany), available at http:// www.mortality.org or http://www.humanmortality.de (data downloaded on July 18, 2011) and (2) Arias, Elizabeth, 2011, United States Life Tables, 2007, National Vi- tal Statistics Reports, 59(9), Hyattsville, MD: National Center for Health Statistics. SOURCE: Adapted from Ho and Preston (2011, Figure 2). lost by cause for age groups under age 50, as reported by Ho and Preston (2011).14 Years of life lost before age 50 is a measure that combines the intensity of a particular cause of death with its age incidence. It indicates how many potential years of life below age 50 are claimed by a particular cause of death—that is, how many additional years would be lived before age 50 if deaths from a particular cause were eliminated. To facilitate comparisons with the United States, Ho and Preston (2011) created a composite of the other 16 peer countries by calculating an unweighted average of the age- and cause-specific death rates across these countries and grouping causes of death into the major categories used in the 14  For deaths by cause after age 50, see National Research Council (2011).

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50 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE Sweden Netherlands Japan Italy Switzerland Germany Spain Norway Austria Denmark France Australia Portugal United Kingdom Canada Finland United States 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 Years of Life Lost Before Age 50 FIGURE 1-11 Years of life lost before age 50 by males in 17 peer countries, 2006-2008. Fig1-11.eps NOTE: Data for this figure come from the Human Mortality Database (down- loaded July 18, 2011, last updated July 13, 2011); the WHO Mortality Database (downloaded July 18, 2011, last updated March 25, 2011); and Statistics Canada (downloaded July 22, 2011, data released February 23, 2010). SOURCE: Adapted from Ho and Preston (2011, Figure 3). Global Burden of Disease Study (Mathers et al., 2006). As shown in Figures 1-13 and 1-14, the results show that the United States loses a larger num- ber of years of life to all of the major disease and injury groupings than do the other peer countries. Although communicable diseases and nutritional conditions are no longer a leading cause of premature deaths in most high- income countries, the United States still fares poorly in this category. The gap in years of life lost from noncommunicable diseases—which includes heart disease, cancer, and other conditions not caused by infections—is also large. For both males and females, cardiovascular disease and congenital anomalies together account for more than half of the U.S. excess mortality from noncommunicable diseases. Diabetes, digestive diseases, and respira- tory diseases also contribute to the gap. Intentional and unintentional injuries are also major contributors to the excess years of life lost by Americans before age 50. Intentional injuries— homicide and suicide—are particularly important causes of early deaths among U.S. males. Ho and Preston (2011) found that 69 percent of all U.S. homicide deaths in 2007 (73 percent of homicides before age 50) involved firearms (for both sexes combined), compared with a mean of 26 percent

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SHORTER LIVES 51 Sweden Italy Norway Japan Spain Finland Austria Germany Netherlands Denmark Switzerland France Portugal Australia United Kingdom Canada United States 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 Years of Life Lost Before Age 50 FIGURE 1-12 Years of life lost before age 50 by females in 17 peer countries, 2006-2008. Fig1-12.eps NOTE: Data for this figure come from the Human Mortality Database (down- loaded July 18, 2011, last updated July 13, 2011); the WHO Mortality Database (downloaded July 18, 2011, last updated March 25, 2011); and Statistics Canada (downloaded July 22, 2011, data released February 23, 2010). SOURCE: Adapted from Ho and Preston (2011, Figure 4). in the other countries. Both males and females in the United States lose an equivalent number of years of life to unintentional injuries, such as motor vehicle accidents, falls, poisonings, fires, and drowning. Unintentional poi- sonings are the largest contributor to nontransportation-related accidents: in 2007, they accounted for 64 percent and 72 percent of nontransportation- related U.S. deaths under age 50 among males and females, respectively. Drug-related deaths are another category in which the United States loses more years of life than other countries. Drug-related deaths include both drug- and alcohol-induced deaths, which account for 76 percent and 24 percent, respectively, of all drug-related deaths before age 50. This cat- egory includes deaths from medical conditions or complications induced by alcohol or drugs, selected mental and behavioral disorders due to alcohol or the use of psychoactive substances, accidental or intentional alcohol or drug poisonings or overdoses, and deaths with measurable blood levels of alcohol or other addictive drugs (e.g., opiates, cocaine, hallucinogens, psy- chotropic drugs). This category does not include deaths from drunk driving or other accidents, homicides, or other deaths that may be indirectly related to alcohol or drug use.

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52 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE Mean of Other Countries United States Communicable and nutriƟonal condiƟons Drug-related causes Perinatal condiƟons IntenƟonal injuries Cardiovascular disease (CVD) Noncommunicable diseases, excluding CVD UnintenƟonal injuries All causes 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 Years of Life Lost Before Age 50 FIGURE 1-13  Years of life lost before age 50 due to specific causes of death among males in 17 peer countries, 2006-2008. Fig1-13.eps NOTES: Drug-related and other causes are not always mutually exclusive. The largest areas of overlap occur between drug-related causes and noncommunicable diseases and injuries. For example, drug-related digestive diseases (e.g., alcoholic liver disease) and drug-related neuropsychiatric disorders are also included in the noncommuni- cable disease category. Suicide and homicide by drugs fall under both drug-related causes and intentional injuries, and accidental drug overdoses fall under both drug- related causes and unintentional injuries. The drug-related causes category is included to illustrate the excess years of life lost from drug-related causes of death in the United States relative to other countries. Data for this figure come from the Human Mortality Database (downloaded July 18, 2011, last updated July 13, 2011); the WHO Mortal- ity Database (downloaded July 18, 2011, last updated March 25, 2011); and Statistics Canada (downloaded July 22, 2011, data released February 23, 2010). SOURCE: Adapted from Ho and Preston (2011, Figure 5). The specific conditions responsible for the extra years of life lost in the United States are shown in Figures 1-15 and 1-16. Three causes—homi- cide, motor vehicle accidents, and nontransportation-related injuries—each contribute between 16 and 19 percent of the U.S. shortfall for males, and suicide contributes another 4 percent. Thus, deaths from injury of one form or another contribute the majority, 57 percent, of the excess mortal- ity among American males under age 50. This is especially noteworthy given that mortality below age 50 accounts for the bulk of the U.S. male disadvantage in longevity. Noncommunicable diseases among men are also not trivial, accounting for 18 percent of the U.S. excess in years of life lost, with 8 percent coming from cardiovascular disease and 10 percent from all other noncommunicable diseases.

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SHORTER LIVES 53 Mean of Other Countries United States Maternal condiƟons Communicable and nutriƟonal condiƟons IntenƟonal injuries Drug-related causes Perinatal condiƟons UnintenƟonal injuries Cardiovascular disease (CVD) Noncommunicable diseases, excluding CVD All causes 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 Years of Life Lost Before Age 50 FIGURE 1-14  Years of life lost before age 50 due to specific causes of death among females in 17 peer countries, 2006-2008. Fig1-14.eps NOTES: Drug-related and other causes are not always mutually exclusive. The largest areas of overlap occur between drug-related causes and noncommunicable diseases and injuries. For example, drug-related digestive diseases (e.g., alcoholic liver disease) and drug-related neuropsychiatric disorders are also included in the noncommuni- cable disease category. Suicide and homicide by drugs fall under both drug-related causes and intentional injuries, and accidental drug overdoses fall under both drug- related causes and unintentional injuries. The drug-related causes category is included to illustrate the excess years of life lost from drug-related causes of death in the United States relative to other countries. Data for this figure come from the Human Mor- tality Database (downloaded July 18, 2011, last updated July 13, 2011); the WHO Mortality Database (downloaded July 18, 2011, last updated March 25, 2011); and Statistics Canada (downloaded July 22, 2011, data released February 23, 2010). SOURCE: Adapted from Ho and Preston (2011, Figure 6). The causes of the excess years of life lost by U.S. females are more diverse. Homicide, motor vehicle accidents, and nontransportation-related accidents also play an important role, contributing a total of 37 percent of the excess years of life lost in the United States. For intentional injuries, the excess comes from homicide alone, because U.S. women lose fewer years of life to suicide than women in other peer countries. Noncommunicable diseases are more important for women, contributing 29 percent of the U.S. excess in years of life lost compared with 18 percent for men. Of this 29 percent, 9 percent comes from cardiovascular disease and the remaining 20 percent from all other noncommunicable diseases. Perinatal conditions also affect females more than males: they contribute 19 percent to the U.S. excess in years of life lost among females and 13 percent among males (Ho and Preston, 2011).

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54 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE Communicable Cardiovascular diseases (CVD), diseases, excluding 8% HIV, 2% HIV, 2% Residual, Noncommunicable diseases, excluding 7% CVD, 10% Suicide, 4% Perinatal Homicide, 19% condiƟons, 13% TransportaƟon- related accidents, 18% NontransportaƟon- related accidents, 16% FIGURE 1-15  Contribution of cause-of-death categories to difference in years of Fig1-15.eps life lost before age 50 between the United States and the mean of 16 peer countries, males, 2006-2008. NOTES: Because of the overlap with other cause-of-death categories, drug-related causes are not included as a separate category in this figure, which shows mutually exclusive contributions of specific causes of death (see NOTES in Figure 1-13). Data for this figure come from the Human Mortality Database (downloaded July 18, 2011, last updated July 13, 2011); the WHO Mortality Database (downloaded July 18, 2011, last updated March 25, 2011); and Statistics Canada (downloaded July 22, 2011, data released February 23, 2010). SOURCE: Adapted from Ho and Preston (2011, Figure 7). INFLUENCE OF EARLY DEATHS ON LIFE EXPECTANCY AT BIRTH It is useful to consider how much of the U.S. disadvantage in life expec- tancy at birth is attributable to deaths before or after age 50. That is: does the average American newborn have a shorter life expectancy than peers in other countries because of the diseases of old age or because of threats to health earlier in life? Answering this question involves a calculation that combines the actual years of life lost before age 50 (as shown in Figures 1-11 and 1-12) with the probability of surviving to age 50 (as shown in Fig- ures 1-7 and 1-8). The latter is included because individuals who die before age 50 obviously forfeit all years of life beyond that age, but the forfeiture

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SHORTER LIVES 55 Cardiovascular diseases (CVD), Communicable 9% diseases, excluding HIV, 3% HIV, 2% Residual, 9% Suicide, 1% Noncommunicable diseases, excluding Homicide, 7% CVD, 20% TransportaƟon- related accidents, 16% Perinatal condiƟons, 19% NontransportaƟon- related accidents, 14% FIGURE 1-16  Contribution of cause-of-death categories to difference in years of life lost before age 50 between theFig1-16.eps the mean of 16 peer countries, United States and females, 2006-2008. NOTES: Because of the overlap with other cause-of-death categories, drug-related causes are not included as a separate category in this figure, which shows mutually exclusive contributions of specific causes of death (see NOTES in Figure 1-14). Data for this figure come from the Human Mortality Database (downloaded July 18, 2011, last updated July 13, 2011); the WHO Mortality Database (downloaded July 18, 2011, last updated March 25, 2011); and Statistics Canada (downloaded July 22, 2011, data released February 23, 2010). SOURCE: Adapted from Ho and Preston (2011, Figure 8). is attributable to death before age 50. The calculation reveals that about two-thirds of the U.S. shortfall in life expectancy in 2007 relative to France and Japan—two very high-performing countries—were attributable to high U.S. mortality after age 50 (Ho and Preston, 2011). A somewhat different picture emerges when the results are separated by sex and the comparison is made with the composite of the other 16 peer countries. Deaths after age 50 contributed to 58 percent of the U.S. short- fall in newborn life expectancy among females but only to 32 percent of the shortfall among newborn males (Ho and Preston, 2011). That is, most of the life expectancy difference among males is attributable to high U.S. mortality before age 50. This finding also implicates intentional and unin-

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56 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE tentional injuries, discussed above, which together account for a majority of the excess in U.S. male mortality before age 50. CONCLUSIONS Vital statistics paint a definitive and vivid portrait of the relative posi- tion of the United States in cross-national health comparisons. On nearly all indicators of mortality, survival, and life expectancy, the United States ranks at or near the bottom among high-income countries. Its poor performance pertains to both sexes, to all ages below 75, to white non-Hispanics as well as to the population as a whole, and to the most important causes of death. Although the poor ranking of U.S. life expectancy at birth is partly attributable to relatively higher mortality rates after age 50, that is not the entire story: the United States compares unfavorably on mortality rates up to age 75. U.S. performance is particularly poor from birth to age 50, rank- ing near the bottom among peer countries. These findings and those from previous research, including the prior National Research Council (2011) report, suggest that throughout the life course people living in the United States fare worse than their peers, except at the oldest ages. The data reported here highlight specific threats to health early in life, beginning in infancy: the United States has the lowest life expectancy at birth of the 17 peer countries the panel examined. Accidents (unintentional injuries), many of which involve adolescents and young adults, claim about 30 percent of the years lost before age 50, and suicides and violence also contribute to deaths in this age group. Noncommunicable diseases become more of a factor after age 30. In summary, there is a growing mortality gap between the United States and comparable high-income countries. If the United States experienced the same rates of mortality due to unintentional injuries and noncommunicable diseases as do other peer countries, then almost two-thirds of the excess losses in years of life lost before age 50 would be eliminated (Palloni and Yonker, 2012). To add to the analysis in this chapter, which focuses on life expectancy, the next chapter examines how the United States compares with other countries in terms of quality of life, specifically, health status, the prevalence of disease, and the incidence of injuries.