apply to only some of the health conditions for which the United States is experiencing a disadvantage?13

•   To what extent do epigenetic processes help explain the links between environmental factors and the biological outcomes observed in the U.S. health disadvantage?

•   To what extent does the United States lack “protective factors” that buffer the effects of adverse factors, from poverty to adolescent pregnancy?

Stable Funding

Conditions that encourage investigators to commit themselves to long-term lines of inquiry require confidence in a stable source of funding for competitive applications. Solicitations for proposals that are expected to achieve specific aims within 3-5 years discourage ambitious enterprises, like the National Children’s Study, which follow individuals over their life courses. Another limitation is lack of “ownership” of the problem: no entity in government is responsible for studying the U.S. health disadvantage.

Creating an institutional home for such research in the Office of the Director of NIH would give the effort a strategic position to coordinate the research portfolios across the agency’s 27 institutes and centers, to support inclusion of measures from OECD and European studies in relevant NIH-funded studies, and to solicit proposals for developing measures, data collection instruments, and sampling and administration methodologies. Other potential institutional homes include the Office of Global Health at CDC and the U.S. Department of State. Academic centers of excellence, such as the CDC prevention centers, or academic institutions with expertise on social determinants of health, could be further expanded with appropriate funding to study the underlying causes of the U.S. health disadvantage.


Perhaps the largest impediments to furthering research on comparisons of cross-national health are the data collection capacities of countries. Not all countries are positioned, or can afford, to administer large-scale population surveys on an annual basis and to maintain publicly available data repositories for research use by the scientific community. Impediments include limited budgets, pragmatic and bureaucratic constraints, and the absence of international collaborative arrangements. In the United


13Further research is needed to know whether the higher rates of disease for certain conditions in the United States, such as HIV infection, are differentially distributed across social classes.

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