•   Individual behaviors may contribute to the overall disadvantage, but studies show that even Americans with healthy behaviors, for example, those who are not obese or do not smoke, appear to have higher disease rates than their peers in other countries.

•   The problem is not confined to socially or economically disadvantaged Americans; as noted above, several recent studies have suggested that even Americans with high socioeconomic status may experience poorer health than their counterparts in peer countries.

Many conditions that might explain the U.S. health disadvantage—from individual behaviors to systems of care—are also influenced by the physical and social environment in U.S. communities. For example, built environments that are designed for automobiles rather than pedestrians discourage physical activity. Patterns of food consumption are also shaped by environmental factors, such as actions by the agricultural and food industries, grocery store and restaurant offerings, and marketing. U.S. adolescents may use fewer contraceptives because they are less available than in other countries. Similarly, more Americans may die from violence because firearms, which are highly lethal, are more available in the United States than in peer countries. A stressful environment may promote substance abuse, physical illness, criminal behavior, and family violence. Asthma rates may be higher because of unhealthy housing and polluted air. In the absence of other transportation options, greater reliance on automobiles in the United States may be causing higher traffic fatalities. And when motorists do take to the road, injuries and fatalities may be more common if drunk driving, speeding, and seatbelt laws are less rigorously enforced, or if roads and vehicles are more poorly designed and maintained.

The U.S. health disadvantage probably has multiple explanations, some of which may be causally interconnected, such as unemployment and a lack of health insurance. Other explanations may share antecedents, especially those rooted in social inequality. Still others may have no obvious relationship, as in the very distinct causes of high rates of obesity and traffic fatalities. The relationships between some factors may develop over time, or even over a person’s entire life course, as when poor social conditions during childhood precipitate a chain of adverse life events. Turmoil and risk-taking in adolescence can lead to subsequent setbacks in education or employment, fomenting life-long financial instability or other stresses that inhibit healthy life-styles or access to health care. In some cases, the explanation may simply be that the United States is at the leading edge of global trends that other high-income countries will follow, such as smoking and obesity.

Given the pervasive nature of the low U.S. rankings—on measures of health, access to care, individual behaviors, child poverty, and social



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