of its wealthy European counterparts. However, there is little empirical evidence to link these distinctive conditions to adverse health outcomes.2

The panel recognized the need to identify and organize the leading factors that could plausibly contribute to cross-national health differences, which naturally led to the question of what factors affect health in the first place. This chapter begins by examining the determinants of health and then turns to two issues that helped us frame our approach in looking for potential explanations for the U.S. health disadvantage: the need for a social-ecological perspective that reflects both upstream and downstream influences on health and the need for a life-course perspective that considers influences over time. These concepts were instrumental in persuading the panel to map out a systematic approach to examining the role of health systems (Chapter 4), individual behaviors (Chapter 5), social factors (Chapter 6), the environment (Chapter 7), and policies and social values (Chapter 8).


Attempting to explain the cause(s) of the U.S. health disadvantage leads one to the question of what causes health and disease, a topic that social epidemiologists and other social scientists have studied for decades. Some factors are innate biological characteristics, such as age, sex, and genes, that generally cannot be modified.3 Age and other standard sociodemographic factors are highly predictive of health outcomes but, as documented in Part I, the U.S. health disadvantage persists even after adjusting for these factors.

Both the general public and policy makers often assume that health is determined primarily by health care (Robert and Booske, 2011). Thus, it is reasonable to wonder if the U.S. health disadvantage reflects a deficiency in the U.S. health care system. For example, in contrast to many other countries, a large proportion of the U.S. population is uninsured (National Center for Health Statistics, 2012). But even if health care plays some role, decades of research have documented that health is determined by far more than health care. The seminal article by McGinnis and Foege (1993) highlighted the important role of health behaviors. By some estimates, approximately 40 percent of all deaths in the United States are associated


2Subsequent parts of this report do discuss the role of rural conditions in the United States in contributing to health disadvantages, such as access to medical care.

3Although it is possible that differences in population gene pools or other innate biological characteristics contribute to observed cross-national health differences, these and other nonmodifiable risk factors receive little emphasis in this report due to their unlikely contributory role. However, Chapter 6 does address the important topic of gene-environment interactions and the potential role of epigenetics as a causal pathway for social and environmental influences on health.

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