Two things can be said with confidence about life expectancy in the world today. One is that it is really helpful to be rich. If you are middle-aged, exceptionally well-off, and from almost any high-income nation, the chances are excellent that you will live into your late eighties. Someone who is otherwise identical to you but poor—exercises as devotedly, sleeps as many hours, eats a similarly healthy diet, but just has less money in the bank—can expect to die between ten and fifteen years sooner. That’s a lot of difference for an equivalent lifestyle, and no one is sure how to account for it.
The second thing that can be said with regard to life expectancy is that it is not a good idea to be an American. Compared with your peers in the rest of the industrialized world, even being well-off doesn’t help you here. A randomly selected American aged forty-five to fifty-four is more than twice as likely to die, from any cause, as someone from the same age-group in Sweden. Just consider that. If you are a middle-aged American, your risk of dying before your time is more than double that of a person picked at random off the streets of Uppsala or Stockholm or Linköping. It is much the same when other nationalities are brought in for comparison. For every 400 middle-aged Americans who die each year, just 220 die in Australia, 230 in Britain, 290 in Germany, and 300 in France.
These health deficits begin at birth and go right on through life. Children in the United States are 70 percent more likely to die in childhood than children in the rest of the wealthy world. Among rich countries, America is at or near the bottom for virtually every measure of medical well-being—for chronic disease, depression, drug abuse, homicide, teenage pregnancies, HIV prevalence. Even sufferers of cystic fibrosis live ten years longer on average in Canada than in the United States. What is perhaps most surprising is that all these poorer outcomes apply not just to underprivileged citizens but to prosperous white college-educated Americans when compared with their socioeconomic equivalents abroad.
This is all a touch counterintuitive when you consider that America spends more on health care than any other nation—two and a half times more per person than the average for all the other developed nations of the world. One-fifth of all the money Americans earn—$10,209 a year for every citizen, $3.2 trillion altogether—is spent on health care. It is the nation’s sixth-largest industry and provides one-sixth of its employment. You can’t get health care any higher on a national agenda without putting everyone in a white coat or uniform.
Yet despite the generous spending, and the undoubted high quality of American hospitals and health care generally, the United States comes just thirty-first in global rankings of life expectancy, behind Cyprus, Costa Rica, and Chile, and just ahead of Cuba and Albania.
How to explain such a paradox? Well, to begin with, and most inescapably, Americans lead more unhealthy lifestyles than most other people, and that is true at all levels of society. As Allan S. Detsky observed in The New Yorker, “Even wealthy Americans are not isolated from a lifestyle filled with oversized food portions, physical inactivity, and stress.” The average Dutch or Swedish citizen consumes about 20 percent fewer calories than the average American, for instance. That doesn’t sound massively excessive, but it adds up to 250,000 calories over the course of a year. You would get a similar boost if you sat down about twice a week and ate an entire cheesecake.
Life in America is also much riskier, especially for young people. A U.S. teenager is twice as likely to be killed in a car accident as a young person in a comparable country abroad and is eighty-two times more likely to be killed by a gun. Americans drink and drive more often than almost anybody else and wear seat belts less devotedly than everyone in the rich world but the Italians. Nearly all advanced nations require helmets for all motorcyclists and passengers. In America, 60 percent of states don’t. Three states have no helmet requirements at any age, and sixteen others require them only for riders aged twenty or under. Once citizens of those states reach their maturity, they can let the wind, and all too often the pavement, run through their hair. A helmeted rider is 70 percent less likely to suffer a brain injury and about 40 percent less likely to die in a crash. In consequence of all these factors, the United States records a really quite spectacular 11 traffic deaths per 100,000 people every year, compared with 3.1 in the United Kingdom, 3.4 in Sweden, and 4.3 in Japan.
Where America really differs from other countries is in the colossal costs of its health care. An angiogram, a survey by The New York Times found, costs an average of $914 in the United States, $35 in Canada. Insulin costs about six times as much in America as it does in Europe. The average hip replacement costs $40,364 in America, almost six times the cost in Spain, while an MRI scan in the United States is, at $1,121, four times more than in the Netherlands. The entire system is notoriously unwieldy and cost-heavy. America has about 800,000 practicing physicians but needs twice that number of people to administer its payments system. The inescapable conclusion is that higher spending in America doesn’t necessarily result in better medicine, just higher costs.
One commonly accepted yardstick for quality of health care is five-year cancer survival rates, and here there are great disparities. For colon cancer, five-year survival rates are 71.8 percent in South Korea and 70.6 percent in Australia, but just 64.9 percent in the United States. For cervical cancer, Japan comes out on top at 71.4 percent, closely followed by Denmark at 69.1 percent, with the United States at a middling 67 percent. For breast cancer, the United States tops the world rankings with 90.2 percent of victims still alive after five years, just ahead of Australia at 89.1 percent and considerably ahead of Britain at 85.6 percent. It is worth noting that overall survival figures can mask a lot of troubling ethnic disparities. For cervical cancer, for instance, white women in the United States have a 69 percent five-year survival rate, which puts them near the top of world rankings, while black women have just a 55 percent survival rate, leaving them close to the bottom. (That is all black women, rich and poor alike.)
The upshot is that Australia, New Zealand, the Nordic countries, and the wealthier nations of the Far East all do really well, and other European nations do pretty well. For the United States, the result is, at best, decidedly mixed. For Britain, cancer survival rates are grim and ought to be a matter of national concern.
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Nothing in medicine is simple, however, and there is an additional consideration that profoundly complicates results almost everywhere: overtreatment.
It hardly needs pointing out that for most of history the focus of medicine has been to make sick people better, but now increasingly doctors devote their energies to trying to head off problems before they even arise, through programs of screening and the like, and that changes the dynamics of care entirely. There is an old joke in medicine that seems especially apt here:
Q. What is the definition of a well person?
A. Someone who hasn’t been examined yet.
The thinking behind a great deal of modern health care is that you cannot be too careful and you cannot have too many tests. Surely it is better, the logic runs, to check out and deal with or eliminate any potential problems, however remote, before they have a chance to turn into something bad. The drawback with this approach is what are known as false positives. Consider screening for breast cancer. Studies show that between 20 and 30 percent of women given the all clear after a breast cancer screening actually had tumors. But equally, and contrarily, screenings often catch tumors that needn’t cause concern, and result in interventions that aren’t actually necessary. Oncologists use a concept called sojourn time, which is the interval between when a cancer is caught by screening and when it would become evident anyway. Many cancers have long sojourn times and progress so slowly that the victims almost always die of something else before the cancer gets them. A study in Britain found that as many as one in three women with breast cancer receive treatments that may leave them mutilated and even possibly shorten their lives quite unnecessarily.