An American tragedy

Our view: Despite living in the world's richest nation, too many U.S. children die from easily preventable illnesses due to disparities of race, class, income and education

May 25, 2010

The U.S. is the world's richest nation, yet proportionately more children die here before reaching the age of 5 than in some developing countries. That should be unacceptable in a nation that prides itself on having the best health care system on the planet. But according to the authors of two recent reports — one global, the other local — it's a price we've chosen to pay for the growing inequality of our society.

On Monday, population health researchers at the Institute for Health Metrics and Evaluation at the University of Washington reported that the U.S. now ranks 42nd worst among the world's nations in child mortality rates, down from 29th place just 20 years ago. The next day, a study by the Baltimore City Health Department warned that residents with low incomes and little education were much more likely to become sick or die from a variety of ailments than their better-educated, more-affluent neighbors.

Both reports suggest that instead of leading the rest of the world in health care, the country and its cities have been standing still or even going backward on these critical indicators of well-being.

The study of global child mortality rates, published in the British medical journal The Lancet, found the U.S. now lags behind most of Europe as well as countries such as Singapore, Malaysia, Serbia, Chile and Cuba, all of which are reducing child deaths more quickly than we are. And the real tragedy is that most youngsters in the U.S. who die before age 5 succumb to illnesses that are easily preventable with proper medical care.

Alan D. Lopez, one of the authors of the report, said the results point to systemic failures in the American health care system, which is unsurpassed for the treatment of serious illnesses such as heart disease, cancer and stroke but gets poor marks for the kind of preventive medicine that keeps people from getting sick. The problem is especially acute among disadvantaged, less well-educated groups, who even if they can afford to buy health care may not know how to access services or use them effectively.

The city health department report echoed those findings on the local level when it found that although mortality rates in the city and state were generally improving, there remained stark disparities along race, class and gender lines. Black mortality was nearly a third higher than that of whites, and mortality among males was almost two-thirds higher than among women. But the biggest disparity was between those with a high school education or less and those with a bachelor's degree or higher; less-educated residents were more than 2 1/2 times more likely to die than their college-educated peers.

Inequalities of race, class, income and education have been growing steadily in American society for decades, said Mr. Lopez, who cites such disparities as the main reason the U.S. hasn't kept up with the rapid decline in child mortality rates worldwide — and, by implication, why those same disparities turn up in Baltimore's mortality rates.

Although the U.S. rate of 6.7 child deaths per 1,000 live births this year represents a 42 percent drop from 1990, it's still twice that of most of the world's wealthy nations, and it falls far short of the two-thirds reduction some countries have achieved.

Despite its vast resources, the U.S. is no better at reducing child deaths than Kazakhstan, Sierra Leone or Angola. Similarly, the infant mortality rate in parts of Baltimore City has long been higher than that in many of the world's most impoverished developing nations.

How can it be that Americans spend, on average, twice as much on health care as Europeans, yet overall are less healthy and die earlier? Not only are infant, child and adult mortality rates higher than in comparably rich countries, the rate of deaths among women giving birth in the U.S. has actually increased over the past two decades.

One problem is that our dollars are spent overwhelmingly on treating disease rather than on keeping people healthy. Among disadvantaged groups, families often delay seeking treatment for a sick child or fail to take advantage of preventive measures such as vaccines and regular check-ups until a crisis develops. And despite living in a country with the best health-care system in the world, many people still fail to seek treatment because they can't get access to health services they can afford.

The recently enacted health care reform law will extend health care benefits to millions of Americans who previously were shut out of the system. But simply expanding insurance coverage won't be enough if it doesn't give health care providers incentives to improve the quality of services for the most disadvantaged citizens and make it easier for Americans to get preventive care.

The aim should be not only to provide universal access to care but also to teach people to use the health services that are available earlier and more effectively. The country won't see real progress on eliminating the disparities that are crippling our health care system until the rates of mortality among infants and children, adults and mothers giving birth all start coming down at the same time.

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