skip navigation nih record
Vol. LX, No. 2
January 25, 2008

previous story

next story

The English vs. The American Patient
Health Disparity Paper Spurs Debate

On the front page...

When JAMA published an article in May 2006 reporting that Americans in late middle age are “sicker” than their English counterparts, there was a swift, intense reaction.

“How could this be?” wrote a columnist in the Washington Post. “The British diet is terrible.” And, “Forget vitamin D: The English rarely see the sun in a dank climate where the national dress is a raincoat.”

But according to Dr. James Smith, a study coauthor and senior economist with the RAND Corp. who shared this quote in a recent presentation here, the findings are true. In fact, even as critics have posed potential issues with the report, further study has only made the case for the article stronger, Smith believes.


Dr. James Smith

“We were convinced when we wrote it,” he said. “But I’m even more convinced now that what we’re talking about is something real…that in middle age, we Americans are sicker than middle-aged English people.”

He used the article as a takeoff point to discuss reactions to the study and to illuminate some reasons for the discrepancy.

For the article, the authors analyzed data from non-Hispanic, white residents of both countries ages 55 to 64, using two comparable health surveys funded by NIA: the U.S. Health and Retirement Survey and the English Longitudinal Study of Aging. They focused on chronic diseases represented in both surveys including diabetes, hypertension, heart disease, myocardial infarction, stroke, lung disease and cancer. And “lo and behold,” Smith said, “we are number one in all of these diseases by a very large amount.”

They paired this self-reported information with biomarker data, and again, “we were always in a bad state…compared with the English.” They also controlled for risk factors like smoking, drinking and obesity. Still, we came out worse.

Did the authors miss some critical factors in their comparison? Some people thought so. Smith said one frequent reaction concerned mortality. If we’re so much sicker, people asked, why is our life expectancy so similar? The reason, Smith argued, is that life expectancy is a cumulative measure and death rates are higher in England after age 65. This is intriguing, Smith said, but “there’s nothing about mortality rates that contradicts what we say.”

Another issue was how survey respondents measured their general health status, from excellent or very good to fair or poor. If you look at general health as a measure, Americans seem “in pretty good shape,” Smith said. Unfortunately, this is a poor health measure in an international context because the thresholds of what’s considered good health vary greatly from country to country; Americans tend to be optimistic on this subject. “Given the same objective description of someone’s health, Americans are far more likely to say a person’s in excellent or very good health than [people in] any industrialized country we have studied,” he said.

NIH director Dr. Elias Zerhouni (l) thanks steering committee members who just completed their rotation as of FY 2007. They are (from l) NIAMS director Dr. Nora Volkow.

Study author Smith (l) and Dr. Ronald Abeles, special assistant to the director of the Office of Behavioral and Social Sciences Research, greet guests before the lecture.

Some critics suggested that certain aspects of English life—their love of tea, say—could make them healthier. But compared to the average rates in other European countries, whether looking at diabetes, cancer or lung disease, we have the same differential as we do with the English. “Fundamentally then, this seems to me to be an American issue and not something unique to any European country,” Smith said.

Others said the authors hadn’t sufficiently considered the impact of obesity. And though Americans have been in the obesity epidemic longer than the English, Smith explained, “even when we go back and look at our rates of obesity in the late 1970s, our diabetes rate was still higher.” While a critical problem, he said, obesity is “simply not enough to explain the difference.”

So what does explain it? The study authors don’t have final answers yet, but they are investigating a few possibilities.

One of the primary issues they’re considering is disease in childhood. Though this research focuses on people in late middle age, the results might reflect health issues that “happened a much longer time ago,” Smith said. Through early survey results, it appears that a strong connection exists between what happened in a person’s childhood and how a person views his or her current health. When data comes back from the English survey, he said, it might be that the corresponding numbers there are lower.

Perhaps even more intriguing are the “social determinants of health,” or the circumstances of where people live and work over their lifetimes. “We found less evidence that the actual workplace is much different in England and America,” Smith explained. “But we found outside of work to be much different, and that [Americans] may be more socially isolated, especially during the work years.” When survey respondents were asked to place themselves on a figural ladder to mark their position in society, the English placed themselves higher. Americans during work years report being lonelier than the English and a great deal of research shows that loneliness can affect health, Smith said. Americans are also less likely to report getting positive support from their spouses, while the English are less likely to report “negative interactions” with a spouse. This social isolation could have a great impact on our health.

As promising as these factors are, Smith said much research remains to be done. It is clear, however, that “the initial questions over whether this was true” no longer exist, Smith believes. “I think it’s really true” that Americans are sicker, he said. The question, still, is why. NIHRecord Icon

back to top of page