HEALTH STATUS OF THE AMERICAN PUBLIC
Among the 30 developed nations that make up the Organization for Economic Cooperation and Development (OECD), the United States ranks near the bottom on most standard measures of health status. (One measure on which the United States does better is life expectancy from the age of 65 years, possibly reflecting the comprehensive health insurance provided for this segment of the population.) Among the 192 nations for which 2004 data are available, the United States ranks 46th in average life expectancy from birth and 42nd in infant mortality.5,6 It is remarkable how complacent the public and the medical profession are in their acceptance of these unfavorable comparisons, especially in light of how carefully we track health-systems measures, such as the size of the budget for the National Institutes of Health, trends in national spending on health, and the number of Americans who lack health insurance. One reason for the complacency may be the rationalization that the United States is more ethnically heterogeneous than the nations at the top of the rankings, such as Japan, Switzerland, and Iceland. It is true that within the United States there are large disparities in health status — by geographic area, race and ethnic group, and cla**.7-9 But even when comparisons are limited to white Americans, our performance is dismal (Table 1). And even if the health status of white Americans matched that in the leading nations, it would still be incumbent on us to improve the health of the entire nation.
PATHWAYS TO IMPROVING POPULATION HEALTH
Health is influenced by factors in five domains — genetics, social circumstances, environmental exposures, behavioral patterns, and health care. When it comes to reducing early d**hs, medical care has a relatively minor role. Even if the entire U.S. population had access to excellent medical care — which it does not — only a small fraction of these d**hs could be prevented . The single greatest opportunity to improve health and reduce premature d**hs lies in personal behavior. In fact, behavioral causes account for nearly 40% of all d**hs in the United States.12 Although there has been disagreement over the actual number of d**hs that can be attributed to obesity and physical inactivity combined, it is clear that this pair of factors and smoking are the top two behavioral causes of premature d**h.