About Me

I am Associate Professor and Chair of the History Department at the University of Massachusetts-Dartmouth. I am also the Academic Director of the Clemente Course in the Humanities, in New Bedford MA. Author of "Social Security and the Middle Class Squeeze" (Praeger, 2005) and the forthcoming "Saul Alinsky the Dilemma of Race in the Post-War City" (University of Chicago Press), my teaching and scholarship focuses on American urban history, social policy, and politics. I am presently writing a book on home ownership in modern America, entitled "Castles Made of Sand? Home Ownership and the American Dream." I live in Providence RI, where I have served on the School Board since March 2015. All opinions posted here are my own.

Thursday, January 10, 2013

The real American exceptionalism: our lives are stressful, unhealthy, and short

Back in October 2012, New York Times writer Scott Shane described the idea of 'American exceptionalism' as an "opiate,“ inducing a kind of hubristic national stupor that prevents us from seeing things as they truly are.

The idea that God or history has uniquely blessed the United States, justifying a proselytizing posture toward the rest of the world, is an old one.  It returned to our national discourse in the last couple of years, when conservatives accused President Obama of backsliding in his belief that Americans are the 'chosen people.'

As Shane argued, the idea that American identity is a kind of calling can have positive consequences:  “this national characteristic...may inspire some people and politicians to perform heroically, rising to the level of our self-image."  But it can also be deeply dysfunctional, as politicians of all stripes trip over one another to reassure Americans "that their country, their achievements and their values are extraordinary," while profound problems are left unaddressed.

American patriotism has always -- and uniquely -- had this 'Stuart Smalley' taint to it, but as we collectively whistle through the graveyard of apparent national decline, it seems to have over-ripened a bit.  If John Winthrop's idea of America as the 'city on a hill' drawing the "eyes of all people" was to be more than just an expression of jingoism, it demanded (and demands) a delicate balance between description and aspiration.  When it morphs into mere self-affirmation, however, we Americans become a danger to ourselves -- and to others, who increasingly keep their eyes on us for fear of what might happen if they don't.

Sadly, as a recent international health study bracingly reminds us, most of the ways in which the United States is exceptional today are negative.

The Institute of Medicine just released a study comparing American health care outcomes to other industrialized countries.  And all rhetoric about the U.S. having the 'best health care system in the world' aside, the realities are shocking.  Despite spending far more per capita on health care than any other nation, the data make it abundantly clear that the American way of life has become nasty, increasingly brutish, and comparatively short.

The optimistic takeaway here is that almost everything described below is attributable to (and capable of being ameliorated by) public policy -- in health, but in much broader areas as well.  In other words, if we can once again rediscover our aspirational identity as Americans, change is possible.

Physician Steven Woolf, a professor at Virginia Commonwealth University, chaired the panel that wrote the report.  He and his co-authors were "stunned by the findings."  Americans "have a long-standing pattern of poorer health that is strikingly consistent and pervasive" over a person's lifetime, the study found.

The U.S. is at or near the bottom in virtually every health outcome:  life expectancy, obesity, diabetes, heart disease, and homicide.  We have much higher rates of death before the age of 50, accounting for most of the gap between the United States and our peer nations.

According to the report, most of these poor health outcomes are attributable to poor childhood health.

The USA has had the highest infant mortality rate of any developed country for several decades, due partly to a high rate of premature birth and low birth weight.  Dr. Woolf and his colleagues also note that the U.S. has by far the highest rate of child poverty, though they don't really touch on its role as a possible cause. 

Here is a graphic representation of the infant mortality gap:

This gap, interestingly, has a history.  

The gap between the United States and its peer nations was relatively wide in 1950s and early 1960s, and then rapidly closed.  Why did it close, and so quickly?  Policy -- the 'War on Poverty,' including Medicare/Medicaid, among other programs, which for the first time began to connect millions of Americans to the health care system (and to food) on a relatively consistent basis. 

And then, right around 1980, the gap re-emerged.  This coincided, not surprisingly, with Reagan-era cuts in public health and social programs; but it also coincided with an ongoing increase in economic inequality and insecurity.  Since 2000, the gap between the U.S. and its peers has expanded.  While infant mortality rates among African-American and Hispanics are high, this doesn't explain the gap -- white Americans have higher comparable rates as well.

In short, while we have continued to make progress over the past two decades, our peers have had much greater success:  “although U.S. infant mortality declined by 20 percent between 1990 and 2010,” the report notes, “other high-income countries experienced much steeper declines and halved their infant mortality rates over those two decades.”

The report doesn't really offer any explanations for the infant mortality gap, or for the poor health performance of the U.S. more generally, beyond behavioral factors like drug abuse, calorie consumption, not wearing seat belts, and the ubiquity of handgun violence.

I'm not a health expert, but I do think we need to consider one factor:  inequality.

While economic inequality within nations wasn't the focus of the Institute of Health report, we know from research by epidemiologists Richard Wilkinson and Kate Pickett that it strongly correlates with (and is reproduced by) health outcomes -- such as infant mortality (see above).

This is true in two senses.

First, nations with higher rates of economic inequality tend to have poorer health outcomes across the class structure -- in other words, while health outcomes are better the richer or more educated one is, they will still be lower than those of comparably placed people in more equal countries.  The Institute of Health report confirms this.

Second, economic (and educational) inequality and health outcomes are strongly correlated within societies.  In the U.S., life expectancy for white women without a high school diploma is 73.5 years, compared with 83.9 years for white women with a college degree or more.  For white men, the gap is even larger: 67.5 years for the least educated white men compared with 80.4 for those with a college degree or better.

Because the United States is drastically more unequal than any other comparable nation, the socio-economic gradient is much sharper here -- and its getting worse.  Indeed, we now have evidence that the life span of the least educated white Americans has actually contracted, falling a full four years since 1990.  The numbers are worse for women.  Some of this is attributable to changes in the labor market:  the share of working-age adults with less than a high school diploma who did not have health insurance rose to 43 percent in 2006, up from 35 percent in 1993.  While full implementation of the Affordable Care Act in the coming years may help somewhat, the deeper problems of rising inequality and economic insecurity -- and the debilitating stress and anxiety that accompany them -- remain.

Poor health outcomes, as well as inequality, are greatly exacerbated in the U.S. by our social geography, and its intersection with the nation's original sin of race.  American metropolitan areas have become increasingly segregated by income over the past two decades.  We don't yet have a full picture of the health consequences of this trend, though it certainly is both a cause and a consequence of growing inequality during the same period.

But we do know the health consequences of America's stubbornly persistent pattern of racial segregation.  African-Americans not only have poorer health outcomes than whites overall; this is true even when income and education are held constant.  More than 100 studies over the past decade confirm that racism acts as a classic chronic stressor, with serious physiological consequences: higher blood pressure, elevated heart rate, increases in the stress hormone cortisol, suppressed immunity.  Chronic stress is also known to encourage unhealthy behaviors, such as smoking and eating too much, that themselves raise the risk of disease.  Most of these investigations have been done in the United States, but a growing body of literature originates elsewhere.  "Across multiple societies, you're finding similar kinds of relationships," David Williams, a sociologist at the Harvard School of Public Health, told the Boston Globe.  "There is a phenomenon here that is quite robust."

Racism also appears to have an impact on fetal and infant health, setting off a likely cascade of negative consequences.

Epidemiologists James W. Collins, Jr. and Richard J. David have uncovered a disturbing fact:  American-born black women are significantly more likely to have low birth weight babies than white women are, regardless of income level or education.  The cause, they argue, is steady and life-long exposure to racism and its consequences.  Since low birth weight correlates strongly with poor health (and educational) outcomes later in life, the relationship between race, place and health is clearly a big factor in the reproduction of racial inequality in the U.S.

This relationship has been confirmed more recently in a widely publicized study in the January 2013 issue of the Journal of the American Medical Association, on racial segregation and lung cancer.  After controlling for income and smoking rates, Dr. Awori Hayanga and his colleagues found that lung cancer mortality rates (a ratio of deaths to a population) were about 20 percent higher for blacks who lived in the most segregated American counties, than for blacks living in the least segregated counties.  The more segregated the community, the higher the mortality rate for blacks -- and, disturbingly, the lower the rates were for whites.  They surmised that differential access to health insurance and relevant and timely treatment were largely at fault.  The research of Collins and David also directs us towards the stressors of racism itself, which are in part rooted in America's unequal racial geography.

“If you want to learn about someone’s health, follow him home,” Dr. Hayanga, a heart and lung surgeon at the University of Pittsburgh Medical Center, told the New York Times.   This message -- about the relationship between place, health, and inequality -- was perhaps most powerfully conveyed for an American popular audience by the award-winning documentary Unnatural Causes.

In other words, our unequal and insecure American way of life is making us sick -- and more unequal.

While the mechanisms that connect inequality with poor health outcomes are many and hard to disentangle, it seems clear that stress and insecurity are critical.  Both affect the cardiovascular and immune systems, and both are found in abundance and in greater numbers in unequal societies -- and their effects are devastating on the young in particular.

Thomas McInerny, president of the American Academy of Pediatrics, reacted to the Institute of Health study by pointing to recent research on the long-term impact of "toxic stress" on the health and cognitive development of babies and toddlers.   "It's becoming increasingly clear that the first 1,000 days of life are critically important for children's development, and can determine the course of their life span from then on," McInerny says. "Investing in children in the first three years of life provides higher returns, for improving their productivity as adults, compared to intervening later."

Back in 2007, UNICEF put together an index of child well-being.  It measured material and educational factors, health and safety, peer and family relationships, surveys of subjective well-being, and behavioral risks.  When Wilkinson and Pickett lined this index up with rates of income inequality, they found something striking:  the more unequal a society is, the worse its rates of child well-being -- not just among poor children, but overall:

These correlations and comparisons make one thing clear:  America's poor health outcomes, particularly for our children, can be ameliorated.  Why?  Because the differences between the U.S. and its peers, ultimately, are policy differences -- and thus are amenable to collective action.  We can make America healthier (and more productive) by making it less unequal, and by investing in pre-natal care, early childhood health, and high quality and universal pre-school.  "We already know what to do," Dr. Woolf says. "It's more a matter of having the resolve and resources to actually do it."

Notwithstanding the false scarcity of our current austerity politics, we have the resources.

Notwithstanding the libertarian and narcissistic braying of the privileged, our well-being is ultimately inseparable from that of our fellow Americans.

Whether we have the resolve to see this will ultimately determine whether the term 'American exceptionalism' serves to damn or praise our national experiment.

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