When it comes to life expectancy, the US is far from one nation. According to a new analysis of health disparities, there are in fact eight Americas – some of them more reminiscent of developing countries than a global superpower.

Life expectancy in the US varies widely by race and socioeconomic status. Now researchers led by Majid Ezzati of the Harvard School of Public Health have thrown geography into the mix. They examined death records for people in more than 3000 counties and divided the population into eight groups ac-cording to race, income and geographic location.

Some groups were confined to a relatively small area – Native Americans in the western states, for example. Another group, labelled “Middle America”, was mostly white, fairly wealthy, and accounted for the majority of the population.

There were dramatic differences in life expectancies: in 2001, urban black male babies could expect to live for just 68.7 years, whereas for Asian females the figure was 86.7. Such differences across the “eight Americas” have not narrowed over the past two decades (see graphic).


Rural south to inner cities

International comparisons reinforce the picture of a deeply divided country. When Ezzati examined the probability of dying during youth (15 to 44 years) or middle age (45 to 64), the figures for black men – whether in the rural south or inner cities – looked more like those seen in the developing world than in other rich countries.

In contrast, the results for Asians and Middle Americans were similar to those of the UK and Japan.

Income and access to healthcare explained little of the variation. For instance, poor white people living in the northern plains are similar to those in the Mis-sissippi valley and Appalachia by these measures, yet tend to live longer.

While political conservatives may seize on these results to argue that taxing high earners to improve welfare and healthcare for the poor would be unpro-ductive, Ezzati says that would be a misinterpretation. “We’re not trying to say that broader socioeconomic factors don’t matter,” he says. Indeed, studies controlling for other causes have shown that low income is linked to poor health.

Ezzati is focusing on the conditions that cause early deaths in the low-life-expectancy groups. These include injuries and cardiovascular disease linked to risk factors such as obesity, tobacco and alcohol. He believes public health campaigns targeted at particular groups could yield big returns. Others argue that these may not be enough without stimulating economic development in high-risk communities.

Journal reference: Public Library of Science Medicine (DOI: 10.1371/journal.pmed.0030260).