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Perspectives

PERSPECTIVE

U.S. Child Health: What’s Amiss, And What Should Be Done About It?

Abstract

 
This paper addresses the state of health of U.S. children and finds it to be poorer in virtually every way than that of children in other countries. It explores several possible explanations, including population heterogeneity, social (including income) inequality, and inadequacy of the health services system. The latter explanation is found to relate to the underdevelopment of U.S. primary care. In light of the position taken by the World Health Organization regarding the importance of primary care, adopting the recommendations of a new National Research Council/Institute of Medicine report and some changes in health policy could help improve the health of American children.

This paper reviews what is known about the health of U.S. children (particularly in comparison with children in other countries), the way in which personal health services are organized to improve health, the considerable challenges that remain, and the likelihood that they can be surmounted.

The Health Of U.S. Children

Top The Health Of U.S.... Why? The Role Of Primary... Prospects For The Future Editor's Notes NOTES

 
Infant mortality. The most common indicator of child health is infant mortality. In 2000 at least twenty-four countries ranked better than the United States on this measure.² Also, the rate of decline in U.S. infant mortality was poorer than in twenty-six countries in the Organization for Economic Cooperation and Development (OECD). Although some of the international variation in these rates may be attributable to variations among countries in reporting very premature infants as live births, Canada and the Nordic countries, for example, use the same criteria as the United States does, so the low U.S. ranking cannot be explained by differences in statistical practices.³ Moreover, the ranking on U.S. postneonatal mortality was low as well, and this measure is much less sensitive to the issue of very low birthweight. Nor can poor performance be explained by the high prevalence of minority populations with high low-birthweight ratios: Excluding the nonwhite population does not greatly improve the U.S. ranking (twenty-third). The situation is no better for some other age groups. Out of 191 countries, the United States in 1999 ranked thirty-third in its death rate for children under age five (thirty-seventh for females and thirty-first for males).⁴ Out of twenty-six countries, the United States ranked twentieth in its death rate for children ages one to fourteen (twenty-third for injury deaths and fourteenth for non-injury deaths).⁵

Immunizations. The United States also ranks poorly in the percentage of children receiving standard immunizations. Out of 187 countries, in 2001 the United States ranked sixty-eighth in immunizing children against diphtheria-pertussis-tetanus (DPT, three doses by age one); eighty-ninth for polio (three doses by age one); and eighty-fourth for measles (one dose by age one). Also, out of ninety-five countries, the United States ranked forty-sixth for immunizing children against hepatitis B.⁶

U.S. teens. Although there are few other details about the relative health of young children, more is known about teenagers, largely as a result of the international Health Behaviour in School-Aged Children study.⁷ This survey has been conducted every four years since 1985–86 among youths ages eleven, thirteen, and fifteen who self-report. Twenty-eight industrialized countries are ranked; for the U.S. rankings, see Exhibit 1.

Why?

Top The Health Of U.S.... Why? The Role Of Primary... Prospects For The Future Editor's Notes NOTES

 
Why are U.S. children in generally worse health, by all standard indicators, than children in comparably industrialized countries? Explanations related to heterogeneity of the population are not convincing; most countries, including those in Scandinavia, now have diverse populations, particularly in urban areas. Explanations related to risky behavior also are not persuasive; there is less smoking and less alcohol use in the United States than in most of the other comparison countries.⁹

One possible explanation concerns the higher degree of relatively low income in the United States than in the other countries. Indeed, the United States is the most income-inequitable country among the industrialized nations. (Income inequality refers to the incomes of lower-income groups relative to those of upper-income groups.) In the mid-1990s the income of affluent households (having more income than 90 percent of households) with children was six times greater than the income of poor households (having less income than 90 percent of households), whereas it was less than three times as much in most of the other countries.¹⁰ Also, income inequality is growing more quickly in the United States.

Evidence on the relationship between income inequality and health is strong in the United States; most studies show that states and localities that are more income-inequitable have poorer health as measured by a variety of indicators.¹¹ The evidence is less consistent in international comparisons, however.¹² Therefore, income inequality is at least a possible explanation for poorer health within the United States but does not explain why U.S. children are in poorer health than children in other countries.

What might be explanations for the role of income inequality in the United States? One possibility is that policies that permit highly inequitable distribution of income (for example, less progressive taxation) are part of a generally less progressive social welfare policy. The United States has less generous social welfare policies than most comparably industrialized countries.¹³ Because social factors, many of which are responsive to social policy, contribute to both the genesis and the severity/lethality of illnesses, the relationship of income inequality to these other factors could account for its apparently greater influence.

The second possibility is that poorer health may be related to a lack of generosity in health policy. The United States is the only industrialized country to lack universal health insurance. Although health insurance is not directly related to improvements in health, it may be indirectly related through its impact on access to appropriate health services.¹⁴

The Role Of Primary Care

Top The Health Of U.S.... Why? The Role Of Primary... Prospects For The Future Editor's Notes NOTES

 
From an international viewpoint, a strong primary care infrastructure within health systems is recognized as an important strategy for health. The World Health Organization (WHO) has signaled its intention to renew its focus on primary health care.¹⁵

The United States differs from many industrialized countries in the absence of universal access to health services and through its policies that are inimical to primary care. Despite major reports, such as a 1996 Institute of Medicine (IOM) report that recommended a national commitment to primary care, U.S. policies concerning health professional training and payment continue to encourage the growth of other specialties.¹⁶

When WHO in 1978 originally adopted its statement on primary care, it did so without firm scientific evidence of primary care’s utility. Since then, however, such evidence has been accumulating rapidly. The first international study to address the issue demonstrated that the stronger the primary care infrastructure of a health system, the better the health outcomes for children, as measured by infant mortality and by birthweight distributions. This finding was replicated with a larger set of industrialized countries and was robust even after a large number of possible confounding factors, including gross domestic product (GDP), percentage of elderly, physicians per capita, average income in purchasing power parities, and alcohol and tobacco use, were controlled for.¹⁷ (A statistically significant relationship between primary care strength and health outcomes was also found for many other health indicators, including life expectancy at various ages above one, age-adjusted mortality, and years of potential life lost, but the relationship with child indicators was even stronger than with the adult indicators.)¹⁸ Countries with better primary care also rank better on Child Survival Equity, a WHO measure of disparities in child survival to age two among the populations of each country.¹⁹

Evidence from international comparisons regarding the benefits of primary care has been buttressed by evidence from studies done within countries. In the United States, national household data on use of services do not specify the type of practitioner from whom the care is obtained. A few studies, however, have confirmed the strong and significant relationships with a primary care source except when referral to specialist services is required. The evidence consists of less delay in receiving indicated preventive care, lower rates of child hospitalizations, and less emergency room use.²⁰ Infants of mothers who receive their care in community health centers (CHCs), which must provide primary care that meets national standards set by the Bureau of Primary Health Care, have better low-birthweight distributions than sociodemographically comparable infants in the general population, and these health centers reduce the general population disparities between African American and white infants.²¹

Other studies also support the benefits of primary care for effectiveness as well as equity of services. In the fifty states, the higher the ratio of primary care physicians to population (and the lower the ratio of specialty physicians to population), the better health outcomes can be expected, including in infants and newborns. The benefits of primary care are greater in areas that are socially more deprived, as measured by income inequality.²² Because of the paucity of available indicators of child health, most of those in the cited and similar studies have been adult indicators; the studies all show the same beneficial impact of primary care.²³

Prospects For The Future

Top The Health Of U.S.... Why? The Role Of Primary... Prospects For The Future Editor's Notes NOTES

 
Judging from the past, a future of improved health for U.S. children does not look promising. The disparity between this country and similar countries is growing, and social supports to ameliorate the effects of severe and increasing income inequity are shrinking.²⁴ Given the relationship between social disadvantage and health, health disparities are likely to grow. The absence of reliable and valid measures of health other than vital statistics makes it difficult to observe the full magnitude of changes in health, and special surveys to monitor changes and understand their genesis are likely to diminish with increasing budget deficits. Moreover, challenges such as the increased vulnerability of the young to environmental hazards and to social disadvantages are increasingly recognized but not met.

IOM recommendations. A National Research Council (NRC)/IOM committee was charged with confronting these challenges and suggesting ways to assess, monitor, and improve the health of children. Its 2004 report provides a clarion call for the nation.²⁵ The report proposes a new definition of child health, based on the Ottawa Charter but modified to include a focus on developing capacities.²⁶ The recognition of "trajectories" of health—that is, the influence of prior health on current and future health—led to a focus on aggregating data at the level of the individual child and then aggregating to subpopulation and population levels. Recognizing that the challenge for the United States is not only to improve overall health but also to eliminate disparities across population subgroups, the report recommended that data be systematically collected by race, ethnicity, and socioeconomic classifications and that information systems work increasingly toward combining data at the ecological level with data at the individual level, along with protection of privacy and assurance of confidentiality and security.

The report also recommended adding data on previously neglected domains of health (functioning and potential) to current and future surveys, as well as data on neighborhood, community, city, and state environmental conditions. To do this, the report recommended that addresses be geocoded to provide geographic information for surveys and administrative data from clinical encounters.

Responsibility for monitoring child health, broadly conceived (including the development of profiles, in a longitudinal context); for analyzing data on the interactions and relative effects of multiple influences over time; for developing, standardizing, and validating data; and for coordinating the child health–related data collected and maintained by other federal agencies, was assigned to a specific U.S. Department of Health and Human Services (HHS) unit (to be designated by the HHS secretary), with local and state counterparts as appointed by the respective executives. The federal unit also would improve the capacity of states and localities to monitor child health and its influences at these levels.

Such efforts conform to the consideration of child health in its totality rather than just by its parts (individual diseases, conditions, or risk factors). Improvements in individual disease rates can never provide adequate information for national child health policy, because they may paint a misleading picture of overall health. A broader conceptualization of health, concomitant with a health system that focuses on individuals and populations rather than primarily on diseases and individual risk factors, is in order for the United States.

A national imperative. In view of the relatively low and deteriorating position of U.S. children on almost all indicators, and the worsening of social supports for the sizable proportion of the child population living in deprivation, the United States must take steps to reverse the current likelihood of compromised health in coming generations of adults. Moreover, the national imperative to eliminate social disparities in health will not be achieved without concerted attention to childhood, because the largest disparities are initiated and perpetuated through childhood circumstances.

Although change in social policies will be critical to improving child health, the concern here is with changing health policies. National and international analyses indicate that the following strategies will be effective.

(1) Assure that every child has a source of good primary care, through national quality guidelines for such care, disseminated widely to the public and based on characteristics of primary care that are known to be effective; through incentives for family physicians and generalist pediatricians to locate in underserved areas or disincentives to locate in areas with an already adequate physician supply; and through expansion of the program to locate federally qualified CHCs in shortage areas.²⁷ (2) Eliminate copayments and other forms of cost sharing for primary care. (3) Establish disincentives for the seeking of care directly from specialists by, for example, paying specialists a lower fee if a patient is seen without a referral from primary care. (4) Incorporate primary care assessment in all quality assurance activities. (5) Assure federal and state support for increased training of primary care practitioners. (6) Consistent with the recommendations of the 2004 NRC/IOM report, develop information systems that monitor health and professional activities and that incorporate mechanisms to detect systematic differences across population subgroups defined socially, demographically, and geographically. All of this will require strong federal leadership. Many countries have already adopted most of these strategies; some have adopted all of them.

A professional strategy will allow the United States to take a leadership position worldwide—developing rational and evidence-based guidelines for referrals from primary care to specialty care to minimize unnecessary referrals and maximize indicated referrals, and developing methods to better coordinate care. This endeavor could be undertaken by family physicians and pediatricians, working together and with specialists.

The United States has lost ground in both the effectiveness and the equity of its health services during the past several decades. The poor position as to child health indicators and especially the growing social inequities that increase disparities in health are reason enough for national action. We must recover our national pride in achieving better health for all.

Editor's Notes

Top The Health Of U.S.... Why? The Role Of Primary... Prospects For The Future Editor's Notes NOTES

 
Barbara Starfield (bstarfie{at}jhsph.edu) is a University Distinguished Professor at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. She is also the director of the Johns Hopkins University Primary Care Policy Center for Underserved Populations.

This work was supported in part by Grant no. 6 U30 CS 00189-05 S1 R1 from the Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services, to the Primary Care Policy Center for Underserved Populations at the Johns Hopkins University.

NOTES

Top The Health Of U.S.... Why? The Role Of Primary... Prospects For The Future Editor's Notes NOTES

 

1. J. Bunker, Medicine Matters after All: Measuring the Benefits of Medical Care, a Healthy Lifestyle, and a Just Social Environment (London: Nuffield Trust, 2001); and E. Nolte and M. McKee, Does Health Care Save Lives? Avoidable Mortality Revisited (London: Nuffield Trust, forthcoming).
2. E. Arias et al., "Annual Summary of Vital Statistics—2002," Pediatrics 112, no. 6, Part 1 (2003): 1215–1230.[Abstract/Free Full Text]
3. Organization for Economic Cooperation and Development, Health at a Glance (Paris: OECD, 2003).
4. United Nations International Children’s Emergency Fund, The State of the World’s Children, 2001 (Geneva: UNICEF, 2001); and University of Dayton, "International Health Status Comparisons," academic.udayton.edu/health/syllabi/health/International.htm (30 April 2004).
5. Calculated from UNICEF, A League Table of Child Deaths by Injury in Rich Nations, Innocenti Report Card, Issue no. 2 (Florence, Italy: UNICEF, February 2001).
6. UNICEF, "Table 3: Health," in The State of the World’s Children, 2003, unicef.org/sowc03/tables/table3.html (30 April 2004).
7. The Health Behaviour in School-Aged Children (HBSC) study is a cross-national research study conducted in collaboration with the World Health Organization Regional Office for Europe, www.hbsc.org.
8. Ottawa Charter for Health Promotion, First International Conference on Health Promotion, Ottawa, Ontario, Canada, 17–21 November 1986.
9. B. Starfield and L. Shi, "Policy Relevant Determinants of Health: An International Perspective," Health Policy 60, no. 3 (2002): 201–218.[CrossRef][ISI][Medline]
10. S.V. Subramanian, T. Blakely, and I. Kawachi, "Income Inequality as a Public Health Concern: Where Do We Stand?" Health Services Research 38, no. 1, Part 1 (2003): 153–167.[CrossRef][ISI][Medline]
11. L. Rainwater and T.M. Smeeding, "U.S. Doing Poorly Compared to Others," National Center for Children in Poverty News and Issues 5 (Fall 1995): 4; and J.A. Macinko et al., "Income Inequality and Health: A Critical Review of the Literature," Medical Care Research and Review 60, no. 4 (2003): 407–452.[Abstract/Free Full Text]
12. J. Macinko, B. Starfield, and L. Shi, "The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970–1998," Health Services Research 38, no. 3 (2003): 831–865.[CrossRef][ISI][Medline]
13. World Bank, World Development Report, 1990 (New York: Oxford University Press, 1990).
14. B. Starfield and L. Shi, "The Medical Home, Access to Care, and Insurance: A Review of Evidence," Pediatrics 113, no. 5, Suppl. (2004): 1493–1498.[Abstract/Free Full Text]
15. J.-W. Lee, "Global Health Improvement and WHO: Shaping the Future," Lancet 362, no. 9401 (2003): 2083–2088.[CrossRef][ISI][Medline]
16. M.S. Donaldson et al., Primary Care: America’s Health in a New Era (Washington: National Academies Press, 1996).
17. Starfield and Shi, "Policy Relevant Determinants of Health."
18. Macinko et al., "The Contribution of Primary Care Systems."
19. WHO, World Health Report, 2000—Health Systems: Improving Performance (Geneva: WHO, 2000).
20. Starfield and Shi, "The Medical Home."
21. R.M. Politzer et al., "Inequality in America: The Contribution of Health Centers in Reducing and Eliminating Disparities in Access to Care," Medical Care Research and Review 58, no. 2 (2001): 234–248.[Abstract/Free Full Text]
22. L. Shi, "Primary Care, Specialty Care, and Life Chances," International Journal of Health Services 24, no. 3 (1994): 431–458; L. Shi et al., "Income Inequality, Primary Care, and Health Indicators," Journal of Family Practice 48, no. 4 (1999): 275–284; and L. Shi and B. Starfield, "Primary Care, Income Inequality, and Self-Rated Health in the United States: A Mixed-Level Analysis," International Journal of Health Services 30, no. 3 (2000): 541–555.
23. Starfield and Shi, "The Medical Home."
24. L. Rainwater and T. Smeeding, Poor Kids in a Rich Country: America’s Children in Comparative Perspective (New York: Russell Sage Foundation, 2003).
25. National Research Council/Institute of Medicine, Children’s Health, the Nation’s Wealth: Assessing and Improving Child Health (Washington: National Academies Press, June 2004).
26. Ottawa Charter for Health Promotion.
27. B. Starfield, Primary Care: Balancing Health Needs, Services, and Technology (New York: Oxford University Press, 1998).

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