As the director of Virginia Commonwealth University’s Center on Society and Health, much of Steven H. Woolf’s work involves raising awareness about the factors outside of health care – like education, income and public policy – that shape the health of individuals and groups. As we discussed in our interview, vast differences in those factors between communities, states, and countries are leading to great gulfs in life expectancy in people around the world.

Why is the average lifespan in the United States growing more slowly than other countries?

It's not a simple answer. We know from our analysis that there are at least nine different categories of health problems that are responsible for health disadvantages and they vary quite dramatically in terms of potential causes. They include things like obesity and diabetes, but they also include car accidents and homicide. At least on the surface, the factors driving high obesity or diabetes rates are probably different than the factors that are causing high death rates from car accidents or high rates of teen pregnancies. Explanatory factors that would point to a cause for all of these things are pretty limited. There's no magic bullet, although there may be some societal and cultural reasons for them.

Does this health disadvantage include all types of groups in the U.S.?

The striking finding is that the U.S. health disadvantage is pervasive – it cuts across all groups: men and women, children and adults, whites and minorities, the rich and the poor. We looked into the data for well-off Americans and found that they are dying earlier than well-off people in other countries. In fact, in some cases they're dying earlier than poor people in other countries. Disease rates for rich Americans, for college educated Americans, for insured Americans, and for white Americans are higher than they are for comparable people in other countries. The message is we're all in this together – this is not a problem that's restricted to disadvantaged groups. They do have it worse but it's certainly not restricted to them.

How do societal and cultural factors contribute to health outcomes?

Societal attitudes matter greatly. Take teen pregnancy, for example. The United States has the highest teen pregnancy rates among industrialized countries, partly because our teenagers have more limited access to contraceptives than teens do in other countries. Why is that? Well, lots of reasons, but you have to think about societal and cultural factors, how we as a society in America feel about sex among teens, abstinence, and other sensitive issues. Gun ownership is another example when it comes to explaining the U.S. death rate from homicides, which far exceeds rates in other countries. You can’t study this without considering the very striking differences in civilian firearm ownership between the U.S. and other countries, which has an important historical and political backstory. For one thing, those other countries don't have a 2nd amendment, while we—needless to say—have very strong views on that topic that surface whenever there is discussion of making a change. So you can see why societal, political and ideological themes have to be considered to understand why our lifestyle is different and why our health outcomes might be different.

How does public policy contribute to life expectancy?

The use of laws, legislation and government restrictions to promote public health and public safety is different in the U.S. than in other countries. Take, for example, legislation banning the use of motorcycles without helmets. Some states have eliminated those laws, because the voters want to be able to ride their motorcycles without worrying about being ticketed for not wearing a helmet. In states that rescinded the laws, we've seen a steady increase in fatality rates among motorcyclists. In other societies, I think, voters are more willing to put up with restrictions like that in the interest of public safety. Motor vehicle safety is better in those countries because decisions have been made by the government to impose restrictions on the use of cars and invest tax dollars in road design to promote safety.

How do socioeconomic conditions figure in health discrepancies?

There’s a very strong relationship in every industrialized country between socioeconomic conditions, like income and education, and health. The difficulty is in teasing apart a set of issues that are very closely interconnected. For instance, if you just look at education alone, the differences in life expectancy and disease rates are huge when you compare, for example, people who haven't graduated from high school to people who have obtained a college education. But people with different levels of education end up with better jobs, earn better salaries, and more assets—all of which are also strongly connected to health. Another important dimension of this is income inequality. There's a school of thought that income inequality -- how different your income is from other members of society -- is itself a determinant of health. So if that's true then we have another problem in this country, given how dramatically we’ve seen the income gap widening in recent years.

How is education connected to heath? 

Education seems to have a profound impact on health, partly because of the better jobs it brings and the resources to obtain better health care, live a healthier lifestyle, and afford to live in a healthy neighborhood. The kids who do well in school also tend to have better early life circumstances that are important to health. The differences in the health of people with more or less education are huge. As one example, at age 25 people who have not graduated from high school on average live about nine years less than those who've graduated from college. People with less education also have higher disease rates. Take diabetes, which is important not only for people who are concerned about health, but also for the policymakers, employers, and health plans worried about health care costs. Death rates from diabetes for middle-aged adults who did not graduate from high school are three times higher than death rates for those with some college education. What else can cut by one third the death rate from a very profound and costly disease? Similar numbers exist for other chronic diseases like heart disease. It's pretty obvious that if we were to do something about addressing socioeconomic conditions like education we'd not only improve health outcomes but also probably take a big bite out of health care costs.

Is the gap in life expectancy in this country likely to shrink?

Probably not. The trend we’ve seen since the early 1980s is that the life expectancy gap between the haves and the have-nots is widening. So unless we change what we're doing I predict it will continue to widen. The only way that's going to change is if we get serious about trying to improve our health by changing the social and economic factors that shape health. We are falling further and further behind the health of other countries, so unless we make a significant change in what we are doing, that will likely continue.

In the parts of this country where life expectancy has increased on pace with the rest of the world in the last two decades or so, why is that?

The improvements in life expectancy that we’ve seen in this country and other industrialized nations generally have to do with advances in health care, early detection of diseases like cancer, and changes in our health behaviors. There have been improvements in our lifestyle. Smoking rates in the U.S. are now about 18 percent, whereas back when the Surgeon General first released the report in 1964 showing that smoking was bad for your health, smoking rates were more than 40 percent. There are other important changes in lifestyle as well that are contributing to that. For example, while it's true that Americans die on the highways at higher rates than people in other countries, the death rates are still lower than they once were because we use seat belts and car seats. In health care, there have been some important advances in evidence-based treatments that have had a big impact on death rates from heart disease, stroke and other conditions.

Is the U.S. unique in its longevity gap?

There are definitely gaps like this in other countries, but not to the degree we’re seeing in the U.S. It’s interesting to think about why that is – why are poor people in the U.K. or in Sweden not impacted as adversely as they are in the U.S.? One of the obvious answers is that their health may be protected more because there are support systems and programs that buffer the adverse health impact that Americans in poverty experience with food insecurity, unstable housing, challenges with child care, and the struggling schools, crime, pollution, and unhealthy housing that exist in low-income neighborhoods. Poor people in other countries may have to deal less with this.

Is there reason to believe that the large differences in lifespan between countries will narrow at some point in the future?

One scenario is that it just gets progressively worse, that the health of Americans falls further and further behind. An alternative possibility is that the U.S. is on the leading edge of a trend and that other countries might unfortunately start catching up with us. Although we've done very well with cutting smoking rates, other countries have not done as well. Smoking rates are still quite high in some of those other countries, and it takes 20 to 40 years between the peaks we see in smoking and the rising incidence of tobacco-related diseases like lung cancer and emphysema. One school of thought holds that their time will come and those countries will start experiencing the adverse impacts of smoking that probably already peaked in the U.S. But I do really think this trend that we've seen since 1980 or perhaps earlier is due to structural decisions that we've made in the U.S. Unless we make a substantial change then were going to continue to see the trend worsen. And making a substantial change doesn’t mean spending more money on health care. It means doing something about education, creating jobs and economic vitality not only of American families but also neighborhoods and communities, investing in early childhood to get the next generation off to a great start, and channeling some of our country’s enormous wealth into investments to create a healthier and safer environment. These investments can improve the economy along with saving lives. I don’t think we can afford to not take this step.

Interview by Jordan G. Teicher.