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Stephen Bezruchka, "Born Sick in the USA: Improving the Health of a Nation" (Cambridge UP, 2026)
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C
Welcome to the New Books Network. I'm Stephen Pimper and we are joined today by Stephen Bezruchka. We just went through this. I am so very sorry. Who is the author of Born Sick in the USA Improving the Health of a Nation from Cambridge University Press. Stephen, thank you for joining me. Much appreciated.
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D
Thanks for inviting me.
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C
I wonder if you might tell folks a little bit about who you are, what you do, and what it is that brought you to this particular book project.
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D
So it's a long story. I started out being a mathematics graduate student at Harvard, and along the way I decided I wanted to do something more useful than mathematics. And so I decided to go to medical school as I thought providing medical care was probably the best thing could do in a society. And so I went to Stanford medical school in 1970 and that was a fascinating process in which in one class a professor pointed out that in the 1950s, we used to be one of the healthiest countries in the world, but since then, other countries had surpassed us. I only know that because I reviewed my notes from that class a while ago, and I realized the driver of my life had actually been presented in a classroom in 1971. Anyway, so I began working as a doctor in a variety of situations. I've spent about 11 years in Nepal, some of it working in a community health project a week's walk from the road. And along the way, in the 1980s, I found evidence that our health in the United States was not the best. It wasn't even that stellar. And this confused me, as I thought we had tremendous medical care delivery system, or so I thought. And I didn't know what to. I was teaching courses in remote parts of Nepal to American doctors and medical students, and my Nepali counterpart at one point asked me, how come men in Bangladesh live longer than men in Harlem. I couldn't. I couldn't explain that. So I decided in the early 1990s, since I didn't know what was going on, to explain our poor health status, that I went back to public health school and I went to Johns Hopkins, the largest such school in the world at that time. And I learned that political and social factors mattered most. And I already knew that health care didn't amount to as much as I originally thought. So there I was in the mid-1990s with this newfound knowledge, trying to decide what to do. And I thought, well, people in my profession, I should begin by presenting this material to them, Namely, we don't live long lives in this country, and so on. I discover that doctors aren't interested in health. We treat illness and injury and health, that's something else. That's somebody else's purview. So I came back to Seattle and joined the public health school here. And surprise, surprise, people in the public health school were also not interested in health as I conceived it. Namely, how healthy is a country as measured by mortality rates? I came to see mortality rates as extremely important measures of health, first from my work as an emergency doctor. That's what I did for some 35 years, because the easiest diagnosis I could make in the ER was that somebody was dead. Hard to fake. So I filled out a death certificate that was then collated with that person's birth certificate, allowing you to calculate mortality rates. So all rich countries have these mortality rates and many other countries as well, and there are ways to estimate them. So here I was in my public health school, trying to tell My other faculty that we didn't live such long, healthy lives. And they sort of dismissed me. I tried to find ways of expressing these ideas. So I thought of. I coined the term health Olympics. Suppose health were an Olympic event and the race was how long you lived. Life expectancy, if mortality rate stayed the same, it would be the average length of life, or in statistical terms, the expectation of life. You know, it's a mathematical function. And so I would ask people, if health were an Olympic event, the race was how long you lived, how would the United States do? And I usually preface it by saying, you know, we spend almost half of the world's health care bill, and so surely we must be up there getting one of the medals in the end. And so I put a little graph up, asking how many think we're in the top five, top 10, top 20, top 30, and so on. And using the latest data presenting us in the best possible light, namely using United nations data, since, for example, Taiwan is not a UN country, we rank 44th. We're tied for 44th with Cuba in 2022. Think of it. We have the same length of life as Cuba, the country we've been strangling for 63, four years. That's really a paradox. So why then I ask why? And that leads us into a variety of other issues. Then you have to ask the question, what is it that makes a population healthy? And after I left Hopkins, politics and social factors matter most. And the social and political factors. Well, our longest lived state, our healthiest state, is Hawaii. And Hawaii in its department of Health, now in one of its reports, has a graphic on page two showing that socioeconomic status. And then above that, political context and governance matter most for producing health. And health care is far downstream, and personal behaviors are far downstream. So that's really an important issue, that personal behaviors don't matter that much and health care doesn't matter that much. That leaves us at a disadvantage in this country. Surveys show that people think healthcare matters most and politics matters least, but it's the opposite. Our language doesn't serve us. We speak of accessing health, paying for health, getting health, insuring health, when all those relate to health care. So naturally, because we conflate the terms health and health care, they must mean the same. So if you ask someone, do you want health or health care, they're confused. What I did starting in the. When I came back and joined the public health school, was I began a variety of activities trying to inform the public and public health, and anybody who would listen that we are dead first. You know, I came up with a whole bunch of phrases that sort of jar people and hopefully get them to question what's going on. So I teach a course called the Health of Populations in which the patient is the country. And in yesterday's class we looked at measures of well being and healthy life expectancy. Namely, life expectancy is just looks at whether you're alive or dead and it's calculation. Healthy life expectancy looks at whether you're in a healthy state or not. And if we're 44th in just plain life expectancy, we're actually considerably lower in healthy life expectancy. That is the fewer years we live are sicker years than those in many other countries. And happiness, well, remember our Declaration of Independence. It entitles us to life, liberty and the pursuit of happiness. Well, our life that we're entitled to is only a short one. Liberty is an illusion since we house the most prisoners of any country in the world. Almost one in a hundred Americans are behind bars. And the pursuit of happiness, well, that's all we're allowed to do, is pursue it. We pursue it with a vengeance. And we're falling further and further behind. And the students are really, they accept that there's something happening with happiness. They sense that our happiness is declining. And I don't know what it's like in New York, but how many times have you been told to have a nice day today? So far we're not having nice days and being told to have them is not going to work. So with all the efforts at broadcasting this information, you know, I began besides teaching, I would write, write for academic and publications. I would do TEDx talks, wrote the book Inequality Kills Us All a few years ago. And then Born Sick reflects not just being dead. Inequality Kills Us all, but looks more at the state of our health, our illnesses, and points out that even the healthiest of us in this country are less healthy than the average in many other countries. In other words, none of us can claim stellar health. And we have all these people who have all these regimens that they follow to be healthier and healthier. And it's just not pointed out. The current issue of Time magazine is all about longevity. And there's not a single mention in there of our being dead first.
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C
So let's explore the why a little bit.
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D
Right.
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C
As you observe, we spend more per person on health care than pretty much any other country on the planet. And as you've told us, we have really terrible results as a consequence of that. So how do we make sense of that? How do we explain it?
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D
So the Department of Health and Human Services just released Data that for 2024, we spent $5.3 trillion on healthcare. It was a big increase from the year before. It amounts to 18% of our total economy, about $15,500 per person. And that represents, if you add up all the numbers for the whole world, almost half of all the money spent on health care in the world. So clearly there's a disconnect there. It's not buying us health. And I can vouch for that, having played doctor for so many years. So what matters? Well, political factors, right? And social factors. So what are those political factors?
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C
Well.
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D
In the 1990s, I came across studies showing that income inequality is linked to. To life expectancy outcomes among rich countries. And so that became an important measure, how much inequality there is in society. And so my sort of way of working to understand things is to get to know the people who propose these ideas. And so the leading exponent was a guy, Richard Wilkinson, that wrote a paper in the British Medical Journal in 1992 looking at income inequality and life expectancy and showing that countries where inequality increased had smaller increases in life expectancy over time. So I got to know Richard, spent time with them, got to know others who were presenting these ideas just to get a sense of were they believable or not. So that became a major focus. Inequality is sort of like a highly toxic, odorless, colorless, poisonous gas that kills us from the usual diseases we die from, and we're totally unaware of it. How does it do that? Well, inequality creates a lot of stress. We're basically an altruistic species. That is, if we look at our hunter gatherer forebears, everybody was pretty well equal in those societies. And once we transitioned to agriculture, about 10,000 years ago, we developed hierarchies. Somebody could say, I'm your lord. I want you to grow my crops. I want you to build a castle to store my food and build a moat around it and go to war to protect my food. And so the advent of agriculture led to an increase in hierarchy and a decline in human health. Now, we didn't have birth and death measures back then to tally life expectancy, but there were various archaeological findings, such as the length of your bones. Taller people are, by and large healthier than shorter people. And we saw a decline in the length of, say, the femur, the. The bone in your thigh. We also saw signs of infectious diseases in the bones, signs of nutritional problems in the bones, in agricultural skeletons. Compared to those in the Paleolithic. So something happened then that led to. And by the way, all of these, you find strong evidence in the literature and the academic literature. You don't find any contradictions. I'm always looking for ideas that contradict what I'm speaking about to see what I can learn from that. So our health declined, and it's only in the last couple of hundred years that has begun to increase. And why has it increased? Well, most of it has had to do with improving the standard of living, providing clean water, and removing fecal waste. And so we live in a somewhat cleaner society. The standard of living has improved, but along the way, we've created a lot of poverty. You know, one of the things that happened in the feudal era that I sort of spoke of before feudal lord can say, you know, grow my crops, and I'll give you a small amount of those. And we accepted somehow that we would have less than others. And countries structured poverty as a result of policies. It's interesting. You and I have both written chapters in this book, Divided. I realized that where you presented some of your ideas on poverty, and I presented them on inequality. So we in the United States have the most poverty of all rich nations, the most child poverty of all nations, and we have huge inequality. The paradoxical thing, and I mention it in Born Sick, is that when Americans are presented with the bad things that inequality does to them in comparison to five or six other rich countries, and then ask what to do about it, they seem to want to increase inequality. This paper by Culpepper that I cite in the book, that's the paradox. Americans seem to want to have more inequality even though it's killing us. And why might that be the case? I mean, I really scratch my head about that, but, you know, I'm reminded of a cartoon in the New Yorker a while back with a banker dude and a worker dude in a bar. And the worker dude says to the banker dude, I'm all for tax cuts for the rich because I might win the lottery someday. The American dream, you know, you're going to go from rags to riches. And the American dream is a nightmare. You've got to be asleep to believe in it. So the other factor. So I'm rambling on, but besides inequality, I came to see that early life really mattered a great deal. By the time from conception to your second birthday, first thousand days, roughly half of your health as an adult is programmed. So healthier nations privilege that period by a variety of means. There are only two countries in the world that don't give a working woman who's pregnant paid time off after she has her baby. One is the United States and the other is Papua New Guinea. And we say we can't afford that, although there's some support for paid pregnancy leave. And we have. But we only have the. The legislation passed in 1993 to give a working woman four months off, unpaid under certain conditions. So other countries privilege early life. One of the healthiest, Sweden spends more government money on the first year of life than in any subsequent year. We spend far much less money and we spend it on later years to make up for what we didn't spend early on. The new finding that is reflected in the title by the time we are conceived, the stress that our parents faced before our conception really impacts our health as much as the early life period. So we've got to do something about that enormous amount of stress that we're under.
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C
What is the role that race and racism plays?
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D
So I noticed it was a Dr. Graves you had on your program a while back. So yes, African Americans die younger than whites, but even. And American Indians have the worst health outcomes, the highest mortality rates. I like to show a map of life expectancy among U.S. counties. And the worst is in Lakota county in South Dakota where Pine Ridge Indian Reservation is. And surprisingly the longest lived counties are in the middle of Colorado, Summit county and places where the rich live, such as in Aspen. And there's a huge gap in life expectancy there.
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C
I do. Sorry, I do a similar thing. I show a map of Native American reservations and density of slave populations in the 19th century and then show a map of poverty and inequality in the United States today. And the alignment is shocking. If that's not a thing that you are aware of.
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D
Yes, no, that makes perfect sense. When you sort of stratify by ethnic origin, there's all Indians do. The American Indians do the worst, then African Americans, then we gringo and gringa. And then slightly better are those of Latinx or Hispanic origins. They're not rich by and large. So why do Latinos do a little better than non Latino whites? And you know, this has been pretty well studied. One factor in understanding health is culture. And it's perhaps the least understood part of health production. And it's hard to study from my own personal experience as an emergency doctor, I never saw a Latino patient in a gurney that was a stretcher. It wasn't surrounded by a whole bunch of family and friends there to support them. Meanwhile, here's a white guy moaning alone so they support one another. And it's that family and extended network support that is an important social factor that ameliorates some of the better, the worst effects of poverty. And that explains that still higher still in terms of mortality are those of Asian descent. And that gets into another variety of issues. Japan's the longest lived country has been since 1978. We can claim that we did something to Japan at the end of the Second World War that made it the healthiest country in the world. Remember, we firebombed Tokyo, we dropped two atomic bombs, we destroyed the country. Its life expectancy in 1945 was about 24 years. Then we sent in the Allied occupation force that was headed by a five star general, Douglas MacArthur. He set up shop across from the Emperor and he basically put in place policies that made Japan the healthiest country in the world. He wrote the Constitution by cutting and pasting. Article 9 says Japan shall never wage war. They will resolve all disputes peacefully. Article 23 makes the government responsible for the health of the people. MacArthur said there are these big family corporations or zaibatsu, that control the country and we can't have such concentrations of wealth and power. So he broke them up. He legislated a maximum wage for the country. And Japan was a rice farming economy. And 37,000 landowners owned the land and 50 million peasants farmed it. And so he bought the land from the landowners and sold it to the tenants at a fixed price per acre and gave them a 30 year interest free loan almost to buy back the land. And the Japanese paid off the loans. And historians call it the most successful land reform program in history. So that was the medicine Japan needed. Demilitarization, decentralization and democratization. And by 1978 it was the longest lived country. And to make another point, now it's about seven life expectancy years ahead of the United States. Does that just mean a few more years drooling in a nursing home or what does that represent? Well, our three leading killers, disease killers in 2022 were heart disease, cancer, and then unintentional injuries. If we eradicated those three, which will kill about half of us, we gain about seven life expectancy years and be the maybe the longest lived country. So it's a very significant gap.
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C
So as we work our way toward concluding what's the answer, what do we do about this?
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D
Well, we have to inform the public. You know, it's the best kept secret in the country. Though of course there are many documents that present this information and one that the Institute of medicine produced in 2013 had the title US Health and International Perspective. Shorter Lives, poorer Health. Title says everything. I always tell my students craft the title that says everything. And so we need to, number one, inform the public. And there are a variety of ways to do that. One I think that would make sense is in our State of the Union address. It's required by the Constitution. Only one president has ever said that the State of the Union is not good. Suppose the State of the Union address was required to make comparisons with other unions. And suppose we would speak about our health and say, well, we die younger than people in 40, 50 other countries. I'm sure Americans you would prefer. That would not be the case. Then the media would pick it up. Then maybe we would teach about that. You know, I've, in my efforts over the years, I've managed to find ways of presenting these ideas in grade school, high school, besides college and so on, a way to ensure that this gets taught. Remember, we teach to the test in our public schools. Suppose the test included asking questions about how healthy America is. Then we would teach to it. Similarly for the SAT test you take at the end of high school, suppose there were questions on that test about how healthy America is. Then we'd have to teach to it and so on. GREs Law School admission test, you name it. So we have many ways in which we can structure the requirement to inform Americans of our poor health status. But it's difficult because it's an abstract concept. I remember back in 1957 when Russians launched Sputnik and suddenly we had this satellite out in space that was beeping signals to the earth and this galvanized American angst. You know, we had no space program, so we set a goal of landing a human on the moon by the next decade. And so countries can have goals, and we could set a goal in this country that we stop our decline life expectancy and begin to increase it. I mean, there are all sorts of ways of putting in place automatic zeitgebers of sort of factors to make better known how things are. And that gets to the idea. What gets measured gets done. You know, what's the thing we measure every minute of every business day? The stock market index that's important for the wealthy to see how much their wealth is increasing, or the gdp or, you know, we measure things that are good for the rich to know, except that they don't live long, healthy lives. And that's what we need to broadcast.
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C
You're listening to the Public Policy Channel of the New Books Network, and we have been speaking with Stephen Bezruchka, who is the author of Born Sick in the usa, Improving the Health of a Nation from Cambridge University Press. Stephen, thank you for joining us today.
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D
Much appreciated. It's been a pleasure. Thank you, Stephen.