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Health reform alone is pointless

BMJ 2013; 346 doi: (Published 08 February 2013) Cite this as: BMJ 2013;346:f832
  1. Edward Davies, US news and features editor, BMJ
  1. edavies{at}

People in the United States are less healthy, have more chronic disease and disability, and die at a younger age than people living in other wealthy nations.

BMJ podcast: American life

The US falls short in health outcomes at every age from birth to 75 years and the deficiencies are found at all levels of society.

Even high income, college educated, white Americans tend to be sicker and die younger than their peers in other rich countries.

These conclusions from a panel convened by the US National Research Council and the Institute of Medicine were so damning that the panel urged that they become the basis for a “national discussion” when its report was published last month (BMJ 2013;346:f215).

And it is in that spirit that the BMJ podcast this week opens its discussion with Steven Woolf, professor of family medicine at Virginia Commonwealth University in Richmond, Virginia, and chairman of the panel, on how we’ve reached this point and what needs to happen next. And the picture is a complex one (

Americans are used to hearing about the shortcomings of their health system—fragmented healthcare, a shortage of primary care, a lack of public health services—but what Woolf talks about are things that are far more difficult to change: social, environmental, and cultural factors, intrinsic to the American way of life.

“There were some recurring themes that led us to start thinking about political science issues and how we govern in the United States,” he says. “How our values and lifestyles may be shaping a lot of these issues. There were common themes behind the fact that Americans are more likely to engage in unhealthy behaviors … it brought us back to thinking about the value system in the United States and how it might be a factor.”

The report flags poverty and income inequality, declining educational achievement, an unhealthy food culture, communities designed for cars rather than walking and other physical activity, and high risk behaviors involving drug use, reckless driving, and firearms. These are not health problems that can be solved by legislation. They ask fundamental questions of an entire way of life.

The report makes no attempt to answer these questions, but serves as a healthy, open place from which to start that difficult discussion.


Cite this as: BMJ 2013;346:f832