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The exceptional United States

We were discussing health expenditures around the world in class today when the professor put up a chart showing health expenditures in countries that are “developed.” (You’ll see why I use “scary quotes” for “developed” in a little bit.) He pointed out that the United States of America spends more than double the amount of money per capita in healthcare than other developed nations. A conversation ensued on what equity and equality means. Then I had a question.

I asked the professor if it was fair to compare the United States to other developed nations, especially the smaller European nations, given that we’re nothing like them. I explained that we’re made up of 50 states and that cultures, economies, political views, racial proportions, etc., are all very different between the states and even within the states. I explained that it was my opinion that we cannot aim for a national public health policy because it doesn’t translate very well and, besides, it’s up to the states to do public health. It’s their constitutional authority.

You should have heart the comments I got back from other students after I said this.

One student in particular said that she was offended by my statement. She seemed to believe that I was justifying inequities in health care, and that I was justifying them because of our different racial makeup as a nation. (She must have missed the part where I spoke of other characteristics.) She then said that we must move ahead despite those differences. I apologized to her for offending her, but I remained firm that we’re better served with state-level public health policy than one big over-arching policy for a country of 300+ million who are very diverse in a whole lot of ways.

I don’t think that it is reasonable to have a public health policy that covers all 50 states and all the territories without some sort of leeway for those states and territories to adjust according to their needs… And to their differences. I explained in class that the policies of conservative, “red” Nebraska are much more different than policies in enormous, “blue” California. Even within Nebraska, Lincoln is a bastion of more liberal approaches to governing than, say, North Platte. And the same goes for California.

This is why I was initially concerned with the Affordable Care Act way back when it was first introduced. It seemed to me to be too over-arching and not flexible enough to adjust to the way of governing of the different states. In class today, I gave the example of the migrant workers. (I volunteer at a migrant camp clinic. My wife works there on an as-needed basis.)  I explained to the class that the healthcare that the migrant workers get in Pennsylvania is very different than the care they would get in Florida. (For starters, they probably would have Spanish-speaking healthcare providers there and not the patchwork of interpreters we have here.) It’s not a good or bad thing, per se. It’s just the nature of a country made up of 50 federated states.

One of the countries being compared with the United States is New Zealand. New Zealand is an island nation in the South Pacific. It has 4.4 million people living in it, a little over 1% of the US population. Its population is 69% of European descent. In the US, the population of European descent is 72%, if we include Hispanics. Take out Hispanics and the population of Whites is 64%. Then we have 16% Hispanics and 12% Black. Less than 1% of our population is Native American, while New Zealand’s Maori make up more than 14% of the population, followed by about 9% Asian and about 7% non-Maori Pacific Islanders.

In essence, we’re different. The US is bigger in population, in geographic size, in political units (e.g. states), and in who are neighbors are. The US faces an influx of immigrants unlike few countries in the world, stirring up the melting pot (in more ways than one) and contributing to our population growth though fertility rates in the US are below replacement. New Zealand’s fertility rate is above replacement, so their growth comes from within.

Now look at where our ancestries are from:



We’re a hodgepodge of cultures.

We also compared the US to Holland, and someone shot back at me that “they speak three different languages in Holland.” So what? We speak these many languages here:

Screen Shot 2015-02-23 at 7.43.00 PM

Source: US Census

The Netherlands (the other name for Holland) is made up of 16.8 million people in an area the size of two New Jerseys. About 13.2 million (almost 80%) of the residents are Dutch, while the next largest ethnic groups are Turkish, Moroccan, and Indonesian. Holland is also a member of the European Union, which is a federation of sorts.

I’ll quit the comparisons because you know where I’m going with all this.

Now, the reason why I wrote “developed” in “scary quotes” is because I lived in the Lower Valley in El Paso, Texas. If that is a “developed” part of the world, then I have a bridge to sell you. Most of the homes there when I was growing up lacked potable water. Most had well water. A lot of the roads were unpaved. Things have gotten better there since then, but there are still plenty of places in the United States where the conditions do not exist as they do in developed countries.

Again, we’re 50 states and territories all put together by history, geography, and war. (Puerto Rico is a US territory because of the Spanish-American war. Several of the territories in the Pacific are US territories because of World War II.) We’re held together by economic interdependence, security concerns, political will, and maybe even because of the experiences from the Civil War back in the 1860s. To say that all public health policy can apply to urban, liberal Baltimore and to rural, conservative Garrett County (both in Maryland) is a bit of a stretch. Many policies can apply to both. Some things just make sense. But the differences are big enough to make a nationwide policy that addresses nationwide problems a little difficult to agree on and even implement.

“So who do we compare the United States to?” the professor asked.

“I don’t know. That’s why I’m here,” I answered. After thinking about it for a day or so, I’ve come to the conclusion that we just might not be able to accurately compare the United States to other countries on a one-to-one fashion. We might compare to India in terms of geographic size and political divisions but not so much in cultural differences. We might compare to Mexico in terms of a federation of states rather than one big nation state, but not so much in terms of cultural variety. We might compare to the European Union in terms of economies (e.g. GDP, income per capita), but the European Union is not a federation as much as it is a confederation.

So maybe we are exceptional, and maybe our differences are a hindrance to achieving our public health goals. But we won’t get anywhere by being offended over it. We’ll get somewhere by acknowledging the problems and working on the solutions.

Categories: Blog

René F. Najera, DrPH

I'm a Doctor of Public Health, having studied at the Johns Hopkins University Bloomberg School of Public Health.
All opinions are my own and in no way represent anyone else or any of the organizations for which I work.
About History of Vaccines: I am the editor of the History of Vaccines site, a project of the College of Physicians of Philadelphia. Please read the About page on the site for more information.
About Epidemiological: I am the sole contributor to Epidemiological, my personal blog to discuss all sorts of issues. It also has an About page you should check out.

4 replies

  1. A few notions arose immediately when you claimed states exclusive rights in matters of public health.
    These words came to mind as I was reading:
    “We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.”
    “The Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence and general Welfare of the United States; but all Duties, Imposts and Excises shall be uniform throughout the United States;”
    And finally,
    “This Constitution, and the Laws of the United States which shall be made in Pursuance thereof; and all Treaties made, or which shall be made, under the Authority of the United States, shall be the supreme Law of the Land; and the Judges in every State shall be bound thereby, any Thing in the Constitution or Laws of any State to the Contrary notwithstanding.”

    Note two times the welfare of the nation and her people were mentioned. Note the primacy of federal and Constitutional law.
    If your standard were accepted as law, our smallpox and polio vaccination programs would have failed and both diseases would still be common in this “developed” nation.

    I’ll also comment on one niggle; I was unaware that well water was not potable water! If one can safely drink one’s water supply, it’s potable water. For the alternative is untreated surface water, greywater and blackwater.
    That said, one can have non-potable well water, as my sister in law learned the hard way after her well was contaminated by surface runoff. But, in that case, treating the wellhead cleared the contamination.


    1. Trust me, that well water was definitely not potable. Diarrheal diseases were the order of the day for most of us.
      As for the constitutionality of public health, you’re right, the federal government does all those things. I guess my main message is that there are many public health policies that we disagree on between the states and even within the states, so federal mandates are at the least controversial and at the most useless or even counterproductive. Now, remember that the police power to enforce public health law lies only with the states. CDC can’t rush into help unless the state requests said help, or unless the situation occurs on federal land, at a federal institution, or has something to do with international travel or trade. So I stand by me thesis that slow and steady implementation of public health interventions at the state level are recommended to guarantee their sustainability and longevity than one big, over-arching policy from the federal government, at least where public health is concerned. (Other issues can and should be implemented at a federal level.)


      1. That’s interesting that those wells were contaminated. That suggests either runoff overflowed the wellhead or human waste was being inappropriately disposed of.
        There is one other condition that the federal government can enter into a state without being requested by a state, when the state’s resources are so overwhelmed that the civil government is unable to respond. Fortunately, such disasters are extremely rare.


        1. It was the “lower valley,” after all. We were downhill from the city and close to a lot of irrigation ditches for the cotton fields. They carried grey water. Whenever it rained, in June-August mostly, the runoff from the fields flooded the homes. So I’m sure it got into the wells that way. Funny, we went from air conditioned homes with running city water and natural gas to a shack with well water and space heaters. I’m sure it all taught me some valuable lessons. Never will I dare to say that people living in shanty towns are there because they’re lazy or just don’t want a better life bad enough.


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