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Amenable Mortality rates: Evidence for the US Health Care System’s Inferiority

            I asked my cousin to pass the gravy. After I took the bowl and spread the brown goo over my turkey, my uncle went on to ask, “So Nick, what do you think of Obamacare?” Knowing he wasn’t really looking for my opinion but an argument, I poked the bear. “I think it is ridiculous a great industrialized nation like the US doesn’t offer health care for all its citizens,” I responded. Immediately, my cousin exclaimed, “BIG DEAL! You know how many people from those ‘socialized’ nations in Europe come here for their health care… It is not a problem with OUR health care system but the health of people here are poor, because we have the freedom to live the way we want…”


Before I turned this into a full on debate that would surely ruin Thanksgiving dinner, I ended the conversation with a “let’s agree to disagree.” Nevertheless, I started to think about what my uncle said. Yes, the health of the US is surely not stellar but does the health care system really not play a role in this. Maybe. One study cited that health care only has a 10% contribution to total US health, while behavioral patterns accounted for 40% (1). But does that really mean that US health care is as good or better than other countries?? Then I remembered an article and concept that I read in a previous policy class which would have surely won the argument: AMENABLE MORTALITY RATES.

Amenable mortality, or mortality that “should not occur in the presence of timely and effective health care,” (2) is a strong indicator of the US’s mediocre health care system. It is one of the methods that attempt to separate the contribution of health care to population health from other determinants of health. Dr. Nolte and Dr. McKee in a 2012 Health Affairs article showed that, between 1999 and 2007, Americans under 65 years old had a worse amenable mortality rate than some of its peers across the Atlantic, including UK, France, and Germany. In this time period amenable mortality rates dropped the least for the US, 18%, and at the end of 2007, US had the overall highest rates. However, rates were similar in the over 65 years old population. This led to the authors’ conclusion that health care in the US is effective but only to those who have access to it (over 65 -year olds have access through Medicare). Furthermore, in the discussion, the authors cited a separate study, which showed that those most likely to receive appropriate care were associated with those who used VA services and had insurance (2). Therefore, it is hard to doubt that the ACA and universal access to insurance will lead to greater access to health care and better health for America overall.



  1. Schroeder M.D., Steven A. “We Can Do Better – Improving the Health of the American People.” New England Journal of Medicine. no. 357 (2007): 1221-8.
  2. Nolte, Ellen, and C. Martin McKee. “In Amenable Mortality – Deaths Avoidable Through Health Care – Progress in the US Lags that of Three European Countries .” Health Affairs. no. 9 (Sep 2012): 2114-22.

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What does trade or climate have to do with health??


Let me start off asking you, the reader, a question. When you think of the global health system, who do you consider the most important actors?

The World Health Organization… of course.

Doctors without Borders or MSF… merci.

Bill and Melinda Gates Foundation… duh

Well what about…

The World Trade Organization… huh?

Or the

The Climate Group… Who is this joker?

Let me explain.

I admit after three years of medical school, I have become a product of the disease- and intervention-focused American medical education system. However, it is clear from my first month of global health studies that confronting social determinants, like wealth and education, plays as an important role in ensuring the health of the global population, as behavioral modifications, medications, and surgical procedures do. Therefore, it is imperative that the global health system, already oversaturated with numerous agencies and groups with their own priorities, somehow involve those actors, like the WTO, who influence the social determinants of health. Dr. Julio Frenk, dean of the Harvard School of Public Health, identifies this need for “cross-sector interdependence” as one of the three main challenges that the global health governance system needs to overcome, asserting that “global health actors today are largely unequipped to ensure that health concerns are adequately taken into account in crucial policymaking arenas such as trade, investment, security, the environment, migration, and education”[2].

The challenges of these different policymaking arenas and the challenges to achieve interdependence between such arenas seem daunting. With the emergence of economic globalization, it is clear trade and health are interconnected. However, commercial interests often overshadow health interests in policymaking decisions concerning trade. For example, the WHO plays a limited role in trade decisions, only having “observer status” as WTO meetings – they can audit meetings but cannot participate in decision making procedures[3]. Another arena in which cross-sector cooperation is needed is the environment. Per a report by the University College London Institute for Global Health Commission, the effects of climate change on health are vast and extremely threatening, from the expansion of vector-borne diseases to the “indirect effects of climate change on water, food security, and extreme climatic events”[4]. However, as with trade, commercial interest surely acts as one of the main impediments to progress against climate change – for example regulating coal emissions will continue to be an unpopular policy if it negatively impacts the “bottom line” for many corporations and economic progress, in general.


I could make similar arguments for education, immigration policy, sanitation, and numerous other social drivers of health but that will surely put you to sleep. The point is that there are many non-health arenas with which the global health system needs to participate, and if the groups that make up the global health governance don’t cooperate with groups in such arenas, then they will certainly fail in ensuring the “physical, emotional, and social well-being”[6] of every citizen of the world.


[2] Frenk, J., Moon, S., Governance Challenges in Global Health The New England Journal of Medicine, 368;10, pp. 936-942

[3]Lee K., Sridhar D., Patel M. Bridging the divide: global governance of trade and health  The Lancet, 373 (9661), pp. 416-22

[4] Costello A., Abbas M., Allen A., et al.; Managing the health effects of climate change. Lancet and University College London Institute for Global Health Commission. (2009) The Lancet, 373 (9676), pp. 1693-1733.


[6] WHO Definition of Health: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”

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