“For nearly two hundred years America was one of the healthiest and longest-lived countries, but today, over thirty countries have better health by many measures. What happened? In answering this question, the distinction between health and health care is a critical one, but something that seems not to be well understood by the lay public, health care professionals, or policy makers. Every time we hear the word health, we should ask ourselves whether that term refers to health itself, or to the much more limited concept of health care. If the culprit of the decline in health is not health care, are individual health-related behaviors, often blamed for the high death rates in some groups, causing our low ranking in health? Apparently not. Americans smoke less than both men and women in the healthier countries, so tobacco, though important, is not a significant cause for our higher mortality. Diet and other similar individual behaviors prevalent in the United States also don’t account for our health disadvantage compared to other rich nations. When asked to identify solutions to our poor health status as a nation, many respond that we need more education. Many see education as the solution to a wide range of problems. But on average the U.S. population has more years of schooling than in any other country in the world. And while we spend a great deal of money on education, we don’t get much bang for those bucks.”

• Income inequality, mortality, and self rated health: meta-analysis of multilevel studies, BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b4471 (Published 11 November 2009). Cite this as: BMJ 2009;339:b4471