« All right, all right, all right | Main | The Dog Whisperer »


Jason Clark

I wonder if I am asking the obvious, and this shows that the US overspends on healthcare, and the UK provides the same for far less. Medical insurance costs, drug company cost, seem the main reason the US spends double the UK.

Jeff DiNunzio

I could respond to this ad nauseam, I believe, but as Douglas the Commenter below so wisely pointed out, we’re dependant on our bosses for healthcare and tenure. So, to not jeopardize that, I’ll keep it brief.

It almost seems as though American business culture thrives on its citizens (of which I am one) owning perpetual ailments- a citizenry, a collective culture perhaps, of hypochondriacs. There are countless ads for beating this affliction and that affliction with this drug or that drug. Whether it be relieving stress or correcting erectile dysfunction, every condition has a myriad of pharmaceutical resolutions (for lack of a better term). Things people may not have ever thought of on their own are elucidated by many advertising campaigns. Not too mention that the food argument made by Laura Bennett in her comment to this entry also makes perfect sense. The brutal eating habits that America is notorious for do nothing but exacerbate our chances of getting sick- Boo Ya for fast food!!!! Who knows, maybe Brits are less ill than Americans b/c they simply don't know as many ways to be as such. I'd be careful with this kind of column; you could be labeled "unpatriotic" by adhering to a study not done in America that acknowledges the (albeit statistical) detriment of Americans' health.

Anyway, I always enjoy you’re blogs, Mr. Gladwell. If you find yourself compelled to update more frequently, I’d like to support that urge.


Jeff, I think deep down every American knows it's their general food and lifestyle habits that is the greatest source of health problems but it's easier to ignore this, medicate, and whine about a broken healthcare system. No offense to doctors but I think this country would be far better served with more nutritionists and fewer physicians. It's not their fault - the at-risk population would rather drink some more red wine, eat a few boxes of lean cuisine with cans of Diet Pepsi, and get a prescription for Lipitor than spend the time to cook a small, nuritious meal and spend 30 minutes to exercise. Everyone wants to look for the shortcut and if a doctor only has 15 minutes with a patient, well if they won't respond to simple advice then the physician has no choice but to medicate. Our Lipitor generation is just begging for the next blockbuster CVD drug so they can eat 5 cheeseburgers guilt-free.

Disc: I consult for pharma and medical device clients who work in CVD. If America radically changed its habits tomorrow and got healthy, I'd be out of work and frankly, I'd be happy as a Care Bear.

Julian Jonas

Maybe we should just make the most obvious conclusion: the prevalent type of healthcare available in the US is not good for our health. Removing or suppressing symptoms through drugs & surgery without resolving underlying problems - such as diet, lifestyle, etc. - may have short term benefits, but the long term consequences won't be so positive. The fundamental state of the body will be just as unhealthy, and the illnesses it expresses will become more insidious. This is to say nothing of the repercussions of indulging in the pharmaceuticals.

Alan Creveling

If you really want to have fun with this study, try examining the US on a state by state basis. Hawaii is near the top or at the top of the list in Diabetes, hypertension, and a myriad of heart ailments.

The problem in Hawaii is diet. Are the foods we eat worse because of trans-fats, perservatives, or hormones? Maybe. Is it because South East Pacific Islander foods tend to be fatty and high in cholesterol? Perhaps. My guess is that it's probably both.

But, any way you look at it, you need only spend a week in Hawaii to know the answer is not stress.


For the well being of all readers who doesnt print your post out to read, please change your fonts to san-serif


I don't think anyone is arguing that stress level alone is what makes the American sample less healthy.


An interesting discussion. Diet is likely a part of the story (US diets are generally quite different than UK diets); stress isn't a bad thing to reduce; walking is more prevelant in the UK -- but one other factor contributing to morbidity and mortality is air pollution, notably the amount of small-particulate pollution inhaled by Americans in their cars as they commute. Being in one long string of cars for an hour or more per day, Americans inhale an obscene amount of small-particulate air pollution, leading to more heart, lung, and nervous system problems. Moving just a dozen feet to the side decreases exposure immensely, so the average UK commuter, who takes a train and walks alongside the road, will inhale far less small-particulate air pollution on daily basis.

So, we eat worse food, are total stress bags, are more sedentary, and suck tailpipe a good portion of most days. I think this is multivariate, but completely explicable.


Hi Malcom,
Delighted to find your blog, as I just finished reading 'Blink' and very much enjoyed it.

As a healthy Englishman (albeit with crooked teeth!) who has spent much time in the US, I'd make the following observations.

1. Americans I have known and spent time with spend far too much time sitting on their backsides. I recall an evening in the States where I went for dinner with a friend. We left his apartment and set off for a restaurant half a mile away - in his CAR! It was a sunny evening, it would have taken 10 minutes to walk, but he insisted on driving. I don't think this type of short journey by car is exactly uncommon in the US.

2. Tea!
George Orwell described tea as one of the "mainstays of civilization", and we Brits do drink a hell of a lot of it. There is much evidence that there is a health benefit in daily tea consumption, from the antioxidants and minerals that tea contains which assist the immune system.

3. Most of my American friends are on a staggering variety of medication treatments. I'm no doctor, but I question the need for young men in their 20s to to be filling themselves up with little pills every day for the most minor of ailments.

I may be accused of cynicism, but I also wonder if the US health system is a cash-cow for pharamacutical companies, rather than our (very far from perfect but socialist-minded) national health system which in theory, puts patient before profit.

4. Another factor in over-medication may be that Americans are bombarded with TV advertisments for the latest pills ("Ask your Doctor about... etc") which create a demand to solve a problem that probably has a more holistic, less chemical solution.

5. As far as Diabetes goes, bottomless cups of sugary soda springs to mind. Getting a free refill in the UK is like finding gold-dust! If we had such an approach to commerce over here, we'd be filling out like balloons overnight.


One flaw in your thinking, I think, is that we do not see paralleled results WITHIN the U.S.

For instance, using your logic NY City dwellers should be much sicker than say backwater southerners. But, that's not the case.


I'm surprised no one has brought this up yet:

High Fructose Corn Syrup instead of Sugar. The higher obesity rates has to be a major factor and more and more I'm coming to believe the theory that using Fructose instead of real sugar so much in the US is a major reason for our obseity (in addition to the general lack of excersize people get)


I believe this is the correct article:


Disease and Disadvantage in the United States and in England
James Banks, PhD; Michael Marmot, MD; Zoe Oldfield, MSc; James P. Smith, PhD

JAMA. 2006;295:2037-2045.


I think I'll go have myself a stiff drink!


I relocated from New York to London two years ago, and I'm just waiting for a study about mental health in the U.S. vs. the U.K. Americans go to the shrink, the British go to the pub. And still they're healthier.


More illness in the U.S. than U.K. and higher costs per year for medical care. Hmm... Interesting that everyone is reading the causation in one direction and drawing conclusions about what the average medical care dollar is buying in the US (less than it should - and perhaps it is even causing the greater incidence of ill health).

SIMPLER EXPLANATION: When you're sick, you spend more on doctors, tests, and medicine. The U.S. is sicker, so we need more medical care, hence the bigger bucks.

In other words, these data might not have any implications for the effectiveness or efficiency of the medical care system in the US. Perhaps, given how sick we are as a country, we could be spending more - or less - but the data don't address that question.

Stephen Bezruchka

In response to the material Elizabeth mentioned about my talk on Alternative Radio, I sent the following letter to the NY Times after Krugman's piece appeared.

"Dr. Krugman has difficulty with the diagnosis in today's column Our Sick Society. Our Institute of Medicine's 2003 report, THE FUTURE OF THE PUBLIC'S HEALTH IN THE 21ST CENTURY, has it on page 59: "More egalitarian societies (i.e. those with a less steep differential between the richest and poorest) have better average health." Inequality kills. The issues Dr. Krugman has been writing about for years are the medicines we need to achieve better health, namely those that address taxation, subsidies and welfare for other than the rich who would be healthier without them.

Good health in this country has never been a goal although 50 years ago we were one of the healthiest nations in the world when there was more economic justice. Like landing on the moon by the end of the 60s decade, we could make it a goal in the USA."

There is little to dispute of the JAMA study findings. There are a whole host of others that are consistent. Some material including courses I teach on this at the website below.

Stephen Bezruchka MD, MPH
Senior Lecturer: International Health Program
Department of Health Services
School of Public Health and Community Medicine
University of Washington
Box 357660
Seattle, Washington 98195-7660,
(206)616-2901, Fax (206)685-4184


I'm a 50 year old Canadian. I've never driven a car (don't know how) so I tend to walk a lot. I drink a lot of tea (always have) and wine.

So I'll let you know how it goes! (By the way, as far as I'm aware I have no ailments and haven't had a cold or flu in over a year.)

By the way, while Malcolm suggests stress as a factor I don't believe he says it's the only one. What he says above is, "Our health is in reality a function of the broader society in which we live--the pressures and conditions and environments in which we find ourselves."

This can include stress but is not exclusive to it. Diet, exercise, advertising etc. can all come under this rather broad umbrella.


Pitbulls and Wine

The study that purported that wine drinking is healthy was flawed in that the sample of non-drinkers included those who had ceased imbibing due to its effects. Like-wise, as in a previous Gladwell blog, our overall perception of pitbulls may be flawed because very few other breeds can withstand the conditions that make a pitbull truly ferocious.

The death rate in the UK is ~ 10.13/1000 and the in the US it is ~ 8.26/1000 which is quite a significant gap given the similar demography. The sample in the U.K. study, therefore, does not include the dead which, by the way, is worse than being sick. The healthcare spending model in the UK, I imagine, is similar to the Canadian model which means that health care is universally available and resource utilization is very high which translates into long lead times. Each case is prioritized according to its severity; this drives a behaviour that favours professional treatment as a last resort. The demographic being studied (non-Hispanic whites) in the US strives for health care availability which translates into un-used capacity in their health care system which in turn drives costs upward.

The two key points is the disparity in the death rates and productivity in the Health Care sector. Lower productivity in this case may be a measure of availability.

Buster G.

As someone who has visited the UK often, I can endorse the observations noted by others that the lesser reliance on autos and greater degree of walking should be considered as a significant cause of the Brits' better health.

By the way, Americans probably don't get 2 1/2 times the health care that the Brits do; we just pay more for it. The same drugs cost way more in the US, the doctors are given obscenely greater compensation, the insurance cos. cost us greatly in administrative expenses and reap great profits, etc.


I wonder how often the average U.S. male goes to the doctor, and when they do whether they go to a hospital treatment room, a local GP, etc.

In Britain, amongst most men, there is a "snap out of it" culture. We don't tend to go to the doctor unless something is worryingly, and noticeably wrong, such as partial paralysis, or pain that is still there after several weeks.


Dear Malcom,

Intriguing is your insight into economic success and poor health habits. My solution: establish a monarchy in the US and disburse titles and orders. That will result in less heartattacks, as rich Americans can stop worrying about money, and start relishing their hereditary status in the American nobility!

Jim Bass

How odd. I keep reading about one health crisis after another and yet life expectancy continues to increase.

Such studies are Rorschachian. Liberal scolds and knee-jerk busybodies can't wait to start telling people how to live.

Socialists point to the gap between rich and poor. See Paul Graham's essay "Inequality and Risk" to understand why said gap may be a good thing.


You might also enjoy reading David Asman's account of his wife's falling sick in London. He writes about what's good and bad in both systems. Read it here:


More grist.

P.S. Someone complained about serif type on the blog. It doesn't bother me. What does is the lazy typists who can't seem to find the shift key unless they're capitalizing UK and US.

Hint: capital letters were invented for a reason -- to make it easier to read. One e.e. cummings was enough.

C Stephen

Are Americans really in worse condition or better diagnosed? Maybe both. Possibly visiting DR more often (as it is fashinable in some circlesin America to visit the DR frequently and not put off exams - big business). Couple increased visits with a series of other enviromental conditions (pollution of: water, air etc) perhaps exposed to more irritants which over time bring about a greater perceived need for medical care. Was there a comparision of health care costs? While an exam or MRI in say Canada is free or low cost you wait for months, in America the cost is high but you go today! Economic trades which increase diagnosis? Pre-Diabetic conditions remain hidden until "coming out" by other medical symptoms. However, emperical experience indicates the frequency of medicla visits and aavalability of medicla care has risin - regular visits to the DR may catch the disease possibilties sooner.


Several good comments above cover most of what I intended to say. The mention of the fact NHS lets people in certain circumstances die, while heroics to prolong life (even slightly) are paid for by public and private health insurers in the U.S., is a big item. And there is the consideration that you may die while on a waiting list for a number of procedures in the U.K., especially those which are the most costly, while no one will ever fail to get under a surgeon's knife or an expensive machine in the U.S.

Not covered above, however, is the mental health cost problem we have in the U.S. Our psychologists and psychiatrists will tell you 30% or more of all of us "need treatment," and if you hooked them to a polygraph on the question they would pass. Our healthcare appropriators mostly defer to advice from such "professionals" and authorize foolish mental health expenditures, thus enabling this uniquely American stream of waste. Other excessive medical costs like unnecessary tests are demanded by our insane malpractice claims system, also a uniquely American nightmare.

The question has been asked for generations whether the American people are happy or unhappy compared to others in the world, often with an accompanying allegation that our self-reliance under capitalism is too stressful. Perhaps there is some truth in that. In the Old World a man was happy if he could be as good a fisherman as his father, or as good a baker, tailor or candlestick maker. In America everyone frets because he isn't a millionaire--except that the number who are actually becoming millionaires has rapidly turned this stupidity on its ear!

Mark Richards

Huge fan Malcolm...but as Morrissey sings in his latest song, "You have killed me".

I'm at a loss as to how someone as intellegent as yourself who was acutally born in the UK could make the classic American mistake of refering to people from the UK as "English". It's like Salma Hayek referring to everyone in South America as Mexican.

Keep up the good work...but without alienating the Welsh, Scottish and Irish!!

The comments to this entry are closed.

My Photo


  • I'm a writer for the New Yorker magazine, and the author of four books, "The Tipping Point: How Little Things Make a Big Difference", "Blink: The Power of Thinking Without Thinking" and "Outliers: The Story of Success." My latest book, "What the Dog Saw" is a compilation of stories published in The New Yorker. I was born in England, and raised in southwestern Ontario in Canada. Now I live in New York City.

    My great claim to fame is that I'm from the town where they invented the BlackBerry. My family also believes (with some justification) that we are distantly related to Colin Powell. I invite you to look closely at the photograph above and draw your own conclusions.

My Website


  • What the Dog Saw

    buy from amazon


    buy from amazon

    buy from amazon UK


    buy from amazon

    buy from amazon UK

    Tipping Point

    buy from amazon

Recent Articles

Blog powered by Typepad