Nation's health depends more on social than medical factors

THE United States, where health-care expenditures exceed $1 billion a day, is the world's healthiest nation, right? Wrong.

Or so says Leonard A. Sagan in his recently published book, ``The Health of Nations'' (Basic Books, New York, $19.95).

True, the infant-mortality rate - a key indicator of a nation's health - dropped from just under 200 per thousand live births in 1900 to 10.9 per thousand in 1983 in the United States. In the same period, Dr. Sagan reports, the life expectancy of the American population (another key indicator) rose from 49.2 years to 74.7 years.

But 17 other nations, including Greece, Spain, and Italy, boast a higher life expectancy than the US. Yet only Sweden exceeds the US in per capita health expenditures.

What, exactly, is America getting for its money? And why, after spending 11 percent of its gross national product on health, are the trends beginning to reverse, with health in the US beginning to decline?

Sagan, a physician and epidemiologist based in Palo Alto, Cal., has combed the medical, sociological, and demographic literature to put together his engaging and provocative answers to such questions.

His thesis is captured in an epigraph he draws from Benjamin Franklin: ``Nothing is more fatal to health than overcare of it.''

The problem, for Sagan, is that Americans have not only been overcaring but misplacing their care. They think better health arises from better health care - a claim Sagan labors to dismiss. America's health, he demonstrates, cannot be explained by the nation's level of medical care, or by the absence of infectious diseases, or by habits of nutrition and exercise. The best predictor of the health is what he calls the ``modernization'' of a nation.

Sagan starts with some obvious observations. What he calls ``premodern'' societies - agricultural, preliterate, authoritarian, and without an industrial base - have the poorest health. By contrast, the ``modern'' societies - technological, urban, industrial - have the greatest life expectancy.

Next, Sagan charts a nation's health against various measures. He notes that, among Western nations during the past century, nutrition has improved, sanitation has reduced disease, and medical care has grown more pervasive.

But a funny thing happens when you try to chart those trends against life expectancy: You can't find a causal relationship. In fact, you find that health in America has increased despite these things - or (as in attempts to control infectious diseases) well before medical advances had time to take effect.

So how to explain the century-long increase in US health? Well, try charting it against education and literacy. They turn out to be excellent predictors of health. By 1850, Sagan notes, 90 percent of white US males were literate - and the nation's health was rising steadily.

But is that simply because higher levels of education are associated with higher income levels - and therefore with better access to medical care? No, Sagan argues. It's measurably true, he observes, that the higher the social class, the better the health. But what happens when governmental subsidies are used to remove class barriers to medical care - as has happened to a large extent in Britain and America? The differences in health among various economic and social classes remain.

For Sagan, however, the most important determinant of health is the strength of the family. ``My thesis,'' he writes, ``is that ... modern parenting behavior has had a major and generally unrecognized influence on the health and development of children, who are bigger, smarter, and more competent as children and adults.''

And that leads Sagan to his real concern. How, he asks, can the United States be encouraged to shift resources away from medical care - which, he says, ``has not materially contributed to increased life expectancy for the population as a whole and may not have a significant influence on life expectancy even today''? When will the nation understand the need to bolster those things that do have a provable correlation to health and longevity - better families, broader education, higher self-esteem, sounder economies? ``Why is it,'' he asks, ``that the public holds such an exaggerated view of the influence of environmental agents on health and has so little concern about personal or psychosocial factors as determinants of disease?''

Good questions, these. To be sure, the book has its flaws. It's somewhat repetitious, and it's overly broad in its generalizations about ``premodern'' societies - as though every developing nation was cut from the same cloth.

But at least it points a responsible finger at the social, mental, and moral currents that underlie individual health. As policymakers struggle to distribute scarce resources, they could well ponder Sagan's conclusion that, in the future, ``improvements in health will fundamentally depend upon a new vision of human health and its determinants.''

A Monday column