✚ The false epidemic of chronic illness among young, rich Americans

I read a recent article in The Atlantic entitled, ‘Living Sick and Dying Young in Rich America,’ with great interest [1]. In this article, Leah Sottile writes about the chronic illness her young family faces—

I thought this would be the time when we’d be preparing for the rest of our lives: earning money, going on fun vacations, having families, building our careers. And we are, but at the same time, we’re doing it while we’re trying to manage pain symptoms, chase down prescriptions, and secure stable health insurance…

I wondered if this was normal. Do we know so many people who are dealing with pain because people are just getting sicker in general?…It turns out that chronic conditions like what Joe and my friends are dealing with are one of America’s biggest health emergencies.

I read on with incredulity. I have been in medical school 4 years. I have studied and followed public health for the past 9 years. I had no idea America was facing an epidemic of chronic illness among 30-somethings. Why haven’t I heard about this? Why haven’t I been learning about it in my classes or on the wards?

After reading through the source material referenced by The Atlantic, I have a hard time coming to the same conclusions as this article.

The article begins with the author writing about her husband’s struggle with ankylosing spondylitis (an autoimmune disease). Then goes on to talk about a close friend dealing with lupus (another autoimmune disease) and fibromyalgia.

In our close group of friends—who range from 25 to 35 years old—we know people with everything from tumors to chronic pain.

Though this last statement is quite vague, it seems from the initial few paragraphs there is an epidemic of autoimmune disease among young Americans. (The epidemiology of autoimmune diseases is quite dynamic. While the incidence of some have increased, others have decreased.) However, the article only uses the word ‘autoimmune’ four times; instead, the argument is framed in terms of ‘chronic’ diseases (mentioned 10 times).

In support of this epidemic of chronically ill young adults, the article links to a 2013 report by the National Research Council and Institute of Medicine entitled, ‘Shorter Lives, Poorer Health,’ and states—

But it’s not just that Americans are getting sicker—it’s that young Americans are getting sicker…“The panel was struck by the gravity of its findings,” it reads. “For many years, Americans have been dying at younger ages than people in almost all other high income countries.”

Though the quoted sections above are accurate, the conclusion that ‘young Americans are getting sicker’ is not (at least not in terms of chronic diseases). In the summary for the NRC/IOM report, the authors list nine domains where America fares worse than their peer countries:

  1. Adverse birth outcomes
  2. Injuries and homicides
  3. Adolescent pregnancy and sexually transmitted infections
  4. HIV and AIDS
  5. Drug-related mortality
  6. Obesity and diabetes
  7. Heart disease
  8. Chronic lung disease
  9. Disability (noting this specifically amongst older Americans)

In reference to this list, the report notes—

The first half of the above list occurs disproportionately among young Americans. Deaths that occur before age 50 are responsible for about two-thirds of the difference in life expectancy between males in the US and peer countries, and about one-third of the difference for females.

The first half of the list (items 1 - 5) do not encompass any chronic disease [2]. The causes of America’s worse outcomes in these domains are most closely linked to poverty, risky behaviors, and poor access to health care. The report goes on to note that the poor health status of Americans at age 50 is caused by ‘chronic diseases that arise from risk factors (e.g.—smoking, obesity, diabetes) that are often established earlier in life.’ They do not link such poor health status of 50 year-olds in the US to a mysterious explosion of autoimmunce diseases among 20 - 30 year-olds.

The Atlantic article also points to a report from the Univ of Washington’s Institute for Health Metrics and Evaluation entitled, ‘The State of US Health: Innovations, insights, and recommendations from the Global Burden of Disease Study,’ and says—

In fact, a recent report…says that “in some U.S. counties… life expectancies are on par with countries in North Africa and Southeast Asia.”

The report indeed states this, but the report does not support the implied assertion that these lower life expectancies are from an epidemic of autoimmune diseases among young Americans. The IHME writes—

In the US, we found that life expectancy increased, but the number of years Americans spend living with disability also increased. Ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease (COPD), and road injury were responsible for the greatest number of years of life lost in America in 2010. Musculoskeletal, mental, and behavioral disorders, such as low back and neck pain, depression, and anxiety, were the leading causes of years lived with disability. Looking at risk factors for disease and injury, GBD researchers found that dietary risks, such as eating too little fruit, nuts, and seeds and too much salt, were the largest contributors to disease burden, followed by smoking, high body mass index, high blood pressure, high fasting plasma glucose (high blood sugar), insufficient exercise, and alcohol use.

The Atlantic piece also refers to testimony by Steven Woolf MD MPH, director of the Center on Society and Health at Virginia Commonwealth University, in front of the US Senate. They link to a YouTube video from Senator Bernie Sanders as a reference; this video does not contain any of the testimony attributed to Dr Woolf in the article [3]. In fact, during his brief appearance in the video, Dr Woolf mostly discusses the link between poverty and poor health in the US.

Living with a chronic disease—autoimmune or otherwise—at any age is difficult. Doing so at age 30 would undoubtedly be life-changing. I do not wish to minimize any person’s experience dealing with a chronic disease. I do wish for people to accurately understand the nature and distribution of disease so that we can have a meaningful dialog about improving health care. Unfortunately, I believe this article in The Atlantic misrepresents disease in America and detracts from such dialog. Many people worked very hard to produce this research; it is important to honor their work.

The subtitle for this article is, ‘Chronic illness is the new first-world problem.’ Chronic illness has always primarily been a problem in developed countries. In fact, the real news is that chronic illnesses are increasingly a problem in poor counties. The whole world is struggling with chronic illness, not just young, rich Americans.

  1. This article appears in The Atlantic’s ‘Health 2014: Bright spots in a troubled system’ series.  ↩

  2. Arguably, HIV/AIDS (due to advances in anti-retroviral treatment) and drug-related mortality (as outcomes due to chronic mental illness) are now chronic illnesses.  ↩

  3. The YouTube video does contain some testimony from Dr Woolf, starting at the 2:05 mark. However, it doesn’t contain the specific testimony quoted in The Atlantic.  ↩