The Poor State of America’s Health: Population Health Ethics

Despite spending more on healthcare than any other nation, Americans live shorter sicker lives than their counterparts in other rich and some middle-income countries. The “US health disadvantage” is explained primarily but not completely by the poor health and truncated life spans of America’s poor and low income populations. Contributing, too, are poor levels of health among America’s middle- and upper-classes, who fare worse than their counterparts in other rich nations. Within the U.S., people experience vastly different health and longevity outcomes. Numerous national reports have documented the poor state of America’s health and laid a foundation for action.

Some two decades ago, U.S. bioethics increasingly began to address questions raised by stark differences in health associated with social class, race and ethnicity, geography, and gender. Which health inequalities constitute health inequities? What role does health play in those judgments? How should we think about responsibility for health? Is health a societal, individual, or shared responsibility? How can we address inequities without marginalizing communities burdened by poor health? These are just a few of the central questions of population health ethics.

Addressing Social Determinants of Health

These social conditions embody resources and risks that work through complex psychological and physiological pathways to produce profoundly different health and longevity outcomes. Healthcare matters to human health but far less than most Americans understand. The US County Health Rankings and Roadmaps Project, funded by the Robert Wood Johnson Foundation, estimates that the contribution of clinical services to health outcomes is 20% (Figure 2).

Ethical analyses of such questions reach far beyond medical services and healthcare to address the primary drivers of health inequalities—the “social determinants” of health. Social determinants refer to the social conditions in which people grow up, live, work, play, and age (Figure 1).

Population Health Ethics Programming

The Center’s John B. Francis Chair, Erika Blacksher, PhD, appointed on September 1, 2020, has been working on issues in population health ethics for two decades. Her current research focuses on questions of responsibility and justice raised by worsening white mortality trends, so called “deaths of despair,” and related roles of early life adversity, socioeconomic deprivation, and whiteness. Her work has also addressed debates over the ethics of wellness programs and stigmatization as tools of disease prevention and health promotion. She also explores the vital role of participatory engagement as a facet of policies and programs that aim to promote social and health equity.

Her familiarity and respect for the Center’s community-based engagement model and participatory research efforts comes from her working at the Center early in her career. Dr. Blacksher’s research in community-based deliberations by convening diverse communities in informed discussions about health disparities in search of priorities and solutions will continue as she rejoins her colleagues at the Center. She publishes and speaks frequently on these issues.

See Erika's curriculum vitae for more.

S.H. Woolf, A. Laudan Aron. US Health in International Perspective: Shorter Lives, Poorer Health. Washington, DC: National Academies Press 2013.
US County Rankings and Roadmaps. Measures and Data Sources. Available at:

Center for Practical Bioethics

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