U.S. Women: Many Missing From the Picture of Health

Jun 4, 2013, 4:21 PM, Posted by

Susan Dentzer Susan Dentzer

The missing women. The concept was first put forward by Nobel Prize-winning economist Amartya Sen in the 1980s. He pointed to demographic evidence that hundreds of millions of women were simply missing from the planet—most likely never having been born, or died, due to discrimination or neglect.

Biologically, females are stronger than males; as a result, in much of the world women outnumber men in population sex ratios. But Sen found the ratio was flipped in India, Pakistan, and Bangladesh. Subsequent investigations show a similar pattern in other parts of the world where women are at substantial economic and social disadvantage to men—including other countries in Asia, the Middle East, North Africa, and central and Eastern Europe.

Now, research sponsored in part by the Robert Wood Johnson Foundation raises the question: Is there a growing corps of “missing women” in the United States as well?

The University of Wisconsins Population Health Institute, a grantee of the foundation’s Mobilizing Action toward Community Health program, has shown that female life expectancy is falling in two out of five U.S. counties, about 1200 counties across the nation (see map below). By contrast, in the vast majority of counties male life expectancy is stable or rising. Shockingly, most of the rising mortality in women isn’t occurring in old age, but rather among those who are below age 50.

The causes are diverse, say David A. Kindig and Erika R. Cheng, researchers at the Population Health Institute, who wrote an article on the topic in the March 2013 issue of Health Affairs. Chronic or noncommunicable illnesses, such as cardiovascular or respiratory disease, are a major factor. Low birth weight or complications of pregnancy and childbirth also play a major role. But so do unintentional injuries like traffic accidents and drug overdoses, especially from prescription painkillers such as oxycodone. Many of these conditions also appear linked to mental illness and mood disorders like depression.

These trends contribute substantially to the US “health disadvantage” relative to other rich countries that is highlighted in the Institute of Medicine report, U.S. Health in International Perspective: Shorter Lives, Poorer Health. That study built on previous ones, including the work of

RWJF’s Commission to Build a Healthier America, founded in 2008 and recently relaunched to focus on early childhood and creating healthy communities. All of these efforts have identified many fundamental causes of the relatively poor health of Americans: smoking, poor diet and physical inactivity, as well as social and economic influences such as relatively low levels of income and education.

If potentially millions of U.S. women are now “missing” due to poor health and premature death, what can be done? Improving the quality and effectiveness of health care delivered to chronically ill populations could help. But the more consequential changes are likely to be greater investments in the fundamental determinants of health: the quality of schools and education; the availability of jobs and incomes, and the alleviation poverty. 

It’s also possible that specific contributors to ill health will vary from county to county across the United States. The RWJF-funded County Health Rankings, produced by the University of Wisconsin, demonstrate these considerable disparities in health factors and outcomes, even within states. The rankings are motivating many communities to examine the data and consider ways to arrest negative trends.

As the map below suggests, some of the worst health outcomes for women are seen in rural communities and in the nation’s heartland. We know some of the reasons, as the National Rural Health Association points out: rural residents are almost twice as likely to die from unintentional injuries, including gunshots, as urban residents; and they are more likely to live below the poverty level. But the nation needs more insight into what is driving the broad trend of rising female mortality.

On behalf of the missing women across the country, we should all be demanding answers—and solutions.


Change In Female Mortality Rates
From 1992–96 To 2002–06 In US Counties

Change in Female Mortality Rates from 1992–96 to 2002–06 in U.S. Counties Kindig D A, and Cheng E R, Health Affairs 2013;32:451-458