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WASHINGTON (AP) -- Americans are living longer than ever, but not as long as people in 41 other countries.

For decades, the United States has been slipping in international rankings of life expectancy, as other countries improve health care, nutrition and lifestyles.

Countries that surpass the U.S. include Japan and most of Europe, as well as Jordan, Guam and the Cayman Islands.

"Something's wrong here when one of the richest countries in the world, the one that spends the most on health care, is not able to keep up with other countries," said Dr. Christopher Murray, head of the Institute for Health Metrics and Evaluation at the University of Washington.

A baby born in the United States in 2004 will live an average of 77.9 years. That life expectancy ranks 42nd, down from 11th two decades earlier, according to international numbers provided by the Census Bureau and domestic numbers from the National Center for Health Statistics.

Andorra, a tiny country in the Pyrenees mountains between France and Spain, had the longest life expectancy, at 83.5 years, according to the Census Bureau. It was followed by Japan, Maucau, San Marino and Singapore.

The shortest life expectancies were clustered in Sub-Saharan Africa, a region that has been hit hard by an epidemic of HIV and AIDS, as well as famine and civil strife. Swaziland has the shortest, at 34.1 years, followed by Zambia, Angola, Liberia and Zimbabwe.

Researchers said several factors have contributed to the United States falling behind other industrialized nations. A major one is that 45 million Americans lack health insurance, while Canada and many European countries have universal health care, they say.

But "it's not as simple as saying we don't have national health insurance," said Sam Harper, an epidemiologist at McGill University in Montreal. "It's not that easy."

Among the other factors:

- Adults in the United States have one of the highest obesity rates in the world. Nearly a third of U.S. adults 20 years and older are obese, while about two-thirds are overweight, according to the National Center for Health Statistics.

"The U.S. has the resources that allow people to get fat and lazy," said Paul Terry, an assistant professor of epidemiology at Emory University in Atlanta. "We have the luxury of choosing a bad lifestyle as opposed to having one imposed on us by hard times."

- Racial disparities. Black Americans have an average life expectancy of 73.3 years, five years shorter than white Americans.

Black American males have a life expectancy of 69.8 years, slightly longer than the averages for Iran and Syria and slightly shorter than in Nicaragua and Morocco.

- A relatively high percentage of babies born in the U.S. die before their first birthday, compared with other industrialized nations.

Forty countries, including Cuba, Taiwan and most of Europe had lower infant mortality rates than the U.S. in 2004. The U.S. rate was 6.8 deaths for every 1,000 live births. It was 13.7 for Black Americans, the same as Saudi Arabia.

"It really reflects the social conditions in which African American women grow up and have children," said Dr. Marie C. McCormick, professor of maternal and child health at the Harvard School of Public Health. "We haven't done anything to eliminate those disparities."

Another reason for the U.S. drop in the ranking is that the Census Bureau now tracks life expectancy for a lot more countries - 222 in 2004 - than it did in the 1980s. However, that does not explain why so many countries entered the rankings with longer life expectancies than the United States.

Murray, from the University of Washington, said improved access to health insurance could increase life expectancy. But, he predicted, the U.S. won't move up in the world rankings as long as the health care debate is limited to insurance.

Policymakers also should focus on ways to reduce cancer, heart disease and lung disease, said Murray. He advocates stepped-up efforts to reduce tobacco use, control blood pressure, reduce cholesterol and regulate blood sugar.

"Even if we focused only on those four things, we would go along way toward improving health care in the United States," Murray said. "The starting point is the recognition that the U.S. does not have the best health care system. There are still an awful lot of people who think it does."

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On The Net:

Census Bureau: http://www.census.gov/ipc/www/idb/

National Center for Health Statistics: http://www.cdc.gov/nchs/fastats/lifexpec.htm

© 2007 The Associated Press.

KANO, Nigeria (AP) -- A security guard in this dusty Nigerian city is living with tragedy - a 14-year-old son whose dazed eyes, slow speech and uneven gait signal brain damage. Mustapha Mohammed says he knows who to blame - Pfizer Inc., the world's largest drug maker.

New York-based Pfizer is facing four court cases - two filed by the Nigerian government and two by officials in the northern Nigerian state where Mohammed lives - over a decade-old drug study that included Mohammed's son.

The company, which denies any wrongdoing, is accused of using a 1996 meningitis epidemic to push through a sloppily managed drug study that contributed to death in some and infirmities in others.

The fallout provides a case study of the ethical dilemmas that arise when Western medical priorities run into Third World poverty and ignorance. The communication gap between those handing out medical alms and those receiving has bred mistrust and anger in Kano - with damaging, far-reaching effect.

The Pfizer case was cited as one reason residents of Kano and the state of the same name boycotted a polio vaccine in 2003, fearing it was a plot to make Africans infertile. Polio exploded in Nigeria and eventually spread to 25 previously polio-free countries.

Though the meningitis epidemic is long over and the polio vaccination program is back on track, misinformation and suspicion persist.

Mohammed is sure no one asked his permission to test a drug on his child. But he also wasn't asking many questions when he rushed his son to the hospital in 1996.

"We were desperate for drugs. We just took it in good faith," said Mohammed, who lives in a tiny house off a dirt road in one of Kano's poorer neighborhoods. Mohammed - who can't read or write - only later found out that the pink paper he kept with Pfizer's name and treatment dates meant his son had been in the study.

Pfizer says it explained the study to families using practices in line with U.S. and international guidelines, even employing Nigerian nurses and doctors who spoke Hausa, a main Nigerian language. Written permission was obtained when possible, or oral consent if parents were illiterate.

Across town, Abu Abdullahi Madaki can't be sure if her daughter Firdausi took part in the Pfizer study. Citing privacy concerns, Pfizer has declined to release the names of the 200 children it treated.

All Madaki knows is she took a feverish 8-month-old infant to the hospital in 1996, and now her daughter suffers severe brain damage that left her unable to sit up or talk.

Meningitis - a brain infection - leaves 10 percent to 20 percent of survivors with mental damage, hearing loss, or learning disabilities, according to the World Health Organization.

But Madaki said: "My younger sister had meningitis, but it was nothing like this. My younger sister is now a mother with children."

Madaki, who is illiterate, said she'd always felt that the hospital did something wrong. She decided when she heard about the charges against Pfizer on the radio that her daughter must have been in the study.

Pfizer says it brought the drug - an antibiotic called Trovan - to Nigeria as a humanitarian effort. Trovan had already been tested on humans in the U.S. It was a tablet, which could be easier to use with children than the standard meningitis treatment - a painful injection.

More than 11,000 children died in Nigeria during the epidemic.

"When this epidemic occurred, the government asked people to come and help them," said Ngozi Edozien, regional director of the Pfizer branch that covers Nigeria. She said Pfizer wanted to help, but could only offer Trovan through a clinical study because the drug was not yet approved.

Edozien argued that approval to use Trovan to treat epidemic meningitis would not have been a windfall for the company, but for the poor countries that face the disease. She also noted that Pfizer donated medical supplies and equipment to the government to help in the epidemic.

Trovan was approved in the U.S. in 1997 to treat a number of infections, though not for meningitis. It was later pulled from the market because it was shown to cause serious liver damage.

Death rates were similar among the 100 children taking Trovan and the 100 Pfizer gave the standard meningitis treatment. Five of the Trovan subjects died, compared with six in the control group - rates comparable to those of Western hospitals, according to Pfizer.

Still, families and the government argue that Pfizer kept some children on Trovan even though their condition was worsening, that the doses of the standard treatment should have been higher and that dubious procedures used in pushing the experiment through mean Pfizer should be held accountable for any future health problems in those it treated.

It's hard to know if truly "informed consent" is possible during a health care crisis among a widely uneducated, isolated population.

"If you're sick and trying to get health care and somebody says to you, 'Do you want to be in a research study?' If somebody is not familiar with the idea of a research study, it becomes more difficult for them to evaluate," says Benjamin Wilfond, head of Seattle's Treuman Katz Center For Pediatric Bioethics.

But if the people of Kano were uninformed, it's not just a U.S. drug company that's to blame. Lawyers for the study families say the government failed to guard its citizens.

Ali Ahmad, who brought a class action suit on behalf of Kano subjects against Pfizer in the U.S., said he also wanted to sue the Nigerian government, but no government workers would testify.

The U.S. suit was turned down in New York for lack of jurisdiction, though Ahmad said lawyers are in the process of appealing and refiling the case.

He argues that the Nigerian government is now taking advantage of the families' plight to enrich itself. A victory in the Nigerian cases will not mean money for families, but for government coffers in a country that watchdog groups routinely call one of the most corrupt in the world. The federal government is seeking $7 billion in damages and the state government $2 billion; they each have filed one criminal case and one civil suit.

Government lawyers say they were slow to file charges because the details of the 1996 trial have been hard to get from Pfizer. They claim that the administration was duped along with the study subjects.

"What the government did was to give Pfizer the benefit of the doubt, and obviously naively trusted Pfizer," said government prosecutor Babatunde Irukera.

Six years after the meningitis outbreak, a Kano doctor printed out a series of diatribes he found on the Internet calling the polio vaccine a Western plot to reduce the world's Muslim population. Many of the area's influential Muslim clerics took up the cause and led a 16-month boycott.

Local officials say Kano was primed to believe the rumors. Residents already found it strange that they were given free polio doses but nothing for bigger killers like malaria and measles. And the Pfizer controversy was still simmering.

"When people heard about (the Pfizer charges), they started really hiding their children," said Alhahi Ibrahim Jibrin Mai-Anguwa, head of a 3,000-person neighborhood ward in Kano.

The state governor stopped the vaccination program while doses were sent abroad for testing, a move that shocked the West but may actually be the bright spot in Kano's story - an official listening to the concerns of his constituency. When test results confirmed the vaccine was safe, people began to embrace it again.

But some damage can't be erased.

Twice a week, mothers arrive in the physical therapy ward of a Kano hospital carrying children with the jerking legs and lifeless arms of polio for massages and sessions under heat lamps.

Four-year-old Fatima Yau, whose mother refused to have her immunized in 2003, lies on the examination table with legs splayed out flat and unresponsive.

Her mother says she's hopeful for Fatima's future. Her daughter just started school. She's carried to classes each morning on an older sibling's back.

© 2007 The Associated Press.

NEW YORK (AP) -- Increasingly, American consumers are shopping for health care the way they buy a hamburger or milk shake at a fast-food chain: By standing in line at a local store under a menu.

Store-based health clinics - which are staffed mostly by nurse practitioners and offer quick services for routine conditions from colds and bladder infections to sunburn - aren't just a health care fad anymore, but fast becoming a serious industry.

About 7 percent of Americans have tried a clinic at least once, according to an estimate by the Convenient Care Association, an industry trade group formed last year. That number is expected to increase dramatically, as major pharmacy operators like Wal-Mart Stores Inc., CVS Corp., Target Corp. and Walgreen Co., partner with miniclinic providers like RediClinic and MinuteClinic to expand operations. The trade group estimated there will be more than 700 by year-end, up from the more than 400 now, and 2,000 by the end of 2008.

With the nation's $2 trillion health care system in need of repair, such an express approach to health care - which offers a wait time averaging about 15 minutes and evening and weekend hours - is being heralded as serving up a cheaper and quicker alternative than a doctor's office or an emergency room. A physical exam costs on average $60, while a flu shot typically costs about $20. A strep throat test has a price tag of about $15.

"I was frankly very impressed with how thorough (the examination) was," said Susan Anthony, who visited a clinic at a Phoenix, Md., Target for a dry cough. "And it was fast. I walked in at 10:30 a.m. and was in my car a little after 11:00 a.m."

The American Medical Association said a growing number of medical practices are extending their office hours or forming their own clinics to compete. But concerns about quality of care are rising among physicians and some industry experts say the clinics' services need to be more comprehensive if they are going to have a big impact on reducing overall health care costs.

The competition is already spawning expanded services as well as new spinoffs. Consumer Health Services Inc. - founded by a former investor of MinuteClinic, considered the pioneer in the industry - just started rolling out walk-in doctor's offices at Duane Reade Inc. drugstores in the New York City area. The clinics offer broader services that include wart removal and treatment for sprained ankles.

The ventures are promising enough that big-shot investors are jumping into the game. RediClinic got an undisclosed cash infusion from Revolution LLC, the investment house launched by AOL founder Steve Case.

Support among health insurance companies is also growing; about 40 percent to 50 percent of clinics accept insurance from providers like Humana Inc., UnitedHealth Group Inc. and Aetna Inc., according to CCA.

"(Store-based clinics) provide another access point for our members," said Allen Karp, vice president of health care delivery for Aetna.

But concerns are rising in the medical industry that these operations remain largely unregulated and are prone to conflicts of interest. Some physicians are also concerned that the clinics could disrupt the continuity of care and result in serious underlying health conditions going undetected.

In June, the American Medical Association urged state and federal agencies to look into whether pharmacy chain-owned clinics urge patients to get their prescriptions filled on site. That followed buyouts of miniclinics by two big-name pharmacy operators: Walgreen bought Conshohocken, Pa.-based Take Care Health Systems in June, and CVS acquired Minneapolis-based MinuteClinic last year.

Dr. Peter Carmel, a trustee on the AMA board, said "the path of abuse is wide open," and the clinics need to be better regulated.

A growing number of states have passed legislation to better define the role of the nurse practitioner at these clinics, but store-based clinic executives say some of the state rules are too burdensome and hinder growth. According to the American College of Nurse Practitioners, approximately 23 states allow nurse practitioners to treat patients on their own. The remainder requires some formal relationship with a physician, which varies from supervision to collaboration. In Texas, for example, the physician is required to be at the site for 20 percent of the time a clinic is open.

Store-based health clinics are held to the same high standards as doctors' offices, said Tine Hansen-Turten, executive director of the Convenient Care Association. She pointed out that store clinics are either monitored by a state board of nursing or board of medicine, and sometimes by both.

AMA also wants to ban the practice of health insurance companies waiving or lowering co-payments for clinic patients, which it calls a conflict of interest.

Dr. David Plocher, the senior medical officer at Blue Cross Blue Shield of Minnesota, said that "the normal market forces should determine such things." His company has reduced or waived co-payments for 25 member companies who use MinuteClinics and several other store-based clinics.

The savings can be significant.

A visit to a store-based clinic averages about $60, but a doctor's visit costs twice as much, particularly in urban markets, according to Barry Barnett, a health care consultant for PricewaterhouseCoopers. That compares to about $300 for an emergency room visit, according to Barnett.

About 40 percent to 50 percent of clinics take insurance. Hansen-Turten estimated 50 percent of clinic customers pay cash, but she noted that the majority have insurance.

Like many of his industry peers, Michael Howe, president and CEO of MinuteClinic, said the concerns about quality are overblown.

"I wouldn't call it express care. I would call it efficient care," added Howe.

The AMA denies that its criticism of these clinics is being driven by economic interests, though there's no doubt that primary physicians could lose some business as their insured patients go elsewhere for minor ailments.

But health care consultants say that while the clinics may help save customers money and time, their ability to reduce overall health care costs will probably be limited given that they are really tackling the most minor of health problems.

A bigger effect lies in increased worker availability as employees don't have to take as much time out of their work schedules to go to a doctor's office, according to Dr. Tim Newman, senior medical consultant for Watson Wyatt Worldwide.

The growing number of onsite clinics at workplaces, staffed by physicians, actually have more of a potential to reduce overall health care costs since they focus on disease management, not episodic illnesses. The onsite clinics are not part of the Convenient Care Association's total count, since they are not store-based clinics and have a different model.

Store clinics are proving to be good business; they take about 12 to 18 months to break even. For retailers, the highest-margin products continue to be pharmaceutical, and clinics average about one drug prescription per patient, according to clinic providers. Also, stores can enjoy additional sales when sick customers pick up other items.

But it's still big challenge to gain trust among consumers wary about being treated at a local drug store. Dr. Susan Bowers-Johnson, the medical director for the current four clinic locations at Duane Reade, said that a father recently brought in his 4-year-old child who had a sore on his hand. He said if she was going to prescribe antibiotics, he would rather get them through his family physician.

"Many people are skeptical," she acknowledged.

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On the Web:

http://www.ama-assn.org

http://www.chscorp.com

http://www.convenientcareassociation.org

http://www.minuteclinic.com

http://www.rediclinic.com

http://www.takecarehealth.com

© 2007 The Associated Press.

DENVER (AP) -- The Army has launched a nationwide program to teach soldiers and their families how to identify signs of possible psychiatric injuries suffered in the war on terrorism that may have gone unnoticed.

The Army is responding to widespread reports that soldiers returning from Iraq and Afghanistan with mild brain damage and post-traumatic stress disorder were treated as malingerers or unfairly dismissed from the service.

The training program, called "chain-teaching," was implemented last week at the Pentagon and is intended to reach all active-duty soldiers and reservists within 90 days.

Fort Carson officials plan to discuss the program with media Tuesday, base spokesman Capt. Gregory Dorman said.

The military has acknowledged facing an unprecedented problem, and said that even with the best treatment and preparation, some soldiers will suffer lifelong mental injuries.

"At no time in our military history have soldiers or Marines been required to serve on the front line in any war for a period of 6-7 months, let alone a year, without a significant break in order to recover from the physical, psychological, and emotional demands that ensue from combat," a military report released in May said.

Previously, the draft had guaranteed commanders had replacements for those who had spent considerable time in combat.

Capt. Scot Tebo, surgeon for the 4th Infantry Division's 3rd Brigade Combat Team, said the goal is to identify soldiers with problems as soon as possible so treatment can begin.

"It is important to remember, although you may not be struggling, your battle buddy may be," Tebo told the Fort Carson Mountaineer.

The program will teach soldiers and their families to spot possible indications of post traumatic stress disorder, brain damage and other injuries resulting from service in combat. Additional resources will be available online.

© 2007 The Associated Press.

PHILADELPHIA (AP) -- Obese elementary schoolchildren miss a couple more school days on average than their normal-weight classmates, according to a study that says being fat is a better predictor for absenteeism than any other factor.

Researchers said their results suggest that childhood obesity, in addition to serious medical issues, can lead to a plethora of additional problems down the road.

"It's clear in all the literature that the more days of school you miss, it really sets you up for such negative outcomes: drugs and AIDS and (teen) pregnancy," said Andrew B. Geier, a doctoral candidate at the University of Pennsylvania and lead author of the study released Friday.

He said the findings should serve as a clarion call to school officials.

"At this early age to show that already they're missing school, and missing school is such a major setup for big-time problems, that's something school policy people have to know," Geier said.

The researchers from Penn and Temple University looked at 1,069 fourth- to sixth-graders for one academic year in nine Philadelphia schools, where teachers took attendance each morning. Based on body mass index, a standard measure of height and weight, each child was classified as underweight, normal weight, overweight or obese.

Of 180 school days, researchers found that on average the normal weight students missed 10.1 days, overweight kids missed 10.9 days and obese children missed 12.2 days. For reasons that aren't clear, underweight children had the fewest absences - 7.5 on average.

In decades of research about student performance, race, socioeconomic status, age and gender have been tagged as the top predictors for absenteeism. The new study, in the latest issue of the journal Obesity, concludes that weight tops them all, Geier said.

The study didn't explore why the children missed school. Researchers theorize it's got less to do with medical issues - many children at this young age haven't yet developed major obesity-linked maladies - and more to do with the stigma of being fat.

"They're missing school because they don't want to be bullied and called names," Geier said.

Researchers tried to make the test group as homogeneous as possible by picking schools that were among the city's poorest, with the assumption that education and income levels would be fairly even.

Nationally, obesity rates have nearly quintupled among 6- to 11-year-olds and tripled among teens and children ages 2 to 5 since the 1970s, according to the Centers for Disease Control and Prevention. Obesity can lead to diabetes, high blood pressure and cholesterol, sleep apnea and orthopedic problems.

The study adds to growing research into non-medical complications of being fat, including data suggesting that obese adults miss more workdays and go to college less frequently than people of normal weight, Geier said.

"This is exactly the kind of study that will get the attention of policy makers," said Jim Bogden, healthy eating project coordinator for the National Association of State Boards of Education. "The correlation with absenteeism is very powerful."

He likened the results to studies linking academic achievement to participation in school breakfast programs - research that prompted lots of schools to start offering such programs. In this case, changes could include anything from improving nutrition education and cafeteria offerings to getting parents to serve healthy meals at home.

"Those of us working in school health do all we can to publicize this information, and it seems to be starting to sink in," Bogden said.

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On the Net:

Obesity journal: http://www.obesityresearch.org

© 2007 The Associated Press.