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The longest-living Americans can expect to survive decades longer than the worst off – and the explanation is far more complex than poverty, a startling report on health disparities says.

It turns out that where you live, combined with race and income, plays a huge role in whether you die young, says a study issued Monday that contends that the differences are so stark it is as if there were eight separate United States instead of one.

Worse, the gaps in lifespan have persisted over 20 years, despite efforts to tackle them, Dr. Christopher Murray of the Harvard School of Public Health concluded.

“That's pretty devastating,” said Dr. Murray, who published the exhaustive analysis in the on-line science journal PLoS Medicine. “Whatever it is that we're doing isn't working. That's a wakeup call.”

Leading the United States in longevity are Asian-American women who live in Bergen County, N.J., and typically reach their 91st birthdays, concluded Dr. Murray's county-by-county analysis.

On the opposite extreme are American Indian men in swaths of South Dakota, who die about 58.

Millions of the worst-off Americans have life expectancies typical of developing countries, Dr. Murray said. The Asian-American women can expect to live 13 years longer than low-income black women in the rural South. That is like comparing women in wealthy Japan to those in poverty-ridden Nicaragua.

Compare those longest-living women to inner-city black men, and the life-expectancy gap is 21 years. That is similar to the life-expectancy gap between Iceland and Uzbekistan.

Health disparities are widely considered an issue of minorities and the poor being unable to find or afford good medical care. Dr. Murray's government-funded study, however, shows that the problem is far more complex and that geography plays a crucial role.

“Although we share in the U.S. a reasonably common culture ... there's still a lot of variation in how people live their lives,” he explained.

The longest-living whites were not the relatively wealthy, which Dr. Murray calls “Middle America.” They are edged out, by a year, by low-income residents of the rural Northern Plains states, where the men tend to reach age 76 and the women 82.

Yet low-income whites in Appalachia and the Mississippi Valley die four years sooner than their northern neighbours.

“If it's your family involved, these are not small differences in lifespan,” Dr. Murray said. “Yet that sense of alarm isn't there in the public.

“If I were living in parts of the country with those sorts of life expectancies, I would want ... to be asking my local officials or state officials or my congressman, 'Why is this?'”

This more precise measure of health disparities will enable federal officials to better target efforts to battle inequalities, said Dr. Wayne Giles of the Centers for Disease Control and Prevention, which helped fund Dr. Murray's work.

The CDC has some county-targeted programs – such as one that has cut in half diabetes-caused amputations among black men in Charleston, S.C., since 1999, largely by encouraging physical activity – and the new study argues for more, Dr. Giles said.

“It's not just telling people to be active or not to smoke,” he said. “We need to create the environment which assists people in achieving a healthy lifestyle.”

Murray analyzed mortality data between 1982 and 2001 by county, race, gender and income. He found some distinct groupings that he named the “eight Americas:”

– Asian Americans, average per capita income of $21,566, have a life expectancy of 84.9 years.

– Northland low-income rural whites, $17,758, 79 years.

– Middle America (mostly white), $24,640, 77.9 years.

– Low-income whites in Appalachia, Mississippi Valley, $16,390, 75 years.

– Western American Indians, $10,029, 72.7 years.

– Black Middle America, $15,412, 72.9 years.

– Southern low-income rural blacks, $10,463, 71.2 years.

– High-risk urban blacks, $14,800, 71.1 years.

Longevity disparities were most pronounced in young and middle-aged adults. A 15-year-old urban black man was 3.8 times as likely to die before the age of 60 as an Asian American, for example.

That is key, Dr. Murray said, because this age group is left out of many government health programs that focus largely on children and the elderly.

Moreover, the longevity gaps have remains constant for 20 years, despite increasing national efforts to eliminate obvious racial and ethnic health disparities, he found.

Dr. Murray was surprised to find that lack of health insurance explained only a small portion of those gaps. Instead, differences in alcohol and tobacco use, blood pressure, cholesterol and obesity seemed to drive death rates.

Most important, he said, will be pinpointing geographically defined factors – such as shared ancestry, dietary customs, local industry, what regions are more or less prone to physical activity – that in turn influence those health risks.

For example, scientists have long thought that the Asian longevity advantage would disappear once immigrant families adopted higher-fat Western diets. This study – the first to closely examine second-generation Asian Americans – found that their advantage persists.