Mortality in the USA

One of the most startling and under-reported trends over recent decades has been in US life expectancy. There has been remarkably little attempt to discover the root causes for the trend. If we knew the causes we might be able to reverse it, and other countries might be able to avoid the same declines – after all what happens in the US today often spreads around the world tomorrow.

The data are clear, albeit frustratingly limited. The only reliable comparisons I could find were with other OECD countries. In 1950, the USA was in the leading group for men and women, and whether measuring life expectancy at birth or at a later juncture. By 1990, the USA had slipped to the bottom of the pack. By 2010, a gap had opened up to make the US an outlier. And since then others have continued to move forward while the US has actually gone backwards – for three years in a row, for the first time in a hundred years. The trend is large and sustained, and robs a typical American of maybe five years of life compared with what might have been expected in 1950 (compared with others; in absolute terms life expectancy in the US has increased).

When I try to read up about causes, I find proximate answers and a few theories, but not enough analysis. The three proximate answers for the period since 2010 are obesity, opioid overdoses and suicide. All of these can and should be worked on, but there are also deeper root causes behind all of those symptoms.

Such analysis is not simple, which might start to explain why I can find so little of it; scientists don’t like such uncertainty in their papers. Such analysis that I do read is often hopelessly biased – for example starting with an all-encompassing hypothesis about a healthcare system, guns, race, and so on. So I am tempted to bring in my own experience, which does include living in the US and many of the stronger performers. But I have to recognise that my personal dataset is tiny and hopelessly biased as well, across many dimensions. Still, the question is so important that even biased hypotheses must be better than nothing; at least these can inform more research over time.

Obesity might be the most important factor, because it started to become a problem in the US around the time the trends turned negative, and remains much more prevalent there than anywhere else studied. But what are the root causes of US obesity?

The obvious place to start is diet, and the most obvious culprits are fizzy drinks, fast food and processed food. This leads us immediately to large corporations looking for high margins and locked- in customers. They have success lobbying lawmakers to permit unhealthy recipes, follow misleading marketing practices, and take advantage of poorer people in under-served neighbourhoods, including their schools.

Then we can expand into exercise. Here, we have a bifurcated society. In the US, a lot of people exercise furiously and work hard to maintain a body shape that is so healthy that it is actually unhealthy. They are always at the gym or on their Peloton or in their jogging shoes. Then there is everybody else, whose exercise consists of tiny walks between air-conditioned homes, cars, workplaces and malls. Some cannot afford a gym, others cannot offset their awful diet even if they try hard, and once somebody starts to fail the path to recovery becomes harder – exercise is really hard for fat people. It is telling that New York City is the least obese in the US. It is because we all exercise a bit in our daily lives, walking to the subway for example.

From diet and exercise we can expand into healthcare. Good healthcare can turn people around from a lifestyle prone to obesity. In the US, many have little access to affordable healthcare, while the rest of us are peddled a whole set of dodgy solutions designed mainly to offer profits to healthcare providers.

Are there root causes behind these root causes? People in the US moved from being under- to over-nourished within just a couple of generations, which predisposes obesity; this may be especially true of African-Americans. Then there is urban design; I tried to walk in Houston, but failed, owing to an absence of navigable sidewalks. People are now living in places with climates that don’t suit an outdoor life. We can also posit that long working hours and terrible childcare squeeze out time for cooking or mild exercise for all but the wealthy.

Drug overdoes, and specifically opioids, have overlapping and distinct causes. The most obvious culprits are the under-regulated pharmaceutical companies, egged on by lawmakers eyeing their lobbying dollars. The Sacklers deserve their comeuppance - it would be good if it were extended to all the lawmakers tainted by their money.

But why are people seeking so many painkillers in the first place? One cause might be obesity, and all of the root causes of it. But there might be other explanations, including stress from tough lives and unfulfilled expectations. It is striking how regional the opioid epidemic is, and most of the afflicted areas seem to be communities that have lost major employers and have a feeling of decline. With such a wide geography, the US is especially susceptible to creating such places, especially with local and state tax bases playing a bigger role than federal ones.

Suicide is even more prone to an analysis that stops at the proximate level. It is fair to look at the availability of guns and pills and the lack of societal support for those under extreme pressure. Addressing suicide success rates can surely help, because studies show that the urge to take one’s own life is often fleeting and may never return if once thwarted.

But how are there so many desperate people in the first place? And surely for everyone one person that attempts a suicide there must be a hundred who are depressed or otherwise seriously unfulfilled. A society with increasing rates of suicide must be hiding a lot of unhappiness.

Here we can circle back to inequality of opportunity, racial and other disparities, and also lifestyles with terrible childcare and few opportunities to recharge. We can add in social media, but the US is hardly unique in that one. But perhaps we have to cast the net even more widely?

There are many possible culprits; sadly the US is an OECD outlier in many areas, at the wrong end of the spectrum. Maternity deaths, road deaths, violent deaths, chemicals in the air or food, and incarceration all spring to mind. There is also the non-compliant spirit that came with the pioneers, which hampers vaccination programs and other civic benefits. But I have two personal favourite theories.

The first is the so-called American dream. The US is one of the most socially immobile rich countries, but the idea persists in the culture that you can achieve anything if you try hard and trust to God or some other benefactor. People watch LeBron on the TV and hear about his money, and somehow feel that such stories are widespread and can apply to them. Ambition can be a great thing, but this notion causes people to be reckless in their abandonment of common sense or studying and in their investments of time and money. When disappointment usually follows, lives can be easily ruined.

The second is serious debt. It is so easy to fall into debt here. The average family has eight credit cards – all opportunities to fall prey to debt. Commercials mislead and hide mountains of small print, and deferred payment is a universal marketing tactic. Peer pressure abounds. The financial sector holds many people captive, and such lives can easily spiral downwards.

The American mortality trend is important; it reverses a previous pattern and could be replicated elsewhere if the root causes are misidentified. It deserves more serious attention, not just a load of partisan theories (like some of mine), or bland scientific studies that essentially claim that people die because they stop breathing. It must be more complex than something like race, because that was just as much of a problem back in 1950 when the US was doing well. No doubt the science will catch up soon; I hope so, and will follow it with interest.