America the Unhealthy: Inequality kills

In the United States, life expectancy at birth, a common way to measure a country’s health, rose steadily for decades — it was 69.9 years for a baby born in 1959 and 79.1 years for one born in 2014.

Then it dropped for three consecutive years.

That did not surprise Stephen Bezruchka, a University of Washington health services researcher who wrote about the deterioration of US health status, as compared with other nations, in the 2012 Annual Review of Public Health. Nearly two decades ago, Bezruchka came up with the idea of a “Health Olympics,” in which the nations of the world compete on life expectancy. Japan is the current champion, with a life expectancy of 84.5 years, far ahead of the US.

Earlier this year, new data from the Centers for Disease Control and Prevention showed that US life expectancy ticked up slightly — by 0.1 year — in 2018. (There are several ways to estimate life expectancy, which yield slightly different numbers. But the trends remain consistent.) We checked in with Bezruchka, who is also a medical doctor, for an update on his perspective. Have we turned the corner?

The discussion has been edited for length and clarity.

How are we doing in the Health Olympics?

If the race is how long we will live, the most recent data published last December in the United Nations Human Development Report, which ranks countries by length of life, puts us at number 36, meaning that 35 nations have longer lives than the US.

A baby born in the US in 2018 has a life expectancy of 78.9 years. Is life expectancy the most important indicator of a nation’s health?

It’s the easiest one for most people to understand. I think infant mortality — death under the age of 1 — may be a better indicator. But since everybody that you talk to has survived infancy, that’s not so meaningful to them. It’s the same with child mortality.

The US has a child mortality problem?

In the US, the child mortality rate — that is, the proportion of children who die before their fifth birthday per 1,000 live births — is 6. Compare that with Slovenia’s child mortality rate of 2.6, which shows what is achievable.

If the US had Slovenia’s child mortality rate, we would have 43 fewer children die every day in this country. That shows we tolerate a large number of deaths that needn’t occur.

I have my students do this calculation because they are more likely to believe it if they look up the data themselves. I choose Slovenia because it has a longer life expectancy than we do and it’s also the country of birth of our First Lady. Slovenia doesn’t have the lowest child mortality rate, by the way; Finland and some other countries have lower rates.

How does life expectancy for whites in the US compare with that of other racial and ethnic groups? Do you see the same pattern in other countries?

Hispanic or Latinx life expectancy in the US is a little better than that of non-Latinx whites. African-American life expectancy is lower than for whites although the gap has been narrowing. The difference is now about three years, and that has come down from much higher.

We are the only country that systematically collects data by race; race is not a biological construct, so what is race? So to compare the US with other countries you have to get at the question indirectly. Brazil, the United States and Cuba are countries in which the largest segment of the population is white, but each has a relatively large black population. There was a study done by a Harvard professor in the 1990s that looked at life expectancy differences among blacks and whites in each of those countries. The difference was about one year in Cuba, but six or so years in Brazil and also in the United States.

In the 1950s, the US was one of the top 10 nations for life expectancy. What happened?

We have changed from a country that, in the 1950s, believed in economic justice. We had high tax rates on the rich, and we had welfare programs for other people. But we have changed from a community focus, or a collective focus, to one in which today we have to pursue our health as individuals.

I make two points about this. One is that early life — probably the first thousand days after conception, or up to around age 2 — is incredibly important for our health as adults. The risk for disease — heart disease, lung disease and others — is programmed in early life. You can’t give somebody a pill to redress childhood abuse and you can’t put a stent in a coronary artery to redress the stress resulting from the lack of support your parents gave in your early life. Every country in the world has a national policy that gives working moms paid time off work after they have babies, except for Papua New Guinea, Suriname, a few South Pacific Island nations and the United States. We also have the most child poverty of all rich countries in the world. We don’t invest in the part of life that really matters.

The other point is that healthier societies have a smaller gap between the rich and the poor than we do. That gap causes an enormous amount of stress in our society — road rage, air rage, stress at work, child abuse. I say stress is the 21st century tobacco. We have learned that inequality kills.

Inequality kills?

The higher the income gap between the rich and the poor, the more stress we feel if we’re not on top. There are studies in the US showing, at the county level, that if you have a big gap between the rich and poor and you have high incomes in a county, you’re going to have more mass shootings, defined as four or more victims.

Stress and frustration get acted out in different ways among different segments of the population. Obviously, not everybody is going to grab a gun and start shooting people. Anne Case and Angus Deaton at Princeton found that mortality rates were going up for white people in the 45-to-54 age range, unlike African-Americans and people in a half-dozen other rich countries. They looked at causes of death for these people and found high rates of alcohol-related illnesses, suicides and other conditions that they call “deaths of despair.”

Do your fellow doctors agree with you that inequality is to blame for America’s poor health status?

I think that has changed over time. When I first presented this at a conference of doctors in 1995, it made sense to some, and to some it was nonsense. About 10 years ago, these ideas became more acceptable. More doctors recognize our poor health status and some know it’s due to more than personal behavior. We have the health of a middle-income or poor country, in many respects.

If income inequality is the culprit, does that mean well-off Americans with good health habits are protected from our nation’s relatively short life expectancy?

There are a couple of ways to look at this. Yes, richer people are going to have longer lives than poorer people. But studies comparing richer people in Europe versus richer people in the United States show longer life expectancy among the richer in Europe than here.

I want to read a quote from a book by the National Research Council and the Institute of Medicine — “US Health in International Perspective: Shorter Lives, Poorer Health” — that came out in 2013: “Americans with healthy behaviors or those who are white, insured, college-educated or in upper-income groups appear to be in worse health than similar groups in comparison countries.”

That may be because of the tremendous amount of stress and frustration in our society, and everyone is affected. The nature of relationships changes in big-income-gap situations: We drive bigger cars to show that we are superior to others, and we wear designer clothes to make a statement. Some of these things may be harmless, but we have higher rates of heart disease and lung disease and almost all other causes of mortality, except for cancer, than comparable countries.

In a study that compared pain levels among different countries, the people in this country report more pain than people in the other rich countries. We consume more than half of the world’s opioids. Pain comes in two varieties, social pain and physical pain. And the stress and frustration that I’m talking about is a manifestation of social pain.

So better health habits aren’t the fix to our problem?

We tend, in this country, to think that the choices you make are what determine your health. But individual behaviors are less important for the health of a society than we think. Diet and exercise are important, but not as important as other factors in a society.

We have the lowest rates of smoking on the list of 30-odd countries that I track in the Health Olympics, and Japan has the highest. In most of the European countries, people smoke much more than we do. And yet their lives are longer. It seems to matter which country you smoke in. We are now getting confirmatory evidence of this with a study that shows Finnish women are less harmed by cigarette smoking than women in the United States.

Perhaps we should spend more money on health care?

We spend more on medical care than any country in the world. Since our mortality and other health indicators are not so good, then it is logical that more medical care is not the solution.

The US needs to increase social spending. And that money should come from decreasing the income gap through taxation.

Elizabeth Bradley at Yale was the first to compare social spending and medical-care spending among countries. And what you see is the healthier countries prioritize social spending, whereas we in the US focus on medical-care spending. The reason the other countries are healthier is they subsidize housing, early childhood education, transportation and so forth, which reduces inequality between rich and poor.

And they have policies that support their citizens. You know, the United States has no national paid vacation law and all the other rich countries do. We have no paid parental leave laws at the national level.

One study showed that if we had the average level of social spending of countries in the Organization for Economic Cooperation and Development — that’s the rich countries of the world — we would gain over 3.7 years in life expectancy.

How will Covid-19 affect our life expectancy in the US?

During the Great Depression, mortality dropped precipitously, and the same thing happened in other major recessions. It’s counterintuitive, but mortality tends to go up when business is booming. The reasons are variable, but when there is a recession people are not working as hard and have more time to spend with friends and family. Social support is really an important part of producing health.

So it’s quite possible that although there are many excess deaths from the pandemic, there may also be fewer deaths because the economy is tanking. Whether this will be true in this situation is hard to say at this point. This is quite speculative.

In 2018, US life expectancy increased slightly after three consecutive years of decreases. Are we heading back in the right direction?

We have the highest rate of opioid deaths of all high-income countries, and our opioid death rate, which has been rising, went down slightly from 2017 to 2018. That may be one of the explanations for our not falling further in 2018.

Here at the University of Washington, the Institute for Health Metrics and Evaluation used some models to predict US ranking in life expectancy by 2040. They forecast that Spain will edge out Japan for first place in life expectancy by that time, and the United States will fall to 64th.

So I don’t think we’re going to see great improvements soon.