COMMENTARY

Americans Are Dying Younger--Why?

F. Perry Wilson, MD, MSCE

Disclosures

November 26, 2019

Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I'm Dr F. Perry Wilson.

For the first time in modern US history, life expectancy is decreasing.

The history of the industrialized world since 1950 has been one of continually increasing life expectancy as technology and medicine advanced in the modern era. A decrease in life expectancy is a particular example of American exceptionalism and is brought into stark relief by this study, examining 70 years of data, appearing in the Journal of the American Medical Association.

From 1959 to 1979, US life expectancy increased, keeping pace with other industrialized nations. After 1980, though, that increase slowed down and the US began to fall behind.

US life expectancy peaked in 2014 at 78.9 years, and since then it has been falling.


 

Now, in contrast to some earlier reports, the decrease in life expectancy was seen across races, sexes, and age groups, though it was driven by an increase in mid-life deaths. There seem to be some broad forces at play here, and the paper (which is really worth a deep read) tries to tease some of these apart.

So, first of all, yes, drug overdoses have skyrocketed. From 1999 to 2017, the rate of drug overdoses in midlife increased by 385%. Overdose deaths increased by more than 500% among those aged 25-34, and by a staggering 909% among those aged 55-64.


 

Suicides and alcoholic liver disease, the other components of so-called "deaths of despair," increased as well. But this is not the full explanation for our declining life expectancy. Deaths of despair only explain 15% of the disparity in life expectancy in the United States versus other countries.

For clues as to what else is causing life expectancy to fall, we need to look deeper into the data. You can see here the states most profoundly affected by falling life expectancy—[Florida] and the Ohio Valley, which are driving these results.


 

What was happening in those states when life expectancy was stalling and then falling? An economic downturn, the erosion of the middle class, and rising income inequality. In fact, much of the disparity between life expectancy in the United States and other economies was driven by those at the lower end of the income spectrum.

It's hard to discuss discrepancies in mortality between the United States and Europe without addressing the differences in our social support systems and the provision of healthcare. Our lack of a universal healthcare system, another bit of American exceptionalism, may explain some of the difference here as more individuals fall through the cracks.

But that's not the only explanation. After all, deficiencies in healthcare delivery wouldn't explain why our death rates from cardiovascular disease and cancer have fallen while deaths due to other diseases have risen.

Increasing levels of psychological distress and rising obesity rates may play a role too. In other words, there probably isn't one solution here.

Does any single factor link all of these potential explanations? The authors don't speculate. But I wonder if this isn't a consequence of the American psyche—that fiercely independent mindset, that value on personal responsibility that has made the country so productive but also leaves some individuals vulnerable economically and vulnerable to isolation and despair. Balancing the unique American character with our obligations to each other may just be the prime challenge of the next 70 years.

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale's Program of Applied Translational Research. His science communication work can be found in the Huffington Post, on NPR, and here on Medscape. He tweets @methodsmanmd and hosts a repository of his communication work at www.methodsman.com.

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