Why do Americans die earlier than Europeans? | Samuel Preston and Yana Vierboom
A 30-year-old American is three times more likely to die at that age than his or her European peers. In fact, Americans do worse at just about every age. To make matters more grim, the American disadvantage is growing over time.
In 2017, for example, higher American mortality translated into roughly 401,000 excess deaths – deaths that would not have occurred if the US had Europe’s lower age-specific death rates. Pre-pandemic, that 401,000 is about 12% of all American deaths. The percentage is even higher below age 85, where one in four Americans die simply because they do not live in Europe.
The tremendous losses caused by the Covid-19 pandemic have been widely publicized. The US government estimates that 377,000 deaths in 2020 were attributable to Covid-19. This means that the mortality penalty that the US pays every year is equivalent to the number of American pandemic deaths in 2020. And since people tend to die from Covid at much older ages than America’s typical excess deaths, the total number of years of potential life lost in an average year is three times greater than those lost to Covid in 2020 (13.0 million versus 4.4 million).
There have been many efforts to account for the US mortality disadvantage. There is no single answer, but three factors stand out. First, death rates from drug overdose are much higher in the US than in Europe and have risen sharply in the 21st century. Second is the rapid rise in the proportion of American adults who are obese. In 2016, 40% of American adults were obese, a larger proportion than in Europe. Higher levels of obesity in the US may account for 55% of its shortfall in life expectancy relative to other rich countries. Third, the US stands out among wealthy countries for not offering universal healthcare insurance. One analysis suggests that the absence of universal healthcare resulted in 45,000 excess deaths at ages 18-64 in 2005. That number represents about a quarter of excess deaths in that age range.
Why does the US perform so poorly in these realms? We would argue that a lack of federal oversight and regulation, powerful lobbying structure, deindustrialization of American jobs, and systemic racism combine to create an annual tsunami of excess deaths.
Both supply and demand factors are involved in the increasing number of US deaths from drug overdose. Large pharmaceutical companies marketed pain relievers without adequate federal oversight of their safety claims in the 1990s, fueling overdoses of prescription opioids. Big pharma’s lobbying power protected their sales campaigns. Although restrictions were eventually put in place, the damage had been done. Illegal use of opiates grew dramatically, especially among people in economically depressed areas and with lower levels of schooling.
Noting that this increase coincided with increases in mortality from suicide and alcohol-related deaths, the economists Anne Case and Angus Deaton have argued that American society is suffering from a growing tide of despair. They argue that one of the main drivers is de-industrialization, which eliminated millions of well-paying jobs for people who did not attend college. This is the group with the largest increase in premature mortality during the 21st century.
Above age 65, healthcare insurance coverage is nearly universal via Medicare. An international review of medical practice by the National Academy of Sciences suggested that the US does comparatively well in identifying and treating cardiovascular diseases and many cancers. But the prevalence of these diseases, the principal killers in wealthy countries, is unusually high in the US. Heart disease, a type of cardiovascular disease and America’s number one cause of death for decades, is strongly linked to lifestyle factors such as obesity. Although the connection between obesity and health risks is well known, consumer preferences for unhealthy food are strong. Not just because humans are biologically vulnerable to sweets and fats, but because major food producers and distributors are incentivized to turn this weakness into profit.
The systemic racism present in US society generates inequalities in resources and power, which in turn have a major impact “downstream” on the health of people of color. Healthcare inequalities and provider bias are importantly associated with infant and maternal mortality. For example, many physicians (usually white and male) have been shown to take the health concerns of Black and Latinx people less seriously during pregnancy and childbirth, resulting in poorer health outcomes for both mothers and their children. Black infants have significantly better outcomes when treated by Black doctors.
The US also has exceptionally high income inequality, superimposed on its yawning racial divide. And social policy in the US is less likely to correct inequality than elsewhere. One study concluded that US life expectancy would be three to four years longer if the country had the social policy generosity of other OECD countries. A factor in the social policy shortcomings in the US, including in providing health insurance, is the sense on the part of the white majority that more generous policies would disproportionately benefit African Americans.
All of this suggests that our shortcomings are not simply a product of what happens in a sector called “medicine and public health”. Rather, these shortcomings are deeply embedded in enduring features of American society. The failure of the United States to adequately protect its members from premature death casts doubt on American civic processes and undermines any effort of the US to serve as a model for other countries.
Yana Vierboom is a social demographer working as a postdoc at the Max Planck Institute for Demographic Research in Germany. Her work focuses on health inequalities throughout the life course
Samuel Preston is professor of sociology at the University of Pennsylvania. His research focuses on determinants of population health
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