Lower life expectancy in the US: A reflection of racism, classism, and social inequity

One of the things that most fuels self-deception is imagining that we should be living, or maybe even still live, in what we imagine was a better past. Of course, the past was not always better – in fact, it was overall, for most people, worse – but our minds repress the bad and remember the good from when we were children, as I have discussed in my other blog, “Life, the Universe, and a Few Things” (Brooklyn Nostalgia, August 21, 2011). Sometimes there is a conscious effort, a movement if you will, to block out the really bad things that have happened in the past not only from our individual memory but from our history books and schools. Clearly, this is happening now with regard to the primary founding evils in US history, extermination of the indigenous inhabitants (Native Americans, Indians) and slavery. That these were real is incontrovertible. That they were horrific, inexcusable, and must be remembered both to honor the victims and prevent recurrence should be obvious. But the effort to suppress teaching of this history, parallel to suppressing teaching about the Holocaust (which is not suppressed in Germany) is ongoing, vicious and wrong. To add insult to injury, advocates are adopting the language of microaggression, justifying their racist efforts to whitewash history with ostensible concern for “making white children feel bad about themselves”.

This is, in addition to every other evil and reprehensible aspect of it, also a way to divert those children – and their parents – from knowing and worrying about the things that they should be worried about, such as climate change and nuclear war. And the incredible inequities in American society (not to mention the world!) that have actually led to terrible social and individual outcomes. For example, the drop in life expectancy in the US. Yes, drop. People living shorter lives than they used to. Due in part to the COVID pandemic, but due in the US more to the vast inequities in wealth, social support, access to health care, jobs, use of harmful substances (such as alcohol, opioids, and tobacco) and every other determinant of health. What this has to do with self-deception and living in the past is the false idea that things are always, automatically, better in this country, the USA, a belief that persists in the face of evidence.

Of course, some things were, in fact, better in this country for earlier generations, some of whose members are still alive and sentient. America may not have always welcomed its immigrants, even those from Europe, and viciously and continuously repressed and oppressed members of many minority groups (particularly Natives and the descendants of Black slaves), but in the first half of the 20^th century, major parts of life were often better here for poor people than in many other countries. This was even more so after World War II, when the economies of most of the rest of the developed world were destroyed but the US' was intact, with no wars fought on its soil. This resulted in great success for US manufacturers (no competition!) and other benefits. One was life expectancy, due in large part to better nutrition. In the second half of the 20^th century it was widely observed that children of immigrants were bigger than their parents, because from infancy they were better nourished. Then, even later, at the end of that century and into the 21^st, some of the major causes of premature death saw a decline, mainly tobacco use.

But the premature death rate in the US is going up, life expectancy is going down. An important paper, published in 2014 in the Annual Review of Public  Health by Mauricio Avenando and Ichiro Kawachi, ‘Why do Americans have shorter life expectancy and worse health than people in other high-income countries?’, provides extensive documentation and discussion, including a supplement with several tables comparing life expectancy among different countries (a representative one, Female Life Expectancy at 40, is reproduced here).

 

While it has long, forever, been true that the life expectancy of underserved minority populations was less than for white people, the decrease in life expectancy for the “majority” group was shockingly revealed by data provided in 2015 by economists Anne Case and Angus Deaton, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”, and has been demonstrated for larger and larger portions of the US population. As I noted in this blog (Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015) this was a shock for those who held to the belief that it was only true for minorities (and in perverted way, found this reassuring). Indeed, while the life expectancy for Black Americans was and is still shorter than for whites, it was slowly rising while for many whites (of course, especially lower-income whites) it was dropping. Case and Deaton, noting the large increase in mid-life death (kind of an oxymoron, but meaning “middle age”) attributed this to “deaths of despair”, specifically due to opioids and suicide. On November 29, 2019 I wrote about an article by Steven Woolf and Heidi Schoonmaker, “Life Expectancy and Mortality Rates in the United States, 1959-2017” (Decreasing life expectancy in the US: A result of policies fostering increasing inequity), and I noted that, amazingly, women in lower income groups born in 1950 had shorter life expectancies than their mothers born in 1920!

Woolf and his colleagues RK Masters and LY Aron have recently come out with a new publication looking at life expectancy in the US and other OECD countries for 2019-2021. (Note: at the time of publication, the paper, in medRxiv, had not been peer-reviewed). They found that the pandemic shortened the life expectancy in almost all countries, but

US life expectancy decreased from 78.86 years in 2019 to 76.99 years in 2020 and 76.60 years in 2021, a net loss of 2.26 years. In contrast, peer countries averaged a smaller decrease in life expectancy between 2019 and 2020 (0.57 years) and a 0.28-year increase between 2020 and 2021, widening the gap in life expectancy between the United States and peer countries to more than five years.

In addition, ‘The decrease in US life expectancy was highly racialized: whereas the largest decreases in 2020 occurred among Hispanic and non-Hispanic Black populations, in 2021 only the non-Hispanic White population experienced a decrease in life expectancy.’ So while in 2020 the most vulnerable populations took the greatest additional hit from COVID, by 2021 they were slowly recovering, while white populations continued to lose life expectancy.

So why? This may be cognitive dissonance for the self-deluding, or racist, or narrow-minded, or those who think “America is always better”, but it is true. And the reasons for it are the inequities of American life, much of which is detailed in the Avenando and Kawachi paper, as well as Masters, Aron, and Woolf. We do not have universal health insurance, and we do not have universal access to health care. Even many “insured” Americans have very poor insurance, many Americans do not have geographic or physical access to health care services, and thus many people forego health care altogether or until it is too late. Our infant mortality rate is far higher than that of comparable countries. We still have large numbers of people who are “food insecure”, which often means chronically hungry and undernourished, not to mention those who are “housing insecure”, often homeless. And we have phenomenal income inequities which have grown tremendously since the 1980s Reagan assault on the social safety net. A paper by economists Emanuel Saez and Gabriel Zucman, widely covered, shows examples of this: since 1982 the wealth of the 0.00001% (18 families!) has increased from 0.1% to 1.2% of all US wealth.

 

Just from 2009-2022 the wealthiest American has gone from $40B to $265B, while average income has decreased from $54,283 to $53,490, and the minimum wage ($7.25/hr) has stayed the same! So the US remains an outlier, with great social and economic inequity, poorer health, and shorter (and decreasing) life expectancy. You can believe what you want in terms of political and social theory, but you have to be willing to accept the consequences.

I find these consequences, completely unnecessary, intolerable.

Trump's "bad doctors": mostly greedy and bad for the public's health

My recent post, Doctors and health reform: maybe they do stand for health!, March 25, 2017, lauded the positions of many medical organizations, including the American Medical Association (AMA) for their positions in opposition to the American Health Care Act (AHCA), the Trump-Ryan bill that never even got to a vote, and apparently was never even available to House members to read before the vote was scheduled.  But I also pointed out some “bad” doctors, defined as those who advocate policies that are bad for the health of the American people. They argue that they are really for health, but this means mostly health care, especially medical care, for those who can afford it. There is no small tinge of racism as well as classism in these positions, because poor people and minorities are those most likely to be left out, and because, well, these perpetrators don’t care.

The prime example I cited was Secretary of Health and Human Services Tom Price, who, as a representative from a wealthy suburban Atlanta House district, continuously railed against the Affordable Care Act (ACA), as well as, in fact, Medicare. Dr. Price is an orthopedic surgeon, and my essay noted that this specialty is over-represented in the cohort of opponents of expansion of access, possibly because their high average income puts them in an elite economic group, and many are more concerned with their self-interest than the health of the overall population. Price was not the only bad doctor I mentioned; I also cited the “tone-deaf” comments of Rep. Roger Marshall of Kansas, an obstetrician-gynecologist. “Tone deaf”, of course, is a mild and polite term for his racist, classist comments, summarized as “the poor just don’t want health care”. Tone deaf, by the way, is also the term commonly used to describe the demeaning commercialization of the Black Lives Matter protest movement evident in Pepsi’s commercial featuring Kendall Jenner, now mercifully withdrawn. That was a result of the strong and sustained protest of a large number of people, especially on social media.

Price and Marshall are abetted by the non-physician politicians in Congress and the administration who also would deny health care to a lot of people, and even, through changes in Medicare and Medicaid, make the coverage of many people who now feel moderately secure in their insurance status greatly at risk and much more expensive. Speaker of the House Paul Ryan and Vice President Mike Pence met with the “Freedom” Caucus of the House to discuss just how regressive a health care bill would have to be to get their support. Pretty bad, it turns out. Its chairman, Rep. Mark Meadows of NC, is quoted by the NY Times as saying “Lower premiums have to be our first and only priority. By repealing community rating and the essential health benefits, it allows for lower premiums across the board.” Well, lower premiums are something everyone wants (except probably insurance companies) but there are different ways to get there. “Repealing community rating” means that insurers would no longer have to cover people who have chronic disease and are often older (and, ironically, often Trump and Freedom Caucus voters) at the same rates as less sick people. Those people would not have lower premiums; their premiums would either be fantastically higher, as they were before the ACA passed (and when many of them were without coverage) or be altogether unavailable. This is not something that the vast majority of Americans want. Similarly, “essential health benefits” are, well, essential. Like, for example, maternity care, and preventive health care. The fact that Rep. Meadows used that word and didn’t replace it with some euphemism, illustrates how tone-deaf he is.

But not all doctors who I would characterize as “bad” are reactionaries who are trying to figure out how to deny health care to the American people. Some are just traditionally greedy, seeking to fill their own pockets with as much money as possible. This is not a problem limited to the right; even folks who are progressive on social policies can be guilty of “going where the money is”. An excellent example is Trump’s nominee to head the FDA, Dr. Scott Gottlieb. Gottlieb, like many researchers, has been highly paid (at least on the order of hundreds of thousands of dollars) by drug manufacturers. Gottlieb assures us that this will not affect his decision making at FDA, and that he can be trusted, as in the title of the NY Times article of April 5, 2017, in which he “deflected” criticism. While some Democrats, like Sen. Patty Murray of Washington, noted that he had ‘“unprecedented financial entanglements with the industries he would regulate,”’ Republicans like Lamar Alexander of Tennessee agreed with Dr. Gottlieb that “his experience with the pharmaceutical industry would be an asset in regulating it.” This is terrific tortured fox-guarding-the-henhouse logic, like having Goldman Sachs financiers regulating Wall Street, or petroleum company flaks running EPA (which we, in fact, have). This concept worked fine on “It Takes a Thief”, but not so much in real life.

Taking huge amounts of money from drug companies may be morally reprehensible (or not, depending on your view; in mine it is), but more concerning are the positions that Gottlieb has taken. While he is open (he says now) to lowering drug prices by importing drugs from Canada, something Trump has occasionally voiced support for, he has previously written against it (when he was in the pay of the drug companies). The issue is what the policies pursued by the FDA, HHS, CMS, and the overall Trump administration and Congress regarding the people’s health will be. Disrespect for preventive care (“essential services”) and environmental pollution bodes very poorly for public health, as the core principle of “cut benefits” does for medical care. And, as always, the most vulnerable – from poverty, age, illness, geographic region – will suffer the most.  It would be really good if we could count on doctors like Price, Marshall and Gottlieb to protect the health of the people, but don’t count on it. We are going to need huge public protest, at least as big as those that ending up canceling the Pepsi commercial.

Well, it could be worse. Another physician, Dr. Bashar al-Assad, is gassing his own people with chemical weapons. And there was also Dr. Josef Mengele. So far, none of Trump’s nominees are in that league.

Racism, classism, and who we take into medical school: Who will care for the people?

I work in a medical school. I see and teach medical students. They are a smart group. When measured by grades and scores on standardized exams, they are even smarter. Some of them – but not nearly enough – are members of socioeconomic and ethnic groups or geographic areas under-represented in medicine. Sometimes, these students struggle with grades in medical school. Occasionally, this elicits comments, sometimes smug, sometimes rueful, that this is the result of affirmative action, as if this were a negative thing. Given the alternative, the default of taking all people who look alike, who come from the same background, who want to do the same things – in brief, to stereotype, white 22 year old men who come from economically privileged and professional families (many of them medical) who want to be subspecialists in the suburbs – this is pretty scary.

It is affectively, intellectually, and morally scary, yes, to think that we could accept this kind of regression to an archaic, not to say racist and classist past where becoming a doctor was a privilege limited to only a few. It is also scary in very practical terms, because the people who need health care the most are those least likely to be served by the “default” group. Indeed, in fulfilling their personal goals, the result will be to “serve” already overserved communities, largely in specialties in oversupply. There is good data that shows that students from rural areas are more likely to serve rural communities, that students from underrepresented minority groups are more likely to serve members of those groups, that students from less-privileged backgrounds are more likely to serve needier communities. And that all these groups are more likely to enter primary care specialties, those in most short supply. This is what we want. But they represent a small percentage of our medical students. Why? Because we still, despite all the data showing what predicts service to people most in need, stay wedded to incorrect and outdated ideas of “qualified” for medical school that overwhelmingly bring us the same old same old.

Many (although clearly, given the above, not most) of medical students, from all backgrounds, have some difficulty with the first two years of medical school despite being not only smart but are well-educated from top small liberal arts colleges. There is a relationship here; these colleges emphasize thinking and creativity and problem solving, exactly the skills needed to be an effective physician. They teach largely in small and interactive classes, fostering self-confidence and independence and thoughtfulness and sometimes non-conformity, exactly the temperament needed for an effective physician. They grade largely on the basis of essay tests, requiring integration of information, literacy, and demonstrating an ability to think, not on multiple-choice tests, just what we want from physicians. Unfortunately, this is not the best preparation for the first two years of medical school, overwhelmingly consisting of large lectures characterized by a presentation of a huge number of facts, and designed to reward memorization of those facts using massive multiple-choice tests. Good preparation for this: being a science major at a large university whose courses overwhelmingly consisted of large lectures characterized by a litany of factoids and rewarding successful regurgitation of those factoids on massive multiple choice tests. QED.

Not, of course, the best preparation for being a curious, open-minded, thinking, problem-solving doctor. But this is what we get. Yes, it is certainly true that some of our students from large universities, or from professional or high socioeconomic status, or majority ethnic groups, or suburbs, or all, are incredibly committed to making a difference. Many want to enter primary care, many more want to serve humanity’s neediest, in our country and abroad. They are humble, and caring, and smart. We are lucky to have them in our schools and entering medicine. But they, along with those who are from less-well-off families, and ethnic minority groups, and rural communities, remain a minority among all the sameness. And remain more or less in the same proportions over time. We continue to do the same thing, and have the audacity to wonder why we do not get different results. This is Einstein’s definition of insanity.

On November 16, 2014, Nicholas Kristof published his column “When Whites Just Don’t Get It, Part IV” in the New York Times. He discusses the continuing racism in this country, the legacy of slavery, the fact that “For example, counties in America that had a higher proportion of slaves in 1860 are still more unequal today, according to a scholarly paper published in 2010.” And, of course, he discusses the responses he received (from white people) to Parts I-III, saying it is all in the past, stop beating that drum, it is not my fault, I work hard and don’t get the special privileges that “they” do, and why don’t they take personal responsibility, and our President is Black, isn’t that proof that the problem is gone? I won’t begin to get into the question of how much of the vicious attacks on our President are in fact the result of the fact that he is Black; rather while I observe that the fact that he was elected says “Yes, we have made incredible progress,” I note that this does not eliminate “Yes, we still have lots of racism and it has major negative effects on people as individuals and society as a whole.”

Kristof talks about the fact that he and his Times colleague, Charles Blow, are both promoting books. He notes that while he (Kristof) is white and from a middle-class background, Blow is black and was raised largely in poverty by a single mother. But he also makes clear that this doesn’t prove that the playing field is even, but rather that Blow was very talented, very hard working, and also lucky. That some members of minority groups, or people with very disadvantaged backgrounds (or both) succeed is a testimony to them, to their drive and intelligence and talent and luck, and the support that they have had from others such as family or friends which, while obviously not financial, was significant. It absolutely doesn’t prove that those who are from such backgrounds who have not succeeded are at fault. Indeed, the converse is true; how many of those who are from well-to-do, educated, privileged and white backgrounds, who have had all the financial and educational supports all their lives, who are now in medical school or doctors or professors or leaders of industry would have gotten there if they had started as far down the ladder as, say, Charles Blow, or some of our medical students? Some, for sure, but not most. They are folks born on second, or even third, base, who make it home and look at those who started from home and made it around all four bases, and say “why can’t they all do that”? Most of you, starting in the same place, would, like those who actually did start there, never have had a prayer.

It is common for classes of medical students to develop a “personality”, more self-centered or more volunteering, more intellectually curious or more grinding, more open or more closed. I suspect that this probably has to do with a few highly visible people, because most of the students don’t vary that much. I have heard faculty complain about the inappropriate behavior, the lack of professionalism (especially when they get to the parts of school that involve caring for patients), the sense of “entitlement” that many students have. But this is not true (overwhelmingly) of those who are the first in their families to go to college, who are grateful for the opportunity and hard-working, and committed to making a difference in the world. If we think that entitled, unprofessional students are not desirable, why are we accepting those who fit that mold?

We can do better. We can scale up programs to accept caring, humble, committed, smart people instead of self-centered, arrogant, and entitled ones. Indeed, if we hope to improve the health of our people, we must.