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.

Rising white midlife mortality: what are the real causes and solutions?

 A widely covered and important health research study was recently published by Princeton economists Anne Case and Angus Deaton in the Proceedings of the National Academy of Sciences, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”. The main message is contained in the title – mortality rates for white middle-aged Americans are going up – but there are three other important findings that emphasize its significance.

The first is that mortality rates are going down for every other age and ethnic group, as well as for whites of the same age in other developed countries (see graphic). This means something special is happening to this population group in the US. The second is that this increasing mortality rate is not evenly distributed across class, but is concentrated in the lower-income, high-school-educated or less, group of people. This begins to suggest what is special about this group: that they are being hit hard by societal changes that particularly affect them. The third is that the mortality rates for African-Americans, while decreasing, still significantly exceed those of this group of midlife whites. All of these bear further examination.

That these death rates are rising was apparently surprising to the study’s authors, according to the New York Times article “Death Rates Rising for Middle-Aged White Americans, Study Finds” by Gina Kolata on November 2, 2015, which begins with the sentence “Something startling is happening to middle-aged white Americans.” It surprises not only Case and Deaton, but also numerous commentators quoted in the article and in subsequent coverage. An example cited by Kolata is Dr. Samuel Preston, professor of sociology at the University of Pennsylvania and an expert on mortality trends and the health of populations, whose comment was “Wow.”  I guess this is an appropriate comment about an increase in mortality rates of 134 more deaths per 100,000 people from 1999 to 2014, which Dr. Deaton says is only matched by HIV/AIDS in current time.

But the findings are not too surprising to me. After all, Deaton and Case are economists, not physicians or health researchers, and they came upon this data almost serendipitously while studying other issues (such as whether areas where people are happy have lower suicide rates). But others, those who are physicians and health researchers, should know better. Maybe the doctors expressing surprise are those who don’t take care of lower-income people. And the health researchers are those who have not been reading. In a blog piece  from January 14, 2014 (“More guns and less education is a prescription for poor health”) I cite  Education: It Matters More to Health than Ever Before, published on the Robert Wood Johnson Foundation website by researchers from the Virginia Commonwealth University Center for Society and Health, which notes that “since the 1990s, life expectancy has fallen for people without a high school education, a decrease that is especially pronounced among White women.” This was reported over a year and a half ago, and discusses a trend in place for two decades!

Or maybe I am not surprised because I am a doctor, and see these patients both in the clinic and in the hospital. We do take care of lots of lower income people – those not in the 1%, or the 20% or even the top 50%. Yes, the bottom half of the population by income do exist, and many of them are white, and they are not doing well. The study by Case and Deaton indicates that the causes of death that are increasing the mortality rates in this group of people are not increases in the “traditional” chronic diseases such as diabetes, heart disease, and cancer, but are rather due to substance abuse (illegal drugs, prescription narcotics, and alcohol) and suicide. This is not to say that we don’t see much illness and many deaths from those other chronic diseases in this population; we do, and they account for the high baseline mortality among this group, but these other causes are the reasons for the rising mortality rate.

We have seen the explosion of prescription opiate use in people who (like Dr. Case, as it happens) have chronic musculoskeletal pain (despite increasing evidence that opiates are not very effective for such pain). This often results from their work as manual laborers, either from a specific accident or from the toll wreaked by chronic lifting, bending, twisting, and straining. We also see increased use of alcohol, that traditional intoxicant. While sometimes it seems that we hear more about studies touting the benefits of a couple of glasses of wine a day, the reality is that millions of lives are destroyed directly and indirectly by alcohol use: those of the drinkers, those of their families, those of the people they hit when driving drunk. And in both urban and rural areas (people in rural areas were particularly affected by the mortality increase in Case and Deaton’s study) the use of methamphetamine. And as the drop in standard of living for people who used to make their living with their bodies doing jobs that have disappeared or they can no longer physically do becomes clearly irreversible and leads to serious depression, often compounded by chronic pain and substance use, increasing rates of suicide.

What is only alluded to in some of the coverage of this study is the most important point: this is about our society failing its people. It is about the “social determinants of health” writ large. Yes, the direct causes of the increased death rate in this population are alcohol and drug use and depression leading to suicide, and we do need better treatment for these conditions. But to leave it there would be like looking at deaths from lung cancer and chronic lung disease and concluding only that we need better drugs to treat these conditions without considering tobacco. Our society has, for at least four decades, been somewhere between uncaring and hostile to a huge proportion of its people. Where once we were a land of rising expectations, where people who worked hard could expect to have a reasonably good life, this changed beginning in the 1970s. Jobs for those with high school educations started to become rarer, and in the Reagan 1980s, “Great Society” programs that supported the most needy were decimated. (For the record, the “War on Poverty” actually worked; poverty rates went down!)

In the 1990s, economic growth hid the concomitant growth in income disparities. With the crashes of the tech and housing bubbles leading to severe recession in the mid-2000s, the impact of these disparities became apparent. While there were protests in response (e.g., the “Occupy” movement), the banks were bailed out, the wealthy continued to grow wealthier, and working people have seen their jobs, incomes, standards of living, health, and ultimately lives disappear. Only the blind or willfully ignorant could have not seen this coming.

To a large extent, then, this is an issue of class, however much “important people” decry the use of that word. It is also an issue of race, since, as noted, mortality rates for African-Americans (although not for Latino/Hispanics) continue to exceed those of whites; even as they begin to converge, there is still great disparity. Camara Jones, MD, the new president of the American Public Health Association (APHA) uses the term “social determinants of equity” to describe why African-Americans are so over-represented in the lower class.  The current data showing that lower-income whites are moving toward the long-term disadvantaged should not obscure this fact, but rather remind us that white people have had a privilege that is now, for the lowest income, being eroded.

The irony is that many of the people in the groups reported on, and their friends and relatives and neighbors, voted for those in Congress and their states who pursue policies that make their situations worse. That the 1%, or 0.1%, or 0.001% (after all, 153 families have contributed 50% of all campaign donations this year!) like these policies is understandable provided that they are not only rich but selfish, but they alone don’t have many votes. That their money controls votes, both by buying advertising and directly buying politicians, is undeniable. Maybe poor people cannot contribute as much as rich people, but they can vote (most of the time) and there are so many more of them. If we must reject “trickle down”, we must also reject appeals for votes that are implicitly or explicitly racist; lower income white people are not benefiting by voting for the racists.  The lives and health of Americans will be improved by improving the conditions in which they live, by an economy whose growth is marked by more well-paying jobs, not money socked away by the wealthiest corporations and individuals. People, of all races and ethnicities and genders and geographical regions need dignity and opportunity and hope that is based in reality, not false promises.

We need to treat the diseases that affect people and cause rising mortality, but we need to treat the conditions that lead to them even more urgently.

Research on disparities/inequities, in practices and communities needs much greater funding

This is my first attempt at a blog in several weeks; indeed only one in the last month. I took (and time will tell if I passed) the Family Medicine recertification exam, so I am now able to raise my head above water.

Research is the way we gain new knowledge. It is how we discover if the things that we are doing are the right things to do, or if they are of little or no value, or perhaps even of harm. In the decades after World War II, when the country was optimistic and growing and seeking new frontiers, science was a major area for investment by our government. Things were getting better, returned GIs found a plethora of well-paying jobs, were able to buy houses and cars and plan to send their children to college. American industry did extremely well, if not solely because of great planning and management here, because there was no competition from the rest of the world which had been devastated by the war.

Things were not all good, especially on the political front; there was the cold war, and the associated fanatic fear of Communists epitomized by Senator McCarthy, and there was a legitimate fear of nuclear. But, on the economic front, things were going well for the US. The growth benefited many more people, and the gap between the income of the average worker was large but not unconscionable. Not like today, where as demonstrated by much research, and the title of this HuffPost article, “CEO Pay Grew 127 Times Faster Than Worker Pay Over Last 30 Years”, (“It’s good to be a CEO!”), or in this graphic from Prof. GW Domhoff of UC-SC.

The most dramatic expenditures on science were on space travel; after the Soviet Union launched Sputnik, the first artificial satellite, in 1957 and the space race was on. With the election of John Kennedy in 1960, space exploration moved front and center. All of us who were schoolchildren, in addition to hiding under our desks to protect us from nuclear weapons, were much more productively engaging in a new-found, broad-based physical fitness program encouraged by the President. While Harry Truman was unsuccessful in passing a national health insurance plan, thanks to both the reactionary opposition of the AMA, and the fact that labor unions chose to demonstrate their effectiveness by negotiating health coverage rather than seeking political change as the Labour Party successfully did in Britain, in other areas of science, health moved to the forefront.

The National Institute of Health (NIH) became the major government institution funding medical research and saw enormous growth in the ensuing decades, including a doubling of the budget from about $15B to about $30B in the decade surrounding the last millennium. This fueled the development of an enormous expansion of medical research in laboratories, primarily in universities and medical schools. In addition, corporate support, mainly from pharmaceutical research companies, further enhanced the growth of these laboratories. There were many successes, of which the most famous is the sequencing of the human genome, but our understanding of human biology and how it might contribute to human health and diseases has been remarkably enhanced. Some of this research has led to true medical breakthroughs, with the creation of new drugs and treatment modalities that have sometimes been of great help to large numbers of people with common diseases, and sometimes of enormous help to a few with uncommon ones.

However (and you knew that there was going to be a “however”), the focus on laboratory research and new discoveries at the molecular, protein and genetic levels left unfunded areas of research at least as critical, but not seen as “hard science”, and thus not generally funded by NIH and drug companies. This is a problem. Yes, there are “clinical” research studies, but these are mostly trials of drugs and interventions in populations. The number of studies based in communities, looking at health disparities, and trying to discover how most effectively to have a positive influence on the health of people, populations, rather than occasional individuals, remains small.

 

Certainly, it has grown. As demonstrated in the graph, after the NIH budget doubled, it leveled off, “stagnated” given inflation, until the one-time infusions of American Recovery and Reinvestment Act (ARRA) funds in 2009. Funding for health disparities research has increased, both from NIH and from other federal agencies such as the Centers for Disease Control (CDC) and the Agency for Healthcare Quality and Research (AHRQ), which has but a tiny fraction of the funding that NIH does. NIH created Clinical Translational Science Awards (CTSAs) which funded centers at many medical schools to look at moving research into the community, but much more from the basic science laboratory to first-in-humans trials (or even from one basic science laboratory to another). A major new initiative of the Affordable Care Act (ACA) is the creation of the Patient-Centered Outcomes Research Institute (PCORI), designed to evaluate not just new treatments but how they affect people. However, even the community-based research has focused largely on the recruitment of research subjects to studies designed by academic researchers, rather than on directly studying issues that would improve the health of the people in those communities.

Part of the problem is that it is difficult to get community members to think about what would be in the best interests of their health and that of their communities. They are, after all, not trained in such assessment. In addition, particularly in the communities that are the most vulnerable, that have to greatest health inequities, people are just focused on getting by, paying the rent, buying food, working multiple low-wage jobs. However, another part of the problem is that research at this level is seen as less important and significant, particularly by those who have always focused on new discoveries in the lab and who control most of the agencies such as NIH.

But it is not true. No matter how wonderful the discoveries in the lab, no matter how much they might lead to new understanding, new drugs, new treatments, these are only of value if people benefit from them. So this requires clinical research in the real world, with actual people. But beyond this, if they are to benefit not just a chosen few, the interventions have to be studied among diverse populations, including people facing economic, social, psychological and environmental challenges. In addition, the delivery of these treatments is sporadic. It is clearly demonstrated that administration of aspirin is of benefit to people who have had heart attacks. So it should be used. Why, then, are half the Americans who should be on aspirin not? I don’t know. It probably isn’t cost. It requires research to find out why and to change it. Saying (as is often done) that “new medical knowledge takes 10-20 years to penetrate into practice” is not adequate. Finding out how to get this effective treatment to the people who need it is as important as discovering the treatment. This is known as “fidelity” research.

Finally, effective research on improving people’s health needs to involve medical practices, where the people are being seen. There are many Practice-Based research networks (PBRNs) around the nation, but they are all challenged by how busy the providers are seeing patients; this is at least as true in practices such as Federally-Qualified Health Centers (FQHCs) that care for poorer populations. And yet, without involving them in research, how can we know what is effective in delivering the “best quality” care, and how can practices at the point of care be changed?

This is not to say that we should not fund basic biomedical research or early clinical trials. Nor is it to say that the current programs from NIH and PCORI and others to fund work in health disparities and inequities, and in population and community health are not good. But they are too little. People working in basic laboratory research, early clinical research, practice-based research, and community health should not be competing with each other. There should be more money for all of it, but especially a lot more for fidelity research, community-based participatory research, and practice based research.

Where will the money come from? From policies that are used in every other successful country, and every time the US has been successful, progressive tax policies that take some of our wealth out of the control of private corporations, who use it only to sock away more money, and into the public sector where it can be used to benefit us all.