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Why is the US still in such poor health, despite its wealth?


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People wait in line to receive a vaccine at a pop-up covid-19 vaccination site in Orlando, Florida, US.

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People in the US are observing with growing alarm the advancing age of their elected leaders in Washington DC: the two current leading candidates for the 2024 presidential election are now 81 and 77 years old. But the longevity of the leadership class is in sharp contrast with realities in the rest of the country. Americans are sick and dying – literally.

Ten years ago, I directed a study for the National Academy of Sciences (NAS) that documented for the first time a US disadvantage in health and survival among high-income countries. Our report showed that the US had the lowest life expectancy among peer countries, and higher rates of morbidity and mortality for dozens of causes. This shortfall in health and survival had been growing over four decades and was pervasive – affecting both sexes, young and old, rich and poor, and all races and ethnicities.

Life expectancy

In the intervening years, other studies have confirmed these trends, along with worsening conditions of life and death. After plateauing for several years, life expectancy in the US declined for three consecutive years before the global pandemic. What followed was devastating: covid-19 killed more than 1 million people in the US, pushing life expectancy down by another two years – and by twice as much among Hispanic, Black and Native American people. This was the most abrupt drop in life expectancy since the second world war, and nothing remotely comparable occurred in other wealthy nations.

During the pandemic, eight of the ten leading causes of death also increased, including maternal and child and adolescent mortality. Given these stark realities, an urgent question is why are Americans so unwell? In a New Scientist commentary 10 years ago, I observed that the reason is simple and yet deceptively complex: it is almost everything.

Even a casual glance at life in the US today reveals conditions that are hard to believe. The country is entering the third decade of a deadly nationwide opioid epidemic – unleashed by the pharmaceutical industry – that claimed 110,000 lives in 2022 alone. And alongside the drugs are the bullets. In 2020 and 2021, guns killed more US children aged 1 to 17 than any other cause of death.

The conditions that cause poor health, such as high levels of economic inequality and precarity, alongside limited safety net schemes and social support systems, are seen in every aspect of the lives of children and teenagers in the US. For more than a decade now, cross-national comparisons of child and adolescent well-being in rich countries show that US children are worse off than their peers in virtually every area measured.

Health insurance

Given the poor health of Americans, the country needs a healthcare system it can rely on. But the US is well known for having one of the most complex, fragmented and expensive healthcare systems in the world. Almost 30 million people in the US are without health insurance, and for millions of others, quality, affordable, accessible healthcare is simply out of reach or effectively unavailable.

A final feature of the US landscape is one of the most important contributing factors: systemic racism and its attendant injustices. In 2021, life expectancy was 84 years for Asian Americans, 78 years for Hispanic Americans, 77 years for white Americans, 72 years for Black Americans, and 67 years for Native Americans. Native communities have long experienced some of the starkest health inequities in the country, a direct reflection of the cumulative violence, trauma and injustice inflicted on them over generations. It is hard to overstate the effects of racism in the US today.

If health is wealth, the US is far from the rich and powerful country many people imagine it to be. Other countries would do well not to follow Americans down this deadly path. And the US should consider the many ways other advanced democracies are achieving far superior and more equitable health outcomes, and at far lower cost.

A longer version of this article was first published at Der Pragmaticus Verlag AG in German

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