People in the US are observing with growing alarm the 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 (NAS) that documented for the first time a US disadvantage in health and survival among high-income countries. Our 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 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 , and nothing remotely comparable occurred in .

During the pandemic, of the ten leading causes of death also increased, including and mortality. Given these stark realities, an urgent question is why are Americans so unwell? In a żěè¶ĚĘÓƵ 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 – unleashed by the – that claimed 110,000 lives in 2022 alone. And alongside the drugs are the bullets. In 2020 and 2021, aged 1 to 17 than any other cause of death.

The conditions that cause poor health, such as high levels of economic and , alongside limited schemes and social support systems, are seen in every aspect of the lives of in the US. For more than a decade now, 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 healthcare systems in the . Almost people in the US are , and for millions of others, quality, affordable, accessible healthcare is simply or effectively .

A final feature of the US landscape is one of the most important contributing factors: systemic racism and its attendant injustices. In 2021, 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. 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.

AMERICANS die younger and experience more injury and illness than people in other rich nations, despite spending almost twice as much per person on healthcare. That was the startling released earlier this year by the US National Research Council (NRC) and the Institute of Medicine (IOM).

It received widespread attention. concluded: “It is now shockingly clear that poor health is a much broader and deeper problem than past studies have suggested.”

What it revealed was the extent of the US’s large and growing “health disadvantage”, which shows up as higher rates of disease and injury from birth to age 75 for men and women, rich and poor across all races and ethnicities. The comparison countries – Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands and the UK – generally do much better, although the UK isn’t far behind the US.

The poorer outcomes in the US are reflected in measures as varied as infant mortality, the rate of teen pregnancy, traffic fatalities and heart disease. Even those with health insurance, high incomes, college educations and healthy lifestyles appear to be sicker than their counterparts in other wealthy countries. The , a non-partisan think tank, described the report as “a catalog of horrors”.

Findings that prompted this reaction include the fact that the rate of premature births in the US is the highest among the comparison countries and more closely resembles those of sub-Saharan Africa. Premature birth is the most frequent cause of infant death in the US, and the cost to the healthcare system is .

“The rate of premature births in the US more closely resembles those of sub-Saharan Africa”

As distressing as all this is, much less attention has been given to the obvious question: why is the US so unwell? The answer, it turns out, is simple and yet deceptively complex: it’s almost everything.

Our health depends on much more than just medical care. Behaviours such as diet, physical activity and even how fast we drive all have profound effects. So do the environments that expose us to health risks or discourage healthy living, as well as social determinants of health, such as education, income and poverty.

The US fares poorly in almost all of these. In addition to many millions of people lacking health insurance, financial barriers to care and a lack of primary care providers compared with other rich countries, people in the US consume more calories, are more sedentary, abuse more drugs and shoot one another more often. The US also lags behind on many measures of education, has higher child poverty and income inequality, and lower social mobility than most other advanced democracies.

The breadth of these causal factors, and the scope of the US health disadvantage they produce, raises some fundamental questions about US society. As the NRC/IOM report noted, solutions exist for many of these health problems, but there is “limited political support among both the public and policymakers to enact the policies and commit the necessary resources”.

One major impediment is that the US, which emphasises self-reliance, individualism and free markets, is resistant to anything that even appears to hint at socialism. Interestingly, as a group, classically liberal nations like the US and the UK – free market-oriented with less regulation, tax and government services – are the least healthy among wealthy democracies.

By contrast, social democratic countries such as Sweden – in which the state emphasises full employment, income protection, housing, education, health and social insurance – enjoy better overall health, although are not always the smallest.

contend that there are important trade-offs between economic growth and innovation on the one hand, and growing inequality, high poverty and a weak social safety net on the other. Unfortunately, these debates often fail to factor in our health. That needs to change.

And, as it turns out, the . It may tax less and spend less on social programmes than most rich democracies, but when you add in tax-based subsidies and private social spending, it , just after Sweden. What distinguishes the US is how that money is spent. More goes on healthcare – while still leaving many without health insurance or access to care – and less on children, families and the disadvantaged.

Digging into the social determinants of health can be tricky. Social scientists and other researchers are rightly trained not to confuse correlation with causation. But the – how social and economic conditions affect our health and survival – is rapidly building.

Following the World Health Organization’s 2008 , countries such as Finland, Australia and Canada are taking a “health in all policies” approach that promotes health through public policies in areas as diverse as transportation, housing and agriculture. In the US these ideas have yet to gain much traction.

Moving beyond the dismal headlines generated by the NRC/IOM report, we can hope that the evidence of a health disadvantage in the US is now so compelling that the terms of the conversation and even the political calculus will begin to change. Then, perhaps, we can start addressing that disadvantage and stop paying for it with our lives.

This article appeared in print under the headline “Paying with our lives?”