University of Oxford professor John Bell, a native of Canada, offers a sobering assessment of what other high-income nations see when they view life expectancy in the United States.
“You know you’ll never be last, because America is always last,” Bell said.
It is a paradox that confounds the world: The United States is among the wealthiest nations in history, and yet its citizens die earlier than those in some poorer nations.
It wasn’t always this way. In 1980, the United States was in the middle of the pack of wealthy nations, according to a detailed analysis of more than 40 years of life expectancy data by The Washington Post.
Life expectancy was rising before it flatlined, drifted downward and then cratered during the coronavirus pandemic. That is despite having much of the world’s most cutting-edge medical research and higher health expenditures per person than any other nation.
“You’re looking at a situation where we are performing extremely poorly relative to our income, relative to our educational attainment, relative to our history,” said Samuel Preston, professor of sociology at the University of Pennsylvania.
Nicola Triglione, a cardiologist in Milan, visits the United States often to study the latest health-care innovations. But, he said, he would never move to the United States. He knows too many Italian doctors who moved to the country but found the lifestyle unsustainable. The problem wasn’t their patients’ health — it was their own.
“After maybe 10 years, they come back, and they say: ‘I’m done. [The Americans] work too much, it’s a money game, they have, I don’t know, four weeks of vacation a year?’” Triglione said.
While the United States specializes in high-tech interventions for acute illness, other countries emphasize preventing illnesses.
As far back as the 1970s, experts showed that as countries got richer, the gains from their wealth in terms of life expectancy became smaller. But what is happening now with the United States is something else entirely.
The collapse of the Soviet Union in the 1990s, notably, occurred after a decline in health that got even worse during that period. Some experts see an alarming parallel.
“Historically, demographic trouble tends to presage broader difficulties of social division,” said former treasury secretary Lawrence Summers, recalling that it was demographers who foresaw the collapse of the communist system by identifying hugely surging mortality rates.
“There are lots of arguments about how to measure GDP, satisfaction, unemployment,” Summers said, “but death is kind of unambiguous.”
And it’s not just a matter of divergence between other high-income nations and the United States. Even within the United States, the disparities are stark: How long you live often depends on where you live.
The Post analysis shows that the gap between the richest and poorest areas was far wider than in other wealthy nations. And despite this widening gap, people living in the wealthiest areas of the United States don’t live longer lives than people in the poorest parts of France, where health outcomes are far more equal.
In France, overall life expectancy has increased about equally in the richest and poorest areas. In the U.S., there’s been a widening gap.
The divergence between wealth and health is a relatively recent trend. For much of history, there has been a direct link between economic growth and people living longer.
The United States, a booming economic superpower after World War II, saw life expectancy increase substantially at that point.
The dramatic rise in life expectancy during the 20th century is largely attributed to the spread of treatments for infectious diseases. In the latter half of the century, declines in smoking in many countries pushed down cardiovascular disease, another major killer.
During that time, the practice of medicine in the United States shifted in a way distinct from other high-income nations. Robert L. Phillips, a professor of family medicine at Georgetown University and executive director of the Center for Professionalism and Value in Health Care, said only 13 percent of internists go into primary care, with the rest choosing to become specialists.
Primary care doctors, also known as general practitioners or family doctors, are supposed to be the first to see patients, catching potential problems early. They treat relatively simple problems themselves or send their patients on to specialists.
In the United States, there is little incentive to work in primary care. Studies show that American specialists earn far more than primary care doctors.
Despite being a specialist, Triglione, the Italian cardiologist, said he found the low status of American primary care doctors jarring. In Italy, these doctors are the central hub of the health-care system, seeing patients regularly for years and earning more than most specialists.
Primary care doctors work like a “movie director,” he said, coordinating all aspects of care. “You go to the specialist, but then you come back to your general practitioner. It’s a relationship.”
During the coronavirus pandemic, this lack of centralization became a painfully obvious failing of the U.S. health-care system, especially compared with highly centralized systems such as those in Taiwan, which was able to contain the outbreak to a far larger extent and saw a much lower number of deaths per capita than the United States.
America not only had a population with chronic illnesses that made it susceptible to covid-19, but a patchwork health-care system that struggled with the coordination needed to prevent its spread.
Could the United States get back on track? It certainly has the resources to do so.
Many other countries, including high-risers such as Portugal and Taiwan, have achieved vast improvements in life expectancy during the past 40 years while the United States stagnated. Both countries did so, in part, by creating national health services, but they also did so with significant economic growth and transitions to democracy.
The worry for many experts is that other nations may be following the destructive trends seen in the United States. Even successful countries are having to adjust and resist the spread of New World Syndrome — the processed foods and sedentary lifestyle that are factors in lowering U.S. life expectancy. Even high achievers, such as Norway and other Nordic nations, are seeing an alarming increase in inequality in life expectancy.
Notably, obesity is rising around the world. “There’s not one population globally that we have data on that has reduced obesity, which is a pretty bad scorecard,” said Christopher Murray, director of the Institute for Health Metrics and Evaluation at the University of Washington.
Outside the United States, some experts hope they can chart a new course. Britain, one of America’s closest allies, is seeing a particularly sharp slowdown in life expectancy gains and suffered greatly during the pandemic, led by many of the same trends as in the United States.
Britain has a national health system focused on people, not profits. Bell, the Oxford professor, is spearheading a plan in hopes that Britain and other nations can make up lost ground by combining new diagnostic technologies with lessons from the pandemic in delivering vaccines, screening and other preventive measures expeditiously.
“The problem in America in this world of prevention of disease is: Who is going to pay for it?”
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