America's not-so-hidden public health crises

The new year is a good time to issue a report card on the health status of the American people. On every front, I marked the box that says "needs improvement."

I saw something extraordinary in the smart phone videos taken inside the burning Japanese airliner on Tuesday. Despite the dense smoke inside and shooting flames outside, no one panicked. Everyone followed instructions. And every one of the 379 passengers and crew got out alive.

I lived in Japan during the first half of the 1990s while serving as the Chicago Tribune’s chief Asia correspondent. Its economy, which only a few years earlier had been touted as the next world leader, had just suffered through a burst real estate bubble. The country was sliding into a deep recession, which was followed by two decades of no or slow economic growth.

Yet throughout what became known as Japan’s lost decades, unemployment rose only slightly. Its corporations and small businesses retained their employees to the greatest extent possible through reduced hours, hefty government subsidies and a gradual loosening of its “lifetime” employment system.

What did Japan’s frontline managers rely on through both these crises, whether they be flight attendants, government bureaucrats or business leaders? A public whose communal DNA included social solidarity, a social norm that teaches people to respect the lives of their fellow citizens. They seem to understand intuitively that by acting in concert and with purpose, whether it be in an immediate emergency or a long-term economic crisis, they will assure the greatest good for the greatest number.  

In my recent review of a new book about our bungled response to the COVID-19 pandemic, I noted that over the past 3 ¾ years, social solidarity has been in short supply in the U.S. While historians can point to instances in American history when social solidarity reigned, it is in remission now.

A sizeable fraction of the American public responded to the COVID-19 public health emergency by pursuing their own agendas. Many individuals preferred preserving their personal freedoms (no masks, no social distancing, no shutdowns, no vaccines) over protecting others. Corporations profiteered. Politicians pandered.

The results are still with us. U.S. longevity, already a laggard among industrialized economies in the Organization for Economic Cooperation and Development, fell much farther than other countries during the pandemic. And it has recovered more slowly, remaining well below pre-pandemic levels (see chart below).

The report card

I am going to start this new year with an overview of the status of key public health indicators – a report card, if you will, on where we stand as a nation. It is a useful exercise because, as the Japanese taught us during our own years of industrial decline (after they learned it from an American industrial engineer named Edward Deming), you cannot improve what you do not measure.

Deming and the Japanese also taught us that the best way to achieve higher quality and better products is by making steady small improvements in both processes and products. This applies just as much to health care as it does to industrial and commercial activities.

A report card on public health sets the baseline for where we are. It also points us in the direction of where we need to go.

The current report card is damning. Our baseline is low. The distance to catch up with peer nations is far. The path upward begins with making steady small improvements.

Subject: Longevity

The decline in U.S. life expectancy compared to peer nations began long before the pandemic. In 1980, the year Ronald Reagan won the presidency, the U.S. was only two years behind Japan, then as now the country with the longest average lifespan. Today the gap is five years.

Digging beneath the surface of that single data point reveals an even more disturbing reality. People living in white, wealthier communities have a life expectancy that is not much different than those found in western European nations (though still behind Japan). People living in low-income neighborhoods of any color and Black middle-class neighborhoods often lag far behind. And people living in low-income Black neighborhoods have a life expectancy that is more than a dozen years behind white areas that are only a few miles away.

The racial gap began to shrink during the Obama administration. But the pandemic worsened the disparities. Between 2019 and 2021, the first two years of the pandemic, life expectancy fell 6.6 years in native American communities. Black and Hispanic life expectancy fell 4.0 and 4.2 years, respectively. Native American life expectancy is now 65.2 years, over 11 years less than white people. Blacks can expect to lead lives that are six years shorter on average.

Putting the U.S. on the upward path toward parity will require addressing the social conditions that drive ill-health. Food, housing and income insecurity are just as prevalent in the largely white, de-industrialized towns of middle America as they are in inner cities, even though a larger share of minority populations live under those conditions.

Programs that address the social determinants of health don’t have to be race-based to have a disproportionately larger impact on improving the lives and life expectancy of minority communities. For an excellent discussion of this point, and an introduction to the work of William Julius Wilson, whose books The Declining Significance of Race, The Truly Disadvantaged and When Work Disappears greatly influenced my own thinking in the 1980s and 1990s, read yesterday’s post by Matt Yglesias on Substack.

Subject: Infant Mortality

The nation’s infant mortality rate had been falling steadily for more than two decades – until last year. According to a CDC report released last November, there were 5.6 deaths per 1,000 live births in 2022, up from 5.44 deaths the previous year. That’s nearly 21,000 dead babies, lost either in childbirth or the first year of life.

But those decades of gradual improvement did not match other countries. Internationally, the U.S. ranked 12^th highest in infant mortality among the 44 countries tracked by the OECD. We’re only slightly ahead of Bulgaria, but do worse than both Russia and the People’s Republic of China.

As Dr. Elizabeth Cherot, CEO of the March of Dimes, told the AP: This first uptick in years “underscores that our failure to better support moms before, during, and after birth is among the factors contributing to poor infant health outcomes.”

Subject: Obesity

America’s collective waistline has been expanding for a long time. Obesity prevalence rose to 42.8% of the population in 2021, up from 30.5% two decades earlier. Severe obesity nearly doubled during that period and now hobbles 1 in every 11 Americans.

Obesity is a major risk factor for heart disease, cancer, stroke, diabetes, and kidney disease, which are half of the 10 leading causes of death in the U.S. The rate of diabetes, which is the disease most directly related to obesity, grew from 10% to 13% of the population in the past two decades. A third of adults have elevated blood sugar levels and are classified as pre-diabetic.

The CDC estimates the U.S. health care system spends $173 billion a year treating the medical conditions caused by obesity. Each obese individual incurs annual medical costs that are $1,861 higher than people with a healthy weight.

The medical research establishment, drug and device companies, patient advocacy groups and the press pay enormous attention to developing new treatments for each of these obesity-related diseases. The same is true for treating obesity itself. On any given day, I can read at least one article about the new weight loss pills or bariatric surgery.

Almost no attention is paid to obesity’s underlying causes. Americans today are living sedentary, screen-focused lives, both at home and at work. Many schools have cut or reduced physical education requirements. Few corporations offer mid-day physical activity breaks or gym membership benefits.

Fewer and fewer jobs involve intense physical activity. More and more farmers, truck drivers, machine tenders, office workers, and call center operators spend their working hours sitting, and then return home to do the same thing.

Our food and restaurant systems produce and market an inordinate amount of junk food, sugar-laced drinks and calorie- and carbohydrate-dense meals. Daily calorie intake has fallen slightly in recent years but is still 20% higher than the average American diet of 1960. The government’s agricultural programs subsidize the crops that fuel that unhealthy diet, not to mention feeding the cattle, pigs and chickens that not only lard our diets with artery-clogging saturated fats but despoil the environment.

No president since JFK has made physical fitness a national priority. Two recent presidents – Donald Trump and Bill Clinton – were significantly overweight and used their time in the bully pulpit to make a public display of their unhealthy eating habits. Meanwhile, Congress does nothing to redraw the nation’s skewed agricultural support programs, which are subsidizing the nation’s farmers to produce unhealthy food.

The government does require chain eateries to list calorie counts on menu items. But it doesn’t appear to have embarrassed anyone into changing their offerings or the choices made by their customers. Would you like sprinkles on that Mocha Cookie Crumble Frappuccino (590 calories)?

Subject: Unintentional Injuries and Violence

As the COVID-19 pandemic wanes, unintentional injuries will once again become the third leading cause of death in the U.S. after heart disease and cancer. Accidental poisoning (including opioid overdoses), motor vehicle accidents, drownings and falls killed over 224,000 Americans in 2021, the highest number ever. Poisoning deaths accounted for nearly half the total.

While opioid overdose deaths have leveled off in recent years at about 17,000 annually, the same can’t be said for victims of gun violence, which took 48,830 lives in 2021. More than half of those deaths were self-inflicted. Another 43% were murders. Just 537 deaths or 1% of the total involved law enforcement officers.

The U.S. has the highest suicide rate among all high-income countries in the OECD. Our rate is double that of the U.K., according to the Commonwealth Fund. One simple fact accounts for this dubious distinction. Nearly 8 in 10 suicide attempts here involve a gun, which is nearly always fatal. Self-administered drug overdoses – the preferred method in countries where guns are not so prevalent – are much less likely to succeed.

Much can be done to lower the accidental death rate in the U.S. First and foremost, something has to be done about the proliferation of guns in our society. It is tragic that our politicians can’t bring themselves to reinstate the assault weapons ban, whose removal in 2004 enabled a growing number of ideologically motivated or deranged killers to murder dozens of people in a single incident. If Congress can’t even do that, what hope is there of doing something about the proliferation of handguns, which have driven the murder and suicide rates to levels not seen since the mid-1970s?

The path forward

We’re at the beginning of an election year. I predict none of the issues outlined here will be given serious attention by either the campaigns or the media. In the years just prior to the outbreak of the pandemic in February 2020, economists Angus Deaton and Anne Case called attention to the “deaths of despair” – the opioids overdoses, suicides, alcoholism and gun violence deaths – that are ravaging so many communities and lowering life expectancy in the U.S.

Heard much about that lately? In a way, it’s odd that we haven’t because these are the social conditions that laid the groundwork for the rise of the Trump-led mob that now controls the Republican Party.

In the coming months, epidemiologists at the CDC, whose work this report card uses, will give us new data from which to measure progress from this baseline. Will 2024’s reports mark the start of a turnaround? I doubt it.

No interest, much less help, will be coming from Washington or the campaign trail. The headlines will be dominated by the atrocities and war crimes perpetrated by Israel in its war against Hamas, which provoked the conflict with the worst mass killing in Israeli history; Russia’s merciless invasion of Ukraine, which seems to be escalating daily; the rise and looming triumph of an openly authoritarian and extra-legal movement within the Republican Party; the divisions within the Democratic Party; and the media’s endless and mindless horse race coverage of the polls and primaries ahead of an election where American democracy faces its gravest existential threat since the Civil War.

The deteriorating health of the American people doesn’t stand much chance of breaking into the public’s consciousness in the face of these escalating crises. Yet people who care about public health must soldier on, doing what they can to make small incremental improvements. Here’s hoping the new year will see progress on every front.