Failing health of the United States | The BMJ – BMJ – Feb 2018 “The role of challenging life conditions and the policies behind them.” by Steven H Woolf, director, and Laudan Aron, senior fellow
The subtitle says it all: our country doesn’t know how to handle “challenging life conditions” because we’ve been the “land of plenty” for so long.
But with surging income inequality, the number of people living in poverty is on a relentless climb. With the previously existing economic and social safety nets dismantled, what is to become of us?
When other options are impossibly difficult or inaccessible, we “poor” face what amounts to a life-sentence of poverty these days… and we know it.
Facing such a hopeless future, the wonderful temporary escape offered by mind-altering substances like alcohol or opioids seems an almost reasonable response.
When the patient’s care is evaluated against corporate profit, it’s no wonder the quality of our healthcare is in decline.
Life expectancy in the US has fallen for the second year in a row. This is alarming because life expectancy has risen for much of the past century in developed countries, including the US.
The decline in US health relative to other countries, however, is not new; it has been unfolding for decades (fig 1).
In 1960, Americans had the highest life expectancy, 2.4 years higher than the average for countries in the Organisation for Economic Cooperation and Development (OECD).
But the US started losing ground in the 1980s. US life expectancy fell below the OECD average in 1998, plateaued in 2012, and is now 1.5 years lower than the OECD average.
A joint panel of the National Research Council and Institute of Medicine investigated the US health disadvantage in 2013.
It found that Americans had poorer health in many domains, including
- birth outcomes,
- adolescent pregnancy,
- diabetes, and
- heart disease.
It also found that many factors contribute to the health disadvantage; for example, Americans are more likely to
- engage in unhealthy behaviors (such as heavy caloric intake, drug abuse, and firearm ownership),
- live in cities designed for cars rather than pedestrians or cyclists,
- have weaker social welfare supports, and
- lack universal health insurance.
The panel reported high death rates in the US from drugs, a problem that has grown over time.
Between 2000 and 2014, the rate of fatal drug overdoses rose by 137%, a crisis fueled by the growing use of highly addictive opioid drugs.
The country is belatedly scrambling to reduce access (with, for example, prescription drug monitoring and drug take back programs), improve emergency responses to reverse overdoses (such as naloxone programs), and enhance access to effective addiction treatment (such as medication assisted treatment).
But the opioid epidemic is the tip of an iceberg, part of an even larger public health crisis in the US:
death rates from alcohol abuse and suicides have also been rising.
Between 1999 and 2014, the suicide rate rose by 24%.
These “deaths of despair,” as some have called them, are disproportionately affecting white Americans, especially adults aged 25-59 years, those with limited education, and women.
The sharpest increases are occurring in rural counties, often in regions with longstanding social and economic challenges.
Why white Americans are dying at higher rates from drugs, alcohol, and suicides is unclear, complex, and not explained by opioids alone.
The answer—likely some combination of factors in American life—must explain why the rise in mortality is greatest in white, middle aged adults and certain rural communities.
- the collapse of industries and the local economies they supported,
- the erosion of social cohesion and
- greater social isolation,
- economic hardship, and
- distress among white workers over losing the security their parents once enjoyed.
By contrast, greater resilience might explain why black Americans—who have contended with longstanding structural disadvantages, discrimination, and higher all cause mortality—have not experienced a surge in drug deaths or suicides.
Other data are also enlightening. Over the three decades in which survival advances slowed in the US,
- educational performance weakened,
- social divides (including income inequality) widened,
- middle class incomes stagnated, and
- poverty rates exceeded those of most rich countries.
The US is rich,
but its wealth is not inclusive.
Its social contract is weaker than in other countries—those in need have less access to social services, healthcare, or the prevention and treatment of mental illness and addiction.
The “American dream” is increasingly out of reach, as social mobility declines and fewer children face a better future than their parents
Ironically, leaders are outspoken about ending the opioid epidemic and bemoan spiraling and unsustainable healthcare costs.
Solutions to both problems—which involve investment to support struggling families and communities and thereby improve public health—are often rejected, usually by leaders with competing self interests or ideological objections.
The consequences of these choices are dire: not only more deaths and illness but also
- escalating healthcare costs,
- a sicker workforce, and
- a less competitive economy.
Future generations may pay the greatest price.
Original article: Failing health of the United States | The BMJ