Increasing Mortality and Declining Health Status in the USA: Where is Public Health?
Mortality increases at the national level are very rare phenomena this century. In the 1900s, mortality only increased in countries greatly affected by World War I and II, and in the 1990s in Sub-Saharan nations with high AIDS prevalence as well as after the collapse of the Soviet Union in 1991.
Beginning this century, mortality is now increasing in the United States. The National Center for Health Statistics reports that life expectancy is declining, and infant mortality is increasing 1. The reported life expectancy decline is for the period 2014 to 2016 and will continue through 2017. This three-year decline is unprecedented in the U.S. All-cause death rates are similarly increasing except for those over age 65 2. For adults, aged 24 to 65, mortality has increased for all race-ethnicity groups 3. This includes all-cause mortality, as well as cause-specific mortality that includes hypertensive, alcoholic liver, and respiratory diseases, drug overdoses, as well as suicides and homicides.
Relative declines in U.S. life expectancy compared to other nations have been observed for half a century. That is, while mortality had been decreasing in the U.S., the improvements were better in many other nations. Life expectancy in the USA lags 4.5 years behind Japan. If we eradicated our leading killer, heart disease, we still wouldn't bridge the gap 4. If health were an Olympic event, our performance would be falling behind 35 to 60 other nations depending on the mortality indicator chosen. This represents a marked change compared to the early 1950s when our mortality rates were among the lowest in international comparisons. The relative decline has been more marked in women. Huge expectations are placed on women in the US without much support from government in comparison to other nations. A 2013 report from the Institute of Medicine documenting this 5 has received little attention or response by our federal institutions responsible for our health status.
Public health agencies at the federal, state and local level have not drawn attention to this most mortal of all perils. Why? There are almost no public surveys of our health status as a nation. A population-based survey of medical students carried out in 2002 found that a third of medical students thought the United States led the world in the highest life expectancy and lowest infant mortality 6. No attention is devoted to our health as a nation, in comparison to other nations, in our health care schools. The same is true for schools of public health.
Medical care is about diagnosing and treating illness and injury, which focuses on individuals and their issues. The United States spends more on health care than the rest of the world combined. Logically, medical care cannot be responsible for our health decline. Even with the advent of the Affordable Care Act, it is difficult to demonstrate related health improvements. The same was true after the adoption of Medicare. The public doesn't distinguish health from health care. We access health, we pay for health, we invest in health, we get health and so on, but those statements are all about health care. The question that should be asked is whether we want health or health care. Ideally we should have both. We do not.
Modern public health was founded on the guidelines of assessment, policy development and assurance 7. Assessment was not considered beyond the local level. With limited health improvement goals, everything seemed in order. What is the standard of normal health at the population level? Geoffrey Rose concluded the first paragraph of his seminal book 8, "There is no known biological reason why every population should not be as healthy as the best."
Reasons for the health decline in the United States are debatable. Although personal behaviors and health care are considered the factors most implicated in producing health, most analyses demonstrate more upstream factors such as political context and governance as well as socioeconomic conditions as most important 9.
Economic or income inequality has emerged as a major determinant of the health of populations 10.
Early life, the first thousand days after conception, is now recognized as the most formative period for overall health 11. Healthier societies privilege this period in producing time and resources for families to raise children. The United States stands as one of two nations worldwide that has no federally mandated paid maternity leave legislation. The other is Papua New Guinea. Adverse Childhood Experiences, or ACEs have emerged as major contributors to early death. These are categorized as: emotional, physical and contact sexual abuse; household dysfunction such as an incarcerated household member or mother treated violently; and physical or emotional neglect. Among rich nations, USA may have about the highest child maltreatment mortality 12. Child maltreatment is now very prevalent and linked to income inequality at the country level 13.
The launch of Sputnik in 1957 was a wake-up call for Americans that led to a goal achieved in 1969, landing humans on the moon. Our health decline requires informing the public that the Titanic is sinking and requires setting a goal to stop further mortality increases by national policies to decrease inequality and attend to early life.
About the Author
Stephen Bezruchka M.D., M.P.H. is a Senior Lecturer in the Departments of Health Services and Global Health at the School of Public Health of the University of Washington. His work involves underscoring the importance of socioeconomic determinants in the health of populations.
- National Center for Health Statistics. Health, United States, 2017 With Special Feature on Mortality. Hyattsville, MD: US Health and Human Services, Centers for Disease Control; 2018.
- Ho JY, Hendi AS. Recent trends in life expectancy across high income countries: retrospective observational study. BMJ. 2018;362.
- Woolf SH, Chapman DA, Buchanich JM, Bobby KJ, Zimmerman EB, Blackburn SM. Changes in midlife death rates across racial and ethnic groups in the United States: systematic analysis of vital statistics. BMJ. 2018;362.
- Arias E, Heron M, Tejada-Vera B. United States life tables eliminating certain causes of death, 1999-2001. National vital statistics reports. 2013;61(9):1-128.
- Woolf SH, Aron L, editors. U.S. Health in International Perspective: Shorter Lives, Poorer Health: The National Academies Press; 2013.
- Agrawal JR, Huebner J, Hedgecock J, Sehgal AR, Jung P, Simon SR. Medical students' knowledge of the U.S. health care system and their preferences for curricular change: a national survey. Acad Med. 2005;80(5):484-8.
- Institute of Medicine, Committee for the Study of the Future of Public Health. The future of public health. Washington, D.C.: National Academy Press; 1988.
- Rose GA. The Strategy of Preventive Medicine. New York: Oxford University Press; 1992.
- Pobutsky A, Bradbury EaW, Tomiyasu D. Chronic Disease Disparities report 2011: Social Determinants. Honolulu: Hawai'i State Department of Health: Chronic Disease Management and Control Branch; 2011 June.
- Wilkinson R, Pickett KE. The Spirit Level: why greater equality makes societies stronger. New York: Bloomsbury; 2011.
- Bezruchka S. Early Life Or Early Death: Support For Child Health Lasts A Lifetime. International Journal of Child, Youth and Family Studies. 2015;6(2):204-29.
- UNICEF Innocenti Research Centre. Innocenti Report Card No.5 ‘A league table of child maltreatment deaths in rich nations’. Florence: UNICEF; 2003.
- Eckenrode J, Smith EG, McCarthy ME, Dineen M. Income inequality and child maltreatment in the United States. Pediatrics. 2014;133(3):454-61.