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 12th 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.”