Urgent need to examine
systemic causes of declining health in the US
BMJ
The ongoing opioid
epidemic in the United States is a key contributor to the most recent declines
in life expectancy, suggests a study published by The BMJ.
A second study shows
an increase in US death rates in midlife (people aged between 25-64 years)
involving all major racial groups, and cites a broad range of conditions as
potential causes.
Together, these
findings point to an urgent need to examine systemic causes of declining health
in the US.
Life expectancy is a
measure of the health and wellbeing of a population. Widespread or sustained
declines in life expectancy may signal problems in a nation's social and
economic conditions or in the provision or quality of its healthcare services.
The first study,
authored by Jessica Ho at the University of Southern California and Arun Hendi
at Princeton University, looked at trends in life expectancy across 18 high
income countries and found that most countries experienced declines in life
expectancy in 2015.
This is the first time
in recent decades that these many high income countries simultaneously experienced
declines in life expectancy for both men and women, and the size of these
declines were larger than in the past.
In the non-US
countries, these declines were largely concentrated at ages 65 and older and
likely related to a particularly severe influenza season. The main causes of
death driving these declines included influenza and pneumonia, respiratory
disease, cardiovascular disease, and Alzheimer's disease and other mental and
nervous system disorders.
But in the US, the
decline was concentrated at younger ages, particularly those in their 20s and
30s, and largely driven by increases in drug overdose deaths related to its
ongoing opioid epidemic. The authors point out that the US decline is
particularly troubling in light of its already low life expectancy ranking
relative to its peer countries.
And unlike other
countries in the study, life expectancy in both the US and the UK continued to
decline in 2016, which the researchers say raises questions about future trends
in these countries.
A second study suggests that the problem is larger than the opioid epidemic. It shows increased death rates from dozens of causes among people in all racial and ethnic groups.
Using national data to
compare midlife death patterns from 1999 to 2016, Steven Woolf at Virginia
Commonwealth University and colleagues found that although drug overdoses,
suicides, and alcoholism were the leading cause of excess deaths, mortality
rates also increased dramatically for organ diseases involving the heart, lung,
and other body systems. "The opioid epidemic is the tip of an
iceberg," said Woolf.
Previous studies had
documented a rise in "deaths of despair" among middle-aged white
people in the US, but this is the first study to show that the trend now encompasses
multiple body systems and is striking multiple racial and ethnic groups. These
increases are offsetting years of progress in lowering death rates among black
and Hispanic adults.
Furthermore, although
overall death rates were higher among men than among women, the relative
increase in fatal drug overdoses and suicides was greater in women, consistent
with other reports of the worsening health disadvantage among women in the US.
The authors say
"no single factor, such as opioids, explains this phenomenon" and
suggest that their study "signals a systemic cause and warrants prompt
action by policy makers to tackle the factors responsible for declining health
in the US."
Both studies are
observational, so no firm conclusions can be drawn about cause and effect, and
the authors highlight several limitations that may have affected their results.
Nevertheless, taken
together, these two studies highlight warning signs that must not be ignored
and should prompt urgent review of systemic causes of declining health in the
US.
In a linked editorial,
Domantas Jasilionis at the Max Planck Institute for Demographic Research in
Germany says life expectancy is a key characteristic of human development and
declines should be taken seriously. Historical evidence suggests that
discontinuities in secular trends can lead to prolonged health crises -- they
are warning signs of fundamental and longstanding societal and health problems.
He points to the
negative health consequences of growing social deprivation and austerity policies,
but notes that high life expectancies in the UK and many other high income
countries (including the Nordic countries with strong pro-equitable social
policies) coexist with large or even increasing health disparities.
In future, persisting notable health disadvantages of some population groups may become an important obstacle for sustainable health progress at the national level.
In future, persisting notable health disadvantages of some population groups may become an important obstacle for sustainable health progress at the national level.
He calls for more
reliable data to underpin effective policies, and says "more effort must
be made to convince international and national agencies to invest in robust
register based systems that allow timely and accurate monitoring of changes in
longevity," he concludes.