Inside Story

When wealthier doesn’t mean healthier

Covid-19 hit the United States hard, but life expectancy was already falling. The lessons for other countries are clear

Lesley Russell 11 February 2021 2198 words

Focus on equity: Joe Biden with House speaker Nancy Pelosi and House majority whip Jim Clyburn during a meeting about the economy and Covid-19 relief in the Oval Office last week. Brendan Smialowski/AFP via Getty Images

If we needed more evidence that national wealth, scientific knowledge, technical know-how and sophisticated healthcare don’t guarantee healthier lives, then the impact of the coronavirus pandemic has provided it. Covid-19 is cutting life expectancy in many wealthy Western countries, cancelling decades of gains already under threat from growing inequality.

The United States is the stand-out failure. For decades, enormous spending on healthcare has failed to produce better health and longer lives than in many other countries that spend less. Covid-19 has added hugely to the mortality toll, with a disproportionate number of deaths among already-lagging minority populations. But even before the pandemic, average life expectancy in the United States, and in Britain, had fallen in recent years.

Life expectancy is the traditional broadbrush measure of population health. It gauges the effectiveness of the healthcare system and the effectiveness of healthcare spending. But it also gauges the impact of the social determinants of health — poverty, housing, education, discrimination and other non-medical factors that play a major role in health and wellbeing. Because life expectancy figures are an average across the population, some groups could actually experience decreases in a particular period while the population as a whole is going forward.

On the basis of the 275,000 US deaths attributed to Covid-19 by early December (the figure is now more than 470,000), University of California researcher Patrick Heuveline estimated average life expectancy for American babies born in 2020 to be lower by more than a year, the biggest fall since the end of the second world war. Heuveline compared the expected mortality rate in 2020 with the actual rate, which included deaths from Covid-19 and the “excess” deaths among people who didn’t get necessary medical care. The more young people are affected, the worse the impact on life expectancy. By comparison, the HIV epidemic reduced the US life expectancy at birth by 0.3 years at its peak in 1992. Covid-19’s impact on US mortality can be expected to cancel a decade of reductions in all other causes of mortality combined.

These findings are confirmed and extended in a study published just this month. American researchers Theresa Andrasfay and Noreen Goldman estimate that US life expectancy at birth has fallen by 1.13 years, to 77.48 years, lower than any year since 2003, and they project a 0.87-year reduction in life expectancy at sixty-five. The African-American and Latino populations, which have experienced a disproportionate burden of Covid-19 morbidity and mortality, are estimated to experience declines in life expectancy at birth of 2.10 and 3.05 years respectively.

This has the effect of increasing the Black–white life expectancy gap from 3.6 years to more than five years, eliminating the progress made in closing the gap since 2006. Latinos, whose mortality rates are consistently lower than white Americans’ (a phenomenon known as the Hispanic paradox), will see their three-year-plus survival advantage reduced to less than one year.

The picture is almost certain to look bleaker in 2021. Further reductions in life expectancy can be expected beyond 2020 because of continued Covid-19 mortality and the long-term health, social and economic impacts of the pandemic. Moreover, most epidemiologists consider that the number of infections in the United States has been severely underestimated and that excess mortality (deaths from causes other than Covid-19) will be higher with hospitals and healthcare systems operating under pressure.

The United States is not the only country to have suffered such a setback. Life expectancy will fall in any country or region that has experienced a coronavirus infection rate higher than 1 per cent, especially if the mortality rate in younger patients is high. A 10 per cent Covid-19 prevalence rate in North America and Europe means a loss of at least one year of life expectancy at birth.

In Bergamo in Italy’s Lombardy region, where serological tests have shown a 50 per cent infection prevalence rate, a group of European researchers has estimated a loss of life expectancy of 4.1 years for men and 2.6 years for women. (In this case the measure is average life expectancy for the population as a whole, so direct comparisons with US findings are not possible.) Demographers at Oxford University’s Leverhulme Centre calculate that life expectancy for both men and women in England and Wales was reduced in 2020 by more than a year (one year for women and 1.3 years for men) as of December 2020, wiping out gains made on life expectancy in the past decade. Australia has escaped this trend, thanks to low infection rates and a high concentration of deaths in the oldest age groups.

For Americans, this dismal news comes on top of several decades’ evidence that life expectancy at birth is lagging, the existence of a large and rising “mortality gap” between Americans aged fifty and older and their international peers, and data showing that even highly advantaged Americans are in worse health than their international peers.

In 2013 the US National Academies of Science (then the National Research Council and the Institute of Medicine) issued a report, Shorter Lives, Poorer Health, that ranked the United States last in life expectancy for men and second-last for women among high-income countries. Edward Alden of the Council on Foreign Relations described the report’s findings as “a catalogue of horrors.” (I was commissioned by the Institute of Medicine to write a discussion paper, Reducing Disparities in Life Expectancy: What Factors Matter?, for the report.)

The research team that produced Shorter Lives, Poorer Health aimed to elucidate why the United States suffers the health disadvantages it documented. Common explanations — obesity, lack of access to healthcare, health disparities between population groups — were all at play, but the exact cause, or combination of causes, wasn’t clear.

Despite the glaring deficiencies this report exposed, the situation has only worsened. The United States now ranks forty-third out of 195 countries for life expectancy at birth (Australia is fifth). In the absence of significant action, is expected to rank sixty-fourth by 2040. The figures are worse for African Americans, Native Americans, and people in poor and rural areas. The US maternal mortality rate ranks last among similarly wealthy countries and its infant mortality rate thirty-third out of thirty-six OECD countries. Many Americans are not living to see old age; the United States has consistently had the lowest or second-lowest probability of surviving to fifty.

The overall pace of mortality improvement has slowed in a number of European countries, and even in Australia, over the past decade. Dementia is the major contributor, along with rising obesity and diabetes and adverse trends in inequalities. The distinguished epidemiologist Michael Marmot succinctly outlined the challenges for Britain — but generally applicable in other developed countries — in his Marmot Review 10 Years On last February.

While access to healthcare is important, it contributes only modestly to longevity. Between a third and a half of these life expectancy gaps are explained by differences in the social determinants of health, including rates of poverty and educational disadvantage.

Poverty has a major impact on health and premature death. The longer people live in disadvantaged circumstances, the greater the risk of ill health. People who are unemployed, and the families of those who are unemployed, experience a much greater risk of premature death. Education is also key. Highly educated adults in the United States have lower yearly mortality rates than less-educated people in every age, gender and racial/ethnic subgroup of the population. These differences are somewhat wider among men than women.

The United States is also confronted with rising mortality rates caused by alcohol, drug overdoses, the opioid epidemic, gun violence and suicide. These “deaths of despair” are exacting an increasing toll on middle-aged, non-Hispanic white Americans, especially those without a college education. Indeed, the most meaningful risk factor for such a death is not having a university degree.

It’s not hard to see how these risk factors were all in play during the pandemic, with access to healthcare and social services more important than ever, employment and income at risk, and the demoralisation and grief brought on by the loss of jobs, social contacts and loved ones. The Trump administration must obviously be blamed for the pandemic’s disastrous impact in the United States, but the foundations for failure were decades in the making. The Shorter Lives report’s catalogue of horrors was a harbinger of things to come.

In the search for answers about inequalities, the report contains a final chapter (regarded by the research team as almost an afterthought) that discusses whether values seen as typically American — individual freedom, free enterprise, self-reliance, a major role for religion, federalism — influence the development of policy and its enactment in ways that are detrimental to Americans’ health.

Recent analysis of state politics and policies has found that American states with more progressive policies have longer life expectancy rates than those with more conservative policies. On this measure, American states have increasingly diverged since the early 1980s, shortly after the federal government began transferring policymaking authority for Medicaid and welfare programs to them. In 1959 Connecticut and Oklahoma had the same life expectancy; by 2017, Connecticut had gained 9.6 years while the more conservative Oklahoma had gained just 4.7.

The researchers estimate that if all states adopted policies similar to those of Hawaii (which has strong laws on labour rights, prohibiting tobacco and environmental protection, and a healthcare system that acknowledges the Native Hawaiian culture), US life expectancy would be on par with those of other high-income countries. These findings are partially countered by an analysis that found even if everyone achieved the health outcomes of white Americans living in the richest counties, health indicators would still lag behind those in many other countries.

The relationship between politics and health is also reflected in voting patterns. In 2016, counties with stagnating or falling life expectancies were more likely to vote Republican. This aligns with the strong support for Trump and Republicans among white Americans without a college education. Many of these Republican-voting areas are now also those with the highest infection and mortality rates from coronavirus.

For president Joe Biden and his team, these data highlight the size of the task ahead. Primacy, of course, must be given to controlling Covid-19, getting everyone vaccinated, and tackling the pandemic’s economic fallout ahead of boosting access to healthcare (including mental health and substance abuse services), housing, employment and education. But if these efforts are not targeted at the most needy communities they will simply widen existing socioeconomic gaps.

There are lessons in these figures for Australia, too. The pandemic has highlighted the inadequacy of the social services safety net — hence the large but temporary lift in the JobSeeker rate — along with the fragmentation of the healthcare system and the widening health disparities. For too many Australians life expectancy is a postcode lottery. For Indigenous Australians the life expectancy gap has not narrowed since 2006.

Better health is undoubtedly related to social expenditure, and social protection may be more important for health outcomes in more unequal societies. In a recent edition of the Medical Journal of Australia, Shane Kavanagh, Anthony LaMontagne and Sharon Brennan‐Olsen warn of the likely impact of calls to prioritise rapid reductions in government debt through cuts to health and social services. Government spending on health, education and social supports has the potential to increase economic growth, they argue, and “avoiding austerity measures will better serve the health of Australia’s population, and indeed the health of the nation.”

The political preference is too often for policy solutions that are readily to hand and simple. A medicine that allows patients to live with diabetes is seen as a more desirable announcement for the health minister than the grinding job of changing food and exercise policies so that fewer people are overweight and prone to the disease. Evidence from the United States suggests that policies on tobacco, labour, immigration, civil rights and the environment appear to be particularly influential for life expectancy.

It is shocking how quickly the hard work of improving life expectancy can be overturned. But there is also evidence that better policies can turn things around relatively quickly. Within four years of the introduction of mandatory health insurance, known as Romneycare, in Massachusetts in 2006 the death rate had fallen by 3 per cent, with the steepest declines seen in counties with the highest proportions of poor and previously uninsured people.

Joe Biden has committed to tackling the social inequalities and inequities in the United States. He quickly appointed a White House health equity task force headed by physician Marcella Nunez-Smith, which will make recommendations on mitigating and preventing health disparities. The task force’s initial focus will be on the equitable allocation of resources, vaccines and relief funds to deal with the pandemic.

The new president has also signed executive orders aimed at improving racial equity across the nation. These include measures to strengthen the anti-discrimination housing policies weakened under Trump and to enhance the sovereignty of Native American tribes. More far-reaching changes are expected in the months ahead.

Biden says he plans to infuse a focus on equity into everything the federal government does. All Australians — but especially those whose lives are shortened and diminished by the lack of an adequate income, housing, education, healthcare and employment — would benefit from a comparable commitment from Scott Morrison and his government. •