Walk into the Rebound recovery centre, on the Main Street of Hazard, Kentucky, a small Appalachian coalmining town, and you will get an instantly friendly welcome. Yet the stories you hear are bleak. On a white board at the end of the room, across from the sofas, the names of former clients who have died of overdoses in the past few years are listed. Though the town has a population of just 5,000, there are at least 20 names. James Colwell, a 33-year-old former heroin addict, who has been clean for eight years, and who now works at the centre, says that the toll keeps growing. Heroin addiction is actually less common than it used to be, he says, thanks in part to the proliferation of treatment. The problem is that “everyone is on meth. And they’re putting fentanyl in the pills.” The very next day, he says, he is going to the funeral of a middle-aged former nurse who died after accidentally taking fentanyl, a powerful synthetic opiate.
Hazard was named after Oliver Hazard Perry, a naval hero of the war of 1812, rather than for its character. Yet it is an appallingly dangerous place to live. In 2019, even before the deadly pandemic, the town and surrounding area, Perry County, came sixth-from-bottom out of America’s 3,142 counties on a measure of age-standardised mortality. At every age, people were far more likely to die. Opiates, which began to spread around 25 years ago, when doctors prescribed them to former coalminers for chronic pain, are a large part of the reason. But heart attacks are also more common. So are traffic deaths, something local police put down to the refusal of people driving on the winding mountain roads to wear seat belts. Last year the town flooded, and mountain walls slid onto houses. And guns are everywhere. It all adds up to a lot of death. On average, people in Perry could expect to live to just 69 in 2019, compared with 79 in America as a whole.
In the past 20 years, on economic measures, America has outperformed other rich countries. Over that period, median wages grew by 25%, compared with just 17% in Germany. Managers at Buc-ee’s, a Texas-based chain of stores, can make more than experienced doctors earn in Britain. But on a more fundamental measure of wellness—how long people live—America is falling behind. To its detractors, this is a cause for schadenfreude. “Many people say it is easier to buy a gun than baby formula in the US,” gloated a statement released by the Chinese Ministry of Foreign Affairs last year, which also pointed to declining life expectancy in general. In the past few years, according to some estimates, life expectancy in China overtook that in America. For Americans, that ought to be a more serious source of introspection than it is.
According to a study by Jessica Ho of the University of Southern California, published last year, which looked at 18 high-income countries, from a fairly average position in 1980, by 2018 America had fallen to dead last on life expectancy. In the 1960s Americans could expect to live seven or eight years longer than people from Portugal, the country in the study that now has the next-lowest life expectancy. By 2018 they could expect to live over a year less. Areas like eastern Kentucky, which have been worst hit, help illustrate why.
In the past three years, all of those figures have probably worsened, owing partly to the coronavirus. A study by KFF, a non-profit organisation, found that by 2021, in the worst of the pandemic, Americans could expect to live fully six years less than people in other rich countries (see chart 1). The virus reduced American life expectancy by just over 2.5 years; in peer countries, the average decline was two months. Though the virus now kills far fewer people, overall mortality rates remain elevated. Death caused by opiates, car crashes and murder have all increased. The pandemic underlined something that has been true for decades: America does not do a very good job of keeping its people safe.
What is killing Americans so much more? Ask almost any public-health expert, and they will point to the huge burden of poor health. Tom Frieden, a former head of the Centres for Disease Control and Prevention (CDC), explains that progress on reducing mortality from chronic diseases has stalled. In the 20th century laws helped improve public health dramatically, bringing about massive reductions in smoking and air pollution. Cholesterol levels tumbled, too. But now the rising burden of obesity is countering the benefits. Roughly 11% of Americans suffer from diabetes, against a figure of just 6% in France; two-fifths of American adults are clinically obese, double the rate across the OECD, a club of mostly rich countries. “Despite the fact we’re making progress in some areas, we’re going backwards overall,” says Dr Frieden.
But this does not fully not explain why America is doing so much worse than elsewhere. Obesity and diabetes are rising almost everywhere; rates have been higher in America for decades. And indeed, increasing access to the best health care is one of the few ways in which Americans are catching up with, or even leaping ahead of, people in other rich countries. Cancer-survival rates in America are the highest in the world. Of sufferers of prostate cancer, in America 98% survive for at least ten years. In Britain the figure is only 78%. Access to health care has improved greatly. Last year the proportion of Americans without health insurance fell to its lowest-ever level.
The problem lies outside the doctor’s clinic. Covid-19 aside, in recent years it is rising violent deaths that explain America’s divergence from the rest of the rich world (see chart 2).
The facts of death
To quote William Farr, an early pioneer in medical statistics, “Death is a fact. All else is inference.” Life-expectancy estimates are made by extrapolating probabilities from the total raw death rate at every age each year. This means that deaths at younger ages have bigger effects. Something that shaves a year off everybody’s life has a similar effect on life-expectancy estimates as something that leads to the premature death of one baby in 80. And what is most shocking about America is how many people—especially men—die young.
In 2021, 38,307 Americans aged between 15 and 24 died. In England and Wales the equivalent figure was just 2,185. As a share of the population, roughly three times as many Americans of that age group died in 2021 as English and Welsh. Ms Ho’s research suggests that Americans are more likely to die than people in other rich countries at every age up to 85. If you make it to that advanced age, your chances of surviving longer are roughly the same as elsewhere.
Even in 2021, as covid deaths soared, increases in what the CDC calls “unintentional injuries” accounted for 16% of the decline in life expectancy they estimated happened that year over 2020. Opiates are a huge part of that. In 2021, according to the CDC, 107,000 people died of drug overdoses, the vast majority linked to heroin or fentanyl. No other rich country comes close to this rate of drug deaths (though Scotland is not that far off). And in 2021 around 43,000 Americans died in car crashes, which was the highest figure since 2005 (the number fell a bit last year); in Germany the rate was a quarter of America’s. Around 26,000 were murdered, against just 300 in Italy.
In fact, almost any horrible death you can think of, Americans are more likely to suffer it. Over 5,000 people died in 2021 in workplace accidents, up by 9% on the previous year; the figure in Britain was 123. Nearly 4,000 people died in fires, the highest number in close to 20 years, making for a death rate of nearly twice that of western Europe. Americans are more than twice as likely to drown as the Dutch (though the French, with their long holidays by the ocean, drown at even higher rates).
For an explanation, a look at America’s geography is revealing. According to Laura Dwyer-Lindgren, an academic with the Institute for Health Metrics and Evaluation at the University of Washington in Seattle, who analysed decades of mortality data by county, the national trend of stagnant life expectancy reveals huge regional variation (see map). In a place like Hazard, in eastern Kentucky, life expectancy is lower now than it was in 1980. In a place like Manhattan, or some wealthier counties of Colorado, it has increased by not much less than anywhere in Europe. According to Ms Dwyer-Lindgren’s data, somebody in their early 60s living in Manhattan is four times less likely to die in a given year than somebody in Hazard. The highest death rates are in a band that runs across the south and south-east of the country. The lowest are increasingly concentrated on the coasts, and in rich, mountain retreats, like Colorado.
This partly reflects diverging economies. Eastern Kentucky is desperately poor. Many people turned to opiates after losing their jobs in coalmining, says Tom Vicini, of Operation UNITE, an NGO which tries to tackle addiction in the region. “If you look at the community that I live in now, it’s changed drastically over the last 20 or 30 years, from a thriving coal industry to….now almost no jobs,” he says. Other places that have suffered as badly are also dirt poor—they include Indian reservations in South Dakota, which never had many jobs to begin with, and rural parts of the Mississippi Delta where agricultural work has dried up. But poverty cannot entirely explain what is happening. Hazard is not that poor by international standards. Next to the Rebound Centre is a hip coffee shop and a smart toy shop; the streets are lined with expensive cars. Nor is death limited to the poor. Across the southern United States people on average incomes die at higher rates than even the very poor in New York City.
The problem is not only that America has become less safe (though in some ways it has). It is also that other countries have improved and America has not. Take, for example, car crashes. Calculations by the Urban Institute, a think-tank, show that in the 1990s French people died in crashes at a rate slightly higher than Americans—and per mile driven, at a rate roughly double. Now, however, Americans are more than twice as likely to die in car crashes. Over the past two decades European roads have been redesigned with roundabouts, speed cameras and pedestrian barriers. American ones have been widened. Other countries have tightened up gun ownership. America has expanded it. Even opiates stand out. In the 1980s Europe also suffered a devastating epidemic of heroin abuse when heavy industry declined. Unlike America, it quickly made substitutes such as methadone widely available, and did not have another.
Could this help explain America’s drifting politics? A generation ago Ronald Reagan won re-election with an optimistic slogan, “It’s morning again in America”, depicting people living happy, sunny lives. In May Donald Trump launched his own version—”It’s mourning again in America”—featuring fentanyl, transgender athletes and a doddering Joe Biden. Mr Trump thrived in the areas with the highest death rates, and in particular among white working-class voters, for whom death rates have increased most. In places where people die less, the Democrats are generally doing better. Katherine Cramer, a political scientist from the University of Wisconsin-Madison, suggests that much of Mr Trump’s success is driven by “resentment”, particularly that of white rural people who feel left behind relative to people in big cities. Dying so much earlier would seem a legitimate cause for resentment.
Yet Mr Trump’s solutions hardly seem likely to fix things. Matthew Ruther, a geographer at the University of Louisville, argues that the problem is in part cultural. “The social contract is different here than it is with other countries,” he says. Americans, he suggests, have a strong belief in personal responsibility, and do not expect the state to shield them from poor decisions.
A drive around Kentucky tends to support the impression that personal choices do indeed play a part. Your correspondent counted a dozen motorcyclists on his visit. Not one was wearing a helmet. Half of passenger deaths in car crashes involve somebody who is not wearing a seat belt. A visit to a gun shop in London, a town around 50 miles west of Hazard, is also revealing. Asked about opiate deaths in eastern Kentucky, the owner laments the toll but then says: “They choose to do it! I guess they just think it won’t be them.”
“The mentality in the United States is to pull yourself up by your bootstraps. Yeah no they can’t,” says Barbara Ramp, whose son Alec died of a heroin overdose nearly a decade ago, at the age of 20. She describes how Alec was told not to seek methadone treatment for his addiction, because he should focus on getting truly clean. “Our government just doesn’t seem to be protecting people,” she says. Some Republicans suggest that it is not the government’s job to protect people. “It’s worth [it] to have a cost of, unfortunately, some gun deaths every single year so that we can have the Second Amendment,” said Charlie Kirk, a prominent conservative activist, in April. Live free and die.
In fact, Americans do still generally see protection from death as the responsibility of government. The problem is that they often search for outside enemies to defeat, rather than solutions that would help Americans help themselves. To combat fentanyl, politicians such as Dan Crenshaw, a congressman, have proposed launching military strikes against drug gangs in Mexico. Yet the politicians take years to implement more direct life-saving measures. Until April this year, in Kentucky fentanyl testing-strips—which can save lives by alerting drug users to contaminated wares—were classed as illegal “drug paraphernalia”. A few other states also legalised the strips this year, including hard-hit ones such as Mississippi, Ohio and Pennsylvania. But they remain illegal in several others, including Texas, Mr Crenshaw’s home state.
Reducing the death toll will take more than bombing Mexico. It will also take a politics that is more sympathetic to human frailty, and at times more willing to inconvenience people. Change can happen. Under Pete Buttigieg, the transport secretary, federal money for highway improvements made available under the Infrastructure Act increasingly comes with requirements that roads be redeveloped to be safer to drive on. That mostly means making drivers go more slowly. Last year, a modest gun-control bill that expanded background checks was passed by Congress with bipartisan support, despite the opposition of the National Rifle Association, which argued it will inconvenience law-abiding gun purchasers. For tens of thousands of Americans a year, such changes cannot happen soon enough. ■