Another unacceptable life expectancy gap

Life expectancy differs by 20 years between some US counties

Another unacceptable life expectancy gap

  • Life expectancy in the United States increased to 79.1 years in 2014
  • Residents of counties in central Colorado can expect to live the longest

(CNN)Life expectancy at birth differs by as much as 20 years between the lowest and highest United States counties, according to new research published Monday in the medical journal JAMA Internal Medicine.

Dr. Christopher J.L. Murray, lead author of the study and director of the Institute for Health Metrics and Evaluation at the University of Washington, estimated life expectancy for each US county from 1980 through 2014. Murray and his colleagues analyzed county-level data and then applied a mathematical model to estimate the average length of lives.

Life expectancy at birth increased by 5.3 years for both men and women — from 73.8 years to 79.1 years — between 1980 and 2014, Murray and his colleagues wrote. During that time period, men gained 6.7 years, from 70 years on average to 76.7 years, while women gained four years, from 77.5 years to 81.5 years.

But the numbers aren't the same everywhere. Looking at the finer details, Murray and his colleagues calculated a gap of 20.1 years between US counties with the lowest and highest life expectancies.

The counties with lowest life expectancy are located in South and North Dakota, while counties along the lower half of Mississippi, in eastern Kentucky, and southwestern West Virginia also showed lower life expectancies compared to the rest of the nation. The North and South Dakota counties include Native American reservations.

At the other extreme, residents of counties in central Colorado can expect to live longest, Murray and his colleagues said.

'Drastically different life expectancies'

While the study does not directly answer why we see low or high life expectancies in specific counties, it does look at what factors contribute to the overall gap between some counties, said Murray.

“We can see that many of the counties with very low life expectancies in the Dakotas, Oglala Lakota County in South Dakota, overlap with large Native American reservations including the Pine Ridge and Rosebud reservations,” said Murray.

Conversely, Summit County, Colorado, ranked as the county with highest life expectancy in 2014 at 86.8 years, is home to several ski resort towns.

“For both of these geographies, the drastically different life expectancies are ly the result of a combination of risk factors, socioeconomics, and access and quality of health care in those areas,” said Murray.

Yet, socioeconomic factors are not everything, said Murray, explaining that “60% of the differences in life expectancy across counties can be explained by socioeconomic factors alone” yet that leaves a “substantial amount of unexplained differences.”

“Behaviors smoking and physical activity, along with risk factors obesity and diabetes, are also very important,” he said.

Still, almost all counties throughout the nation showed improvement over time, though the number of additional years varied across the nation. Counties in central Colorado, Alaska and along both coasts experienced larger increases than most other counties. Meanwhile some southern counties in states from Oklahoma to West Virginia experienced either no improvement or very little over time.

The most positive note is that, over the study period, all counties show declines in the risk of early death for children under the age of 5 years old, say the authors. And, nearly all counties (about 98%) show declines in the risk of early death for people between the ages of 5 and 25, as well as those between 45 and 85.

However, people between the ages of 25 and 45 show an increased risk of death in 11.5% of counties over the study period.

The study didn't evaluate what might drive changes in mortality risks for specific age groups, Murray said, but he speculates that the same general factors that impact life expectancy overall may drive differences for those ages 25 to 45.

What causes differences in life expectancy? The reasons for life span inequality have been explored in previous studies so the current study examined the extent to which just three factors contributed to lower or higher survival. The three factors are socioeconomic levels and race/ethnicity, behavioral and metabolic risk, and health care.

“Risk factors — obesity, lack of exercise, smoking, hypertension, and diabetes — explained 74% of the variation in longevity,” said Murray. “Socioeconomic factors, a combination of poverty, income, education, unemployment, and race, were independently related to 60% of the inequality, and access to and quality of health care explained 27%.”

The authors used new methodologies that are more precise than past models, but county level data are all subject to error, the authors note. If recent trends are allowed to continue, the differences in life expectancy across counties will increase, not decrease, the researchers add.

'A gap of 20 years … is absurd'

For the first time since 1993, US life expectancy in 2015 dropped significantly for the entire population, not just certain groups, the Centers for Disease Control and Prevention reported in late 2016. CDC researchers warned that a one-year shift does not mark a trend.

Ellen Meara, a professor or health economist at the Dartmouth Institute for Health Policy and Clinical Practice, said many factors impact life expectancy. She was not involved in the new research.

“Socioeconomic factors education and poverty can shorten lives of individuals, and it may be bad to live in areas with high rates of poverty and less educated adults,” said Meara.

“Similarly, sedentary lifestyles (which are reflected in obesity rates) and smoking are two of the biggest individual risks of poor health and premature death.

For people who develop a disease diabetes or hypertension, also measured in the study at the county level, risk of death is higher.”

Meara noted that the authors used “rigorous methods” to gain a more “comprehensive look” at deaths by county and age group. “This research echoes what we have been learning from studies in other settings over the past decade,” she said. “Disparities in mortality have widened over time.”

Still, understanding differences across geographic areas can provide clues, said Meara, about what might contribute to improvements over time.

“To have a gap of 20 years in a country as wealthy as ours is absurd,” she said.

Murray agrees. “The inequality in health in the United States — a country that spends more on health care than any other — is unacceptable,” he said. “Every American, regardless of where they live or their background, deserves to live a long and healthy life.”

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Executive summary

Another unacceptable life expectancy gap

The world's biggest killer and the greatest cause of ill-health and suffering across the globe is listed almost at the end of the International Classification of Diseases. It is given the code Z59.5 – extreme poverty.

Poverty is the main reason why babies are not vaccinated, why clean water and sanitation are not provided, why curative drugs and other treatments are unavailable and why mothers die in childbirth. It is the underlying cause of reduced life expectancy, handicap, disability and starvation.

Poverty is a major contributor to mental illness, stress, suicide, family disintegration and substance abuse. Every year in the developing world 12.2 million children under 5 years die, most of them from causes which could be prevented for just a few US cents per child.

They die largely because of world indifference, but most of all they die because they are poor.

In the time it takes to read this sentence, somewhere in the world a baby has died in its mother's arms. For that mother, the message that her neighbour's infant will live is no consolation.

It does not stem her grief to know that 8 10 children in the world have been vaccinated against the five major killer diseases of childhood, or that globally since 1980 infant mortality has fallen by 25%, while overall life expectancy has increased by more than 4 years, to about 65 years.

Beneath the heartening facts about decreased mortality and increasing life expectancy, and many other undoubted health advances, lie unacceptable disparities in health.

The gaps between rich and poor, between one population group and another, between ages and between the sexes, are widening.

For most people in the world today every step of life, from infancy to old age, is taken under the twin shadows of poverty and inequity, and under the double burden of suffering and disease.

For many, the prospect of longer life may seem more a punishment than a gift.

Yet by the end of the century we could be living in a world without poliomyelitis, a world without new cases of leprosy, a world without deaths from neonatal tetanus and measles.

But today the money that some developing countries have to spend per person on health care over an entire year is just US $4 – less than the amount of small change carried in the pockets and purses of many people in developed countries.

A person in one of the least developed countries in the world has a life expectancy of 43 years according to 1993 calculations. A person in one of the most developed countries has a life expectancy of 78 – a difference of more than a third of a century. This means a rich, healthy man can live twice as long as a poor, sick man.

That inequity alone should stir the conscience of the world – but in some of the poorest countries the life expectancy picture is getting worse. In five countries life expectancy at birth is expected to decrease by the year 2000, whereas everywhere else it is increasing.

In the richest countries life expectancy in the year 2000 will reach 79 years. In some of the poorest it will go backwards to 42 years.

Thus the gap continues to widen between rich and poor, and by the year 2000 at least 45 countries are expected to have a life expectancy at birth of under 60 years.

In the space of a day passengers flying from Japan to Uganda leave the country with the world's highest life expectancy – almost 79 years – and land in one with the world's lowest – barely 42 years.

A day away by plane, but half a lifetime s difference on the ground. A flight between France and Côte d'Ivoire takes only a few hours, but it spans almost 26 years of life expectancy.

A short air trip between Florida in the USA and Haiti represents a life expectancy gap of over 19 years.

The purpose of the report is to highlight such inequities and to tackle the wider question: what are the global health priorities? It also tries to answer other crucially important questions.

Which are the major diseases, the major causes of death, handicap, disability and diminution of the quality of life? Which conditions cause most misery, although they may not be fatal? Which countries, or communities within countries, have the greatest health needs? Where should health resources be targeted?

The report, for the first time, has attempted to examine the burden of ill-health not just by disease, but also by age, as the impact of illness differs across the age spectrum. Where possible, the analysis of health status has been carried out for infants and children, adolescents, adults and the elderly.

On the basis of the data available and considered to be reasonably reliable, ten leading causes of death, illness and disability have been identified.

There is also an explanation of what WHO is doing to bridge the gaps in health, an attempt to assess health trends in the coming years, and an effort to chart a health future for mankind – a future in which a baby lives, not dies, in its mother's arms.


Kentucky Is Home to the Greatest Declines in Life Expectancy

Another unacceptable life expectancy gap

The three longest-living counties were all in Colorado: Summit, Eagle, and Pitkin, which are home to wealthy, outdoorsy enclaves such as Vail and Breckenridge. There, people live until they’re about 86, on average.

Interestingly, the study finds that the risk of dying under age 5 dropped in all counties since 1980, possibly thanks to programs that target improving the health of infants and children. Meanwhile, the risk of death between the ages of 25 and 45 rose in about 12 percent of all U.S. counties.

The authors found that much of the disparity in life expectancy was explained by risk factors obesity, physical inactivity, hypertension, smoking, and diabetes, but that poverty, education, and unemployment also play a role.

That could be why eight of the 10 counties with the largest decreases in life expectancy since 1980 were all in lower-income areas of Kentucky. According to the study, the counties with the largest decreases in life expectancy between 1980 to 2014 were:

  • Owsley County, Kentucky (-3 percent)
  • Lee County, Kentucky (-2 percent)
  • Leslie County, Kentucky (-1.9 percent)
  • Breathitt County, Kentucky (-1.4 percent)
  • Clay County, Kentucky (-1.3 percent)
  • Powell County, Kentucky (-1.1 percent)
  • Estill County, Kentucky (-1 percent)
  • Perry County, Kentucky (-0.8 percent)

Rounding out the bottom 10 were Kiowa County in southwestern Oklahoma, with a 0.7 percent decline in life expectancy, and Perry County, Alabama, with a 0.6 percent decline.

Kentucky has one of the highest rates of death from drug overdoses, with about 30 deaths per 100,000 people. Owsley County is the country’s poorest white-majority county, according to a 2016 analysis by Al Jazeera, with about 45 percent of its roughly 4,500 residents living in poverty.

The decline of coal mines and tobacco fields have battered the county, whose population peaked in 1940. (Indeed, the JAMA study authors acknowledge that part of the life expectancy trends might be due to healthy people moving away from blighted areas, and “high-risk” people remaining in them.


In an emailed response to the study, Doug Hogan, spokesman for the Kentucky Cabinet for Health and Family Services, said, “This is our number one public health issue in Kentucky.

The causes are multifaceted, but began with prescription opioids and have progressed to heroin and illicitly obtained fentanyl.

Extensive and coordinated efforts are in place including broader prevention measures, expansion of treatment options and an array of harm reduction strategies. Unfortunately, there is not an easy or quick solution.”

Although opioids explain some of the inequality in life expectancy, experts say poor diets and financial strain are also major reasons for the worsening health of less-educated, white Americans. In parts of Appalachia, for example, more people are dying of heart disease now than were in 1980.

“The inequality in health in the United States—a country that spends more on health care than any other—is unacceptable,” Christopher Murray, director of the Institute for Health Metrics and Evaluation, said in a statement. “Every American, regardless of where they live or their background, deserves to live a long and healthy life. If we allow trends to continue as they are, the gap will only widen between counties.”

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Life Expectancy | See Why Location Matters in America

Another unacceptable life expectancy gap

For public health officials who study life expectancy, learning that both minor and major differences exist among global populations may come as no surprise. However, a recent study’s revelation that drastic differences in life expectancy exist among Americans has caught even experienced researchers off guard.

Learn what this 24-year study reveals about the life expectancy of Americans and discover what public health experts can learn from this data.

How Researchers Designed This Longevity Study

Researchers have long observed that people who live in certain parts of the country live several years longer than others. To better understand why this happens, whether it is increasing or decreasing, and which factors may contribute to differences in longevity, a group of researchers designed a comprehensive study.

As JAMA Internal Medicine explains, researchers created tables that tracked populations at the county level across the United States from 1980 to 2014. To do this, they used a combination of death records from the National Center for Health Statistics (NCHS), along with population records from the NCHS, the U.S. Census Bureau, and the Human Mortality Database.

With this information in hand, researchers determined the average life expectancy at birth and age-specific mortality risk in counties across the nation. Researchers incorporated factors such as race, ethnicity, socioeconomic status, metabolic risk, and access to health care into their conclusions.

What This Study Reveals About Life Expectancy

After analyzing the data and calculating the results, Jama Internal Medicine reports that the researchers determined that in 2014, the average life expectancy for both male and female Americans is 79.

1 years.

While life expectancy increased by an average of about five years across the nation, this measure is remarkably inconsistent from county to county, with a 20-year difference among various locations in the U.S.

As the Washington Post reports, those who enjoy the highest life expectancy in the U.S. dwell in the mountains of central Colorado, where many live an average of more than 85 years. In other areas, such as southwestern South Dakota, the average person lives just 67 years.

According to NPR, the life expectancy gap among U.S. counties echoes the differences between longevity in low- and high-income parts of the world. Socioeconomic status does appear to factor into the 20-year life expectancy gap revealed in this study of the U.S.

Residents of areas with a high life expectancy, such as Summit County, Colorado, are some of the most well-off and highly educated in the nation.

In contrast, residents of areas with a low life expectancy, such as Oglala Lakota County, South Dakota, or parts of southern Mississippi and eastern Kentucky are much poorer and have less education.

As Jama Internal Medicine explains, this study asserts that socioeconomic and race or ethnicity factors account for 60 percent of the variation in life expectancy among counties. Behavioral and metabolic risk factors account for 74 percent, and access to health care accounts for 27 percent of the difference in longevity.

In addition, the study reveals that geographic differences in the risk of death decreased among children and teenagers from 1980 to 2014, but this factor increased among older adults during the same time period.

In fact, the gap between low and high life expectancy has increased by about two years over 34 years.

This means the inequality in life expectancy actually increased during the 34 years that this study covered, and the longevity gap could continue to increase rather than even out over time.

What Public Health Officials Can Learn From This Study

While the study reveals numerous issues, many see it as a call to action. In fact, public health professionals may be able to implement targeted actions and policies to help close the gap.

For instance, as NPR reports, smoking and obesity have ly contributed significantly to lowering life expectancy in some of the hardest-hit areas.

While many communities around the nation have responded to public health issues these with anti-smoking and anti-obesity initiatives, others, such as those in southwestern South Dakota, have made little progress toward eradicating these issues in 34 years.

Along the same lines, other public health researchers have surmised that young adults facing worse economic prospects than their parents did have made choices that lower their life expectancy in certain parts of the country.

For instance, choosing low-quality, unhealthy food that contributes to obesity may be more acceptable in counties plagued with lower than average incomes.

Ultimately, the proliferation of obesity, smoking, and so-called “diseases of despair” may lead to lower life expectancy.

Public health experts may take a closer look at some counties in which life expectancy experienced the greatest increase during the 34-year study. For instance, some counties in Northern Virginia and central Alaska experienced double-digit increases in life expectancy.

Officials in the U.S. may also be able to use other nations’ policies as models. As the Washington Post explains, policymakers in Australia have long since established methods for eliminating smoking and obesity. Encouraging physical activity, improving access to healthy food choices, and limiting the ability to smoke all help to curb these risk factors.

While the full results of these policies remain to be seen in Australia, implementing similar procedures in the U.S. could have important implications. For instance, since life expectancy in the U.S.

is actually on a slight downward trend, the nation as a whole is slowly becoming less productive and less competitive on an international scale.

Improving life expectancy through forward-thinking public health policies could improve quality of life, productivity, and competition, ultimately addressing socioeconomic issues at the same time.

As a professional working in the public health field, you will ly focus on improving health in varied communities and positively impacting life expectancy. If you are interested in working on important issues this, learn more about the MPH degree program at the Keck School of Medicine. An advanced degree could enable you to pursue a rewarding career in public health.


As U.S. Life Expectancies Climb, People In A Few Places Are Dying Younger


Life expectancy gap between rich and poor is widening

Another unacceptable life expectancy gap

The gap in life expectancy between the prosperous middle classes and those in the most deprived homes is widening sharply, latest health figures show.

The emerging pattern suggests that the well-off are adopting healthier lifestyles while the poor are still drinking and smoking and cannot afford to change diets.

Men in Blackpool now live on average up to 73.2 years, 10.5 years fewer than their counterparts in Kensington and Chelsea. Women in Hartlepool have the lowest female life expectancy at 78.1 years, around 9.6 years less than in the central London borough.

While life expectancy rates are increasing overall, they appear to be rising much faster for the affluent than for those who struggle to make ends meet, according to the latest district-by-district NHS health profiles, published this week.

Over a three-year period – from 2004-06 to 2005-07 – the figures reveal that the gap between local authorities at opposite ends of the health spectrum grew by 0.4 years for men and 0.8 years for women.

Average male life expectancy in England has now risen to 77.7 years, compared with 77.3 years three years ago; average female life expectancy has risen to 81.8 years from 81.6 years.

The minister for public health, Gillian Merron, welcomed the figures: “The health of the nation is improving …

It is good to see that people can expect to live longer, that early deaths from heart disease, cancer and smoking-related diseases are decreasing.

“But people living in some areas are still healthier than those living in other areas, which is unacceptable. The NHS and local authorities need to work with this published information to identify what the issues are in their area and take action for the sake of the health of their local population.”

Alan Walker, professor of social policy and social gerontology at the University of Sheffield, said: “Messages about wellbeing and healthy lifestyles penetrate more rapidly into the middle-class professional households than they do into working-class homes and households on benefits.

“It's easier on a comfortable income to make those lifestyle choices. When you are poor you simply can't choose what you eat. Try to tell a hard-pressed mother to stop smoking – she may say thats it's the only thing that gets her through the day.

“It's much easier for those on higher incomes. The health inequality statistics are a mirror of other inequalities. Those differences are getting wider. It's hard cash, child benefits, that is going to make a difference.”

Life expectancy has been increasing for at least the past 180 years – since records in the UK began. It is increasing, on average, at the rate of one month every six years.

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The Gross Inequality of Death in America

Another unacceptable life expectancy gap

Oneof the most disquieting facts about life in the United States today is that therichest American men live 15 years longer than the poorest men, while for womenit’s 10 years. Put a different way, the life expectancy gap between rich andpoor in the U.S. is wider than the gap between the average American and theaverage Yemeni or Ethiopian.

Thisgap is only gettingwider.According to a report by the HealthInequality Project, from 2001-2014, the richest Americans gainedapproximately three years in life expectancy while the poorest Americansexperienced no gains.

A three-year difference in life expectancy may seem trivial,but, as the report’s authors note, this gain in lifespan is the equivalent of curingcancer for only the rich.

Going back further,the numbers only getworse:The richest American males gained six years in life expectancy from 1980 to2010, while outcomes for the poorest men remained stagnant.

Thesefacts would seem to justify the Democratic Party’s widespread support for universalhealth care.

Presidential candidates including Bernie Sanders, Elizabeth Warren,Cory Booker, Kamala Harris, and Julian Castro support someform of Medicare for All, and many of the candidates who haven’t fully endorsedMFA have gone to all lengths to convince voters—sometimesunconvincingly—that their plans will guarantee low-cost universalcoverage.

Whenit comes to the health-wealth gap, though, Medicare for All may not be the silverbullet that progressives hope for. Most evidence suggests that while universalhealth care is a necessary step to closing this gap, it is nowhere near enough.That’s because there are two other major factors that cause the rich to live somuch longer than the poor.     

Ifthe health-wealth gap is merely the product of access to quality health care,then the gap should largely disappear when health care access is equalizedacross society. But that’s not the case in countries that already have universalhealth care coverage.

In France, which has one of the best andmost extensive health care systems in the world, the health-wealth gapis about 11years.

Even in the United Kingdom, home to the most robust single payer health caresystem on the planet, the rich live about 9 years longerthan the poor.

Theresearchers at the Health Inequality Project found a similar result whencomparing states within the U.S. “Differences in life expectancy among the poor,”their final report stated, “are not strongly associated with differences inaccess to health care.”

Thehealth-wealth gap also exists for diseases that have nothing to do with health careaccess,namely juvenile diabetes and rheumatoid arthritis. Furthermore, the recent fall inlife expectancy in the U.S.

has been driven by what Princeton economistsAnne Case and Angus Deaton have dubbed “deaths ofdespair”—namely,suicides and drug overdoses—which have little to do with health care access anddisproportionately impact the poor nonetheless.

(These conditions do, however,have much to do with mental health and drug addiction services.)

Thishealth-wealth gap also remains when taking behavior into account—for example, thefact that poor people tend to be heavier smokers and drinkers.

The famous Whitehall studies of theBritish Civil Service led by epidemiologistMichael Marmot found that only about one-third of the health-wealth gap can beexplained by “risk” factors such as smoking, alcohol consumption, andreliance on fast food.

When you add in “protective” factors such as access tohealth care or workout facilities, the number still represents less than halfof the total gap.

So,what is responsible for the majority of the health-wealth gap? Stanfordneuroscientist Robert Sapolsky, who has been speaking and writing on this questionfor decades, offers a simpleanswer: poverty itself. Or, as Sapolsky puts it, “the psychosocial impact oeing poor.”

Drawingon research from neuroscience, psychology, and neurobiology, Sapolsky found apowerful link between poverty, chronic stress, and severe health outcomes.

As ourbody’s adaptive response to external threats, short-term stress can be a goodthing: It prompts the fight-or-flight response that can help us survivedangerous situations.

However, human beings uniquely experience what is knownas “chronic stress”: prolonged psychosocial stress that can last formonths or even years.

Chronicstress can literally kill us. It increases the risk and severity of diseases type 2 diabetes and gastrointestinal disorders, impairs the growth ofchildren, suppresses our immune system (rendering us less able to fight evenbasic sicknesses), and increases our lihood of becoming depressed oraddicted.

Whileall humans experience stress, Sapolsky points out that the experience of chronicstress is not evenly distributed across society. An extensive biomedicalliterature indicates that people are more ly to experience stress-relateddiseases when they lack control over, and social support for dealing with, stressfulconditions. The poor disproportionately face such conditions.

Alife of poverty can mean a life of constant stress. The poor have littlecontrol over their work schedules or wages. (In theWhitehall studies, one’s level of control in the workplace, even for workerswithin the same organization, accounted for one-half of health disparities.)They fear suddenly losing their job and being unable to pay the bills.

Theydespair over their own future, and how to give their children a better life. Theyare exhausted and socially isolated by second or third jobs, long commutes, andweekend shifts. They lack the means to take much-needed time off or pay forrelaxing hobbies. And often their social support systems are decimated byincarceration, addiction, and depression.

It’sno wonder that the poor have consistently worse health outcomes. Their brainsare working overtime all the time.

Yetpoverty and its antecedents may only be the beginning. As Sapolsky notes, recent researchindicates that living in “poverty amidst plenty”—inequality—is also animportant part of the health-wealth equation.

For example, Psychologist NancyAdler hasdemonstratedthat how people rate how they are doing, relative to others, is at least aspredictive of health or illness as are any objective measures such as actualincome level, and research by epidemiologistsRichard Wilkinson and Kate Pickett has shown that by just about every healthindicator—infant mortality, overall life expectancy, obesity, you name it—inequality can be even worse than poverty. In the Whitehall studies, Marmotfound a fourfold difference in rates of cardiac disease mortality between thelowest and highest rungs of the British Civil Service, despite the fact theywere all paid a living wage.

Whatthis research shows is that health outcomes are not simply a matter of accessto healthcare: Poverty and inequality are themselves matters of life and death.

Policies that provide a basic income, institute a living wage, eliminatecollege debt, guarantee affordable housing, and give workers collectivebargaining power are thus equally important for closing the egregious gap inlife expectancy between America’s rich and poor.

If the health of all Americansis a priority for the Democratic Party, candidates must be as serious aboutlifting people poverty, increasing workers’ control, and reducing incomeinequality as they are about implementing universal health care.

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