A Spanish flu pandemic infected approximately one-third of the global population in 1918. In the United States alone, about 675,000 people died, enough to contribute to a decline in the country’s life expectancy. For a century, this decline remained singular in the annals of American health ― until last month, when the National Center for Health Statistics reported that, between 2016 and 2017, U.S. life expectancy dropped from 78.7 to 78.6 years.
This marks the third consecutive year that life expectancy in the U.S. has decreased, a multiyear drop not seen since that 1918 flu pandemic. And it reflects a longer-term trend in which U.S. life expectancy has lagged relative to other economically comparable countries. Overall, our lives have gotten longer, but at a slower rate than our peers.
Why has U.S. life expectancy slowed to its present reversal? The reasons cited by the National Center for Health Statistics are largely twofold: suicide and opioid deaths. But the real explanation as to why those issues continue to worsen is because America has failed to invest in our nation’s health.
Last year, the number of suicides in the U.S. was the highest it has been in decades: A total of 47,000 suicides occurred that year, up from 45,000 the year before. Suicide is a complex phenomenon; our understanding of its causes is incomplete and continues to evolve. However, we do know that guns are a key driver of suicide deaths. Firearm suicide is responsible for approximately 22,000 deaths each year in the U.S., including the deaths of upward of 950 children and teenagers.
Opioids are an equally urgent threat. The U.S. saw 70,237 drug overdose deaths in 2017, 47,600 of which involved an opioid. These deaths have been driven by the emergence of fentanyl, a powerful synthetic opioid. Fentanyl is 50 to 100 times more potent than morphine — just a few milligrams can be deadly.
“This marks the third consecutive year that life expectancy in the U.S. has decreased, a multiyear drop not seen since that 1918 flu pandemic.”
Both fentanyl and guns have become ubiquitous in the U.S., which has amplified their threat to our health. Fentanyl use, for example, has skyrocketed in recent years. In 2016, synthetic opioids were linked to almost 50 percent of total opioid-related deaths, a significant increase from 2010, when they were linked with just 14 percent of opioid-related deaths. This is due largely to a thriving black market in which the drug is manufactured overseas and shipped into the country. Guns are in ample supply too, due to our uniquely permissive gun laws, and the actions of politicians and special interests who have worked to keep this status quo in place. Their efforts have been so successful that there are now more guns than people in America.
These causes are important. There is a temptation to think gun suicides and opioid deaths just “happen,” that they are a collection of isolated tragedies brought on by fate or poor decisions. We often see this thinking in the wake of gun violence, when politicians say that nothing can prevent such tragedies, that they are an unavoidable consequence of living in a dangerous world, and that “guns don’t kill people, people do.” Many factors play a role in causing gun violence, but at the heart of this epidemic is easy access to guns. Our research team, for example, looked at gun laws in 10 countries and found a link between laws restricting gun availability and a decrease in gun deaths. If guns’ ubiquity drives gun violence, politics — and the currents of power and culture that inform it — lies at the heart of why our country is home to so many guns, and so much violence.
A similar range of factors accounts for the proliferation of opioids. In addition to the spread of fentanyl, the opioid epidemic is a product of the overprescribing of opioids, and the widespread availability of cheap heroin. Taken together, these causes speak to a core truth about the contemporary epidemics of gun suicides and opioid deaths: They do not just “happen.” Rather, they emerge from the social, economic, and political context of contemporary American life. Unless we address this context, we cannot hope to solve these problems.
But have we not already addressed these challenges by investing in health? After all, the U.S. spends more on health than any other country in the world. Why, then, do we have a life expectancy that suggests a society convulsed by plague?
The reason is that we do not actually invest in health. We invest in health care. The vast majority of our health spending goes to doctors, medicines and cutting-edge treatments that help us when we are sick. Far less goes to the social, economic and environmental factors that determine whether or not we get sick in the first place. These factors are shaped by a network of policies and institutions that promote health by providing basic public goods. These goods include clean air and water, safe neighborhoods, high-quality public education, and a fair economy. Without these goods, we cannot be healthy.
“There is a temptation to think gun suicides and opioid deaths just 'happen,' that they are a collection of isolated tragedies brought on by fate or poor decisions.”
If someone grows up in an economically depressed area, without access to a good education, a stable job or quality health care, if she sustains a work injury and is overprescribed opioids and develops an addiction she cannot afford to sustain, and so finds herself buying the cheapest heroin she can find, and fatally overdoses after consuming a batch laced with fentanyl, is it any surprise, in this context, that she came to such an end? Yet in our society, we are much more likely to ascribe her death to her own poor judgement than we are to consider the many external factors that put her in such a desperate position. We are much more likely to think “People with addiction should behave better” than we are to think “How can we create a society where addiction and despair is not the default way of life for so many people?”
It is not easy to embrace the latter perspective. We like to find simple causes for the effects we see. It is easier to think people shoot themselves simply because they are sad, that they overdose because they too greedily pursue the pleasure drugs can bring. But this does not reflect reality. Our modern epidemics are actually the products of immense complexity. Believing otherwise has led to decades of disinvestment in the public goods that create health.
We have embraced the idea that simply maximizing individual freedom at all costs is the key to a better life, and that sickness is just a failure of people to take responsibility for themselves. We have run this experiment while many of our peer countries have indeed invested in health. That our life expectancy now lags behind theirs reflects the dead end our path has led us to. If we do not start investing in health, and the conditions that allow it to flourish, we will not be able to stop current epidemics, or prevent the rise of new ones.
CORRECTION: A previous version of this story misstated the lethal dose of fentanyl as a few grams; in fact, a few milligrams can be deadly.
Sandro Galea, MD, DrPH, is professor and dean at the Boston University School of Public Health. His latest book, Well: What we need to talk about when we talk about health, will be published in May 2019. Follow him on Twitter: @sandrogalea.