Starters: What's Killing Us?
Of course, most people would much rather be healthy than sick or dead. That’s why we Americans spend $4.2 trillion a year on medical care. At nearly $13,000 per person per year, that’s roughly twice as much per capita as what other wealthy countries spend. Then why are we so unhealthy?
In life expectancy at birth, just before COVID-19 scrambled the data, the United States ranked 41st, sandwiched between Nicaragua and Peru. Our life expectancy is closer to that of Bangladesh than the healthiest nation on earth (Japan). It’s embarrassing and it’s tragic.
What’s going wrong, and what can we do about it? I’m starting this newsletter because I believe we need more thoughtful conversations about health. Health, that is, not health care.
I am far from the first person to point out the disconnect between our spending for medical care and our health. But most often, people cite these facts to argue that we need to fix our system of medical care. That assumes that the reason Americans are unhealthy is because they can’t get quality medical care when they are sick.
No question about it: our medical care system is a haphazard, profit-driven mess. I don’t know a single person - patient, doctor, nurse, or administrator - who is satisfied with this system. I’ll write about the benefits, limits, and hazards of medical care later. But for now, please trust me, a lack of access to medical care is not the reason that Americans are sick and die young.
The health of populations is shaped by a web of behavioral, social, economic, and environmental factors - with “environment” defined broadly as the day-to-day world that surrounds us. I believe we can change those factors in ways that prevent disease and help people live longer, healthier lives – which is what I call healthscaping. This newsletter will discuss the factors affecting our health and what we should do about them. I invite you to subscribe and chime in.
A disclaimer: this newsletter is about health policy, not about personal health. Don’t look here for advice on how you can lose weight, avoid COVID-19, or delay Alzheimer’s disease. If you want wellness tips, there are plenty of responsible newspaper sections, websites, and books to turn to.
Health policy should be grounded in data. If we want to get healthier as a nation, we need to understand what is killing us, what’s sickening us, what causes those diseases, and what changes might prevent them. So, to start this conversation, what’s killing us?
The National Center for Health Statistics extracts the underlying cause of death from death certificates and compiles them in different ways. Here’s their rollup of the 15 leading causes of death for 2023:
“Top killer” rankings like this depend on how you lump or split out different causes of death. The top three on this list – heart diseases, cancer, and unintentional injuries - are broad categories. They group health problems with very different causes together, like lumping prostate cancer with leukemia, and drug overdoses with car crashes. Splitting these out can guide prevention better.
NCHS also produces a list of 113 major causes of death. This list retains some categories, but splits out specific types of heart disease, cancer, and injuries. Here’s a ranking of the top 15 of those after removing the bigger lumped categories, which is a little more helpful.
The leading killers are mostly chronic diseases - like ischemic heart disease, lung cancer, and diabetes. That’s new in history: in the 19th century, most deaths were caused by infectious diseases, like cholera, dysentery, typhoid fever, and tuberculosis.
These top killers, for the most part, are not curable. The modern medicine that we pay so much for can treat but cannot cure a heart attack, stroke, chronic lung disease, or Alzheimer’s disease. On the other hand, these diseases are preventable. Ischemic heart disease and stroke can be prevented if people avoid smoking, have healthier diets, and are physically active. Alzheimer’s disease can be delayed much the same way. And chronic lung disease and lung cancer can be prevented by reducing smoking rates.
These common risk factors suggest maybe a better way to think about the biggest killers of our time. What behaviors or exposures are responsible for the most deaths in America?
There is no standard way to count the deaths that can be attributed to, say, smoking or an unhealthy diet. But there are ways to estimate them, based on our understanding of how much these behaviors and exposures increase the risk of death and how common they are.
The Global Burden of Disease project is a massive ongoing analysis of data from countries worldwide to measure health problems. The project estimates the numbers of deaths caused by different diseases and the numbers attributable to common risk factors. Their numbers are just estimates, but they are the best available. Here are their analyses of risk factors for 2021.
So the behavioral and environmental risk factors underlying the most deaths in America are smoking and unhealthy diet (about 360,000 deaths each), and alcohol and drug use (about 120,000 deaths each).
Those numbers may surprise some people. For example, many people that I talk to seem to believe that smoking is yesterday’s problem. It isn’t. Smoking is still killing nearly as many Americans every year as COVID-19 did during each of the worst two years of the pandemic. And while people are beginning to appreciate the health risks of even “moderate” alcohol drinking, many may be surprised that alcohol kills about as many people as opioids, cocaine, crack, and all other illicit drugs combined.
Overall, these are problems that, as a nation, we can do something about.
So far, these stats are counting deaths. But what about diseases that make you sick but don’t kill you? Depression and arthritis, for example, can make you miserable, but they don’t kill - not directly, anyway. Shouldn’t we care about them too?
The Global Burden of Disease project uses a metric for this called the DALY – for disability-adjusted life year. This metric combines data on how many years of life are lost by early death with how many years people are alive but suffer from a disability. Consider DALY counts as very rough estimates with which to rank different types of health problems.
Here are their DALY rankings for the U.S. in 2021:
Because 2021 was one of the two peak years of the pandemic, COVID-19 tops the list; it will probably be near the bottom of this ranking in 2024. After COVID-19, the leading causes of DALYs include not only the top killers but also depression, anxiety, low back pain, and other musculoskeletal disorders like arthritis.
So these are the diseases that cause us to be sick and die young. If we want to be among the healthiest countries in the world, we have to address these diseases and determinants.
What exactly should we do about them? That’s for future newsletters. Read on, and join the conversation.