Why do Americans die earlier than Europeans?

A recent paper by demographers Sam Preston and Yana Vierboom showed that there are an additional 400,000 deaths in the USA in 2017 that would not have occurred it the USA experienced European death rates. That is about 12% of all American deaths and higher than the COVID-19 death toll of around  380,000 in 2020.  In a Guardian article earlier this month they identified major factors contributing to this US “mortality penalty” including overweight and obesity, drug overdose, lack of health insurance, suicide, lack of gun control and racism. These deaths tend to occur at younger ages than Covid deaths on average, so that total potential years of life lost are three times greater for the excess deaths than for Covid in 2020 (13 million versus 4.4 million).

Preston and Vierboom used data from the Human Mortality Database (HMD) for their analysis. They calculated death rates based on the five largest European countries, whose combined population size is very similar to that of the United States: Germany, England and Wales, France, Italy, and Spain. They also argued that using these larger European countries  to provide a mortality standard would avoid unrealistic expectations that might result from comparisons including small countries with possibly exceptional combinations of factors affecting mortality (e.g., climate, diet, social history, and healthcare delivery).

A few days ago, I downloaded updated data from the HMD and replicated and extended their analysis to include years up to and including 2020, drawing on recent data from Eurostat and national health statistics agencies (see here for details of data, sources and methods).

The figure above shows the ratio of US death rates to the average death rates for the five European countries (the “European standard”) by age, in 2000, 2010, 2019 and 2020. US mortality rates are consistently higher than the European standard for all ages below 80 years and the ratio has gotten progressively worse throughout the 21st century. The peak ratio for 25-29 year olds corresponds to death rates for US 25-29 year olds that are three times higher than those of the European standard.

The next figure shows the annual trend in total excess deaths in the USA above the number than would have occurred if the US population had been subject to the age-sex specific death rates of the European standard. This excess rose from 219,000 in the year 2000 to 410,000 in 2019 and 616,000 in 2020. Although there were over 380,000 Covid deaths in the USA in 2020, the European standard also includes substantial numbers of Covid deaths, and the Covid excess for the USA is “only” 136,000 deaths.

I next estimated the contribution of various factors to the US excess death rate using information on cause-specific deaths and death attributable to selected risk factors in Europe and the USA. I also made estimates of the excess deaths associated with lack of health insurance or under-insurance in the USA compared to Europe where all the countries have universal health insurance, based on a study of the death rates in the non-insured in the USA. Together, the six factors identified in the following graph account for around 80% of excess deaths in the USA. 

For 2020, the leading cause of excess deaths was overweight and obesity (around 154,000 deaths), followed by Covid-19 (136,000 deaths), drug use and overdose (103,000 deaths) and lack of health insurance (74,000 deaths). Excess deaths due to homicide and suicide were smaller at 20,200 and 11,200 respectively. If the USA had the European standard death rates for gun homicides and gun suicides, it would have 15,900 fewer gun homicides and 19,200 fewer gun suicides. Around 40% of the latter would still commit suicide by other means. The figure also illustrates the dramatic rise in drug overdose deaths, the vast majority due to opioids both prescription and illicit, which has occurred over the last decade. In a previous post, I examined this in more detail and noted that, in 2019, the USA accounted for an astonishing 40% of estimated global drug deaths.

Why does the US perform so poorly in these areas? Preston and Vierboom argue that a lack of federal oversight and regulation, powerful lobbying structures, deindustrialization of American jobs, and systemic racism combine to create “an annual tsunami” of excess deaths. And that is even without the complete mishandling of the response to Covid by the Trump administration and many state governments.

Psychedelics and the health risks of drugs, alcohol and tobacco

In the last decade or so, there has been a renaissance of interest in the therapeutic potential of psychedelics. While natural psychedelic substances have been used by humans for many thousands of years, psychedelics had a massive cultural impact on the West in the 1950s and 1960s. Albert Hoffman, a research scientist working for the Swiss pharmaceutical company Sandoz, accidentally invented LSD (lysergic acid diethylamide) in 1938 and discovered its psychedelic properties five years later. In 1955, a New York banker named Gordon Wasson sampled the psilocybe (magic) mushroom in Mexico and published an article on his experience in Life magazine.

Scientists discovered the role of neurotransmitters in the brain in the 1950s, and psychedelics inspired scientists to search for the neurochemical origins of mental disorders previously thought to be psychological. Psychedelics were also used in psychotherapy to treat various disorders, including alcoholism, anxiety and depression, with some promising results, although these studies generally did not reach modern standards of research design.

However, psychedelics were also embraced by the counterculture and became linked in the mind of authorities with youth counterculture and the anti-Vietnam war protests. By the end of the 1960s, most Western governments had outlawed and forced underground the psychedelic drugs which had been legal in most places previously, and also shut down all scientific research.

In the 1990s small groups of scientists managed to start conducting various trials of the therapeutic uses of psychedelics and this has led to the so-called psychedelic “renaissance” in which larger well-designed trials of psychedelic use for treating a range of mental disorders are being carried out by research groups at institutions such as Imperial College London, Johns Hopkins University and New York University. Just today, it was announced that the Australian government will be providing $15 million funding for clinical trials into the use of psilocybin and other psychedelics for the treatment of mental illnesses, including depression and PTSD. Michael Pollan’s book How to Change Your Mind gives an excellent account of the history of psychedelics, both above ground and underground, and the psychedelic renaissance, and was a best seller. See also this article by Michael Pollan on the “Psychedelic Renaissance”.

As part of my work on the global burden of disease for the World Health Organization (WHO), I carried out several assessments of the direct and indirect health impacts of the use of drugs, alcohol and tobacco. I recently did an approximate update to year 2019 for deaths directly due to drug use disorders (overdoses and directly toxic effects) and indirect deaths from road injury, suicide and infectious diseases attributable to drug use. A proportion of HIV, hepatitis B and hepatitis C deaths can be attributed to injecting drug use with contaminated needles. The great majority of direct and indirect deaths due to drug use are due to the use of opioids, both illicit and pharmaceutical opioids. Very few deaths are associated with psychedelic drug use, but I was curious to get a ballpark estimate for comparison with other drug deaths. I will present a brief summary of the broad estimates of drug-attributable deaths, then review evidence on the likely contribution of psychedelic drugs.

Continue reading