It’s no secret that life expectancy in the United States is among the lowest in the developed world and has been since long before the Covid-19 pandemic. The United States ranked 29th in life expectancy at birth among peer nations in the Organization for Economic Cooperation and Development despite spending almost twice as much on clinical care per person as the average OECD nation. Yet the United States ranks second in the world when it comes to self-reported health status.
People often blame our health care system — hospitals, doctors and other health providers, insurers — as the reason for the disappointing performance on life expectancy at birth. As physicians and public health professionals, we agree that there are big problems that need to be fixed. But much of Americans’ lagging life expectancy is unrelated to issues in the clinical health care system.
In fact, according to an analysis from the AAMC Research and Action Institute that we co-authored, if we could eliminate deaths from just three external causes of injury and death —alcohol, drugs, and firearms (including firearm suicides) — we would increase the average U.S. life expectancy at birth by about 1.6 years. That would nearly close the life expectancy gap between the United States and other developed countries.
Ten states would see increases in life expectancy at birth by two years or more if these three causes of death were eliminated. The increase in life expectancy for certain racial and ethnic groups would be even greater, as can be seen from our data visualization.
The reasons for the impact of these causes of death, often referred to as “deaths of despair,” are twofold: They are more common in the United States than in many other OECD countries, and they are among the most common to affect young Americans. Since 2020, drug overdose (primarily due to opioids) has been the leading cause of death for Americans aged 20-44, and firearms have become the leading cause of death for children and teens.The per capita rate of firearm deaths and drug-related deaths in the United States are among the highest of all high-income countries. Alcohol deaths are similar to those in some other OECD countries but are increasing rapidly in the United States, particularly among younger age groups.
We admit that completely eliminating deaths from these three common causes of early death is unlikely. But we can make substantial progress on reducing them — independent of the U.S. health care system and its challenges.
These three external causes of death all represent underlying social dysfunction as well as ease of access to these means of harm. That’s part of the reason we saw them rise during the Covid-19 public health emergency. Alcohol, drug, and firearm deaths also cause a knock-on effect of despair for others — thereby worsening the cycle of early death in vulnerable communities. And the presence of one makes the likelihood of death from the others increase.
While clinicians have a role, legislation can make more of a difference. For example, children are less likely to die of gun deaths in states with laws requiring safer storage of guns in the home; increasing the cost of alcohol reduces the number of young people who drink; and reducing access to deadly fentanyl analogues, in combination with increasing access to naloxone and buprenorphine, saves lives. Improved parity in access to and payment for mental health and substance abuse treatment reduces alcohol, drug, and firearm deaths.
But legislation is not always the answer. We can also make tremendous progress by thinking outside of the box. Education, engineering, environmental change, and community connection are important parts of the solution. Some cities have decreased these causes of death through community intervention programs, urban greening, and vacant lot remediation. Kids who have adult mentorship are less likely to die from guns, drugs, or drink. Availability of ride share services, like Uber and Lyft, can reduce alcohol-related motor vehicle crashes among young people. We need more creative solutions like these.
Individual actions matter, too, like keeping firearms stored in a safe or lockbox out of the reach of kids or people struggling with their mental well-being. Don’t drive after drinking, and ensure that those you love don’t do so, either. Consider carrying naloxone to reverse an opioid overdose.
The impact on life expectancy of a death at age 20, versus one at age 80, is tremendous. This lesson is a basic one in public health; it’s why the world saw such dramatic increases in life expectancy after widespread vaccination virtually eliminated common infectious causes of childhood death.
We too often focus on one data point and ignore the things that may make a bigger difference in lives (and life expectancy). It’s time to ask our public officials, and ourselves, to do more to tackle alcohol, drug, and firearm deaths in America.
Atul Grover, M.D., Ph.D., is executive director of the Research and Action Institute of the AAMC. Megan L. Ranney, M.D., Ph.D., is a practicing emergency physician and dean of the Yale School of Public Health.