Study: Life Expectancy Is Dropping

David Brown and Majid Ezzati
Washington Post Staff Writer and Co-Author of Study
Tuesday, April 22, 2008 11:00 AM

For the first time since the Spanish influenza of 1918, life expectancy is falling for a significant number of American women. In nearly 1,000 counties that together are home to about 12 percent of the nation's women, life expectancy is now shorter than it was in the early 1980s, according to a study published today.

The trend appears to be driven by increases in death from diabetes, lung cancer, emphysema and kidney failure. It reflects the long-term consequences of smoking, a habit that women took up in large numbers decades after men did, and the slowing of the historic decline in heart disease deaths.

Washington Post staff writer David Brown and Majid Ezzati, co-author of the study and researcher at the Harvard Global Health Initiative, were online Tuesday, April 22, at 11 a.m. ET to discuss the study.

A transcript follows.


David Brown: Dear chatters and people interested in health and demography, welcome to a chat on the study appearing in PLoS Medicine on the observation that life expectancy is stagnating or falling for 19 percent of the American female population. A link to the article is here:


We will be joined partway through by Majid Ezzati of the Initiative for Global Health at Harvard University, one of the co-authors of the paper.


washingtonpost.com: The Reversal of Fortunes: Trends in County Mortality and Cross-County Mortality Disparities in the United States ( PLOS Medicine)


Rural Md., Eastern Shore: All one has to do is to visit a shopping center or supermarket to see all the obese Americans. How can the government micromanage these peoples' health when these folks can't even discipline their own diets?

David Brown: Well, just to be a little provocative, one might want to consider the view of an English epidemiologist named Geoffrey Rose, whose view was basically that in order to change the health of large numbers of individuals, the social and economic conditions, incentives, culture etc., must be changed. Once that happens, the entire bell curve of the population moves. Here are a couple of quotes from him:

"It makes little sense to expect individuals to behave differently from their peers; it is more appropriate to seek a general change in behavioural norms and in the circumstances which facilitate their adoption."

Rose, Geoffrey, The strategy of preventive medicine. Oxford (Oxford University Press), 1992

"... socio-economic deprivation includes a whole constellation of closely interrelated factors, such as lack of money, overcrowded and substandard housing, living in a poor locality, worse education, unsatisfying work or actual unemployment, and reduced social approval and self-esteem. In turn this constellation of deprivations leads to a wide range of unhealthy behaviours, including smoking, alcohol excess, poor diet, lack of exercise, and a generally lower regard for future health."


San Francisco, Calif.: Is this related to declining health care coverage (including skimpy plans as well as lack of any plan)?

In other words, is this part of the decline in American well- being among the middle and working classes (working poor)?

Or is this part of the end of welfare and Medicaid?

What is the political context, in general?

David Brown: There are obviously many factors contributing to this downward trend. One thing that the researchers found is that it doesn't seem to be a function of race or ethnicity. However, there is almost certainly an effective or at least association with socioeconomic status, which in turn is related to some extent to access to care. Of course, in places where there is a lot of poverty then many people have access to Medicaid, the government health insurance program for the poor. So this is much more complicated than simply an issue of the uninsured.


Silver Spring, Md.: Bet it's hard to walk anywhere -- fast cars, no sidewalks. These areas need sidewalks, crosswalks, and fitness centers with aerobics classes as well as flexibility (yoga, Pilates) and weight training. They need the vision and the means to be strong -- not "delicate," nor dependent upon a relative, often a daughter, to care for them. How many of those who die early are caregivers?

David Brown: Well, there is some thought (I frankly don't know how good the evidence is) that suburban living contributes to obesity because it makes car travel more or less essential for everything. Of course, in the post-war suburbs of America millions of kids rode their bikes to school, so it is more than just the existence of suburbs that explains the lack of outdoor activity and physical activity experienced by many children as a routine part of daily activity.


Jackson, Miss.: Were any of the counties showing a decreased life expectancy for women in Mississippi?

Majid Ezzati: Yes, there were multiple counties in Mississippi that had stagnating or decreasing life expectancy. You can go to the link below and look at Data S-2 that shows trends for every county in the country, organized by state.



Fairfax, Va.: I work in the maternity field and wonder if anyone has looked at the role of maternity care in the drop in life expectancy. The CDC reports that maternal deaths have gone up for the first time in decades and as more and more women are walking around with scars from their abdominal deliveries, surgery-related adhesions can come back to haunt women later in life in the form of bowel obstructions, etc. I'm sure the numbers don't measure against the sheer magnitude of heart disease, but I can't imagine that our less-than-stellar maternity care in the U.S. doesn't contribute 'some' to falling life expectancy. In my experience, the medical community is quick to blame mothers (too old, too fat, too short, etc.) for poor outcomes, and slow to examine their own failure to implement evidence-based care.

Majid Ezzati: The study was not designed to specifically answer questions about maternal health. However, we did see that mortality in the youngest ages, before 5 years of age, improved during this period. The improvement was uneven, but not as uneven as those in older ages.


Richmond, Va.: What about air pollution? We've been breathing more toxic poisons than our grandparents and it's had to have had an effect on rates of asthma, emphazema, and lung cancer.

Majid Ezzati: Many of these counties were rural counties so it is unlikely that air pollution was a major factor for the overall result. However, it may have been a factor in specific locations, and worth looking into in future research.


washingtonpost.com: The Reversal of Fortunes: Trends in County Mortality and Cross-County Mortality Disparities in the United States ( PLOS Medicine)


Burke, Va.: I'm missing something. From 1983 to 1999 life expectancy went from 74.5 to 75.5. Yes, this is less than the nationwide average, but is it more or less than what had previously been seen in the 1,000 counties cited? Also, obesity, smoking, diabetes etc., are mentioned. What about immigration? How many of the people dying earlier than expected are immigrants whose early years were marked with poor health care and/or poor nutrition?

Majid Ezzati: The numbers you refer to are from many counties in the absolute bottom in each year, and cover 2.5% of the population. On average, these ones increased slightly. But there were many individual counties that would spend some years in this group, and over the full 20 years had a decline.

The study could only consider near term immigration, because of the nature of data. Given overall migration patterns, it is unlikely that even long-term immigration was a factor. But even if it had been, the fact that people with worse health are being concentrated in specific parts of the country is not a good outcome.

David Brown: I probably should have been clearer what I meant by the phrase "places with the least-healthy people." That was the counties that make up the 2.5 percent of the U.S. population with the highest mortality those years. In that arguably least healthy segment of the country's population, life expectancy rose only one year over the 1983-1999 period. In the counties that make up the 2.5 of the population with the lowest mortality---i.e., the healthiest places---the female ended that period at 83.0 years. It rose a lot more than the life expectancy of the unhealthiest 2.5 percent of the population. This is different from the 1,000 counties where life expectancy is stagnating or falling---a group that is larger than this 2.5 percent least healthy slice at the bottom of the pile.


Leesburg, Va.: I'm wondering if you have considered the impact of women working outside of the home -- both from the stresses of juggling work and family -- including fast food/poor diet choices, etc.

David Brown: Your question asks important questions for which there are not answers at the county level. One of the things this study points out, at least indirectly, is that to answer what is happening in very small geographic areas one has to collect data other than births, deaths and cause of death there. Otherwise it is just speculation. Do these places where female life expectancy is declining have many more women working outside the home than other places? Do a larger fraction of them have multiple jobs? Do they have more children than women working outside the home in places where life expectancy isn't falling? All good questions for which there are no answers.


Washington, D.C.: Your article mentioned that this phenomenon seems to be uniquely American and that Europe does not follow such a pattern. What's the explanation for this?

Majid Ezzati: The Human Mortality Database (http://www.mortality.org/) provides historical mortality data for many countries, as does the UN Statistical Office and the OECD. The article uses national longevity trends in the different countries to emphasize that life expectancy decline or stagnation, over long periods, is rare for relatively large populations.


Helena, Mont.: Obesity in the poor is often not just not being "disciplined," but because cheaper food is high in carbohydrates and fat. Cheaper meats -- high fat content ground beef, pork, dark meat of chicken, etc. When I had fewer means, I had higher calorie food. If you get commodities from federal government, you get cheese, whole milk (dry), lard, etc. It costs more to eat fresh vegetables and fruit, low fat meats, etc.

Majid Ezzati: As you state, one the implications of this finding should be that public health efforts, be it pricing, access, information, or regulatory, should all go hand in hand to reduce factors like obesity and smoking.

David Brown: You're right, the healthiest food often costs more than the less healthy. There is also a tradition of favoring calorically dense foods and dishes in places and population groups where not getting enough calories was a real problem for centuries. But that's not the case now, at least not in the United States. (I am sure there are few exceptions).


College Station, Tex.: It was mentioned that it "would be a reasonably obvious strategy" to target the 1,000 counties for an aggressive public health campaign, can you elloborate as to some options

Majid Ezzati: Tobacco control has been very successful in many parts of the country, including MA and CA. So there are lessons around taxation, advertising ban, counselling, etc. For blood pressure, there are both population level actions, like reduced salt in prepared/packaged food and personal ones, like access to regular check ups and anti-hypertensives. The fact that blood pressure declines for about 2 decades in both men and women in the US, but then increased among women, is a sign that previous successes are being erroded. Obesity has arguably proven harder but given its large effects, we need to continue trying.


Princeton, N.J.: Look, it must have something to do with our grossly inefficient health care system. Compare our life expectancy (and any other basic public health statistic) with that of any other wealthy developed country. If we had a single payer system such as Medicare for All, you can bet your boots the situation would improve.

David Brown: Well that's a theory, and as you suggest, industrialized countries where this decline hasn't been observed all have some form of national health insurance. But probably more than that is going on.

Majid Ezzati: Good health care system is indeed a necessity but we should also strengthen population level and personal preventive intervention, through primary care and environmental or nutritional changes.


David Brown: It looks like we are out of time. I want to thank Dr. Ezzati for taking time to be part of this discussion. We look forward to further demographic studies from his research.


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