‘Population autopsy’ finds the US with more avoidable deaths than other wealthy countries

The United States appears to be leading all high-income countries in an unfortunate, distinctly undesirable statistical category—excess deaths. 

These are defined as the number of mortalities surpassing the expected tally given existing standards of living. 

Led by Boston University epidemiologist Jacob Bor, ScD, the researchers behind the finding discovered 12.7 million of these potentially avoidable passings in a 24-year period ending in 2022.

That was out of a total death count of around 63.5 million. 

The team found circulatory diseases were the main killers of older Americans while younger subpopulations were more likely to die “deaths of despair”—chiefly drug overdoses, alcohol abuse and suicide. 

For a comparison benchmark the researchers used the population-weighted mean excess-death rate of 17 other high-income countries. 

JAMA Network Open published the research May 8. 

Other informative findings highlighted in the study report: 

• Annual excess deaths increased from approximately 346,000 in 1999 to 905,000 in 2022. The authors note the presence of the COVID-19 pandemic at the tail end of the period they studied.
   
• Circulatory diseases were the leading cause of excess deaths nearly every year. Also known as cardiovascular sicknesses, these include diagnoses like coronary artery disease, heart attacks, strokes, hypertension, heart failure and peripheral artery disease. Bor and colleagues note that, although annual rates of excess circulatory disease deaths decreased from 1999 to 2009, they increased markedly from 2009 to 2022. 
   
• Excess U.S. deaths from diabetes, kidney and metabolic disease followed a similar pattern. These held stagnant from 1999 to 2010 only to skyrocket from 2010 to 2022. 
   
• Drug poisonings and overdoses, along with alcohol-related mortality and suicide, accounted for 24% of the overall increase in excess deaths. Men were hit particularly hard in this category, as did all persons under 45 years old. 
   
• At ages 85 years or older, mental and nervous system disorders were a large and growing cause of excess deaths. Such disorders included not only Alzheimer’s disease but also other conditions marked by dementia. 
   
• The COVID pandemic was responsible for some 19% of excess U.S. deaths in 2020. However, excess deaths from numerous other causes also spiked that year. 

Beyond ‘preventable,’ ‘treatable’ and ‘medically amenable’ 

Bor and fellow researchers suggest their findings tell a two-part story behind the U.S.’s running away with the unwanted mortality title even before the pandemic. 

One part is the sharp climb of deaths from drugs, alcohol and suicide, which largely occurred in younger people. 

The other is the slower but no less lamentable toll taken by circulatory and metabolic disease, which the researchers found mostly in adults in their midlife or elder years. 

COVID only intensified these phenomena while on its own claiming blame for one of every five excess deaths in 2020 and 2021. 

“Excess U.S. deaths may be avoidable with existing policy interventions available in other high-income countries,” the researchers remark. “In this way, international comparisons of mortality are useful because they reveal health gaps attributable to national policy environments that are not visible when comparing population groups within a country or over time.”

What’s more, by comparing mortality rates in this country with those of others in the high-income category, public-health officials and investigators “may offer more achievable and policy-relevant estimates of avoidable deaths than classifying all deaths due to pre-specified causes as ‘preventable,’ ‘treatable’ or ‘medically amenable,” as was the case in some previous research. 
 

Are Americans exceptionally overfed and under-active? 

Bor and co-authors also call out the prevalence of obesity in the U.S., surmising it likely plays a role in the rising rate of cardiovascular disease among Americans aged 45 to 64.

Noting that this rise began a full decade earlier than recorded among those 65 and older, they underscore their finding that excess U.S. deaths due to diabetes, kidney and metabolic conditions followed a nearly parallel track. 

This is consistent with evidence of elevated cardiometabolic risk factors—including obesity, hyperglycemia and poor kidney function—in the U.S. compared with other high-income countries, Bor and colleagues add. 

They conclude: “Despite similar access to advanced medical technology, the U.S. has experienced persistently higher death rates than other high-income countries, possibly driven by differences in health, economic and social policy.”
 

On life expectancy, we fell from contender to non-competitor 

In invited commentary on the present study, Stanford social epidemiologist David Rehkopf, ScD, MPH, notes that life expectancy in the U.S. was essentially on par with that in other high-income countries up until 1980.

“[O]ur fall from that place has been rapid, and we now rank 46th in the world,” Rehkopf points out. 

The Bor et al. study supplies a solid benchmark for “what we should be able to achieve,” Rehkopf writes. 

The work is an empirical test, he adds. As such, it shows that the levels of death we are experiencing in the U.S. are “not natural.”

“Compared with global trends, the U.S. has, for the first quarter of the 21st century, been experiencing a tragedy of a massive scale.” 

The Bor et al. study is posted in full for free, as is the Rehkopf commentary.