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People in the US are observing with growing alarm the of their elected leaders in Washington DC: the two current leading candidates for the 2024 presidential election are now 81 and 77 years old. But the longevity of the leadership class is in sharp contrast with realities in the rest of the country. Americans are sick and dying – literally.

Ten years ago, I directed a study for the (NAS) that documented for the first time a US disadvantage in health and survival among high-income countries. Our showed that the US had the lowest life expectancy among peer countries, and higher rates of morbidity and mortality for dozens of causes. This shortfall in health and survival had been growing over four decades and was pervasive – affecting both sexes, young and old, rich and poor, and all races and ethnicities.

Life expectancy

In the intervening years, other have confirmed these trends, along with worsening conditions of life and death. After plateauing for several years, life expectancy in the US declined for three consecutive years before the global pandemic. What followed was devastating: covid-19 killed more than 1 million people in the US, pushing life expectancy down by another two years – and by twice as much among Hispanic, Black and Native American people. This was the most abrupt drop in life expectancy since , and nothing remotely comparable occurred in .

During the pandemic, of the ten leading causes of death also increased, including and mortality. Given these stark realities, an urgent question is why are Americans so unwell? In a Â鶹´«Ã½ commentary 10 years ago, I observed that the reason is simple and yet deceptively complex: it is almost everything.

Even a casual glance at life in the US today reveals conditions that are hard to believe. The country is entering the third decade of a deadly nationwide – unleashed by the – that claimed 110,000 lives in 2022 alone. And alongside the drugs are the bullets. In 2020 and 2021, aged 1 to 17 than any other cause of death.

The conditions that cause poor health, such as high levels of economic and , alongside limited schemes and social support systems, are seen in every aspect of the lives of in the US. For more than a decade now, of child and adolescent well-being in rich countries show that US children are worse off than their peers in virtually every area measured.

Health insurance

Given the poor health of Americans, the country needs a healthcare system it can rely on. But the US is well known for having one of the most complex, fragmented and healthcare systems in the . Almost people in the US are , and for millions of others, quality, affordable, accessible healthcare is simply or effectively .

A final feature of the US landscape is one of the most important contributing factors: systemic racism and its attendant injustices. In 2021, was 84 years for Asian Americans, 78 years for Hispanic Americans, 77 years for white Americans, 72 years for Black Americans, and 67 years for Native Americans. have long experienced some of the starkest health inequities in the country, a direct reflection of the cumulative violence, trauma and injustice inflicted on them over generations. It is hard to overstate the effects of racism in the US today.

If health is wealth, the US is far from the rich and powerful country many people imagine it to be. Other countries would do well not to follow Americans down this deadly path. And the US should consider the many ways other advanced democracies are achieving far superior and more equitable health outcomes, and at far lower cost.