Even before Covid-19, ‘excess deaths’ in the US were higher than in peer European countries
How many Americans would die each year, on average, if the country had European mortality rates? Far fewer, suggests a new analysis, which compared mortality trends before the Covid-19 pandemic.
Despite spending far more than other wealthy countries on healthcare, the United States has relatively higher mortality rates and lower life expectancy – attributed to a plethora of factors including obesity, opioid overdoses, gun violence, suicides, smoking, road accidents and infant deaths.
Given the US does not have a universal healthcare system like most high-income European countries, researchers also think access to healthcare and medicines is patchwork, a problem exacerbated by pronounced racial and socioeconomic disparities and the rural-urban divide.
In the latest analysis, the authors worked on the basis of a counterfactual assumption – what if the US had the death rates by age and sex of an average peer European country (in this case, the combined mortality rates of France, Germany, Italy, Spain, England and Wales)? – and estimated how many fewer deaths there would have been in the US in 2000, 2010 and 2017 under that assumption.
The lead author, Samuel Preston, professor of sociology at the University of Pennsylvania, first compared mortality rankings between the US and a broader set of European countries in 2010, finding that the US ranked among the worst in people aged below age 75 among the 18 countries considered. “I just decided it would be interesting to update that analysis and was surprised to find how much the excess had grown between then and now,” he said.
In the latest analysis, the authors found mortality conditions in the US have worsened significantly since 2000 – and resulted in more than 400,000 excess deaths in 2017 alone. That year, Americans aged 30 to 34 were three times more likely to die than their European counterparts, which the researchers suggested was probably driven by drug overdoses – in particular opioids – as well as gun violence.
Paradoxically, in 2017, the US had lower death rates in people aged over 85 – the country had 97,788 fewer deaths than if subject to the European standard. The advantage in this age range has only increased since 2000, according to the analysis published in the journal Proceedings of the National Academy of Sciences.
Preston and his co-author Dr Yana Vierboom, a researcher at Germany’s Max Planck Institute for Demographic Research, said they weren’t sure why elderly Americans appeared to be better off. One potential explanation, said Vierboom, was that the US tends to spend more on aggressive end-of-life care and treatments.
The analysis also assessed the performance of the US on years of life lost – a metric that weighed the number of excess deaths at a particular age by US life expectancy at that age (somebody who is younger has more potential years of life to live versus someone who is older).
Overall, the US experienced roughly 13m years of life lost to excess deaths in 2017, which represents a 64.9% increase since 2000, after adjusting for changes in size and age distribution, the authors found.
Jessica Ho, assistant professor of gerontology, sociology, and spatial sciences at the University of Southern California, attributed higher US mortality rates to a combination of behavioral and structural factors.
“Americans … often practice poor health behaviors, and this may interact with structural conditions like patchwork access to health care to produce worse outcomes,” she said. “For example, high rates of homicide are related to inequality and residential segregation; high rates of firearm-related deaths are influenced by both behavioral factors and the greater availability of guns in the US.”
Mauricio Avendano Pabon, professor of public policy and global health at King’s College London, suggested another explanation might be the strong governmental intervention across many dimensions of people’s lives in European countries, such as minimum wage and maternity leave.
“This is, of course, true for the US as well, but in general to a much less degree. While one may argue that less intervention increases efficiency and improves economic outcomes, the market is unlikely to emphasise values that relate to people’s health or inequality.”
The US Centers for Disease Control attributed 376,504 deaths to Covid-19 in 2020, a figure that was eclipsed by the excess deaths and lost years of life in 2017, the analysis found.
Although drug poisoning rates have come down since 2017, the story repeats itself with Covid-19, which again had a greater mortality impact in the US than European peer countries, said Patrick Heuveline, a professor of sociology at the University of California, Los Angeles, who was not involved in the analysis. Preston was one of his PhD advisers in the late 1990s.
Looking at the period between 31 March 2020 and 31 March, 2021 and using the same five European countries as the standard, a little over one-third of Covid-19 deaths in the US during those 12 months (36%) were excess deaths, Heuveline estimated.
So, what does the future look like for the US and peer high-income countries in Europe? It’s difficult to say for sure, Preston and Vierboom said.
“Historically, the US was the first to start smoking at really high rates and then the rest of the world caught up,” noted Vierboom.
“That seems to be happening with drug use, obesity etc … [the US] is like a sad trendsetter.”