The major medical news of this past week, certainly grim and described in many outlets as “staggering,” was the reported decline in average U.S. life expectancy since the onset of the COVID19 pandemic.
The decrease is the largest seen since the devastation of World War II (although roughly ten times less than that of the 1918 pandemic), and resets trends in mean life expectancy in the US back 15 years, to where things stood in 2006.
The significance of this is largely self-evident, and is reverberating through headlines far and wide, so there is little residual need for me to make the case for shock and awe. By and large, that job is done. Accordingly, I will make the case for the hole in the story; the blind spot in our perception; the critical explanation we ignore now and always, and ever at our peril.
When individual deaths to COVID are reported, there is a quite standard journalistic template: to maximize on the immanent drama, and bait the greatest number of clicks, tell the truth and (if a genuinely reputable outlet), nothing but the truth- but bury the whole truth in paragraph 7 (or later).
Before elaborating, I want to be clear that any death to COVID is a tragic loss, because as many of us have experienced – it is not just loss, but loss compounded by separation. My own front-line experiences, my personal experience with loved ones, and tales from my own social networks highlight the rarefied distress of families kept apart at the end of life. In such context, every death is circumstantially tragic, however timely it might otherwise be (we need to be clear that timely death, after a full life, is not intrinsically tragic; we are mortal, we all die, it is the natural culmination of us all).
More tragic still, of course, are untimely deaths- deaths in young people, nowhere near the expectancy for a full life span, reduced or otherwise. These, then, are the stories that are most inevitably propagated: a child dies of COVID, a 20-year-old aspiring pre-med dies of COVID, and so on.
Because such headlines distress me, and because I am professionally obligated to understand the epidemiology of COVID in order to make sense of it for others- I have taken such bait and clicked many times. All but uniformly, somewhere around paragraph 7- which the typical reader presumably never reaches- the other shoe drops: the child had lymphoma, the pre-med had lupus, the young adult succumbing to COVID had severe obesity and poorly controlled type 2 diabetes.
These suppressed, or at best veiled, details of our losses to COVID are crucial not only to understanding the pandemic toll, but to mitigating it as well. In medicine and public health alike, it is the particulars of “why” that most empower us.
Their absence is costly in many ways. It leaves us mired in anxiety, dread, and helplessness- because not knowing “why” invites our morbid imaginations to populate the void. Like the rest of nature, anxiety seemingly abhors a vacuum. Understanding “why” things are as they are is prerequisite to knowing “how” they might best be ameliorated.
Unfortunately, the reporting on epidemiology- the pandemic impacts at scale- has been subject to the same distortion as individual obituaries. We have relegated “why” to the realm of unread paragraphs.
In the case of declining life expectancy, the stories all open as expected: much of this is directly attributable to the mortality toll of SARS-CoV-2. You generally need read only a bit further to discover that the reduction in years of life is not equitably distributed, but like every other aspect of health and disease in America, flows in the channels of obdurate disparity. While Americans have lost on average about a year of life expectancy to COVID, the decline for black Americans is almost three times as great. The gap between white and black life expectancy has abruptly widened to 6 years.
You need read a bit further, but not much, to learn that years of life lost to the pandemic are not only about infection. Just before COVID arrived, we were extricating ourselves from an opioid crisis that had, itself, reduced life expectancy in America. That crisis has been revived and greatly exacerbated by the many implications of pandemic life- as have the diverse “social determinants of death.” Unemployment, on its own, is associated with reduced life expectancy roughly commensurate with the national decline. That all this argues for a focus on total harm minimization as a basis for policy, rather than just the interdiction of infection, is a case fully rendered before now.
To sum up thus far, the opening paragraphs on the topic of declining pandemic life expectancy will lead with losses to the virus, follow with the salience of disparities, and then make a brief nod in the direction of social determinants and other causes. Many readers may make it so far.
But, you need keep reading for quite a few paragraphs more to get to the relevance of prior health, and the burden of chronic disease. Even then, you may only read that diabetes, heart disease, obesity, and barriers to care have long amplified health disparities in America – and thus figure in the disparities now glaringly on display.
What’s missing? The indelible connection between these long-standing liabilities of health, and losses directly to COVID.
The cardiometabolic liabilities most decisively linked to risk of COVID death are hyperendemic in the U.S., meaning they are fixed at high levels. Colleagues and I have published on this matter, more than once, noting that a clear majority of all American adults have at least one, and many have two or more, of the conditions apt to take a COVID19 infection from mild to bad, from bad to grave.
Perhaps because they are hyperendemic, or perhaps because their propagation is accompanied by massive profits for many industries from Big Food to Big Pharma, these fixable maladies hide in plain sight, basking in our indifference. You know what they say about familiarity; this is a case study.
Our contempt for this domain is a travesty, and a calamity. Chronic disease we have known how to prevent with lifestyle interventions for literal decades- siphon away more years from life and more life from years, every year, than SARS-CoV-2 has done in the past year. Even as every loss to COVID echoes through our national discourse, the 500,000 premature deaths each year to poor diet; the 1800 daily deaths to cardiovascular disease that need never develop- and the outsized complicity of these in the toll of COVID- go mostly unheralded, and unaddressed.
Even as pandemic life expectancy declines, Americans may expect business as usual from a culture that conflates junk with food- and tolerates the willful manufacture of dietary addictions feeding hyperendemic obesity, hypertension, diabetes, coronary disease, and more. SARS-CoV-2 is killing so many Americans because like all predators, this one exploits the frail; the massive burden of preventable chronic disease we tolerate and abet makes us just so.
We wring our hands over pandemic consequences, then all hands turn promptly back to peddling the underlying causes. There has been virtually no national dialogue on the critical, timely importance of health promotion- for the sake of acute defense and chronic vitality alike. If the painful evidence now on display does not invite that discourse, what ever would?
We are blithe to the willful manufacture of our extreme vulnerabilities to COVID, and premature death by many other means into the bargain. We are culturally blind to the confluence of social inequities, racial injustice, disparities in recourse to lifestyle as medicine, and the massive burden of cardiometabolic disease we have long had the knowledge to prevent.
The opportunity in this crisis to cultivate chronic health for acute protection, the empowering “why” of our plight- hide here, in what should be plain sight. In (the dawn’s early) light of this, the most American of questions seemingly pertains: oh say, can we see?
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.