H5N1

Perceived health inequalities: are the UK and US public aware of occupation-related health inequality?

Via BMC Public Health: Perceived health inequalities: are the UK and US public aware of occupation-related health inequality, and do they wish to see it reduced? The abstract:

Background  

One underexamined factor in the study of lay views of socioeconomic health inequalities is occupation-related health. Examining health by occupational social class has a long history in the UK but has been comparatively overlooked in US public health literatures, where the relationship between health and work has attended more to hazard exposure.  

Methods  

Representative samples of the UK and US indicated the perceived and ideal lifespan of people working in “higher managerial/professional” and “routine” occupations. We examine perceptions of inequality and desires for equality across occupation groups as a function of country and key socio-demographic variables.  

Results  

67.8% of UK and 53.7% of US participants identified that professionals live longer than routine workers. Multivariate models indicated that US participants were markedly less likely to be aware of occupation-related inequalities after controlling for age, gender, and education. Awareness was negatively related to age (in the US) and recent voting behaviours (both samples). Desiring equal life expectancy was less likely in the US sample, and less likely across both samples among older participants and those with lower levels of education.  

Conclusion  

Employing a novel approach to measuring perceived and ideal life expectancy inequality, this is the first study to examine perceptions of lifespan inequality by occupational groups. It reports widespread understanding of the occupation-related gradient in lifespan and a desire that these inequalities be eliminated in the UK, but considerably less awareness and desire for equality in the US. Greater tolerance for social status inequalities in the US than other similar countries appears to also extend to differences in life expectancy.

The impact of the COVID-19 pandemic on cognitive decline

Via The Lancet Healthy Longevity, a disturbing comment: The impact of the COVID-19 pandemic on cognitive decline.

The effect of the COVID-19 pandemic on the general population has been catastrophic. Despite substantial progress in understanding the virology, transmission, and pathogenesis of SARS-CoV-2, many of the long-term consequences of COVID-19 or the restriction measures implemented around the world remain unknown. Evidence for the associated adverse effects of isolation, loneliness, post-traumatic stress, depression, fear, anger, and confusion is overwhelming. However, changes in cognitive and physical functioning due to the COVID-19 pandemic have been less well documented.  

Anne Corbett and colleagues used longitudinal data from the PROTECT study to evaluate the effect of the pandemic on cognition in older adults in the UK, exploring various factors associated with changes in cognitive functioning. The use of computerised neuropsychological data collected before the pandemic and during its first and second years enabled repeated measures to be obtained for the same individuals across the pandemic.  

Declines in executive function and working memory were observed across the whole cohort in the first year of the pandemic, including in subgroups of individuals with mild cognitive impairment or a history of COVID-19, and the decline in working memory continued into the second year of the pandemic.  

Although initially thought to cause acute respiratory symptoms, the effects of SARS-CoV-2 on other systems—including the central and peripheral nervous system—is becoming increasingly clear. The new findings from the PROTECT study indicate domain-specific cognitive changes for individuals with a history of COVID-19 that mirrored similar trajectories for those with mild cognitive impairment but with a slightly lower rate of decline.  

This study also highlights reduced exercise, alcohol use, depression, and loneliness as key risk factors that affected the rates of cognitive decline in the older population during the COVID-19 pandemic. The study was observational in nature and therefore causality cannot be inferred, but it would be of interest to elucidate some of the potential biological mechanisms involved in these associations.  

Alcohol intake and lack of exercise could have direct effects on psychological wellbeing and cognitive function; for example, alcohol can inhibit the communication between nerve cells and suppress the activity of excitatory nerve pathways. Unhealthy lifestyles are linked to oxidative stress, which is recognised as a contributing factor in ageing and in the development of neurodegenerative diseases, including Alzheimer's disease.  

However, such lifestyle factors could also mediate direct associations between depression, loneliness, and cognitive decline—for example, depression and social isolation could lead to an increase in alcohol consumption and sedentary behaviour, consequently influencing the rate of cognitive decline through systemic inflammation or reduced mental and social engagement. Longer periods of follow-up—in addition to the availability of key data from before, during, and after the pandemic—are necessary. The wealth of longitudinal cohort studies of ageing in the UK could help to provide some of the necessary answers.  

Looking back, COVID-19 has revealed the astonishing vulnerability of our societies, but also the lack of strategy and organisation from so many governments worldwide, and our shared fragility when confronted with infections. Older people (aged ≥50 years) with cardiovascular disease and complex comorbidities have almost double the risk of being infected with SARS-CoV-2 compared with those without chronic conditions.  

Let us remind ourselves that COVID-19 is not a thing of the past, but a reality for which we must continue to adapt and prepare.

The global community needs to do more to tackle the inequality crisis

Via The BMJ, an opinion piece by Sir Michael Marmot, Monica Geingos, and Joseph E. Stiglitz: The global community needs to do more to tackle the inequality crisis.

Progress on health inequalities is now at risk, argue Michael Marmot and colleagues, the chairs of a new Global Council on Inequality, AIDS, and Pandemics.

The climate emergency and the global rise in inequalities are putting us all at risk. Both will damage health. The global community, with successive climate change conferences (COPs), is taking faltering steps to tackle the climate emergency but is doing little about the inequality crisis. In some countries, political and economic forces are increasing social and economic inequalities, with potentially dire consequences for health inequalities and for people’s vulnerability to pandemics. Unfair distribution of power, money, and resources are driving inequalities in health. 

We’ve been through a good period. Global progress in improving health has been impressive throughout the 20th and early 21st centuries, and health inequalities between countries have diminished. Within countries, too, absolute inequalities in health have lessened, although that picture is more mixed.   

But this progress is now at risk. If the AIDS and covid-19 pandemics did nothing else, they showed how fragile these health improvements are. These pandemics have, to some extent, been driven by social and economic inequalities, and their effects have been to expose and exacerbate health inequalities. The effects of the pandemics have also been disproportionate in some communities and related to socioeconomic circumstances, gender, LGBTQ+ identities, and race and ethnicity.  

To deal with the effects of inequalities on pandemics and of pandemics on health inequalities, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has convened the Global Council on Inequality, AIDS, and Pandemics. We are the co-chairs of this global council. The announcement of the new council was made in Brazil at a meeting hosted by the Brazilian Ministry of Health. Our backgrounds as co-chairs are highly relevant to the council’s mission. We seek to bring the perspectives of international and national economic arrangements, social determinants of health, and human rights to bear on our central questions. The need is great as the following examples show.  

Analyses indicate that countries with greater income inequality have higher rates of HIV infection and of death from AIDS and covid-19. In most, but not all, African cities the urban poor are much more likely to live with HIV than those from higher socioeconomic groups.

HIV and AIDS have also exposed gender inequalities. In the west African countries of Cote d’Ivoire, Ghana, and Liberia, HIV prevalence in people aged 20-24 was five times higher in women than in men.

The unequal effect of the AIDS pandemic on men who have sex with men is a political choice. In Thailand, for example, where identifying as LGBTQ+ is not criminalised, the prevalence of HIV is 12 times higher among men who have sex with men than among other adults. In Malaysia, where identifying as LGBTQ+ is criminalised and subject to arrest, the HIV prevalence rate among men who have sex with men is more than 70 times higher than among other adults.

In Brazil, where racial inequalities were not openly acknowledged for a long time, the evidence of the effects of this on health inequalities is stark. Rates of new HIV infections have been falling among white people, while rising among black people.

The United States provides an important case study of the role of socioeconomic influences and racism on health, including during the covid-19 pandemic. Life expectancy had been falling in the years 2016-18, in part owing to deaths of despair, which show a social gradient—the fewer the years of education, the bigger the effect. The decline stopped, and life expectancy rose slightly in 2019, but then fell sharply in the first two years of the covid-19 pandemic. Covid mortality was higher among socioeconomically disadvantaged communities and black people. In New York City, in the first year of the pandemic, life expectancy fell by three years among white residents, 5.5 years among black residents, and six years among Hispanic residents.

The AIDS and covid-19 pandemics send two clear messages, and hopefully the global community is open to receiving them. The first is that inequalities drive the likelihood and consequences of pandemics, and pandemics amplify health inequalities. This is the problem that this global council is set up to tackle.

The second is that medical and technical responses are crucial but are only part of the story. Inequities in access to care are needless, harmful, and immoral, and should be relatively easy to solve. Could there have been a global rollout of covid vaccines, entailing higher levels of production? Most certainly. Technically, it should be possible in future pandemics to have the capacity to vaccinate the world as needed. The money is certainly there. In the first year of the covid-19 pandemic, the rich world found $18tn to protect the economies of high income countries. Against this amount, $25bn for a global rollout of the vaccine is coffee money. And the technology that would have made it even easier to rollout the vaccine more widely wasn’t shared, even though governments had put up the vast majority of funds for vaccine development. As the old saying has it, this was penny wise but pound foolish because everyone would have benefited from dampening down covid-19 globally.

The effects of transnational economic inequalities are striking. During the covid-19 pandemic, high income countries put trillions into health and social spending to fight the pandemic’s effects, including supporting their economies, but low and middle income countries lacked the fiscal resources to make this choice. In 2021, almost half of all low and middle income countries cut healthcare spending, and about 70% cut spending on education.

The clear lessons from pandemics are that paying attention to the social determinants of health, respecting human rights, and involving communities are critical. Inequalities in health this vast are not inevitable. They are the result of policies—both what we do and what we fail to do. To achieve a world with better health and fewer health inequalities we need knowledge, resources, and political will. One of the tasks of the Global Council on Inequality, AIDS, and Pandemics is to synthesise the knowledge we already have. As the example of the money found by high income countries to protect their economies shows, “we”—the global community—also have the resources. The problem is the skewed distribution of financial and other resources. Political will is the great challenge. The global council will work with partners in governments, agencies, and communities to build the political will and public demand for change. Social justice requires it.

Excess mortality and years of potential life lost among the Black population in the US, 1999-2020

Via JAMA, an appalling report: Excess Mortality and Years of Potential Life Lost Among the Black Population in the US, 1999-2020. The key points and abstract:

Key Points 

Question  How many excess deaths and years of potential life lost for the Black population, compared with the White population, occurred in the United States from 1999 through 2020?  

Findings  Based on Centers for Disease Control and Prevention data, excess deaths and years of potential life lost persisted throughout the period, with initial progress followed by stagnation of improvement and substantial worsening in 2020. The Black population had 1.63 million excess deaths, representing more than 80 million years of potential life lost over the study period.  

Meaning  After initial progress, excess mortality and years of potential life lost among the US Black population stagnated and then worsened, indicating a need for new approaches.  

Abstract  

Importance  Amid efforts in the US to promote health equity, there is a need to assess recent progress in reducing excess deaths and years of potential life lost among the Black population compared with the White population.  

Objective  To evaluate trends in excess mortality and years of potential life lost among the Black population compared with the White population.  

Design, setting, and participants  Serial cross-sectional study using US national data from the Centers for Disease Control and Prevention from 1999 through 2020. We included data from non-Hispanic White and non-Hispanic Black populations across all age groups.  

Exposures  Race as documented in the death certificates.  

Main outcomes and measures  Excess age-adjusted all-cause mortality, cause-specific mortality, age-specific mortality, and years of potential life lost rates (per 100 000 individuals) among the Black population compared with the White population.  

Results  From 1999 to 2011, the age-adjusted excess mortality rate declined from 404 to 211 excess deaths per 100 000 individuals among Black males (P for trend <.001). However, the rate plateaued from 2011 through 2019 (P for trend = .98) and increased in 2020 to 395—rates not seen since 2000. Among Black females, the rate declined from 224 excess deaths per 100 000 individuals in 1999 to 87 in 2015 (P for trend <.001). There was no significant change between 2016 and 2019 (P for trend = .71) and in 2020 rates increased to 192—levels not seen since 2005. The trends in rates of excess years of potential life lost followed a similar pattern. From 1999 to 2020, the disproportionately higher mortality rates in Black males and females resulted in 997 623 and 628 464 excess deaths, respectively, representing a loss of more than 80 million years of life. Heart disease had the highest excess mortality rates, and the excess years of potential life lost rates were largest among infants and middle-aged adults.  

Conclusions and relevance  Over a recent 22-year period, the Black population in the US experienced more than 1.63 million excess deaths and more than 80 million excess years of life lost when compared with the White population. After a period of progress in reducing disparities, improvements stalled, and differences between the Black population and the White population worsened in 2020.

Unravelling the commercial determinants of health

Via The Lancet, an editorial: Unravelling the commercial determinants of health. Excerpt:

In early March, in the wake of the COVID-19 pandemic, nearly 200 people—including former UN Secretary-General Ban Ki-moon—signed a letter strongly criticising pharmaceutical companies for putting a desire to make extraordinary profits before the needs of humanity. Selling publicly funded vaccines, treatments, and tests to the highest bidder resulted in inequities that cost more than a million lives, while private companies made billions of dollars. The signatories called on world leaders to ensure that such an injustice is never repeated.  

The conflict between profits and health equity is not new. The global health community fought for decades to provide access to antiretrovirals for patients with HIV/AIDS in less-resourced settings. Many commercial actors attempt to negatively influence national and international policies, undermine science, or to directly attack individuals calling out their actions. The recent Lancet Series on breastfeeding showed how an extensive network of lobbying by formula milk companies has derailed progress on breastfeeding education. 

This history speaks to the central importance to health equity of the commercial determinants of health, the subject of a Series published in this issue of The Lancet, led by Rob Moodie of the University of Melbourne, along with authors spanning 15 countries and six continents, with the support of the Victorian Health Promotion Foundation of Australia.  

The headline findings are startling: four industries (tobacco, unhealthy food, fossil fuel, and alcohol) are responsible for at least a third of global deaths per year. Yet much of the work to understand the harmful (or beneficial) impact of commercial actors has to date been done in health research silos. Each field faces many of the same tactical battles and strategies without a unified agenda to protect health. There is a lack of consensus across fields of health to define and understand the commercial determinants of health.  

The Lancet Series seeks to remedy this long-standing and complex situation with a consensus definition of the commercial determinants of health (“systems, practices, and pathways through which commercial actors drive health and equity”), a framing to understand commercial entities' impact on health, and a commitment to address its challenges in a holistic way.  

The Series authors set out a bold vision in which governments, commercial actors, and civil society contribute first and foremost to improving health and societal wellbeing. Such a vision is needed urgently. As the second paper in the Series outlines, commercial actors are diverse and many play a vital role in society, but the products and practices of many are having increasingly negative impacts on human and planetary health and equity.  

The Series provides a comprehensive agenda for action, recognising the need for regenerative business models and accountable transparent policies (including an end to commercial actors opposition to health regulation and policies).  

Moodie emphasises that the Series is not anti-business; it is pro-health. There are some notable good models of pro-health-acting businesses. For example, nearly 200 leading financial institutions (which together manage more than US$16 trillion) have signed a pledge to support tobacco-free policies across lending, investment, and insurance. However, although Environmental, Social and Governance frameworks are increasingly used to guide more responsible investment, they still lack specific health indicators.  

Health needs to become a crucial consideration of investor frameworks and global capital markets. Doing so will require the adoption of different economic models, new legislative and regulatory measures, civil society advocacy and accountability, and better corporate social responsibility. Governments must be empowered to encourage businesses to prioritise positive health impacts.  

As Tedros Adhanom Ghebreyesus, WHO Director-General, writes in an accompanying Comment, public health cannot progress without action on the commercial determinants of health. The Lancet welcomes the upcoming WHO Congress and first Annual Report on the commercial determinants of health, especially in helping to address non-communicable diseases. Given their huge unresolved impacts, the commercial determinants of health must be recognised—and funded—as a crucial field of research.

The Lancet Series on racism, xenophobia, discrimination, and health

Via The Lancet: The Lancet Series on racism, xenophobia, discrimination, and health. The executive summary: 

Racism, xenophobia, and discrimination exist in every modern society causing avoidable disease and premature death among groups who are often already disadvantaged.

This Series examines how the historic systems and structures of power and oppression, and discriminatory ideologies have shaped policy and practice today, and are root causes of racial health inequities. 

Furthermore, by applying a global lens and intersectional framework, overlapping forms of oppression such as age, gender, and socioeconomic status and their impact on discrimination are analysed. Interventions to address the spectrum of drivers of adverse health outcomes with a focus on the structural, societal, legal, human right, institutional and system level are reviewed. 

Research recommendations and key approaches for moving forward are proposed.

Symptoms and risk factors for long COVID in non-hospitalized adults

Via Nature Medicine: Symptoms and risk factors for long COVID in non-hospitalized adults. The abstract:

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is associated with a range of persistent symptoms impacting everyday functioning, known as post-COVID-19 condition or long COVID. We undertook a retrospective matched cohort study using a UK-based primary care database, Clinical Practice Research Datalink Aurum, to determine symptoms that are associated with confirmed SARS-CoV-2 infection beyond 12 weeks in non-hospitalized adults and the risk factors associated with developing persistent symptoms. 

We selected 486,149 adults with confirmed SARS-CoV-2 infection and 1,944,580 propensity score-matched adults with no recorded evidence of SARS-CoV-2 infection. Outcomes included 115 individual symptoms, as well as long COVID, defined as a composite outcome of 33 symptoms by the World Health Organization clinical case definition. Cox proportional hazards models were used to estimate adjusted hazard ratios (aHRs) for the outcomes. 

A total of 62 symptoms were significantly associated with SARS-CoV-2 infection after 12 weeks. The largest aHRs were for anosmia (aHR 6.49, 95% CI 5.02–8.39), hair loss (3.99, 3.63–4.39), sneezing (2.77, 1.40–5.50), ejaculation difficulty (2.63, 1.61–4.28) and reduced libido (2.36, 1.61–3.47). 

Among the cohort of patients infected with SARS-CoV-2, risk factors for long COVID included female sex, belonging to an ethnic minority, socioeconomic deprivation, smoking, obesity and a wide range of comorbidities. The risk of developing long COVID was also found to be increased along a gradient of decreasing age. 

SARS-CoV-2 infection is associated with a plethora of symptoms that are associated with a range of sociodemographic and clinical risk factors.

This article in The Guardian is likely only the first of many to discuss these findings.

Will COVID force public health to confront America's epic inequality?

Via Nature, an important article by Amy Maxmen: Will COVID force public health to confront America's epic inequality? Excerpt:

On a hazy day in November, Hardeep Singh received a text message from the COVID-19 testing system at Foster Farms poultry company saying that his mother had tested positive for the coronavirus.  

He got the alert because his mother, a 63-year-old line worker at one of the company’s meat-packing plants in California’s San Joaquin Valley, doesn’t speak English and doesn’t own a smartphone.  

Singh couldn’t reach her as she continued to handle chicken parts alongside her co-workers. Her supervisors didn’t tell her, either. In fact, they assigned her more shifts for the week.  

Singh broke the news to her that evening, and convinced her not to return to work, where she might spread the infection to others. But he couldn’t reach anyone at the company for another five days, to ask whether she qualified for paid time off while she isolated.  

Singh’s mother ended up being among the more than 400 employees at the plant who were diagnosed with COVID-19 last year, and one of about 90,000 cases linked to food-production facilities and farm work across the United States. Because the sector feeds Americans and powers part of the US economy, agricultural workers such as Singh’s mother have been considered essential workers during the COVID-19 pandemic.  

That important role comes at a cost. One study1 found that food and agricultural workers in California had an almost 40% increased risk of dying last year, compared with the state’s general population. And within that imbalance lies another contrast. Latinx food and agriculture workers experienced a nearly 60% increase in deaths compared with previous years; the increase for white workers was just 16%.  

The reasons for such disparities, say public-health researchers, include discrimination, low wages, limited labour protections and inadequate access to health care, affordable housing and education. These are some of the ‘social determinants of health’, a concept that has been around for at least 150 years, but which has gained recognition during the pandemic.

Cracks in the foundation: How COVID-19 showed our failures

Via The Lancet, a review by Mary T. Bassett: Cracks in the foundation: how COVID-19 showed our failures.

In 1963, James Baldwin, one of the USA's greatest essayists, published The Fire Next Time. The book's title comes from a slave song—”God gave Noah the rainbow sign/No more water but the fire next time”. Baldwin's words sounded a warning that the USA needed to confront its racial hierarchy by embracing racial equality or doom its future.  

Sandro Galea's book, The Contagion Next Time, is titled in a homage to Baldwin and it also sounds a warning. Galea's central argument is that vulnerability to COVID-19 lies with a societal failure to recognise that the foundation of health rests on a healthy everyday life and not simply in the provision of health care. He ponders why this key lesson is not at the centre of pandemic discourse, which instead focuses on vaccination and treatment. In often lyrical prose, Galea roams across history, culture, literature, moral values, economics, politics, and personal pandemic experience. Although situated in a global context, the book's focus is the USA. Galea considers especially the enduring impacts of racism on health and the centrality of structural racism to understanding the USA.  

Globally, there were more than 6 million COVID-19 deaths by early April, 2022. Amid this carnage, few have asked why, if this novel virus was the spark, there was so much dry grass. The Contagion Next Time is suffused with Galea's anguish that failure to grapple with this question will cost more lives. Worse, the world may fare even more poorly when the next contagion arrives.

After the omicron (B.1.1.529) surge, which occurred after this book was written, the USA is now approaching a staggering 1 million COVID-19 deaths. An analysis in 2021 by the Lancet Commission on public policy and health in the Trump era, to which both Galea and I contributed, found that about 40% of US COVID-19 deaths “could have been averted had the US death rate mirrored the weighted average of the other G7 nations”. In February, 2022, the per capita cumulative COVID-19 death rate in the USA exceeded that of other wealthy nations and during omicron placed the USA in a league all its own. Just what is going on?  

Galea, who is Dean of the Boston University School of Public Health, USA, seeks the answers with erudition and passion. He begins with reflections of an array of relevant data. But most of the book reads as a journey towards understanding why the USA has fared so poorly. The answers have little to do with the scientific breakthroughs that brought us COVID-19 vaccines in such record time.  

Galea points to the US obsession with individualism, making achievement of health a personal project, rather than a collective one, and an attachment to technology that has given priority to medical care over public health. He also posits widespread lack of compassion, which erodes solidarity. Galea does not shrink from naming an aversion to complexity in some quarters that made policy making difficult in the pandemic. COVID-19 demanded high-impact decisions that rested on imperfect, incomplete information. A lack of humility may also have contributed to at times contradictory public pronouncements. And there is a failure to confront racism (embedded in the founding of the USA), marginalisation, and socioeconomic inequality.  Galea ends by observing that choosing health will mean “reorienting our social, economic and political priorities” to support our collective wellbeing.  

But there are questions that go unasked and unanswered. Just why would a belief that medical care creates health persist, faced with decades of public health thinking that has shown the minor share of population health attributable to clinical care? The WHO Commission on Social Determinants of Health began its 2008 final report, “Social justice is a matter of life and death.” It would seem time to ask, who benefits from these unhealthy arrangements?  

And there are answers. At their root lies an unfettered pursuit of profit that is not good for health. The US departure from the health performance of its peer nations began in around 1980 as market-oriented policies triumphed. Nicholas Freudenberg in his book At What Cost: Modern Capitalism and the Future of Health confronts directly how with present predatory capitalism in the USA there is widespread damage to the public's health. Haven’t we seen this also with COVID-19? Millions lost their jobs while the stock market flourished. Income inequality increased as life expectancy plunged precipitously among racially marginalised groups in the USA. Meanwhile, equitable access to COVID-19 treatments and vaccines is not a reality for many people in low-income and middle-income countries. Debates continue over patent protections.  

The impact of anti-communism in the USA has limited interrogation of capitalism. But the USA is a capitalist country. Nearly 60 years ago, Baldwin sounded the alarm for the enduring harm of racism to the future of the USA, a lesson which Galea has amplified. Perhaps a more courageous book that contemplates the next contagion would go a step further in sounding the alarm for the health effects of modern capitalism.

Changes in life expectancy between 2019 and 2021: United States and 19 peer countries

Via medRxiv: CHANGES IN LIFE EXPECTANCY BETWEEN 2019 AND 2021: UNITED STATES AND 19 PEER COUNTRIES. The abstract" 

BACKGROUND Prior studies reported large decreases in US life expectancy during 2020 as a result of the COVID-19 pandemic, disproportionately affecting Hispanic and Black populations and vastly exceeding the average change in life expectancy in other high-income countries. Life expectancy estimates for 2021 have not been reported. This study estimated changes in life expectancy during 2019-2021 in the US population, in three US racial/ethnic groups, and in 19 peer countries.  

METHODS US and peer country death data for 2019-2021 were obtained from the National Center for Health Statistics, the Human Mortality Database, and overseas statistical agencies. The 19 peer countries included Austria, Belgium, Denmark, England and Wales, Finland, France, Germany, Israel, Italy, Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Scotland, South Korea, Spain, Sweden, and Switzerland. Life expectancy was calculated for 2019 and 2020 and estimated for 2021 using a previously validated modeling method.  

RESULTS US life expectancy decreased from 78.86 years in 2019 to 76.99 years in 2020 and 76.60 years in 2021, a net loss of 2.26 years. In contrast, peer countries averaged a smaller decrease in life expectancy between 2019 and 2020 (0.40 years) and a 0.28-year increase between 2020 and 2021, widening the gap in life expectancy between the United States and peer countries to more than five years. 

The decrease in US life expectancy was highly racialized: whereas the largest decreases in 2020 occurred among Hispanic and non-Hispanic Black populations, in 2021 only the non-Hispanic White population experienced a decrease in life expectancy.  

DISCUSSION The US mortality experience during 2020 and 2021 was more severe than in peer countries, deepening a US disadvantage in health and survival that has been building for decades. Over the two-year period between 2019 and 2021, US Hispanic and non-Hispanic Black populations experienced the largest losses in life expectancy, reflecting the legacy of systemic racism and inadequacies in the US handling of the pandemic. 

Reasons for the crossover in racialized outcomes between 2020 and 2021, in which life expectancy decreased only in the non-Hispanic White population, could have multiple explanations.