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Dr. Chokshi is a Bellevue Hospital physician and visiting fellow at the New York Health Foundation. He previously served as the health commissioner of New York City.
Life expectancy in the United States continued to decline in 2021, according to data released by the federal government. Is there a more fundamental barometer of the health of our nation? The stagnation in life expectancy reflects deep societal challenges — not just in our health system but also in our economic and political systems.
For people born in 2019, like my daughter was, life expectancy at birth was 78.8 years. It has been markedly lower in subsequent years: 77.0 years for those born in 2020 and around 76.1 years for those born in 2021, primarily because of Covid-19.
Although life expectancy is not a literal estimate of how long a newborn is expected to live — instead, it reflects mortality trends for adults in a given year — it does represent the world our children are inheriting. The connection becomes visceral when we think of the children we have lost to gun violence, from Uvalde, Texas, to Highland Park, Ill. Or the projected increase in pregnancy-related deaths and child poverty because Roe v. Wade was overturned.
The decrease in life expectancy, as I see it, is a composite of multiple phenomena.
Life expectancy in the United States has lagged that of peer countries since 1980, driven in part by higher mortality rates among Black and American Indian adults and people of lower socioeconomic status. A recent analysis estimated there were about 16 million American birthdays lost — that is, years of life lost prematurely — in 2019, based on a comparison of U.S. death rates with those in other wealthy countries.
Even as Covid-19 was the major reason for the decline from 2019 to 2021, that broad characterization masks the contributions of misinformation and political polarization to preventable mortality since 2021, when Covid-19 vaccines became widely available.
The pandemic’s reverberating effects also extended to increases in overdose deaths, deaths related to pregnancy and childbirth and deaths from chronic diseases such as diabetes, through pathways that are still being understood. In my own clinical practice, I’ve seen the grief, stress and trauma of the past few years show up as spikes in blood pressure and blood sugar or as foregone care.
Although some of the backdrop mortality trends are called deaths of despair, collectively, this is not a time for nihilism or despondency. The decline in life expectancy is not inevitable. We need only look to peer countries like Spain and Canada, where modeling based on preliminary data suggests a life expectancy rebound in 2021 despite Covid-19, in part because of widespread vaccination.
America is at a fork in the road with respect to the health of the nation. One path would parallel what happened after the 1918 flu, known as both the “great influenza” and the “forgotten pandemic.” Although life expectancy increased as the number of flu deaths subsided, its trajectory remained similar to that before the pandemic. The stories of the millions of lives lost perhaps took a back seat to narratives of nationalism and victorious valor in World War I. We are at risk of a similar collective amnesia after Covid-19.
Another path, however, would parallel the response to the unyielding outbreaks of typhus, smallpox, dysentery and cholera in the 19th century. A great sanitary awakening didn’t just save lives; it changed the way society thought about protecting health as a public responsibility.
Disease control at the time included cleaning up and improving the common environment, with a particular focus on impoverished areas and children's health. In New York City, cholera deaths among the poor helped lead to the Metropolitan Health Law, which regulated sanitary conditions and laid the groundwork for modern health departments.
What would a modern Metropolitan Health Law look like at a national scale? Even as it would address different conditions and proximate causes of illness, a focus on low-income people and marginalized communities would remain consistent.
Looking at average changes in life expectancy obscures the fact that before the pandemic, increasing mortality was concentrated among lower-income groups. More recent data from California during the pandemic suggests that the gap in survival by income may have widened further, particularly among Hispanic and Black people.
Given that health is tightly linked to economic security, economic policy must be viewed as health policy. Policy solutions that affect educational opportunities, housing prospects and social mobility have particularly important implications for health. Direct financial and in-kind assistance for low-income families, such as through the Supplemental Nutrition Assistance Program (formerly known as food stamps) and further expansion of the earned-income tax credit, are evidence-based and effective.
Lessons from the Covid-19 response should also lead to investment in a national public health corps, a cadre of community health workers both serving and drawn from the most marginalized neighborhoods across the country, providing a health work force, economic resources and jobs in one fell swoop. Broader preparedness for the next infectious threat must appropriately resource local and state public health agencies, from laboratory capacity to misinformation response.
The country should also derive inspiration from our 19th-century forebears in focusing on the suffering of children. Firearm-related injuries have become the leading cause of death among children, a shocking reality. Climate change threatens infants and other children through extreme heat, food insecurity, insect-borne diseases and more. Beyond advocacy, public health has a particular role in scaling up services to address these and other adverse childhood experiences, for instance through new family home visiting programs. And economic policies such as making the child tax credit permanent, providing baby bonds to address wealth inequality and investment in early childhood education have potential for major health dividends.
Polarization, partisanship and a lack of trust — both in government and interpersonally — can cost lives. Overcoming this will require an embrace of new narratives. For instance, the scholar Heather McGhee describes the zero-sum thinking associated with structural racism: the trope that for some to advance, others must regress. The zero-sum story has eroded our willingness to resource public goods for all of us, from education to transportation.
Here too a focus on children can help. Is there a more powerful identity than that of a parent, grandparent or caregiver? What if the stories we told were rooted in those identities, and our policies were measured against the health benefits that our children could expect? It would start by re-framing each of the policies described above by leading with their effects on our children.
If I could write a sweeping prescription, it would be for the millions of parents who have not voted in a state or national election in the last five years. Organizing to get them to the polls and giving them a reason to vote on the social and economic policies that shape health may be the key to reversing the decline in life expectancy in the United States. I care about that as a doctor, but even more so as a father.
Dave A. Chokshi (@davechokshi) is a physician at Bellevue Hospital and visiting fellow at the New York Health Foundation. He previously served as the 43rd health commissioner of New York City.
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