The missing Americans: Unprecedented US mortality far exceeds other wealthy nations

In 2021, 1.1 million deaths would have been averted in the United States if the US had mortality rates similar to other wealthy nations, according to a new study led by a Boston University School of Public Health (BUSPH) researcher.

Published in the journal PNAS Nexus, the study refers to these excess deaths as "Missing Americans," because these deaths reflect people who would still be alive if the US mortality rates were equal to its peer countries.

Comparing age-specific death rates in the U.S. and 21 other wealthy nations from 1933 through 2021, the authors find that current death rates in the US are much higher than other wealthy nations, and the number of excess U.S. deaths has never been larger.

"The number of Missing Americans in recent years is unprecedented in modern times," says study lead and corresponding author Dr. Jacob Bor, associate professor of global health and epidemiology at BUSPH.

Nearly 50 percent of all Missing Americans died before age 65 in 2020 and 2021. According to Dr. Bor, the level of excess mortality among working age adults is particularly stark. "Think of people you know who have passed away before reaching age 65. Statistically, half of them would still be alive if the US had the mortality rates of our peers. The US is experiencing a crisis of early death that is unique among wealthy nations."

The COVID-19 pandemic contributed to a sharp spike in mortality in the US -- more so than in other countries -- but the new findings show that the number of excess US deaths has been accelerating over the last four decades. Dr. Bor and colleagues analyzed trends in US deaths from 1933 to 2021, including the impact of COVID-19, and then compared these trends with age-specific mortality rates in Canada, Japan, Australia, and 18 European nations.

The US had lower mortality rates than peer countries during World War II and its aftermath. During the 1960's and 1970's, the US had mortality rates similar to other wealthy nations, but the number of Missing Americans began to increase year by year starting in the 1980's, reaching 622,534 annual excess US deaths by 2019. Deaths then spiked to 1,009,467 in 2020 and 1,090,103 in 2021 during the pandemic. From 1980 to 2021, there were a total of 13.1 million Missing Americans.

The researchers emphasize that this mortality crisis is a multiracial phenomenon and is not specific to minoritized groups. Black and Native Americans are overrepresented in these measures, with mortality rates in early adulthood (ages 15-44) that were five and eight times higher than the average of other wealthy nations. The team also says that the history of structural racism in the US, including policies such as slavery and redlining, has contributed to racial and ethnic disparities in wealth and in access to education, housing, and healthcare that drive leading causes of worse mortality rates, particularly at young ages.

Still, two-thirds of the Missing Americans are White, a result of the larger population of White Americans, their older age distribution, and death rates that are significantly higher than other wealthy nations.

"Living in the US is a risk factor for early death that is common across many US racial and ethnic groups. Whereas most health disparities studies assess differences between US racial/ethnic groups, such an approach renders the poor health of Whites invisible and grossly underestimates the health shortfall of minoritized groups," Dr. Bor says. "By using an international benchmark, we show that Americans of all races and ethnicities are adversely affected by the US policy environment, which places a low priority on public health and social protections, particularly for low-income people."

Accounting for future years of life lost due when a person dies prematurely, the team estimates that in 2021, excess U.S. mortality translated to 26.4 million years of life lost relative to the mortality rates of peer nations. They connect the large excess mortality burden to the failure of US policy to adequately address major public health issues, including the opioid epidemic, gun violence, environmental pollution, economic inequality, food insecurity, and workplace safety. The COVID-19 pandemic exacerbated many of these issues, particularly among lower-income and minority groups, and now that most of the safety-net policies created during COVID-19 have expired, vulnerable groups have lost vital support.

"We waste hundreds of billions each year on health insurers' profits and paperwork, while tens of millions can't afford medical care, healthy food, or a decent place to live," says study senior author Dr. Steffie Woolhandler, Distinguished Professor at the School of Urban Public Health at Hunter College, City University of New York. "Americans die younger than their counterparts elsewhere because when corporate profits conflict with health, our politicians side with the corporations."

In comparison to the US, other countries also had higher vaccination uptake and mask policies during the Omicron wave, and this layered mitigation was associated with fewer COVID-19 cases.

The findings raise a number of urgent questions that will be critical to address in future research, says study coauthor Dr. Andrew Stokes, assistant professor of global health at BUSPH. For example, he says, "Which geographic areas are disproportionately responsible for the Missing Americans, and what were their causes of death? Answers to these questions may help to clarify policy solutions."

At the moment, Dr. Bor says he is not optimistic that mortality rates will reverse in the near future, even as COVID-related deaths continue to wane from their 2021 peak.

"The US was already experiencing more than 600,000 Missing Americans annually before the pandemic began, and that number was increasing each year. There have been no significant policy changes since then to change this trajectory," he says.

"While COVID-19 brought new attention to public health, the backlash unleashed during the pandemic has undermined trust in government and support for expansive policies to improve population health," said Dr. Bor. "This could be the most harmful long-term impact of the pandemic, because expansion of public policy to support health is exactly how our peer countries have attained higher life expectancy and better health outcomes."