U.S. life expectancy has decreased for the second year in a row, and an editorial in the BMJ points to three contributing factors: drugs, alcohol and suicides, particularly among middle-age white Americans and those living in rural communities. The authors of the paper paint a bleak picture of the problems facing much of the United States today, but the authors say that policies that bolster the middle-class can help reverse the trend.

The recent drop in life expectancy is alarming, the editorial states, “because life expectancy has risen for much of the past century in developed countries, including in the U.S.” Compared to gains made by other developed countries, however, the United States began to lose ground in the 1980s. Americans’ life expectancy plateaued in 2012, and now is headed in the opposite direction.

“Something is amiss in the health of Americans, and the country, on a population level, is sick and dying earlier,” says the editorial’s lead author, Steven Woolf, director of the Center on Society and Health at Virginia Commonwealth University. “Quite simply, it means that babies born today are likely to live a shorter life than those born a year or two ago.”

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As to why U.S. life expectancy is declining, Woolf says that many people point toward the current opioid epidemic. “That’s certainly a big factor, but it’s also a larger problem that’s been going on for decades,” he says. “We know there are deeper systemic causes, that paint a picture of hopelessness and despair and struggling with difficult living conditions.”

In 2013, Woolf and his co-author Laudan Aron, a senior fellow at the Urban Institute, published a study that found that Americans have poorer health in many areas—including birth outcomes, injuries, homicides, adolescent pregnancies, HIV/AIDS rates, obesity, diabetes and heart disease—when compared to other high-income countries. They also cite lifestyle factors such as high-calorie diets, drug abuse, gun ownership, living in cities designed for cars instead of pedestrians and lack of universal health care as likely contributors.

And while the rate of fatal drug overdoses increased by 137% from 2000 to 2014, Woolf and Aron say, death rates from alcohol abuse and suicides have also gone up. Between 1999 and 2014, the suicide rate rose by 24%, with the sharpest increases among white Americans ages 25 to 59, people with limited education, women and people in rural counties.

It’s not entirely clear why white Americans who live in rural areas are dying at higher rates from these factors, Woolf and Aron say. But experts have suggested that economic hardships, the collapse of local industries, and the loss of security held by previous generations have hit white Americans harder in recent years. Black Americans, on the other hand, “have contended with longstanding structural disadvantages, discrimination, and higher all cause mortality,” the authors write, and may be more resilient as a result.

“The U.S. is rich, but its wealth is not inclusive,” the editorial states. “Its social contract is weaker than in other countries—those in need have less access to social services, healthcare, or the prevention and treatment of mental illness and addiction. The ‘American dream’ is increasingly out of reach, as social mobility declines and fewer children face a better future than their parents.”

The silver lining in this dark data, says Woolf, is that change is possible—and that the same things that are good for America’s economy can also be good for the nation’s health outcomes.

“The solutions to dealing with this problem are not very different from the priorities we should have to strengthen the middle-class overall,” he says. “What people in the health field would recommend is improvements in education, employment, and economic opportunities for the low-income and middle-class segments of our population—and those same investments are going to improve economic prosperity and social mobility for much of America; that’s the win-win here.”

In theory, policymakers should be rushing to implement improvements in these areas. “But the pro-business policy agenda favored by elected officials rarely prioritizes these needs,” Woolf and Aron write in their editorial. “Current policies in Washington are in many ways neglecting the middle class—and in some cases, not just neglecting them but pulling the rug out from under then entirely,” Woolf says. “We can change this, but only if we change our priorities as a society.”

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