Plain English with Derek Thompson: Americans Die Younger Than Those in Any Other Rich Country. Why?

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Hey everyone, quick programming note

before today's episode,

I'm going to be appearing on Wednesday, April 12th

at Politics and Pros Bookstore in Washington DC.

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I'll be talking with the Atlantic's Ross Anderson

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a new anthology of work that I've done

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the future of work.

It's called, I guess appropriately,

Derek Thompson On Work.

If you want to hear me talk about this book,

answer questions about the history of labor,

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the future of work, stop by.

It'd be great to see some listeners of the show

in Politics and Pros.

Again, that is April 12th at Politics and Pros,

the Connecticut Avenue location.

Today's episode is about guns, drugs, cars

and one very big question.

Why do Americans die so much younger

than people in just about every other rich country?

American exceptionalism is a term

that's thrown around a lot.

Americans like to believe we are the richest,

the cleverest, the most creative,

the most swashbucklingly awesome country in the world.

And the truth is, in many ways, we are.

I am not one of these people

who considers anti-patriotism to be a virtue.

You're not gonna get a whole Will McEvoy,

the newsroom, Aaron Sorkin thing out of me.

You know, Seventh in Literacy,

27th in Math, 22nd in Science.

I think there are a lot of very special things

about this big, boisterous, loud, riotously inventive country

and its history.

But on the other side of the ledger,

we are the rich death trap of the Western world.

And this is, in some ways, a novel phenomenon.

Before the 1990s, average life expectancy in the U.S.

was not much different than it was in Western Europe,

Germany, France, the U.K.

But in the last 30 years, something very strange

and clearly very bad has happened.

Americans got much richer than Europe,

but our lifespans started falling further and further

and further behind, similarly rich people

across the Atlantic.

And this ought to create a real dilemma

for those looking to the U.S.

for guidance to the question,

how should a civilized country be?

How should a civilized country behave?

On the one hand, a modern democratic capitalist country,

I think, should want to make citizens rich.

We should want nice stuff.

We should want to reduce poverty

while starting amazing companies,

while having cheap energy, while building ample housing.

But I think we can admit, in the simplest analysis,

that the true test of any civilization

is whether it can keep its citizens alive

to enjoy the abundance of stuff

that the market is creating for them.

And the U.S. just isn't very good at that last part,

the whole keeping its citizens alive thing.

American lifespans have fallen behind Europe so dramatically

that today, the typical American

has the same healthy life expectancy,

the same number of projected years living in good health,

as someone in Blackpool,

the town with the lowest life expectancy

by far in all of England.

That is, the town is in the middle of the world

in England that symbolizes deep, rooted social decline.

Even there, citizens can expect to outlive

the average American.

So, you know where I'm going with this,

what the hell is going on?

Well, the most important thing to say here

is that nothing this important is ever so simple.

You know, someone want to point to,

let's call it, let's say guns alone.

And yes, it is true, Americans are more likely

to kill one another with guns in large part

because Americans have more guns

than residents of other countries do.

But we also have higher rates of death

from infectious disease, pregnancy complications.

Those things have nothing to do with guns.

Others, I know, will want to start by talking about race.

And there's no question that America's legacy

of slavery and racism has absolutely contributed

to unequal access to healthcare

and higher mortality rates among non-white Americans.

This is an astonishing stat.

Black teenagers in the poorest American areas

are twice as likely to die before they turn 20

as teenagers in the richest US counties.

What can you say about that

other than it is a straightforward tragedy?

But here's the really interesting wrinkle.

In the last 30 years,

the black-white life expectancy gap has actually declined.

It's halved from seven years to about three and a half years.

So black and white lifespans

have become steadily more equal during the same period,

the exact same period when American lifespans

fell more and more and more behind Europe.

So guns are a piece of this and race is a piece of this,

but they're not the whole piece.

The full story of America's death gap is a mystery.

To help us unravel this mystery,

today's guest is John Byrne Murdoch,

a data journalist at the Financial Times

who recently published a magisterial investigation

of the American death gap.

Again, the ability of a country to keep its citizens alive

might be the single most important policy story

of that country.

Not every news item is about life and death

at the scale of 300 million people.

This one is.

I'm Derek Thompson.

I'm Derek Thompson. This is plain English.

John Byrne Murdoch, welcome back to the show.

Thanks Derek, great to be here.

I want to start by talking about money.

I don't think many people on either side of the Atlantic

understand how much richer the average American is

than the average European.

So yes, you and I are here to talk about death and longevity,

but I want to begin here with money to put into context.

How much richer is the typical American

compared to say the typical English person?

Sure. So using the best data we have on this,

this is looking at the median

equalised disposable household income.

So just to unpack that a little bit,

that means once you adjust for how many people

are in any given household, this is how much money

you've got to spend discretionary spending

at the end of each week, month, whatever.

And if we take the median, so slap bang

in the middle of the population,

half the people have less, half have more,

so the average US household is about 60% richer

than the average household in Britain.

And I can throw in the likes of Germany

in there as well or France.

So Western Europe as a whole, you're talking about 60%,

so a huge difference.

It's really unbelievable.

And you mentioned, I think, at the top of your essay,

a statistic about the average car wash manager

in Alabama compared to the typical English person.

Maybe just give us that bit of context, if you can,

before we move on to the meat of this discussion.

Yeah. I mean, I should say there,

they weren't strictly averages,

but they were just a couple of eye-catching,

striking examples that I'd seen recently.

So this was a car wash manager, a place called Buckeys

in Alabama where there was a job advert

for a job paying $125,000.

And then we also recently had a job ad go out

for someone to be head of cybersecurity

at the UK's Treasury,

and that one was paid about half less.

So you could get paid about 50% more

to manage a car wash in Alabama

than to head up cybersecurity for the British Treasury.

And yet, despite this enormous advantage in wealth,

as you've pointed out, as many researchers have pointed out,

as I've written about several times in the Atlantic,

Americans die earlier than the English

for just about every level of income

and for just about any age up to 65.

That is, American babies are more likely to die

before they turn five.

American teens more likely to die before they turn 20.

American adults more likely to die before they turn 65.

You've dug into the data here on U.S. longevity.

What is the big picture?

Yeah, look, I mean, as you said there,

it's just so striking.

And this was one of those pieces where at every turn,

every time I calculated something,

I had to double-check it because I thought it can't be this stark.

And there's many ways of looking at it.

I think the point you've made there about the age distribution

is probably the most useful way of thinking about this

because I think there's this instinct

whenever we hear life expectancy,

because the numbers are always in the 70s or 80s,

we think, okay, so this is about older folks.

This is about whether everyone dies at age 84 or at age 79.

It's that kind of thing.

So we're sort of queued up to think about older age,

to think about diseases, to think about cancer,

to think that ultimately what we're saying here is

Americans are dying at roughly five years younger age

than Brits, but it's not really how it works

when you look under the hood.

What we're actually seeing here is that once you get to be

65, 70, 75 in America or in the UK or in Western Europe,

things look pretty similar in terms of your chances

of making it through the next, say, 25 years.

But the big difference is that there are far, far, far, far

more Americans dying aged 15, aged 25, aged 35

than there are Brits, Germans, French.

And when you think about what life expectancy is,

those young deaths make a very big difference

because each of those deaths is wiping out 60, 70, 50 years

of life, whereas if it were just the case,

I say just the case, if it were just the case

that everyone was dying, say, one year earlier,

that would have less impact on the overall number.

So, yeah, it's all about the fact that it's growing up

in the US is far, far more deadly than growing up

in any other developed country in the world.

And that is precisely it.

Growing up in America seems extraordinarily deadly,

especially considering how rich we are.

Throughout the world, it is more or less the case

that rich countries tend to have better healthcare systems,

better technology, better science, better access

to medical science and technology.

They tend to live longer.

It does, if you look at all the countries in the world,

seem to be like one of these cardinal rules,

that one of the benefits of becoming richer

in the society is that you live longer.

It just doesn't seem to be the case in America.

We talk about American exceptionalism a lot in this country.

This is a true case of dark American exceptionalism.

And just to hammer your point home,

because it really is so important in getting people

to understand this longevity gap between the US

and not just the UK, it's the US and Portugal,

Spain, France, Italy, Germany, Denmark, Switzerland,

average life expectancy surged over 80 years

in just about every Western European country in the 2010s.

In the US, it's never exceeded 79.

But if you take a bunch of 70-year-olds from Portugal

and Spain and France and Italy and Germany and the US,

the American groups can have a very similar survival rate.

The problem is what happens

before people turn 30, 40, 50 years old.

And that, I think, is what I really want to talk about

for the rest of the show.

What is going on?

What might explain this extraordinary death gap?

Let's look at five possible explanations.

I want to start with guns.

The US famously has more guns and more gun violence

than any other rich country.

Tell me about the gun problem as you see it

and how big a role it's playing.

Sure.

We talk about gun violence in the US all the time.

No one is surprised to know that this is a major thing

that is happening in a major difference

between the US and other countries.

But I think what people fail to appreciate

is what this means for things like your chance

of making it to age 40 and beyond.

We're talking about, I think, in the most recent year,

we had more than 20,000 gun homicides in the US.

You've then got added to that about 24,000 gun suicides.

That's 45,000 people who've lost their lives

generally decades before they otherwise would have done

that does not happen in any other developed country.

And people will say, well, a lot of these people,

they're not people like me.

But you get a lot of...

Well, I mean, the vast majority of these

we're talking about innocent victims, 99%

but this could happen to anyone and it does happen to anyone

and that does impact aggregate statistics like this.

So it's just something that people think about

this as a crime problem, but it's a life problem

and it's a health problem when you think about it in that way.

And it's one that especially affects younger people.

I'm just looking at information from Washington, D.C.

where I live 66% of homicide victims and suspects

and 64% of non-fatal shooting victims and suspects

are between 18 and 34, the mean age is 29.5, 29.8 respectively.

So you're looking essentially at a social disease of gun violence

that is disproportionately affecting people in their teens

and in their 20s.

And as a result, as you pointed out earlier,

not to be sort of overly accounting about all of this

because these are deaths, not just lives that we can add up

in a spreadsheet, but if you have a lot of people dying

in their teens and 20s, that is going to dramatically

pull down the longevity of an entire country.

So there's the guns factor.

Now, I think that a lot of people who hear this,

that hear that young deaths in America are pushing down

longevity are going to say, well, this is mostly a story about guns.

It's not.

It is not mostly a story about guns.

Guns are an important but small part of the overall story.

John, where should we go next?

Right. And so the big one that I think we could come on to next

then is probably drugs.

Because again, I think just the sheer scale of numbers here

is absolutely enormous.

I mean, I'm just checking the latest numbers we had for,

I think it was 2022, we've got provisional data on drug deaths.

And we're looking there at more than 100,000 Americans

who lost their lives in 2022 or who will have been expected to

once that year is out.

And again, that is just an absolutely astonishing number.

That again, because this doesn't happen in most other countries

and because one suspects for a lot of the types of people

who read the Atlantic, read the Financial Times,

this feels something quite remote.

I think that can lead us not to appreciate quite the scale of this.

But it's an absolutely enormous number.

And again, these are people, some in their teens,

a lot in their 20s and 30s,

and then it sort of tails off into the 40s.

But again, each one of these 100,000 is extinguishing

an enormous number of lives.

Like another way of thinking about this is

we all got rightly very worried about COVID.

But when you look at COVID deaths relative to life expectancy,

on average, COVID deaths were extinguishing about nine years of life.

Now, that is still not zero.

That's still a significant number.

And of course, we will know of people who lost many more than nine years.

But the average number of years of life that are lost to these external causes,

whether it's drugs, whether it's guns,

and we'll go on to talk about others, is over 40.

So again, this is just huge.

When you think about what those 40 years could have held

for those individuals, it's an absolute tragedy.

And it's no surprise when the numbers get this high

that it has a very significant impact on life expectancy.

So we are piecing together the full picture here.

I said we're going to name five possible explanations for this longevity gap.

Number one was guns.

Number two, you've moved right to it and I'm glad that you did.

It's drugs.

We have more drug overdose deaths than any other high income country.

That's true both overall and on a per capita basis.

I want to go one level deeper because in the economic community,

there's this concept of deaths of despair.

This was a term made popular by the economists Ann Case and Angus Deaton.

And they said if you look at this cluster of causes of suicides

and drug overdoses and alcoholic liver disease,

these deaths of despair are rising and rising in the US.

They pointed in part to the opioid prescription epidemic

that has been associated with the Sackler family scandal.

The reason I'm pausing here is that it's really useful to go into the numbers

and look at what exactly is happening.

Prescription opioid addiction deaths are actually declining somewhat from their peak.

They peaked at about 17,000 people a year.

That is a tragedy.

But between 2011 and 2021, deaths from synthetic opioids like fentanyl

went from just about nothing to 80,000 a year.

That means that at peak, the fentanyl crisis is killing more than four times

more people annually than the prescription opioid crisis.

And that is not a simple story of despair.

It is true that low income communities, especially in places that have been

deindustrialized, may have economic and social despair.

But when you have a story of one single drug going from killing maybe 1,000 people

to 80,000 people in 10 years, that tells me it's a little bit more of a drug supply story.

This is about an incredibly dangerous drug that has insinuated itself

into American culture in certain pockets.

And it is killing almost 100,000 people a year.

In your analysis, did you dig into or uncover anything about this extraordinary

rise in synthetic opioids and how it might be driving some of the ongoing

disparities between American deaths and Western European deaths?

Yeah.

I mean, look, I've not done a huge amount that's unpicked the causes.

For example, as you say, I completely agree with everything you've said

that this is fundamentally a supply issue.

One thing that I think is under discussed actually more broadly is that

Scotland in the UK actually has a drug problem as well.

In terms of exactly, it's not on the scale of what we see in the US,

but it's not a million miles away.

And Scottish life expectancy within the UK not only is lower,

but has trended much worse in the last 10 or so years than the rest of the UK

for essentially that same reason.

You've got pockets of the community, disadvantaged deprived pockets of the

community within which you have a lethal substance circulating.

And the fact that this is a problem in Scotland and not in the rest of the UK

kind of points at the same thing.

There are deprived people in the rest of the UK,

but we don't have the supply of that substance circulating.

So I think I'm not answering your question directly,

but it gets to the fact that this is fundamentally a problem that the US,

that Scotland, that some other parts of the world have,

that has to be dealt with in a very specific way that tackles that specific cause.

Of course, we should be focusing on lifting people out of despair as well.

But with these, with the synthetic opioids,

this is a problem that really needs that sort of detailed intervention.

The third category I want to talk about is cars.

The US has a higher death rate from road accidents

than Canada, Australia, Japan, South Korea, and the entire European Union.

And this is true not only because Americans drive more,

but also because on a per-miles-driven basis,

driving in America is more dangerous than driving in Europe.

John, what's the full story with cars?

Yeah, and this is really striking because I think the general story around road deaths

over the last, say, 50 years is one of huge progress.

And we shouldn't be blind to that at all.

The figures for the US are much, much better than they were 50, 60, 70 years ago.

We've seen the advent of seat belts is obviously the big one

and the increased safety in terms of how cars are actually built.

But the US, first of all, the US level all the way throughout that decline

has been much higher than most other developed countries.

The UK, actually, this has been a lot of negative stories around

what's going on in the UK for the last few years, I think for good reason.

But one area where the UK really is very successful is on road deaths.

So if we take a statistic like deaths per million people,

the most recent year in the US, that was 150 per million per year.

And in the UK, it was around 25.

So that's six times as high a mortality rate.

And as you said, Americans drive more.

It's a larger country, public transport networks are not as well established.

But even if we take that measure, there's still an enormous disparity.

And you go from around, let's see, 1.5 deaths per 100 million miles travelled in the US

to around 0.2 in the UK.

So sure, the amount of distance travelled has an impact.

But if you think about this from a mortality point of view

rather than from a sort of road safety point of view,

it doesn't even matter that Americans are driving more.

What matters is what are your chances of being killed in any given year?

And that is just, as I say, six times higher in the US than elsewhere.

And in terms of what's going on, one of the statistics I was really struck by

when I wrote a separate piece on the topic of road deaths earlier in the year

was the number of people in the front seat of a car who don't wear a seatbelt.

Now, in the UK, the idea that that would be anything more than about one or 2%

was, I would find, shocking.

And true enough, in the UK, it's around 2% of drivers.

When they're caught in cameras that monitor this kind of thing,

about 2% are not wearing seatbelts.

In the US, it's 9%.

And again, that's just an absolutely astonishing number.

And it just means that for any given severity of road collision,

there is far, far, far more chance of a lethal outcome in the US.

You've then got, of course, the fact that this does not just mean drivers.

There's also pedestrian deaths, which again are considerably higher in the US,

especially pedestrian deaths to children.

Part of that is, again, a US-specific thing, or at least a more pronounced thing in the US,

which is much larger cars.

Much larger cars, of course, carry that much more kinetic energy.

They also tend to impact people at a higher position on the body,

which can make them more lethal.

So this is, again, a problem that has largely been solved in other developed countries,

yet in the US, we have much worse outcomes.

I want to put some stats on that story that you told,

because I'm so glad you brought up the historical story.

They keep really, really good statistics on vehicular deaths since the 1910s.

On a per capita basis, vehicular deaths in America peaked in 1937

and have more or less been going down since the 1960s.

Unsafe Denny Speed, the famous book written by Ralph Nader

about the designed endangers of the American automobile,

that was published in 1965.

And since then, you really do see the per capita numbers of vehicular deaths

decline pretty significantly in the US, just not so significantly

as to close this gap between American and European deaths in cars.

The other point is that actually overall deaths seem to have peaked in the 1970s.

So no matter how you cut the data, driving in cars in a per capita

and a total basis is a little bit safer.

The problem is also that there's pedestrian fatalities.

And pedestrian fatality has actually very recently hit a 40-year high

and really jerked up in 2020 and 2021.

And part because of, we did a podcast episode about this a few months ago,

this sort of berserking of America as we opened up.

There was all sorts of really just more demented behavior on airplanes,

on roads, and in public spaces in America as people came out of their bunkers

after the pandemic.

So you put all these first three explanations together.

We've talked about drugs, we've talked about guns, we've talked about road deaths.

You published this absolutely fascinating analysis where you said,

what would life expectancy look like if the entire difference

between America and European countries in drugs and violence and road deaths

were totally eliminated?

Let's say there was no special problem in these first three categories.

And according to your analysis, it essentially would have shrunk this death gap

between the US and similarly rich countries by about a third or 40%.

That's it.

That means there's still a lot more mystery to be explained.

And this is where I think we have to bring in diet.

40% of Americans are obese.

That is double the average of most European countries.

It's eight times higher than Korea or Japan.

Tell me what you found when you looked at diet and cardiometabolic disease.

Yeah, absolutely.

And so just to talk a little bit through the sort of background for this as well,

what I'm doing here is I'm not saying let's imagine that anyone who died

from a sort of cardiometabolic issue simply didn't die.

I'm saying, OK, let's just assume that they experienced the same mortality rate

as everyone else in the population.

And yeah, when you do that, when you say, OK, what if people simply weren't dying

from these diseases in the US, in any other country?

Then that US deficit, so this was from 2019.

So just before the pandemic, that deficit goes from 3.6 years down to 2.2 years

among men and from 2.9 down to under two for women.

So it's having roughly the same impact as removing all of those violent deaths.

And the way I think about this is it's quite a different mechanism.

So this is still obviously really, really important.

And the fact that it accounts for another third is very significant.

But in a way, it's a trickier one to solve because when we talk about guns,

when we talk about drugs, when we talk about cars,

these are issues that have already been solved by most other countries.

There are examples right there of, this is what it looks like when you don't have that.

With carbon-calium metabolic issues, these are big problems right around the world.

They are a bigger problem in the US.

They're causing more issues there.

But it's harder to think of examples and say, well, here's how you get rid of that.

It doesn't mean, obviously, and I'm sure we'll get into this,

that we shouldn't be doing more to address that.

But I think it's sort of a broader issue by definition.

This is things that are associated with obesity.

It's also things that are associated with eating and drinking specific types of food.

There will be impacts here in terms of the exercise that people are doing as well.

So it's a broader and slightly fuzzier thing than the precision,

precise causes we were talking about earlier.

Yes, so again, just to continue counting so that people are following.

We have, again, one, guns, two, drugs, three, cars, four.

I initially presented this as diet.

Let's call it number four, diet and exercise.

When I was reporting on my story on the subject last year,

I talked to some people about, are there any ways we can compare American exercise habits

to European exercise habits?

And one demographer I spoke to said, one thing you could look at is the fact that,

going back to cars, the American built environment is different than Europe.

Europe is a little bit more urbanized.

People drive a little bit less.

As a result, they might walk a little bit more.

You should look into that.

So I looked into it and there's a pedometer analysis that was done,

I suppose, looking at wearables and Apple Watches and whoops,

that found that the typical American takes a little over 5,000 steps a day.

The typical Australian takes more than 9,000 steps.

The typical Switzerland citizen, the typical Swiss person,

takes just over 9,000 steps.

The typical Japanese person takes just over 7,000 steps.

Now, that's just one analysis.

Maybe it's wrong, we just did an episode about how these kind of pedometers are sometimes accurate

and sometimes not, but it made me wonder whether the frequency of longer commutes in America,

the fact that we drive more, the absence of walkable areas,

might explain why we are world leaders in the category of sitting on our butts.

And in addition to the fact that the American diet is certainly not famous for its health,

those things together might explain why diet and exercise,

which here we're looking at specifically as cardiometabolic disease,

might explain, as you said, just as much of the death gap as guns and cars and drugs all put together.

Totally.

It's just, as you say, some of those numbers that are astonishing.

And this is something that anyone from the states who comes over to Europe will experience

and the same on the flip side, it's that completely different built environment

just makes sort of how you spend a typical day so, so, so totally different in terms of physical exertion.

And the food thing similarly, I mean, I know people will be horrified to hear a British person

dare to criticize American food.

That's right.

Something that I sort of struggled with on a couple of trips to the US is that everything just has cheese in it.

Salad has got cheese in it.

It's this sort of baseline default of adding sort of unnecessary, I won't say, I don't want to say...

Yeah, yeah, yeah. Don't say unnecessary.

I will shut down this Zoom call in five seconds as you start talking about smirching cheese.

I'm a proud American when it comes to red cheese.

But yeah, there are absolutely differences in diet.

And I have to believe, and your reporting was very persuasive,

but those differences in diet and those differences in average amount of exercise time or just ambulatory time

just walking around might explain a lot.

Let's move on to number five because I want to make sure that we leave some room for big picture conclusions here.

Number five is policy.

And we'll look specifically at insurance and inequality.

The US and our healthcare system is unique in many ways.

We are one of the few countries in the OECD that do not have universal health insurance.

We have among the highest rates of what the OECD calls avoidable mortality.

That includes deaths related to alcohol, shootings, accidents, but also influenza, which we haven't talked about yet.

We don't have the same kind of access to affordable and accessible primary care.

That's in part because the US has significantly fewer general practitioners per capita

than most rich countries, certainly less than the UK.

And you put it all together and you add income inequality, which can exacerbate access to healthcare.

And the US just is unique when it comes to the ability of people who are sick or are becoming sick to reach out for healthcare assistance.

Yeah, so look, I think it's obviously something we can't ignore.

We know for a fact that it is that much more difficult on average,

and especially for certain people in the US, to receive that timely healthcare when they need it.

There have been plenty of studies on this that have shown that mortality rates for any given condition are higher for the uninsured

than for those who have coverage and higher relative to other countries.

There was even a great study, a randomized controlled trial that was done,

taking people who had not been providing the information necessary for them to get healthcare coverage,

sending out a letter to one group of those people and not to others

and seeing among the people who were given that intervention were essentially reminded

that they needed to provide this information to get coverage.

What did that do to their all cause mortality rates in the following months?

And they did find a difference.

It's a relatively small difference because part of what was being tested there

is just how likely you are to need healthcare over any given period of time regardless.

But the point is there is very good evidence that lacking universal healthcare is a problem here.

But I think it's just we need to think about which parts of the US mortality puzzle,

the US life expectancy puzzle, we attribute to this.

Because again, what we're talking about fundamentally is a stagnation

and then decline in US life expectancy over roughly the last 10 years

and then the decline in particular is over more like the last five years.

Now, nobody, I think, is arguing that access to healthcare in the US

has worsened over the last five years.

That's right. Yeah, I'm glad you said that.

Yeah, so just the point being this is absolutely a factor

and nobody should stop campaigning for universal healthcare coverage.

People shouldn't stop pushing at this because it will,

for every individual in the country on average, this will make an improvement.

But if you're looking for explanations of why and how things have got so bad in the US,

in the last five to 10 years, that is from these more specific causes,

especially those external causes, rather than these longer term or even permanent issues.

There was a paper that was published in 2021 by the Northwestern University professor.

I hope I'm pronouncing his name correctly. I think it's Han Schwatt.

And it pointed out that one of the reasons why the US has fallen behind Europe

in this all important statistic of longevity is that Europe's mortality rates

are very similar between rich and poor communities.

So like residents of the poorest parts of France actually live just about as long

as people in the richest parts of Paris.

It is the opposite in the US.

In the US, where you live is much more likely to determine when you'll die.

And that, of course, is the kind of horrific outcome you would expect

when you live in a more individualistic culture that does not have universal benefits

for people no matter where they happen to be born.

There was one other point that I wanted to bring up here before we move to some big picture conclusions.

And that is that there's two really interesting sort of wrinkles to this idea

that America has become this rich death trap.

The first is that the US really does have world-class healthcare

where we have excellent technology and explicit policies to make use of it.

So for example, American men have among the lowest rate of deaths from prostate cancer

of any rich country in the world, of any country in the world.

And this is partly because of a policy of aggressive screening.

Breast cancer mortality rates in the US have fallen faster than in most other countries.

This tells me that the US isn't incompetent when it comes to keeping its citizens alive,

but rather, and perhaps even more frustratingly, we're selectively competent.

We're competent where we pay attention to and where our policies focus on specific outcomes.

The other stunning fact, and I'm sorry just to throw these facts at you and be like, respond,

but that is what we're doing for this particular segment,

is that US immigrants, people born outside the US who moved to the US

seem to live just about as long as anyone in the world.

I don't know exactly what to do with that fact,

but it's a really interesting point.

Foreign-born Americans live so much longer than native-born Americans,

seven years longer for men, six years longer for women,

that immigration alone actually accounted for half of America's total life expectancy gains

between 2007 and 2017.

So there's some very interesting thing happening here between the immigrant population

and the native-born population.

Any of that little buffet that you want to pick from,

either the piece about healthcare technology or the piece about immigration?

Yeah, sure.

So on the healthcare technology part, I think there's a couple of things there.

One is just to completely agree with you in terms of, again,

coming back to this point, by the time you're in your 70s,

you are no worse off really in terms of mortality risk

and that kind of thing in the US than elsewhere.

And part of that is this sort of survival effect.

If you've made it that long, you've probably fended off various other,

let's say, American idiosyncrasies.

So by that point, you were less likely to have a death of despair

at any point, for example.

But it gets to a fundamental point, which I think is sort of good news on the one hand,

but it's less promising in terms of how we actually,

how people tackle the death from external causes, for example.

Because to me, what it demonstrates is that when you have something that is a universal bad,

so whether it's cancer, whether it's heart disease,

whether it's you mentioned things like prostate cancer,

those are things that there aren't any prostate cancer advocates, for example.

There's no one going around saying,

we want prostate cancer to spread as far and wide as it can.

But of course, there are people going around defending the right to bear arms,

pushing people to use more cars and to buy bigger cars.

There are, of course, people supplying fentanyl.

So what makes each of those issues more difficult is we can't just,

we don't have this thing where the entire nation can get behind it.

The money is all going in one direction.

The politics is all going in one direction.

These are actually much thornier issues that will require sort of political solutions to an extent.

So yeah, I think that's, it's just interesting to acknowledge that in terms of,

in terms of what that means for how they can be addressed.

And then, sorry, just remind me what the second point was.

Oh, the second was about immigrants.

But I just want to pick up with where you left off,

because this is such a profound idea, which is that in some cases,

we are discussing concepts that are often framed as a clash between freedom and safety.

And you could expand that conversation about freedom and safety

to include all sorts of things that don't necessarily appear

in the top five reasons why Americans say more than Europeans.

You could talk about swimming pools, right?

You could talk about knives.

You could talk about all sorts of household equipment that sometimes hurts people.

But we have a second amendment in this country that doesn't protect swimming pools or knives.

It protects guns.

And as a result, it will always be a piece of debate in America,

whether or not any particular policy that regulates gun wielding or gun buying

is an infringement on liberty or a necessary law to protect the lives of teens

and 20-somethings who are most likely to die from guns.

With something like drugs, I certainly hope that there's not a lot of people

who are representing essentially big fentanyl.

But there are debates in the US about how much should we liberalize our drug law

because we don't necessarily want a war on drugs to lead to a world

where people are being killed by police officers for simple marijuana purchases.

On cars, yet again, it's exactly what this clash between freedom and safety is quite visceral.

There are people who say, you can't tell me what kind of car I'm allowed to buy

and not allowed to buy.

You can't tell me that I'm not allowed to live in a certain place and drive a certain amount.

I don't think that debate is even on the radar for Americans.

Cars are purely an expression of freedom.

And then on diet and exercise, reminded of the fact that I think it was a mayor, Michael Bloomberg,

in New York City, who wanted to pass attacks on big gulps and especially sugary beverages.

And the response for a lot of people was, you can take my big gulp out of my cold, dead hands.

There's no way that you are going to regulate that.

Again, you have maybe public safety, public health, against the freedom of consumers

to pour into their mouths whatever they want.

Do you feel like, and this gets to maybe one of the bigger stories that we're talking about here,

like there is a certain character of American freedom that we're just in quotes,

or American individualism that is upstream of these differences that we're talking about?

No, I honestly do.

I think, and one of the examples you touched on there that I just find especially remarkable

is the ACLU have been involved in campaigns to stop the rollout of automatic speed camera enforcement.

And this, again, I just find absolutely astonishing because any driver knows

the threat of being caught by a speed camera will cause you to limit your speed.

And in any other developed country, there are speed cameras everywhere.

People know there are speed limits, people drive slower, fewer people die in collisions.

And this is framed as a civil rights and sort of freedom issue in the US,

which is one of those things that as a non-American, the first time I read that I thought,

it seemed like something from the onion.

And I get it, I'm not from the US, I haven't sort of lived in that sort of cultural context.

But it just for me exemplifies how the particular culture around freedom, around individualism,

absolutely is part of the issue here.

And guns are just I think the most extreme example of this because it's quite a red-blue thing

and it's so sort of constantly fought over.

But it absolutely feeds into the stuff around diet and exercise,

it feeds into the stuff around roads as well.

So yeah, I do think there's something there.

I think just to bring this back to the very, very, very start of our conversation,

I think the interesting thing to ponder is whether that's also having an impact in America's much greater wealth

and whether what we're currently seeing at the moment is almost two sides of the same coin where you've got these attitudes

of freedom, of liberalism, of we shouldn't prevent people from doing things,

we should allow people to try lots of things.

That could be the kind of thing that gets you to 60% higher incomes,

but at the same time gets you to five years, five few years of life.

It reminds me the fact that in the vaccine debate, I was just so astonished

that the country that did more than any other nation on earth to mainstream mRNA technology

was also the world's leader in vaccine hesitancy for synthetic mRNA vaccines.

And it goes, I think you're right, to the fact that there is always in politics this tug of war between freedom and safety.

And we put a lot of weight in America between behind freedom.

We celebrate individual choice.

There is a disinclination in the US, I think, to use the interests of the state to pinch the freedom of choice of the individual,

or at least maybe a little bit more sophisticatedly said,

there is always a loud political contingency to argue that efforts by the state to keep individuals safe by pinching their freedoms is horrific and un-American.

That argument might just have currency in this country in a way that it doesn't in either countries,

such that you get to a situation where, as you said, an automated speeding camera seems not like an effort to keep people from dying on the roads,

but rather is fed back into a more general sense of, are we building a 1984 government?

Ironically, that's Orwell. I believe he was your chap.

But we have really held on to this fear that that kind of totalitarian government is creeping wherever we see the state try to impinge the freedom of choice of individuals.

Yeah, totally. And I think there's also this thing of, from my vantage point, it seems like very often this kind of thing in the US gets framed as well,

it's capitalism or it's communism almost.

And there seems to be a complete ignorance of the entire existence of Europe.

Like, you know, France, Germany, Netherlands are not communist countries.

These are capitalist countries. The dial has just turned that little bit more away from sort of complete rugged individualism, freedom, libertarianism,

towards something that is a little bit more concerned with the well-being of those at the very bottom and things like safety nets.

But, you know, these are still companies where people want to be rich.

These are still companies where you get some income inequality.

And I think just a better appreciation of the sort of whole range of options available for running a society might make it easier for people not to see these things as,

oh, well, you know, you're taking away our rights, you're trying to institute a sort of socialist regime, that kind of thing.

This may be a cheap point, but sometimes when people say they blame capitalism for complex outcomes, my response is like, you know, capitalism,

saying I hate capitalism is like saying I hate sandwiches.

There are 17,000 kind of sandwiches. Which ones do you like? Do you not like bread?

Like, that's his own thing. They just don't like bread. Don't say you don't like sandwiches.

There's so many different kinds of sandwiches. There's so many species underneath this genus, like, be more specific.

Most people who say they don't like capitalism, I think, on the left, are saying, let's be more like Denmark.

Denmark has free enterprise. They just have extremely high taxes and a really robust state that provides, you know, exquisite public services.

I want to close, though, on the very, the last point you just made, because it brings us back to the first question.

There's this idea that I remember reading about in biology that's, I think, called antagonistic pleiotropy, which sounds really complicated.

It basically means that there are certain genes that have two extremely different presentations or phenotypes, causes.

They cause one good thing, typically early in life, and they cause one bad thing.

So, for example, a gene that causes, say, early fertility, but also has a much higher risk of that person developing ovarian cancer.

America's attitude toward freedom, I don't think of it as good or bad.

I think of it as pleiotropic.

There's all of these things that flow from this American character.

And sometimes it makes us richer, and sometimes it makes us more creative, and sometimes it makes us more interesting.

And sometimes it makes us the kind of country that, to be honest, the modal smart immigrant wants to move to, of any country in the world,

like the demand to move to the U.S. among immigrant populations around the world is extremely high.

And yet we fail, perhaps because of this very same character, to do the most fundamental thing of any modern state,

which is to keep our children alive and keep our young adults alive.

I don't know that there's an answer here.

I find it really, you know, I find it haunting and important to sort of see this big picture that, you know,

America's freedom-loving nature can have this almost kaleidoscopic effect where, you know, you shine one light through it and has this,

you know, brilliant and bizarre variant of colors that come out of it.

Yeah, I totally agree.

And I was just thinking, as you were saying that about things like large language models,

there's almost a small example of that.

This is something where there's potentially huge upside, and there are certainly some downsides.

And this is something that is booming in Silicon Valley, and it's not booming in Europe,

and it's not booming in other parts of the world.

And it's because of that attitude of, you know, let's just try and do something amazing.

And that, I think you can see how that can result in brilliant outcomes.

Europe has been very openly and vocally envious of Silicon Valley for decades.

And yet nobody in Europe is envious of U.S. mortality rates.

So, yeah, I do think it's...

And Italy just banned chat GPT.

That's a fantastic example.

I mean, talking about an incredibly different approach to large language models, you know,

California built them, Italy banned them.

Yeah, yeah. And as a British, there's constant frustration here about how difficult we've made it here to do certain things

and to build certain things.

I know there's frustrations with difficulties of building infrastructure everywhere, including the U.S.

But, yeah, the sort of the overly sometimes small-minded or overly cautious approach

in the U.K. and some European countries can absolutely be a frustration as well.

But if that's massively reducing our exposure to various sort of social ills,

then you've got to ask whether it's worth it.

Jonathan Murdoch, thank you so much.

Thank you.

Thank you for listening.

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