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OPINION

Life expectancy depends on where you call home

The coronavirus pandemic has been a wake-up call, not just to the looming threat of infectious disease but also to the many social determinants of health that dictate who suffers and who prospers.

Globe staff illustration/Adobe
Globe Staff/Adobe

American life expectancy fell by nearly a year and a half in 2020 — the sharpest one-year decline since World War II. A chilling statistic for sure, but one with a clear explanation: COVID-19 led to a profound increase in excess deaths, particularly among Black and Hispanic residents.

What’s more complex — and just as alarming — is the trend that emerged long before the pandemic took hold.

After decades of remarkable progress, US life expectancy has remained relatively stagnant since 2010, even dropping slightly between 2014 and 2017. Today our lifespans lag behind those in other high-income nations by an average of five years. That’s despite having the highest health care spending per capita in the world.

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Reversing this trend is critical.

Contrary to what the term implies, life expectancy tells us something even more significant than how long a person might expect to live. It’s a key indicator of overall population health, which can be compared across time. More broadly, it points to the overall quality of life in a given place.

A decline in life expectancy — or even a plateau — means that premature deaths are on the rise. In the United States, that reality can be attributed to a range of crises, from rampant substance use disorder to obesity and the rise in infant mortality and chronic conditions like diabetes and cardiovascular disease (all of which put people at higher risk of hospitalization and death from COVID-19).

And it tells a powerful story about inequities across society.

Look no further than our own backyard. Here in Massachusetts, a relatively wealthy, well-educated state with near-universal health care coverage, people have a longer life expectancy than the vast majority of other Americans, at an estimated age of 80.1 years old (compared with 77.3 in the nation as a whole). But zoom in a little closer and the picture isn’t nearly as encouraging.

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Life expectancy varies widely depending on exactly where you call home — not just what town, but what neighborhood. For example, people in the Back Bay are living close to 90 years. But take the T a couple of stops to Roxbury and that number plummets to closer to 60 years. This devastating gap is a reflection of growing income inequality — and systemic discrimination that has siphoned opportunities for health and wellness from marginalized communities for decades.

Our city isn’t an outlier in this respect. All across the country, life expectancy is lower in areas where a large share of people didn’t graduate from high school, lack health insurance, and are low-income or unemployed.

These disparities aren’t simply a matter of health care access, though there’s no question that affordable, high-quality care is essential for maintaining good health. They are primarily driven by other aspects of life. It is widely documented that the conditions in which we live, work, and play, known as the “social determinants of health,” account for 80 to 90 percent of overall health and well-being.

We see this all too vividly in rural America. Chronic financial strain and the erosion of opportunity in recent years have led to an uptick in what we call “deaths of despair,” including overdoses and suicide. Noncollege-educated middle-aged white Americans, particularly those who are no longer in the labor market, are especially prone to these tragedies.

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Then there are the vast and enduring health consequences of structural racism. To understand how they manifest today, one need only look at the disparities between predominantly white and predominantly Black neighborhoods in everything from education and income to pollution exposure, access to green spaces, nutritious food, and affordable housing. This is to say nothing of physical and emotional wear and tear caused by racism itself.

The pandemic has not only laid bare these longstanding injustices, it has also exacerbated them. People in underserved communities have a higher risk of COVID-19 exposure where they live and work, have worse access to testing and vaccines, and are more likely to have underlying health conditions that make the virus more deadly. And they are more likely to face future health consequences from the prolonged isolation, educational disruption, and economic downturn that have accompanied this crisis.

That said, there are reasons to be hopeful.

The past 17 months have been a wake-up call, not just to the looming threat of infectious disease but also to the many social determinants of health that dictate who suffers and who prospers. And that awakening can be a tipping point for change.

Dismantling health inequities will take significant investments in our social infrastructure, like expanding access to high-quality early childhood education, affordable housing, and efficient public transportation. It will require us to enact policies that address racial and economic inequality, from eliminating mass incarceration to promoting wealth-building through initiatives like “baby bonds” and investing in revitalizing historically underserved neighborhoods through programs such as the National Community Reinvestment Coalition.

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All of this change will take partnerships across sectors — not just between lawmakers and health officials, but nonprofit and business leaders, community organizers, and storytellers as well. But imagine, if we come together to seize this moment, we can ensure all people — from the Back Bay to Roxbury and all across the country — can live longer, healthier lives for generations to come.

Michelle A. Williams is dean of the faculty, Harvard T.H. Chan School of Public Health, and professor of public health and international development at the Harvard Chan School and Harvard Kennedy School.