America Fails the Civilization Test

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The true test of a civilization may be the answer to a basic question: Can it keep its children alive?

For most of recorded history, the answer everywhere was plainly no. Roughly half of all people—tens of billions of us—died before finishing puberty until about the 1700s, when breakthroughs in medicine and hygiene led to tremendous advances in longevity. In Central Europe, for example, the mortality rate for children fell from roughly 50 percent in 1750 to 0.3 percent in 2020. You will not find more unambiguous evidence of human progress.

How’s the U.S. doing on the civilization test? When graded on a curve against its peer nations, it is failing. The U.S. mortality rate is much higher, at almost every age, than that of most of Europe, Japan, and Australia. That is, compared with the citizens of these nations, American infants are less likely to turn 5, American teenagers are less likely to turn 30, and American 30-somethings are less likely to survive to retirement.

Last year, I called the U.S. the rich death trap of the modern world. The “rich” part is important to observe and hard to overstate. The typical American spends almost 50 percent more each year than the typical Brit, and a trucker in Oklahoma earns more than a doctor in Portugal.

This extra cash ought to buy us more years of living. For most countries, higher incomes translate automatically into longer lives. But not for today’s Americans. A new analysis by John Burn-Murdoch, a data journalist at the Financial Times, shows that the typical American is 100 percent more likely to die than the typical Western European at almost every age from birth until retirement.

Imagine I offered you a pill and told you that taking this mystery medication would have two effects. First, it would increase your disposable income by almost half. Second, it would double your odds of dying in the next 365 days. To be an average American is to fill a lifetime prescription of that medication and take the pill nightly.

According to data collected by Burn-Murdoch, a typical American baby is about 1.8 times more likely to die in her first year than the average infant from a group of similarly rich countries: Australia, Austria, Switzerland, Germany, France, the U.K., Japan, the Netherlands, and Sweden. Let’s think of this 1.8 figure as “the U.S. death ratio”—the annual mortality rate in the U.S., as a multiple of similarly rich countries.

By the time an American turns 18, the U.S. death ratio surges to 2.8. By 29, the U.S. death ratio rockets to its peak of 4.22, meaning that the typical American is more than four times more likely to die than the average resident in our basket of high-income nations. In direct country-to-country comparisons, the ratio is even higher. The average American my age, in his mid-to-late 30s, is roughly six times more likely to die in the next year than his counterpart in Switzerland.

The average U.S. death ratio stays higher than three for practically the entire period between ages 30 and 50, meaning that the typical middle-aged American is roughly three times more likely to die within the year than his counterpart in Western Europe or Australia. Only in our late 80s and 90s are Americans statistically on par, or even slightly better off, than residents of other rich nations.

“One in 25 American five-year-olds today will not make it to their 40th birthday,” Burn-Murdoch observed. On average, a representative U.S. kindergarten class will lose one member before their fifth decade of life.

What is going on here? The first logical suspect might be guns. According to a recent Pew analysis of CDC data, gun deaths among U.S. children and teens have doubled in the past 10 years, reaching the highest level of gun violence against children recorded this century. In March, a 20-something shooter fired 152 rounds at a Christian school in Nashville, Tennessee, killing three children and three adults, before being killed by police. In April, a 20-something shooter killed six people at a Louisville, Kentucky, bank, before he, too, was killed by police.

People everywhere suffer from mental-health problems, rage, and fear. But Americans have more guns to channel those all-too-human emotions into a bullet fired at another person. One could tell a similar story about drug overdoses and car deaths. In all of these cases, America suffers not from a monopoly on despair and aggression, but from an oversupply of instruments of death. We have more drug-overdose deaths than any other high-income country because we have so much more fentanyl, even per capita. Americans drive more than other countries, leading to our higher-than-average death rate from road accidents. Even on a per-miles-driven basis, our death rate is extraordinary.

When I reached out to Burn-Murdoch, I expected that these three culprits—guns, drugs, and cars—would explain most of our death ratio. However, on my podcast, Plain English, he argued that Americans’ health (and access to health care) seems to be the most important factor. America’s prevalence of cardiovascular and metabolic disease is so high that it accounts for more of our early mortality than guns, drugs, and cars combined.

Disentangling America’s health issues is complicated, but I can offer three data points. First, American obesity is unusually high, which likely leads to a larger number of early and middle-aged deaths. Second, Americans are unusually sedentary. We take at least 30 percent fewer steps a day than people do in Australia, Switzerland, and Japan. Finally, U.S. access to care is unusually unequal—and our health-care outcomes are unusually tied to income. As the Northwestern University economist Hannes Schwandt found, Black teens in the poorest U.S. areas are roughly twice as likely to die before they turn 20 as teenagers in the richest counties. This outcome is logically downstream of America’s paucity of universal care and our shortage of physicians, especially in low-income areas.

There is no single meta-explanation for America’s death ratio that’s capacious enough to account for our higher rates of death from guns, drugs, cars, infant mortality, diet, exercise, and unequal access to care. I’ll try to offer one anyway—only to immediately contradict it.

Let’s start with the idea, however simplistic, that voters and politicians in the U.S. care so much about freedom in that old-fashioned ’Merica-lovin’ kind of way that we’re unwilling to promote public safety if those rules constrict individual choice. That’s how you get a country with infamously laissez-faire firearms laws, more guns than people, lax and poorly enforced driving laws, and a conservative movement that has repeatedly tried to block, overturn, or limit the expansion of universal health insurance on the grounds that it impedes consumer choice. Among the rich, this hyper-individualistic mindset can manifest as a smash-and-grab attitude toward life, with surprising consequences for the less fortunate. For example, childhood obesity is on the rise at the same time that youth-sports participation is in decline among low-income kids. What seems to be happening at the national level is that rich families, seeking to burnish their child’s résumé for college, are pulling their kids out of local leagues so that they can participate in prestigious pay-to-play travel teams. At scale, these decisions devastate the local youth-sports leagues for the benefit of increasing by half a percentage point the odds of a wealthy kid getting into an Ivy League school.

The problem with the Freedom and Individualism Theory of Everything is that, in many cases, America’s problem isn’t freedom-worship, but actually something quite like its opposite: overregulation. In medicine, excessive regulation and risk aversion on the part of the FDA and Institutional Review Boards have very likely slowed the development and adoption of new lifesaving treatments. This has created what the economist Alex Tabarrok calls an “invisible graveyard” of people killed by regulators preventing access to therapies that would have saved their life. Consider, in the same vein, the problem of diet and exercise. Are Americans unusually sedentary because they love freedom so very much? It’s possible, I guess. But the more likely explanation is that restrictive housing policies have made it too hard for middle- and low-income families to live near downtown business districts, which forces many of them to drive more than they would like, thus reducing everyday walking and exercise.

America is caught in a lurch between oversight and overkill, sometimes promoting individual freedom, with luridly fatal consequences, and sometimes blocking policies and products, with subtly fatal consequences. That’s not straightforward, and it’s damn hard to solve. But mortality rates are the final test of civilization. Who said that test should be easy?