Tuesday, January 3, 2023


America's declining life expectancy, explained

For the second straight year, life expectancy in America has dropped significantly. The Centers for Disease Control and Prevention on Dec. 22 announced that "life expectancy at birth for the U.S. population decreased from 77 years in 2020 to 76.4 years in 2021." In 2019, the average American could expect to live to be 79 years old. Now that number is 76. 

Indigenous groups, which include American Indian and Alaska native people, have suffered the worst: Life expectancy in those communities has dropped to 65.2 years from 71.8 in 2019 compared to 76.4 in 2021 from 78.8 in 2019 for white people per Politico. The U.S. life expectancy is now the lowest it has been since 1996. Why is American health doing so poorly? Here's everything you need to know:

Why is life expectancy dropping?

The two stand-out reasons for the drop are COVID-19 and overdose deaths. The number of COVID deaths increased by 20 percent from 2020 to 2021, making it the third largest cause of death, Politico continues. Accidental deaths, which include overdose deaths, were the fourth largest cause of death. 

The conditions of the pandemic, "had a magnifying effect on an already-devastating overdose crisis and exacerbated many of the stressors in society that make people more vulnerable to taking drugs," commented Dr. Nora Volkow, director of the National Institute on Drug Abuse. Deaths from drug overdoses increased by 16 percent in 2021 compared to 2022, clocking in at just under 107,000 casualties. This is largely attributed to the growing opioid epidemic and the rise in fentanyl usage in the U.S. 

The top two contributors to American deaths were heart disease and cancer. Some of the heart disease deaths may actually be related to the coronavirus, Time reports — both because the pandemic overwhelmed understaffed hospitals, but also because a COVID infection "can damage the heart and is thought to have raised patients' risk of dying."

"It's not a good year for the data, let's put it that way," commented CDC statistician Kenneth Kochanek.

Is the U.S. doing worse or better than other countries during the pandemic?

Worse, at least compared to our peer nations. A study in August showed that eight comparable nations actually had a "bounce back" of life expectancy following the worldwide decline due to COVID-19, The Washington Post reports. These included Belgium, Switzerland, Spain, and France. "With the vaccine available, and other pandemic control measures, a lot of other countries did recover," said Steven Woolf, professor at the Virginia Commonwealth University's School of Medicine.

The U.S. was among 12 other countries where life expectancy continued to drop, including Germany, Chile, Bulgaria, Greece, and Estonia, the Post continues. Some of the disparity is probably due to America's "don't tread on me" conservative political culture: "Those countries had more successful vaccination campaigns and populations that were more willing to take behavioral measures to prevent infections, such as wearing masks," notes The New York Times. 

Is this just a short-term thing? 

Unfortunately, no. "American life expectancy began to stagnate around 2010 — while other developed countries continued to see gains," Stat News observes. In 2018, two years before the pandemic began, The Washington Post pointed out that the U.S. was already experiencing the "longest sustained decline in expected life span at birth in a century, an appalling performance not seen in the United States since 1915 through 1918."

Researchers have struggled to find a silver bullet explanation for why American health has declined so precipitously. Theories that stagnating life expectancy can be attributed to obesity rates and opioid drug use "fail to explain a problem that feels broader," The New York Times reported back in 2016.Instead, the Los Angeles Times reported the next year, the problem appears to be driven by a range of factors, including "diseases linked to social and economic privation, a healthcare system with glaring gaps and blind spots, and profound psychological distress."

Why are indigenous communities hit so hard by this trend?

It can't be overstated: COVID has hit native communities with particular viciousness. "American Indians are 2.2 times more likely to die from COVID-19 and 3.2 times more likely to be hospitalized for the virus," NPR reports.

The biggest factor: poverty. One in four Native Americans lives below the poverty line, The New York Times reports. That leads to "inadequate access to health care, poor infrastructure, and crowded housing, much of it the legacy of broken government promises and centuries of bigotry." What's more, the newspaper points out, discrimination has been linked to "the erosion of mental and physical health, as has exposure to polluted air and water." 

Dr. Ann Bullock, a member of the Minnesota Chippewa tribe who formerly served at the Indian Health Services agency, summed it up for the newspaper: "This is simply what happens biologically to populations that are chronically and profoundly stressed and deprived of resources."

What can be done? 

First of all, there is some good news in the numbers. "Mortality's been a little better in 2022 than it was in 2020, so I think it's likely that we would see maybe a slight increase in life expectancy," the CDC's Robert Anderson told Reuters. But it's tough to say whether that trend will last through the end of the year: Deaths usually rise during the winter months.

Even if life expectancy rebounds slightly this year, though, many observers say the latest news means America needs to reconsider both health and economic policy as the country continues to emerge from the pandemic. The trend of shortening life spans is a societal problem, after all. "Life expectancy isn't really a prediction for a single individual," Kate Sheridan says at STAT News. "It's more like a check engine light — an indicator for the health of society as a whole."

Update Dec. 22, 2022: This piece has been updated with the latest figures from the CDC. 

-- Joel Mathis, Devika Rao, The Week

 Americans have ‘tip fatigue’

Tipping 20% at a sit-down restaurant is still the standard however, consumers are less inclined to give as much for a carry-out coffee or take-away snack.

“Part of it is tip fatigue,” says Eric Plam, founder and CEO of Uptip. At the Sweetly Bakery & Cafe in Battle Ground, Washington, near Portland, Oregon, customers seem to be feeling a little less generous lately. With inflation near record highs and consumers increasingly cashstrapped, a gratuity isn’t what it used to be.

“Since everything got more expensive, we’ve seen a decline in tipping,” said Sweetly’s owner, Irina Sirotkina. Like many other businesses, the bakery uses a contactless and digital payment method, which prompts you to leave a tip when you pay. There are predetermined options ranging from 15% to 25% for each transaction. “We encourage people to tip but it’s not mandatory, obviously,” Sirotkina said.

 Although the average transaction at Sweetly is less than $20, which means a gratuity would be a few dollars at most, fewer people leave anything at all. “Only around 1 in 5 people tip,” Sirotkina estimated. Even though many Americans said they would tip more than usual once business activities resumed after the Covid pandemic, consumer habits haven’t changed much in the end. Tipping 20% at a sit-down restaurant is still the standard, etiquette experts say. But there’s less consensus when it comes to a carry-out coffee or take-away snack.

Overall, tipping has remained largely flat at quick-service restaurants, according to Toast’s most recent restaurant trends report. Tips average 17%, nearly unchanged from a year ago. But when it comes to takeout, customers are tipping less--now down to 14.5%, on average, after climbing earlier in the pandemic, the restaurant software vendor found. Other payment software providers have also reported that these types of tips have fallen over the last year.

For example, Toast’s rival, Square, found that the average tip at quick-service restaurants, which includes cafes and coffee shops, fell from 17.2% to 15.2% from March 2021 to the end of February, according to a report from The Wall Street Journal.

“Part of it is tip fatigue,” said Eric Plam, founder and CEO of San Francisco-based startup Uptip, which aims to facilitate cashless tipping.

 “During Covid, everyone was shell-shocked and feeling generous,” Plam said. Now, “you are starting to see people pull back a little bit,” he noted, particularly when it comes to point-of-sale tipping, which prompts customers to tip even before they’ve received the product or service. “This point-of-sale tipping is what people resist the most,” he said, “compelling you to tip right there on the spot.”

 However, transactions are increasingly cashless and workers in the service industry are earning minimum or less than minimum wage so having a method to tip is critical, Plam added. In fact, the average wage for fast-food and counter workers is $14.34 an hour for full-time staff and $12.14 for part-time employees-- including tips--according to the most recent data from the U.S. Bureau of Labor Statistics.

 A landmark bill in California aims to raise the minimum wage to up to $22 an hour for fast-food and quick-service workers at chains with more than 100 locations nationally. California’s current wage floor is $15.50 an hour. President Joe Biden and many Democratic lawmakers have pushed for a $15 hourly wage floor across the U.S. The current federal minimum wage is $7.25 an hour and has remained unchanged since 2009.

“We are sympathetic, but it doesn’t feel good,” Plam said of point-of-sale tipping. “Now that the pandemic is essentially over, it's starting to shake out now,” he added. “The good news is we’re rethinking it.

--Jessica Dickler, CNBC

Brain fog:  Most misunderstood Long Covid symptom

On March 25, 2020, Hannah Davis was texting with two friends when she realized that she couldn’t understand one of their messages. In hindsight, that was the first sign that she had COVID-19. It was also her first experience with the phenomenon known as “brain fog,” and the moment when her old life contracted into her current one.

She once worked in artificial intelligence and analyzed complex systems without hesitation, but now “runs into a mental wall” when faced with tasks as simple as filling out forms. Her memory, once vivid, feels frayed and fleeting. Former mundanities— buying food, making meals, cleaning up—can be agonizingly difficult. Her inner world —what she calls “the extras of thinking, like daydreaming, making plans, imagining”—is gone.

 The fog “is so encompassing,” she told me, “It affects every area of my life.”

For more than 900 days, while other long-COVID symptoms have waxed and waned, her brain fog has never really lifted. Of long COVID’s many possible symptoms, brain fog “is by far one of the most disabling and destructive,” Emma Ladds, a primary-care specialist from the University of Oxford, told me. It’s also among the most misunderstood. It wasn’t even included in the list of possible COVID symptoms when the coronavirus pandemic first began.

But 20 to 30 percent of patients report brain fog three months after their initial infection, as do 65 to 85 percent of the long-haulers who stay sick for much longer. It can afflict people who were never ill enough to need a ventilator—or any hospital care. And it can affect young people in the prime of their mental lives.

Long-haulers with brain fog say that it’s like none of the things that people—including many medical professionals—jeeringly compare it to. It is more profound than the clouded thinking that accompanies hangovers, stress, or fatigue.

For Davis, it has been distinct from and worse than her experience with ADHD. It is not psychosomatic and involves real changes to the structure and chemistry of the brain. It is not a mood disorder: “If anyone is saying that this is due to depression and anxiety, they have no basis for that, and data suggest it might be the other direction,” Joanna Hellmuth, a neurologist at UC San Francisco, told me.

And despite its nebulous name, brain fog is not an umbrella term for every possible mental problem. At its core, Hellmuth said, it is almost always a disorder of “executive function”—the set of mental abilities that includes focusing attention, holding information in mind, and blocking out distractions. These skills are so foundational that when they crumble, much of a person’s cognitive edifice collapses. Anything involving concentration, multitasking, and planning—that is, almost everything important—becomes absurdly arduous.

 “It raises what are unconscious processes for healthy people to the level of conscious decision making,” Fiona Robertson, a writer based in Aberdeen, Scotland, told me. For example, Robertson’s brain often loses focus mid-sentence, leading to what she jokingly calls “so-yeah syndrome”: “I forget what I’m saying, tail off, and go, ‘So, yeah …’” she said. Brain fog stopped Kristen Tjaden from driving, because she’d forget her destination en route. For more than a year, she couldn’t read, either, because making sense of a series of words had become too difficult. Angela Meriquez Vázquez told me it once took her two hours to schedule a meeting over email: She’d check her calendar, but the information would slip in the second it took to bring up her inbox. At her worst, she couldn’t unload a dishwasher, because identifying an object, remembering where it should go, and putting it there was too complicated.

Memory suffers, too, but in a different way from degenerative conditions like Alzheimer’s. The memories are there, but with executive function malfunctioning, the brain neither chooses the important things to store nor retrieves that information efficiently.

Davis, who is part of the Patient-Led Research Collaborative, can remember facts from scientific papers, but not events. When she thinks of her loved ones, or her old life, they feel distant. “Moments that affected me don’t feel like they’re part of me anymore,” she said. “It feels like I am a void and I’m living in a void.”

Most people with brain fog are not so severely affected, and gradually improve with time. But even when people recover enough to work, they can struggle with minds that are less nimble than before. “We’re used to driving a sports car, and now we are left with a jalopy,” Vázquez said. In some professions, a jalopy won’t cut it. “I’ve had surgeons who can’t go back to surgery, because they need their executive function,” Monica Verduzco-Gutierrez, a rehabilitation specialist at UT Health San Antonio, told me.

Robertson, meanwhile, was studying theoretical physics in college when she first got sick, and her fog occluded a career path that was once brightly lit. “I used to sparkle, like I could pull these things together and start to see how the universe works,” she told me. “I’ve never been able to access that sensation again, and I miss it, every day, like an ache.”

That loss of identity was as disruptive as the physical aspects of the disease, which “I always thought I could deal with … if I could just think properly,” Robertson said. “This is the thing that’s destabilized me most.”

 Robertson predicted that the pandemic would trigger a wave of cognitive impairment in March 2020. Her brain fog began two decades earlier, likely with a different viral illness, but she developed the same executive-function impairments that long-haulers experience, which then worsened when she got COVID last year. That specific constellation of problems also befalls many people living with HIV, epileptics after seizures, cancer patients experiencing so-called chemo brain, and people with several complex chronic illnesses such as fibromyalgia. It’s part of the diagnostic criteria for myalgic encephalomyelitis, also known as chronic fatigue syndrome, or ME/CFS—a condition that Davis and many other long-haulers now have.

Brain fog existed well before COVID, affecting many people whose conditions were stigmatized, dismissed, or neglected. “For all of those years, people just treated it like it’s not worth researching,” Robertson told me. “So many of us were told, Oh, it’s just a bit of a depression.” Several clinicians I spoke with argued that the term brain fog makes the condition sound like a temporary inconvenience and deprives patients of the legitimacy that more medicalized language like cognitive impairment would bestow.

 But Aparna Nair, a historian of disability at the University of Oklahoma, noted that disability communities have used the term for decades, and there are many other reasons behind brain fog’s dismissal beyond terminology. (A surfeit of syllables didn’t stop fibromyalgia and myalgic encephalomyelitis from being trivialized.) For example, Hellmuth noted that in her field of cognitive neurology, “virtually all the infrastructure and teaching” centers on degenerative diseases like Alzheimer’s, in which rogue proteins afflict elderly brains.

 Few researchers know that viruses can cause cognitive disorders in younger people, so few study their effects. “As a result, no one learns about it in medical school,” Hellmuth said. And because “there’s not a lot of humility in medicine, people end up blaming patients instead of looking for answers,” she said. People with brain fog also excel at hiding it: None of the long-haulers I’ve interviewed sounded cognitively impaired. But at times when her speech is obviously sluggish, “nobody except my husband and mother see me,” Robertson said.

The stigma that long-haulers experience also motivates them to present as normal in social situations or doctor appointments, which compounds the mistaken sense that they’re less impaired than they claim—and can be debilitatingly draining. “They’ll do what is asked of them when you’re testing them, and your results will say they were normal,” David Putrino, who leads a long-COVID rehabilitation clinic at Mount Sinai, told me. “It’s only if you check in on them two days later that you’ll see you’ve wrecked them for a week.”

“We also don’t have the right tools for measuring brain fog,” Putrino said. Doctors often use the Montreal Cognitive Assessment, which was designed to uncover extreme mental problems in elderly people with dementia, and “isn’t validated for anyone under age 55,” Hellmuth told me. Even a person with severe brain fog can ace it. More sophisticated tests exist, but they still compare people with the population average rather than their previous baseline. “A high-functioning person with a decline in their abilities who falls within the normal range is told they don’t have a problem,” Hellmuth said. This pattern exists for many long-COVID symptoms: Doctors order inappropriate or overly simplistic tests, whose negative results are used to discredit patients’ genuine symptoms.

 It doesn’t help that brain fog (and long COVID more generally) disproportionately affects women, who have a long history of being labeled as emotional or hysterical by the medical establishment. But every patient with brain fog “tells me the exact same story of executive-function symptoms,” Hellmuth said. “If people were making this up, the clinical narrative wouldn’t be the same.”

--Ed Yong, The Atlantic

No comments: