Aaron: A couple of weeks ago, John did a Vlogbrothers video on racism. It was fantastic, and I assume all of you already watched, but if you didn't, you should. One of the things he mentioned is that differences in life expectancy can be evidence of potential differences in how people of different races are treated.

Life expectancy is tricky though. It's something I'm really interested in and it's also the topic of this weeks healthcare triage.

(Intro)

What is life expectancy? Generally it's how long you can expect to live on average. Most people use it as short hand to describe what is more accurately life expectancy at birth. That's how long a baby born today can expect to live on average. 

It's also the metric you hear people quote when they want to talk about how awesome everything is because life expectancy is so much better today than it was say 50 years ago. And it's true. 

Look at this chart showing life expectancy for all individuals at birth from 1950 to 2007. According to this, almost no-one can expect to live much past 65 in 1950. Moreover, there's been a steep climb for the past few decades. If you take this at face value, then we must be awesomely better at keeping people alive longer.

There are problems with this belief though. Let me walk you through an example to explain why. Let's take a theoretical cohort of 100 people. Let's stipulate that the life expectancy at birth of this group is 74. In this cohort there's a baby who dies soon after birth and there are 50 people who live past the age of 65.

Scenario A - I manage to find an excellent treatment for what kills that baby in the cohort. It's not perfect but it allows the baby to live to age 50.

Scenario B - I manage to find a treatment for a common illness that affects elderly people and can extend their life by an average of 1 year. 

In both these scenarios I've managed to add 50 years to the cohort so the average life expectancy at birth has increased to about 74.5 years. But this hopefully shows you the enormous power of saving one baby or child, in that saving one infant for 50 years is the same as saving 50 adults for 1 year.

The take home message here is that treating children well does far more to increase life expectancy at birth than treating adults for illnesses that kill them. And we've had remarkable improvements in the treatment of children and chronic diseases in the last 60 years. Vaccines do wonders. People can live far longer with illnesses that used to kill kids at relatively young ages. Many childhood cancers can be cured and saving those children has resulted in relatively large increases in the overall life expectancy at birth. 

In scenario A I'm not getting older people to live longer at all. In scenario B however, I have increased the life expectancy at 65 for a full year. And if we want to see how much better we've gotten in extending the life of people at the older end of the spectrum, we need a different metric.

We've got one. It's called life expectancy at age 65. That's how long a person who makes it to 65 can expect to live. Here's a chart.
You can see that even in 1950, if you made it to 65 years of age, you can expect to live on average until you were 79. I was shocked when I first learned that. That means that tonnes of people who made it to retirement were making it into their late 70s and even their 80s or more back in 1950. We've made some gains in the 60 years that followed. 

So life expectancy at age 65 increased to almost 84 a couple years ago. So yeah, progress. But it's not nearly the size of the increase that many people think it is. And circling back to John's video, it's not equally shared among all people. Here's life expectancy at age 65 from 1970 through to 2007 by race. But even that doesn't tell us the whole picture.

Part of the problem with data like these is that things like socio-economic status are so tied up in race and poverty is associated with pretty much every bad health outcome you can imagine. So what would be helpful might be a chart of life expectancy at age 65 by income and I found a paper published in Social Security Bulletin in 2007 that did the work for me.

Here's a chart. What you're looking at is the life expectancy of a male who reached age 65 in 1977 to 2007. The blue line is the top 50% of earners. The green line is the bottom 50% and while the top half of earners saw an increase of their life expectancy at age 65 rise about 5 years over these three decades, the bottom half saw their life expectancy at age 65 rise barely a year. 

Not everyone is sharing in these gains. Here's another chart I made from that data comparing the life expectancy at age 65 for social security covered male workers in four different earning percentile brackets in the United States and other OECD countries. 

While the richest 25% of Americans compare favorably to almost any other country, those in the bottom 50% of earners don't. In fact, half the people in the United States can expect to live with shorter lives from age 65 on than the average person in almost all of these other countries. 

Think about that when arguing that the richest country in the world can afford social security and medicare starting at age 65 because everyone in this country is seeing their life expectancy increased. And also don't tell me that it's violence or homicide or drug use or accidents, we're talking about 65 year olds and older. 

And that brings us to even more depressing news. Lots of people aren't seeing their life expectancy increase, they're seeing it decrease.

This is a chart from a study published in Health Affairs 2 years ago. What you're seeing is life expectancy by years of education for a white woman at age 25 in three different years. Again, this gets you beyond the childhood period.

In general, the more educated you are, the longer you can expect to live. But I'm more interested in the trends over time. The blue column is life expectancy for these women in 1990, the green line in 2000 and the red line in 2008.

If you've been to graduate school, your life expectancy has been going up quite nicely. If you finished high school or been to college the gains are less pronounced but they're there. The horror story is if you didn't finish high school. Then in just the 18 year period, your life expectancy is dropped quite sharply.

The trends for white males with less than a high school education were similarly bad. Ironically, Hispanic and black people of both sexes show that even in this under educated group life expectancy increased over time. The decrease, it's mostly in white people. Don't kid yourself. This is just a proxy for socio-economic status or something else. It's very unlikely that somehow education makes you live longer in and of itself. It's just more data on how life expectancy is going down for some. More than some. 

Here's the last chart I want you to think about. The red areas are where life expectancy  fell from 1987 to 2007 for women. I'm willing to bet those also happened in some of the poorest areas in the country. 

Life expectancy at birth is much higher than it used to be. But that's because we're doing a better job of saving kids not because we're making older people live longer. Life expectancy at age 65 is also up but not nearly as much. Those gains aren't equally shared among people of different races and they're certainly not equally shared among the rich and the poor. In far too many areas of this country life expectancy is dropping. 

(Outro)