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Here's a WEAVE through life and death, America and Europe, intimidation and courage. [1]

['This Content Is Not Subject To Review Daily Kos Staff Prior To Publication.']

Date: 2025-05-01

This post is going to be what some would call a weave. Stay with me.

A groundbreaking study published April 2nd, 2025 in the New England Journal of Medicine reveals a paradoxical finding: while wealth correlates with longevity globally, less affluent Europeans outlive their wealthier American counterparts.

This research arrives at a particularly significant moment, as the NEJM itself has become the subject of unusual government scrutiny and intimidation from the interim U.S. Attorney for the District of Columbia questioning alleged bias in publication decisions.

Are the two related?

What should you know about the politics of longevity and citizen happiness, and what actionable insights will this reckoning reveal?

Let’s even weave a thread all the way back to that stinging NEJM editorial in 2020 about leadership malpractice during the early, desperate days of the pandemic.

Americans Die Earlier Than Europeans: The Evidence

Let’s first dive into the new study in the NEJM that some interested parties might find inconvenient. This longitudinal study followed 73,838 adults aged 50-85 across the US and 16 European countries from 2010 to 2022. The statistics paint a stark picture: Americans experienced 6.5 deaths per 1000 person-years compared to just 2.9 deaths per 1000 person-years in northern and western Europe—more than twice the mortality rate.

When examining the adjusted hazard ratios across wealth quartiles, the researchers found consistent protective effects of greater wealth in all regions. Compared to the poorest quartile (quartile 1), the hazard ratios for death were 0.80 for quartile 2, 0.68 for quartile 3, and 0.60 for quartile 4. In practical terms, this means that the wealthiest participants had a 40% lower risk of dying during the study period compared to the poorest participants.

What's truly revealing is the comparison of similar wealth groups across countries. The study's Kaplan-Meier survival analysis showed that Americans in the wealthiest quartile (Q4) had mortality rates comparable to or even higher than Europeans in the poorest quartile (Q1) in northern and western Europe. In other words, the most affluent Americans faced similar mortality risks as the most economically disadvantaged northern Europeans.

Within each wealth quartile, Europeans consistently showed better survival rates than their American counterparts. This pattern held true across all four wealth quartiles, with Europeans in each wealth category outliving Americans in the equivalent category.

Regional differences within the United States were also notable. The Midwest had the highest mortality rate at 7.2 deaths per 1000 person-years, while the West had the lowest at 5.0 – but still significantly higher than any European region studied. The gap between the poorest and wealthiest quartiles was most pronounced in the Midwest and South, regions characterized by greater inequality and less robust social services.

Another reporting of this study that was forwarded to me (thanks NM!) provided this excellent graph of US vs European life expectancies over time. You can see the US was ahead of the EU until the curves started converging in the late 1980’s really. Hmmm.

Why This Disparity Exists

To understand these startling findings, we must examine the complex mechanisms through which wealth influences health outcomes. The authors of the NEJM study acknowledged that the scope of their research could not be used to prove causal mechanisms. And yet several key factors contribute to these startling differences if we do a little outside-the-box reading.

First, ABBA won the Eurovision Song Contest of 1974, unleashing a powerful sense of wellbeing that would last through the modern day:

Second, Penelope Cruz was born in Spain.

And third… we should start over with this analysis, as it has gone a little off track:

1. Healthcare Access and Quality

Wealth directly determines access to preventive care, specialists, and innovative treatments in the US. While European healthcare systems provide universal coverage regardless of socioeconomic status, the American system creates significant financial barriers even for middle-class families. Out-of-pocket costs, insurance complexities, and coverage gaps create a tiered system where quality care correlates directly with financial resources.

Are you happy with your health insurance?

2. Social Safety Nets

European states feature robust social protection systems that buffer health impacts across socioeconomic groups. These include better paid sick leave, family support, unemployment benefits, housing assistance, and retirement security. The United States, by contrast, offers a comparatively threadbare safety net, leaving individuals more vulnerable to health-damaging financial shocks across the wealth spectrum.

3. Income Inequality

The United States has substantially higher income and wealth inequality than most European countries, creating steeper social gradients in health. Research consistently shows that societies with greater inequality experience worse health outcomes across all socioeconomic groups—even the wealthy fare worse in highly unequal societies. This "pollution effect" of inequality may help explain why even wealthy Americans experience worse health than their European counterparts.

4. Built Environment and Transportation

European urban planning generally prioritizes walkability, public transportation, and mixed-use development that encourages physical activity. American communities, particularly in the Midwest and South, often feature car-dependent sprawl that promotes sedentary lifestyles. This structural difference affects daily physical activity levels regardless of wealth status.

I live in Philly, a great, walkable city. Many of my patients express dismay that I live here, as the local news (especially Fox) runs a constant fear campaign highlighting every crime in every rough neighborhood.

On my block there is a Greek neighbor who roasts a whole lamb every summer on a sidewalk spit for the hood and random people walking by, a 96 year old Italian man who stands on his stoop always ready to chat and asks how are you doing as you walk by, young families with kids and dogs, multigenerational informal support networks, trees and flowers and Isaiah Zagar murals, a professional violinist who holds benefit concerts in his living room, that guy with the 4x6’ turtle and lily pond outside his front door, and some of the best cheap eats the world has ever known within a three block radius. And then there’s the world class culture, museums, and universities — you know, all those pillars of truth and tolerance and community that authoritarians despise and destroy. I make it a point to jog past Independence Hall, the Liberty Bell, the Tomb of the Unknown Soldier, Ben Franklin’s grave, and the National Constitution Center several times a week for exercise and inspiration… but I digress.

So I digress some more. Here’s the insulting stuff you get from Fox News Philly, on just one random night, just now as I write this:

It’s all fear, all the time. It makes you tune in. It makes you shrink.

5. Food and Agricultural Policies

Europe maintains stricter regulations on food additives, pesticides, and industrial food production. The "precautionary principle" guides European food policy, whereas the US typically requires definitive proof of harm before implementing restrictions. This regulatory difference affects the nutritional quality of the food supply available to all Americans, regardless of socioeconomic status.

The HHS and FDA did just announce a series of new measures to phase out all petroleum-based synthetic dyes from the nation’s food supply. Sure, that’s cool. And yet more expert people would argue: “This isn’t about science. It’s about vibes, fear, and wellness disinformation.”

6. Cultural Attitudes Toward Health

European societies generally place greater emphasis on work-life balance, leisure time, and community connection. Americans across the wealth spectrum tend to work longer hours with less vacation time, creating chronic stress that negatively impacts physical and mental health. The cultural valorization of overwork affects even wealthy Americans, potentially contributing to their compromised longevity.

7. Gun Violence and Safety

The United States experiences significantly higher rates of firearm-related deaths than European countries. This uniquely American public health crisis affects mortality statistics across all wealth quartiles, though violence disproportionately impacts less affluent communities.

8. Early Life Conditions

Differences in maternal and child health services, parental leave policies, and early childhood education create divergent health trajectories that persist throughout life. European investments in early childhood development help establish healthier foundations for all citizens, while American children face stark disparities based on their families' financial resources.

The Political Dimension

Here’s the next thread in the weave. The NEJM study's findings take on greater urgency in light of current political developments. We non-billionaires are all in this together, whether we like it or not, so I’m going to make an intentional distinction between Republican voters and politicians. Republican politicians’ policies and the implementation of Project 2025 initiatives are exacerbating many of the structural factors driving America's health disadvantage. Friends, Romans, countrymen; center, left, and right; please lend me your ears.

Current Republican politician healthcare proposals focus on dismantling the Affordable Care Act, reducing Medicaid funding, and cutting Medicare benefits. These approaches would likely increase system fragmentation and expand coverage gaps, widening the already substantial mortality disparities across wealth quartiles. Did you know that 77% of Americans have a favorable opinion of Medicaid as a program?

In particular, the proposed Republican politician Medicaid cuts (the budget framing of which has already passed in the House of Representatives) would create a nightmare scenario for vulnerable populations: 40% of all U.S. children depend on Medicaid or CHIP for essential healthcare, pregnant women would lose coverage that currently pays for over 40% of all births, and elderly Americans would face catastrophic consequences as Medicaid covers more than 60% of nursing home residents. Rural hospitals and nursing homes may collapse, straining families in the poorest regions, forcing pregnant women to travel long distances for care and leaving elderly patients without access to essential services. Medicaid enrollees have described these potential cuts as having life and death consequences, particularly regarding mental health care and chronic condition management.

Similarly, cuts to social safety net programs—including food assistance, housing subsidies, and other benefits—will further weaken America's already limited social protections compared to European systems. Project 2025 explicitly calls for converting many federal assistance programs to block grants with reduced funding and imposing stricter work requirements, changes that could remove critical supports for vulnerable populations.

Tax policies favoring high-income individuals and corporations threaten to expand America's already substantial wealth inequality. With Project 2025 advocating for extending and expanding the 2017 tax cuts, reducing capital gains taxes, and eliminating the estate tax, America's wealth concentration could intensify, potentially steepening health outcome gradients.

Transportation and infrastructure priorities under current Republican politicianleadership emphasize highway funding over public transit and oppose federal involvement in urban planning. Project 2025 proposes significant cuts to public transit, rail infrastructure, and walking/biking programs that could further entrench car-dependent development patterns contributing to sedentary lifestyles and people watching violence on the evening news.

Food and agricultural deregulation initiatives, including rolling back food safety regulations, dietary guidelines, and nutritional requirements for school meals, would likely widen the regulatory gap between the US and Europe regarding food quality and safety. Project 2025 specifically proposes reducing the FDA's authority to regulate food additives, pesticides, and other contaminants. The EPA is now a green light for pollution, and oil executives have direct email line to the president to request pollution exemptions.

The rejection of workplace protections—including paid sick leave, family leave policies, and work hour limitations—reinforces cultural attitudes that prioritize productivity over health and wellbeing. Unions are in trouble. These approaches diverge sharply from European models that support work-life balance across socioeconomic groups.

Opposition to gun control measures, combined with Project 2025's explicit calls for rolling back existing gun regulations, would maintain or increase America's significant gap in firearm-related mortality compared to European countries.

Finally, cuts to maternal and child health services, Head Start, and other early childhood programs will preserve or widen disparities in early life conditions that establish health trajectories. Project 2025 advocates shifting early childhood education and care responsibilities entirely to state governments with reduced federal funding, an approach that would likely exacerbate geographic and socioeconomic disparities.

The Intimidation Campaign Against Medical Journals

Still weaving. When studies are published that show how a rigged system is affecting the most vital, measurable outcome, namely life versus death, a resilient government should embrace these studies. Embrace the evidence, respect the science, and self-correct. It’s a beautiful thing.

Is the NEJM being embraced?

This week the New England Journal of Medicine and at least three other scientific journals have received troubling inquiry letters from Edward R. Martin Jr., interim U.S. Attorney for the District of Columbia. Martin was appointed and sworn in “just minutes after Donald J. Trump was sworn in as the 47th President.” NEJM's editor-in-chief Eric Rubin described his letter as "vaguely threatening" and containing accusations suggesting the journal was "partisan in various scientific debates."

Edward Martin is currently facing significant criticism this week (as his Senate confirmation hearing is underway) regarding his qualifications due to his lack of prosecutorial experience and his controversial background as a "Stop the Steal" advocate after the 2020 election. Senate Democrats and career federal prosecutors have raised alarms about his nomination, citing not only his inexperience but also his politicized approach to the role since taking over on an interim basis, including firing and demoting multiple January 6 prosecutors. He gave an award to a reported Nazi sympathizer. Enough said. I’m calling my senators.

This appears to be part of a broader administration effort targeting scientific publications. Health Secretary Robert F. Kennedy Jr. previously threatened journals including NEJM, stating he would "litigate against you under the racketeering laws" and "find a way to sue you unless you come up with a plan right now to show how you're going to start publishing real science."

The Lancet condemned these letters as "an obvious ruse to strike fear into journals," declaring that "science and medicine in the U.S.A. are being violently dismembered while the world watches."

NEJM has already responded with a statement that pushes back: "We use rigorous peer review and editorial processes to ensure the objectivity and reliability of the research we publish. We support the editorial independence of medical journals and their First Amendment rights to free expression."

Recall that besides studies like the one I’ve examined here about health and wealth, in 2020 the New England Journal of Medicine published an unprecedented editorial condemning the Trump administration's handling of the COVID-19 pandemic, marking the first time in its 208-year history that the journal had taken such a political stance to defend scientific principles despite significant political pressure. The NEJM bravely told it like it was:

The United States led the world in COVID-19 cases and deaths, with a death rate more than double Canada's, nearly 50 times Japan's, and almost 2000 times Vietnam's - demonstrating a catastrophic failure of leadership compared to other nations.

Other countries like China, Singapore, South Korea, and New Zealand implemented more effective measures such as strict quarantine, early intensive testing, aggressive contact tracing, and appropriate isolation - outperforming the US "by orders of magnitude."

The US response failed at multiple levels: ineffective testing, inadequate protective equipment, inconsistent quarantine measures, poor social distancing enforcement, politicization of masks, and undermining public trust in vaccines.

Federal leadership abandoned disease control to states, undermined key institutions like the CDC, NIH, and FDA, and damaged trust in science and government by favoring "uninformed 'opinion leaders' and charlatans" over experts.

The consequences of these failures include exacerbated inequality, educational disruption, economic damage, and hundreds of thousands of preventable deaths in what became the deadliest American crisis since World War II.

Hmmm. Is the weave coming together?

The Alternative Journal Effort

If world class medical journals are doing their job publishing rigorous science, and you don’t like it because it conflicts with your agenda, why stop at intimidation and trying to destroy them like Harvard? Why not make up a new journal?

A new scientific publication, the “Journal of the Academy of Public Health,” has been co-founded by Dr. Jay Bhattacharya and Martin Kulldorff. It has unusual editorial policies. Unlike traditional journals, JAPH eliminates paywalls, publishes peer reviews alongside articles, and pays reviewers $500 per review. However, only members of the newly formed “Academy of Public Health” can submit articles, and all submitted articles are published without traditional quality controls.

The editorial board includes scientists who opposed mainstream, consensus Covid-19 public health measures, to put it mildly. The prestigious and real journal SCIENCE warns us that the new journal could become a platform for contrarian views that challenge scientific consensus.

What Can Be Done?

Weaving this all together into a sock now.

What Average Citizens Can Do

Contact Elected Officials Call, email, or write to your representatives expressing concern about political interference with scientific journals

Be specific about recent incidents (like the NEJM case) and emphasize the importance of scientific independence

Attend town halls and ask direct questions about scientific integrity Support Scientific Organizations Join and financially support organizations that defend scientific integrity like the Union of Concerned Scientists or the Climate Science Legal Defense Fund

Share their resources and alerts on social media to expand awareness

Volunteer time to help with advocacy campaigns Engage with Media Write letters to editors about the importance of scientific independence

Support journalism that accurately covers scientific issues

Support Substack science and medicine writers. This is truly a new media ecosystem.

Publicly counter misinformation by sharing accurate, well-sourced information Educate and Mobilize Communities Organize community forums about scientific integrity issues

Form local groups focused on science advocacy

Connect with like-minded citizens through online platforms or local meetings Vote Informed Research candidates' positions on scientific integrity before elections

Support candidates who demonstrate respect for scientific independence

Hold elected officials accountable for their actions related to science Amplify Scientific Voices Share statements from scientific organizations on social media

Attend public hearings where scientific testimony is presented

Help translate complex scientific issues into accessible language for broader public understanding Practice Consumer Activism Support businesses that respect science-based policies

Boycott companies that fund anti-science campaigns

Make purchasing decisions that align with evidence-based practices

I’ll keep the larger picture more brief:

For Scientific Organizations:

Create robust integrity policies protecting editorial independence

Form coalitions across multiple scientific organizations. Think NATO, like how Universities are banding together to share resources in case the president targets one of their members. Unreal.

Establish independent integrity officers for accountability

For Scientific Community Members:

Document and report political interference attempts

Build inclusive coalitions beyond scientific circles

Leverage legal resources for scientists facing harassment

For Systemic Reform:

Advocate for scientific integrity legislation (not possible right now)

Create cross-agency integrity councils (not possible right now)

Train scientists in effective public communication

Conclusion

The NEJM study provides compelling evidence that America's health disadvantage reflects deep structural differences between American and European societies. Even wealthy Americans face mortality risks comparable to poor Europeans, suggesting that no amount of personal wealth can fully insulate individuals from systemic health determinants.

As policymakers debate America's future, this research underscores the urgent need for structural reforms. Evidence suggests that America would benefit from moving closer to European models of universal healthcare, robust social safety nets, reduced inequality, and health-promoting public policies. Let’s move away from the extreme political polarity that algorithms, the media, and the outrage industry have created. Science helps us do that by discerning real truths and facts. Respect to the NEJM for doing what they do for over 200 years as the longest continuously published medical periodical in the world, and the most prestigious. It would be shameful to disrespect that. We should also listen to ABBA more frequently, as that could be the secret sauce, and it is difficult to get mad listening to Dancing Queen.

Every citizen can make a difference by contacting elected officials, supporting scientific organizations, and demanding transparency from institutions that serve as the foundation of evidence-based decision making. We can’t course correct if our compasses have all been hacked to point north all the time. Together, we must stand firm against political interference with scientific integrity.

Make Americans healthy again, indeed.

Most of us agree we want that.

Weave on.

~

This diary was first posted on Examined, a substack I weave about overlooked ideas in primary care. Please join the newsletter list if you don’t want to miss future posts.

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