Death Is Not the Enemy

Death is not the enemy. Human death is normal; we all die. The real enemies are premature death, disability, pain, human suffering, and the prolongation of dying. All the rest is mostly noise.
 —George Lundberg

George D. Lundberg, MD

At its core, the likelihood of an American experiencing premature death is all about availability and ease of access to beneficial and harmful products and services, determined by geography, driven by economics; diverse and often inequitable but with logical, even predictable, outcomes. Humans are easily led in healthy and unhealthy directions. The rest is all about availability.

The average life expectancy at birth is 74.5 years for American men and 80.2 years for American women. The median age at death for Americans, not divided by gender, geography, race, or ethnicity, is 73.7 years. The World Health Organization (WHO) defines premature death as death at ages younger than 70 years.

So, what common diseases, afflictions, or agents kill Americans prematurely, from the youngest to the oldest, and what is the median age of premature death from each?

• Gunshot wounds: median age at death, 28 years

• Fentanyl: 35 years

• Vehicular crashes: 40 years

• Overdose not otherwise specified (NOS): 46 years

• Alcoholism: 57 years

• Tobacco addiction: 66 years

• Cirrhosis: 67 years

• Diabetes: 67 years

• Chronic kidney disease: 68 years

• Lung cancer: 71 years

• Cancer NOS: 73 years

• Stroke: 73 years

• Myocardial infarction: 73 years

All other big causes of death exhibit medians above 73.7, or "not premature." These include Alzheimer's disease, Parkinson's disease, influenza, pneumonia, and sepsis. Obviously, the younger the age at death, the greater the number of potential life-years lost. Using the WHO definition of premature death (before age 70), the cut-off point for premature death would be median age 68 for death from chronic kidney disease.

Many (even most) humans are pretty inept at behavior control, and they easily succumb to temptations. Some of those experiences are one-and-done. But, if pleasant and positive, repeating that initial experience often follows. Such repeats build positive reinforcement. If chemicals are involved, increasing the dose is needed to overcome tolerance. The activity becomes a habit. Again, if the agent is a substance, it could transition into addiction. Some human activities that do not involve a substance can also grow into something akin to addiction.

One simple commonality among almost all phenomena can, and often does, lead to premature death, disability, pain, and human suffering. At the start, during the process, and when fully developed, it is simple availability of some hazardous agent, be it a substance, article, equipment, or experience. Ready availability of unhealthy and harmful things such as sugar, refined carbohydrates, ultraprocessed food, illicit street drugs, fentanyl, alcohol, combustible tobacco, poor schools, unsafe neighborhoods, handguns, and assault weapons facilitates premature death.

The counterpart is ready availability of healthy and helpful things: education, jobs, a home, loving family and friends, safe communities, healthy foods such as fresh fruits and vegetables, clean air and water, and gun-free homes, as a routine to mitigate against premature death.

Up the chrono-scale from the youngest (age 28) to oldest (age 73) median age, and what are the agents of hazard that lead to premature death?

• For deaths from gunshot wounds: guns and ammunition

• For deaths from fentanyl: illicit street fentanyl

• For deaths from vehicular crashes: automobiles, motorcycles, bicycles

• For deaths from overdose: street and prescribed fentanyl, other opioids, a mixture of other drugs

• For deaths from alcohol use disorder: legal alcohol

• For deaths from tobacco addiction: legal combustible tobacco

• For deaths from cirrhosis, alcohol: hepatitis, excess fattening food

• For deaths from diabetes (via obesity): sugar, ultraprocessed foods

• For deaths from chronic liver disease (via obesity and diabetes): sugar, ultraprocessed foods

• For deaths from lung and other cancers (often via obesity): legal combustible tobacco, sugar, ultraprocessed foods

• For deaths from strokes and myocardial infarction (via hypertension, obesity, diabetes): legal combustible tobacco, sugar

There are societal benefits from motor vehicles, bicycles, and walking/pedestrianism. Likewise, alcohol has social benefits. Yet, alcohol intake poses a 12%-15% risk for alcohol use disorder. Once obese, it's difficult to lose weight for the long term. The prevention of obesity (and diabetes) is the answer — eliminating sugar and ultraprocessed foods. Are there any societal benefits from sugar? It's questionable; perhaps jobs. From ultraprocessed foods? Quenching of appetite at relatively low cost. From handguns or assault weapons in the hands of those other than the military and law enforcement? None, other than psychological placation for some. Societal benefits from illicit street drugs? Economic gains for the drug-dealing industry. Societal benefits from combustible tobacco? Economic gains for the tobacco-dealing industry.

Human frailties get the better of many (at some point, even most) people. Unless protected by some force, we often do ourselves in.

On a national scale, since 2018, I find it distressing that the United States has fared far worse than other countries in the developed world at sustaining or improving life span. Of course, COVID had a lot to do with that, but COVID affected all countries.

I am fully aware that an emphasis on eliminating availability of the harmful and promoting availability of the beneficial as the lynchpins is a purely supply-side intervention. However, obviously the right thing to do, in a society with freedom of choice, supply-side intervention usually fails. For most of my professional life, I have believed in demand-side intervention and control. Failing both, as our society continues to do, I favor harm reduction, a common-sense blend of both supply- and demand-side interventions with a leavening dose of reality.

In the end, it's all about choices: individual, family, societal, and government choices, either calculated or foolish. As Mark Twain wrote in Adventures of Huckleberry Finn, "you pays your money and you takes your chance." Life and premature or later death is a calculable risk. Why not choose a longer life and strive to make it even better? Your toolbox is full.

I, George D. Lundberg, am the sole author and I take responsibility for all content. However, I acknowledge the invaluable contributions of Elmer, my bard.google.com avatar, without whose efforts I could not have written this At Large column.

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