The urgency of Social and Policy Reform in the USA

Mental Health Depression

During a recent discussion that I had with two friends who had lived for several years in the USA, I expressed concern in particular regarding three aspects of US society which I had been studying recently—an alarming rise in child depression prompting professional organizations to speak of a national emergency related to this, an alarming rise in the maternal mortality rate and a very high number of poverty-related deaths. My friends simply refused to believe all of this and instead gave me friendly advice on re-checking. However after seeing the relevant references they expressed great surprise how they had missed these important aspects earlier.

      This was not an unexpected response, given the fact that several deeply troubling aspects of US society do not receive the attention these deserve. It is even more difficult to find an honest analysis of several such important aspects.  The response of my friends prompted me to bring together and analyse more such aspects at one place, in the hope that this may contribute in a small and humble to re-emphasizing the urgency of social and policy reform in the USA.

    Concern has been expressed by health experts in the USA that life-expectancy in this country has been reducing steadily in comparison to levels attained in several other rich countries. This has led some researchers to explore the number of excess deaths in the USA (or number of ‘missing Americans’) which they define as the deaths which are in excess of the number that would have taken place if the life-expectancy rates in the USA had remained at par with those of comparable rich countries.


        One such important recent study by Jacob Bor, Andrew C. Stokes and others has been published in the journal PNAS Nexus on May 29, 2023. This study has estimated the number of such excess deaths in the USA in 2019 at 622,534. During the next two years the number of such excess deaths went up to over a million, but as these were COVID years and a number of other issues become involved, we will go here only by the lower number of excess deaths recorded for a normal year at over 600,000. So what this study is saying that on the basis of comparisons with other rich countries, the USA should have been able to achieve the sort of life expectancy that results in avoiding over 600,000 deaths in a year.

        Earlier another study by David Brady on only poverty related mortality published in the USA in JAMA Internal Medicine in April 2023 (for over 15 years age group) had estimated that there are 183,000 poverty related deaths in a year in the USA.

     UN data tells us that at a time when maternal death rate was declining in most countries, in the USA maternal death rate increased to a shocking extent from 12 to 21 during 2000-2020.

        More such data can be provided to show that the number of excess, easily avoidable deaths in the USA is shockingly high at well over half a million every year. A very big contribution to human welfare can be made by taking steps to ensure that these avoidable deaths are actually avoided.

        The steps that are needed for improvements are well-known in a country so blessed with eminent scholars. In a nutshell, health services have to be improved in a big way for all weaker sections without any discrimination, inequalities must be reduced in a big way so that the poorer people have much better access to nutrition, environment and safety must be much better protected, shelter and health and overall social conditions need to be improved to make way for better physical and mental health while avoiding all harmful addictions.

        The bigger question is—when these solutions are well-known, why have not these been adopted and why the situation in some importance respects continues to deteriorate? This is the really crucial question which needs to go beyond the analysis generally available in academic papers as this concerns important political issues of injustice. We need to ask why billions are easily available in the USA for weapons but even millions are not available for some important aspects of social justice, why billions worth of tax gifts can be given to the rich but millions worth of essential expenditure for the poorest is more difficult to find.

        The fact is that a system of injustice has become so deeply established in the USA that solutions outside this system are difficult to implement. What should be emphasized is that this system of injustice is causing even more harm to people of other countries than what it is causing to people within USA.

        Due to this system if 600,000 excess deaths a year are caused in the USA, then a similar or higher number deaths are likely being caused in other countries as well. The number of deaths caused by the USA’s forever wars is in many millions as can be seen by adding up the immediate and longer-term mortality figures of wars in Korea, Vietnam, Cambodia, Laos, Iraq, Libya, Syria, Afghanistan and elsewhere (in addition of course there was the use of atomic bombs against Japan after Japan had already been defeated for all practical purposes). Then there are a large number of deaths caused by arbitrary imposition of wide-ranging sanctions, highly unjust interventions and coups in other countries which resulted in a large number of deaths (in countries like Congo, Chile, Iran, Nicaragua, Haiti, Greece etc.). Then there are also the large number of deaths associated with exports of weapons as well as several highly hazardous products and technologies. Hence in brief we can say that unjust systems in the USA cause avoidable 600,000 excess deaths in the USA and a somewhat higher number in other countries annually. Excess deaths in other countries are defined here as deaths caused by various injustices of the US (or allies acting under US leadership), whether in the form of wars or coups or subversions or exploitation.

        These excess deaths inside and outside USA are two parts of the same unjust system, an important aspect missed by most academic studies. Once you establish an unjust system that inflicts unjust wars on other countries, then the same unjust system adopts internal unjust and discriminative policies within the country too, although this may get partially softened by electoral considerations at times.

        Another reflection of how internal and external injustices are closely related is the fact that the leaders with the biggest promise of justice have been assassinated within the USA as also in other countries with fingers pointed towards the same US agency. This is how the assassinations of President John Kennedy and President Allende are related, this is how the assassinations of Presidential candidate Robert Kennedy Sr. and President Lumumba are related, this is how the killings of Martin Luther King Jr. and Che Guevara are related. Leaders most capable of bringing justice and peace are removed before they can achieve their potential.

        So as several eminent scholars have suggested the solution for the USA to avoid excess deaths is to improve health care and socio-economic conditions for the lower half of the population, but in addition if we go a step further and ask why this has not happened in recent years, then we also need to say more clearly and loudly that the established unjust system must be challenged and replaced by a system that is based on justice internally and externally.

        Such struggles against well-established systems of injustice are needed in so many countries but most of all these are needed in the USA as this is the most powerful and influential country in the world whose policies have a worldwide impact. From a world perspective the struggle is against the unjust establishment of the USA, just the top 5% or so, and never against the people of the USA and in fact the struggling American people need all the worldwide solidarity to help in their struggles. The creation of a justice-based USA is a very important part of the worldwide struggle against injustice. The aim should never be to replace a world dominated by the USA by a world dominated by China but instead our aim should be to create a USA, a China and the entire world based on justice, peace and environment protection.

        The dominant thinking at world-level is of equating ever-increasing income and wealth as well as the accompanying access to more and more material goods and services with increasing levels of happiness. But this is quite often not reflected in the reality of rich or even richest societies. An increasingly important aspect of socio-economic reality of world is that significant levels of distress can exist in the middle of high GNP levels and other signs of prosperity. This can be the result of economic inequalities, social contradictions and other less understood factors.

        In the context of the USA, a study by the Urban Institute in 2018 found that nearly 40 per cent of adults and their families in USA struggled to afford at least one basic need for health care, housing, utilities or food in 2017, even in normal conditions of high employment levels.

        In this study based on a well-being and basic needs survey in the age-group 18-64, 23% said that they were food insecure in the last 12 months. 18% struggled to pay medical bills while almost the same percentage decided to go without some required medical treatment due to costs.

        In a population of 330 million people and 128 million households in the USA, around 45% persons suffer from chronic diseases, many from multiple chronic diseases. Regularity of medicines is very important for all of them, but price of medicines in the USA is often much higher than in comparable countries. Nearly 40 million medically consulted injuries and poisoning cases are reported in a year. 12 million vehicles are involved in crashes in one year.

        With the advent of COVID and much higher unemployment levels, the situation in terms of struggle to meet basic needs worsened. What is more, in 2020 it was reported that child poverty levels have been found to be 1.5 times higher than adult poverty levels. As for senior citizens, the Elderly Economic Security Standard Index found that in 2016 a majority of them lacked the “financial resources required to meet basic needs.”

        The Eviction Lab, Princeton University, has estimated that there are 3.7 million eviction cases in the USA in a typical year. The authorities intervened in COVID times to prevent the likely escalation in evictions by imposing moratoriums but now these are being phased down. The rent relief grants are also getting reduced considerably as funds committed for this have been exhausted in several states.

        Nearly 28 per cent of US households are single person households. A survey by Cigna before the onset of COVID revealed that almost half of the adults feel lonely sometimes or all the time. Increasing loneliness has been associated with significant increase of dementia, coronary disease and stroke.

        Nearly 50% of all US marriages end in divorce or separation. In households with children, 50% of divorces lead to push towards poverty. Children suffer very adverse short-term and long-term impacts of divorce and separation.

        10 to 12 million persons, mostly women, are physically abused in a year by an intimate partner, nearly 20 per minute. On a typical day, about 20,000 phone calls are placed on domestic violence helplines, mostly by women.  A report on child abuse is made every 10 seconds. Authorities trace 656,000 victims of child maltreatment in a year, but the problem is bigger. More than 4 million referrals are made to child protection agencies in a year. 

        About 10 million people face incarceration in a year. Over 1.2 million violent crimes are reported in a year, while the actual number is higher.

        1 in 4 adults –26%–suffer from a diagnosable mental disorder in a given year, several from more, according to the National Institute of Mental Health Disorders. A 2019 study published in JAMA Paediatrics analysing official data reported that 1 in 6 children are affected by a mental health disorder.  During the last decade, a big rise in depression, even self-harm has been reported among adolescents, even before the onset of COVID.

        1.4 million suicide attempts take place in a year. Suicide among 10 to 14 year old girls doubled , while emergency room admissions for suicidal ideation and attempts by children and adolescents also roughly doubled during the last decade.

        A significant part of distress is due to high levels of inequalities– the bottom 50% of population has only 1.5% of the country’s wealth—but different kinds of distress and tensions exist at high levels in all sections of society.

        We have many reports and studies on various aspects of increasing distress from time to time, only to discover some time later that remedial actions based on these have at best provided some temporary relief only while the deeper causes remain. Clearly this must change. Distress reduction based on a comprehensive understanding and deeper linkages must become the main focus of domestic policy.

        At a wider level this draws attention to the highly mistaken notion of equating higher income and wealth necessarily with genuine happiness, let alone any sincerely felt feeling of a life well lived. More debate and dialogue on this, leading to better understanding of the limits of understanding life’s worth in terms of merely income and wealth, can help to pave the way for meaningful social change at several levels.

        All this is particularly important in the context of understanding distress and uncertainly levels among children, adolescents and young adults. The latest official statistics of ‘Youth Risk Behaviour Survey’ (YRBS), USA, 2011-2021 released recently by the Centers for Disease Control and Prevention, (CDC), USA, have revealed truly alarming levels of distress among US youth.

        From a distance youth of other countries perceive life of youth in USA to be a life of joy and fun in a prosperous land free of various social inhibitions, and crave for a similar life. The results of this survey may be an eye opener for them too and highlight the need for a different path.

        As the USA is one of the highest GDP countries, the prevalence, persistence and increase of such high levels of distress among US youth calls for serious analysis to find real causes as well as solutions so that US youth can have a happier and more meaningful life. )

        The YRBS statistics tell us that in year 2021 42% of US high school students “experienced persistent feelings of sadness or hopelessness”. When this figure was reported at 28% in 2011 this was considered to be quite high and hence brought forth calls for several remedial actions. Despite these, the number has increased persistently and steadily during the decade—30% in 2013 and 2015, 31% in 2017, 37% in 2019 and 42% in 2021. In the case of female students, this percentage is even higher—in 2021 as many as 57% of female high school students experienced persistent feelings of sadness and hopelessness.

        Further, in 2021, the YRBS tells us, 29% of high school students experienced poor mental health. In the case of female students, 41% experienced poor mental health.

        What is even more alarming in the YRBS data is that in 2021, as many as 22% high school students in the USA “seriously considered attempting suicide”. Here also we see an overall increasing trend from 16% in 2011 to 22% in 2021. In the case of female students this number was as high as 30% in year 2021. In other words, almost one-third of female high students in the USA were so distressed as to “seriously consider attempting suicide” during this year.

        In fact the YRBS statistics tell us that as many as 18% of high school students in the USA had actually “made a suicide plan” in 2021. This also had an overall increasing trend from 13% in 2011 to 18% in 2021. In the case of female students this percentage was again higher at 24 in year 2021.

        Most sadly, the YRBS survey tells us that as many as 10% of high school students in the USA actually attempted suicide in 2021. This means that one out of 10 USA high school students attempted suicide in 2021. This percentage increased from 8 in 2011 to 10 in 2021. The number of female students who attempted suicide in 2021 was again higher at 13%.

        Another aspect of distress suffered more by female students related to sexual violence. 18% of female students experienced sexual violence by anyone during the past one year.

        These high levels of distress are extremely troubling and have increased despite remedial actions proposed by eminent experts in the past. Instead of merely repeating such advice, there is clearly need for deeper introspection and more sincere efforts to find real causes and solutions. More than individual consultations, efforts to find the illness of entire society are needed.  While eminent experts are deeply concerned about this issue, they may be missing some wider important issues due to examining issues more closely in a narrower framework.

        In particular it is important to examine the links of the increasing internal distress of USA society with the increasing aggression of the USA at international level. As this writer has emphasized several times, such links need to be recognized and will help the peace movement within the USA to mobilize people to create a society which is at peace with itself and with the entire world, devoted more to reducing its own distress as a higher priority.

        Another question that arises relates to the higher distress suffered by female students (compared to male students) according to almost all criteria. If the USA is supposed to be a society based on gender justice, then why is this happening? This should be seen in the context of high levels of violence and distress suffered by women and female children in other contexts also in the USA, for which a lot of additional data is available. However confining ourselves only to YRBS data for the time being, isn’t it alarming that as many as 57% of female high school students experience persistent feelings of sadness or hopelessness, 41% experience poor mental health, 18% experience sexual violence in a year, 30% seriously consider attempting suicide in a year, 24% make a suicide plan in a year and 13% actually attempt suicide in a year, all this at levels much higher than male students.

        The USA has frequently criticized gender injustice in other countries but should it not also look inwards to ask why girls in the USA are so distressed despite the outer appearance of a very free and liberated society. In this context also there is a clear need to explore linkages between internal distress and aggression on the one hand and massive distress caused by aggression in other countries on the other hand.

        Once these wider links are recognized, then these can pave the way for creating a US society which is at peace with itself as well as with the rest of the world. This should be one of the highest priorities for our deeply troubled world.

        Other than YRBS data, there have been several other indications of the deep distress within US society. This is evident from the call given twice in recent times by the top child health organizations in the country for declaring a mental health national emergency for children and adolescents, given the scale of these problems. If this won’t wake up a society to the need for wider introspection, what else will?

      One of the clearer aspects of the existing sad situation is that much more resources are needed for meeting the needs of the bottom 50% of the people of the USA who currently have only 1.5 per cent of the country’s wealth. It will not be difficult to find resources for them as wealth and income are currently so highly concentrated at the top levels in the USA. What is more military spending by the USA is extremely high. Most US official figures mention military expenditure in a year of around 880 billion dollars, but other defence analysts also mention higher figures mention going up to 1.4 trillion or 1400 billion. Without sacrificing defence considerations in any realistic sense and with some overdue reforms to curb corruption, wastage and overpricing by contractors, it should be possible to cut the military spending by about one-half or so, making available between 400 to 700 billion dollars annually for meeting essential welfare needs of American and other people. A figure of just 20 billion dollars has been frequently mentioned in terms of significantly meeting the needs of homeless people in the USA, and a somewhat similar figure would go a long way in reducing hunger to a significant extent in the USA. In the context of reducing extreme poverty and hunger to a significant extent at the world level, figures of 100 to 50 billion dollars per year each have been frequently mentioned.

   Clearly very big gains are waiting to be achieved at the level of the USA and at world level if only the USA can become a country which is much more oriented towards peace, justice and welfare. On the other hand, an idea of the highly destructive consequences of USA’s existing policy distortions is conveyed by the fact that in terms of direct as well as indirect deaths the War on Terror alone has caused 4.5 million deaths (this estimate of Brown University also needs updating and include some other counties as well) and has cost the USA 8000 billion dollars (about a billion dollars a day or 12000 dollars per second over a 22 year period).

  This is why we stated earlier too that while reforms are needed in all countries but it is reforms in the USA for creating a society based on peace and welfare which are most urgently needed and can benefit the entire humanity. Hence the people of the USA who are dedicated to peace, justice and environment protection have a very big responsibility for bringing these reforms. It is people’s movements on which highest hopes rest, keeping in view the increasing alienation of top leadership from these important reforms. 

The writer is Honorary Convener, Campaign to Save Earth Now. His recent books include Protecting Earth for Children, Planet in Peril, Earth without Borders and A Day in 2071.

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