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Medicine Earth United States Science

US Life Expectancy Can Vary By 20 Years Depending On Where You Live (npr.org) 292

After analyzing records from every U.S. county between 1980 and 2014, Christopher Murray, head of the Institute for Health Metrics and Evaluation at the University of Washington, and his team found that life expectancy can vary by more than 20 years from county to county. "In counties with the longest lifespans, people tended to live about 87 years, while people in places with the shortest lifespans typically made it only about 67," reports NPR. From the report: The discrepancy is equivalent to the difference between the low-income parts of the developing world and countries with high incomes, Murray notes. For example, it's about the same gap as the difference between people living in Japan, which is among countries with the longest lifespans, and India, which has one of the shortest, Murray says. The U.S. counties with the longest life expectancy are places like Marin County, Calif., and Summit County, Colo. -- communities that are well-off and more highly educated. Counties with the shortest life expectancy tend to have communities that are poorer and less educated. The lowest is in Oglala Lakota County, S.D., which includes the Pine Ridge Native American reservation. Many of the other counties with the lowest life expectancy are clustered along the lower Mississippi River Valley as well as parts of West Virginia and Kentucky, according to the analysis. There's no sign of the gap closing. In fact, it's appears to be widening. Between 1980 and 2014, the gap between the highest and lowest lifespans increased by about two years. The reasons for the gap are complicated. But it looks like the counties with the lowest lifespans haven't made much progress fighting significant health problems such as smoking and obesity. The study has been published in the journal JAMA Internal Medicine.
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US Life Expectancy Can Vary By 20 Years Depending On Where You Live

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  • by burtosis ( 1124179 ) on Monday May 08, 2017 @10:35PM (#54382165)
    I'm sure the new republican health care plan will provide more comprehensive coverage at much lower costs thus solving americas poor living in third world conditions. /s
    • by Okian Warrior ( 537106 ) on Tuesday May 09, 2017 @12:45AM (#54382475) Homepage Journal

      I'm sure the new republican health care plan will provide more comprehensive coverage at much lower costs thus solving americas poor living in third world conditions. /s

      For those who want a good visualization, here is the US map of the study results [jamanetwork.com],

      and here's the study [jamanetwork.com], click on the "figures and tables" link in the overly complex mishmash of a web page for visualizations and caption explanations.

    • It's amazing how well the map of the worst life expectancy matches the map of places that repeatedly elect republicans.

      It's almost like republican policy on how you treat people of low socio-ecenomic status, and how you deal with health care has a significant impact on areas of the US looking more like the 3rd world than the 1st.

  • Two choices (Score:5, Insightful)

    by Anonymous Coward on Monday May 08, 2017 @10:39PM (#54382179)

    You can have progressive taxation and universal healthcare or increasing inequality and more illness, fear, death and guns. Your choice.

  • by gurps_npc ( 621217 ) on Monday May 08, 2017 @10:46PM (#54382211) Homepage

    Those three things are often correlated, so causation may be falsely determined.

    I.E. theoretically it could be (but isn't) that genetically the natives are subject to major diseases that reduce life expectancy.

    Or, (almost as unlikely), that area could be infectred by a nasty disease.

    Or most likely, it is a matter of money and education, both of which has been systematically denied to the members of the lower class that predominate in that area.

    • by burtosis ( 1124179 ) on Monday May 08, 2017 @11:03PM (#54382273)
      from the actual journal article it states noting about drinking and smoking being the sole cause.

      Question
      Are inequalities in life expectancy among counties in the United States growing or diminishing, and what factors can explain differences in life expectancy among counties?
      Findings
      In this population-based analysis, inequalities in life expectancy among counties are large and growing, and much of the variation in life expectancy can be explained by differences in socioeconomic and race/ethnicity factors, behavioral and metabolic risk factors, and health care factors.
      Meaning
      Policy action targeting socioeconomic factors and behavioral and metabolic risk factors may help reverse the trend of increasing disparities in life expectancy in the United States.

    • RTFA (Score:4, Informative)

      by DogDude ( 805747 ) on Monday May 08, 2017 @11:07PM (#54382283)
      If you'd RTFA, you'd have the answer to your question!

      Socioeconomic and race/ethnicity factors, behavioral and metabolic risk factors, and health care factors explained 60%, 74%, and 27% of county-level variation in life expectancy, respectively. Combined, these factors explained 74% of this variation. Most of the association between socioeconomic and race/ethnicity factors and life expectancy was mediated through behavioral and metabolic risk factors.
    • Wealth Inequality. Poorer counties have shorter lifespans. I suspect if you drill into the details you'll find higher rates of smoking plus a lack of access to to medical care, especially heart disease treatment and pre-cancer screenings and treatment. I guy I work with had heart surgery recently. We make good money with good benefits so it was covered and he was able to work from home for about 90 days while he fully recovered. But if he was the night manager at a gas station he'd have just died. Period.
    • Re: (Score:3, Interesting)

      I.E. theoretically it could be (but isn't) that genetically the natives are subject to major diseases that reduce life expectancy.

      Why do you dismiss this? This is exactly why Oglala Lakota Sioux are at the absolute bottom in life expectancy. About 75% of adults on the Pine Ridge Reservation are alcoholic, and 25% of children are born with fetal alcohol syndrome. More than half the people are diabetic. What could possibly explain that other than genetics? Europeans have been eating starchy grains for 10,000 years, and drinking booze for almost as long. The Sioux have only been exposed to these for about two centuries, which is not

      • by phantomfive ( 622387 ) on Tuesday May 09, 2017 @12:49AM (#54382493) Journal

        What could possibly explain that other than genetics?

        Really? A hopeless life? Being forced into a miserable reservation? Stripped of human dignity?

        • by ShanghaiBill ( 739463 ) on Tuesday May 09, 2017 @01:43AM (#54382605)

          Really? A hopeless life? Being forced into a miserable reservation? Stripped of human dignity?

          They are not "forced" to live on the reservation. They are US citizens and can live anywhere in the country. Those that leave the reservation tend to do far better than those who stay. One of my co-workers in San Jose is a Crow Indian. She abstains from drinking alcohol, and she tries to avoid sugar and starch as much as possible. She has relatives living on the Crow Reservation in Montana, and they have the same problems as Pine Ridge with alcoholism and diabetes, despite the Sioux and Crow having a very different historical relationship with the American government: the Crow were allies of the US in the wars against the Sioux and Cheyenne.

    • Or, (almost as unlikely), that area could be infectred by a nasty disease.

      Central Valley Fever [wikipedia.org]. It's a real thing.

    • by hey! ( 33014 )

      Well, unless the genetic makeup is changing, it is difficult to explain trends this way.

  • by Anonymous Coward on Monday May 08, 2017 @10:48PM (#54382221)
    It's a reasonable bet that the people with lower life expectancy are probably not voting progressive. They have less money, worse jobs and lower life expectancy. They don't see progressive solutions as being in their service. At best progressives will lecture them about how their jobs aren't coming back, they should learn to code, go to university, and move to the rich enclaves on the coasts. Not that conservatives are any better, but conservatives figure out that it's better to pretend to listen, rather than to lecture those with less money, worse jobs and lower life expectancy on how they are all privileged transphobic racists and deserve their lot because of it.
    • by Anonymous Coward on Monday May 08, 2017 @10:56PM (#54382249)
      Yeah, heaven forbid somebody explain to a coal miner that he can find steady work deploying clean energy projects, and will actually be alive to see their child graduate from high school without the aid of portable oxygen...
      • by unimacs ( 597299 ) on Tuesday May 09, 2017 @01:03AM (#54382523)
        Can they? Do the skills transfer that easily? Are there sufficient clean energy projects in the areas where coal minors are located? Do these jobs pay as well, given that at least some coal minors have union jobs?

        I'm not a Republican but I do agree that progressives have not adequately addressed the problems these workers face. I don't think the Democrats wanted to admit that there are losers in the transition to clean energy other than big bad fossil fuel companies.

        Nor do a I believe that Trump has any real solutions for the majority of blue color workers. In fact I see very little hope for that group of people, - not because of clean energy, immigration, or manufacturing leaving the states, but because automation will eliminate those kinds of jobs and lots of others.

        We need a radically different approach that I haven't heard a single politician in the states talk seriously about.
        • Nor do a I believe that Trump has any real solutions for the majority of blue color workers. In fact I see very little hope for that group of people, - not because of clean energy, immigration, or manufacturing leaving the states, but because automation will eliminate those kinds of jobs and lots of others.

          The transportation/delivery industry is also heading full-steam into "humans need not apply" territory. It's frightening when you look up statistics on how many people those fields presently employ.

          Problem is, it's pretty hard to win votes when you tell ol' Jim-Bob that his skills are totally worthless in the economy of the future.

          • by Kiuas ( 1084567 ) on Tuesday May 09, 2017 @04:47AM (#54382995)

            Problem is, it's pretty hard to win votes when you tell ol' Jim-Bob that his skills are totally worthless in the economy of the future.

            This is true, however the added problem is that the alternative is lying to these people.

            This is the underlying issue with right-wing populism: it's easy to score points and votes by telling people that somehow high-paying manufacturing jos are going to come back and everything is going to be okay but it doesn't make it any more true. However low-skilled/uneducated workers who're most affected by this also often lack the education to understand why this is so, making them the easiest segment of the population to deceive into voting against their own interests.

            This is difficult to oppose bevause doing so means talking about realities of the global economy and that makes you an easy target for 'globalist elite' -type of attacks. There's an ongoing attempt in narrative across the entire west according to which there's one side fighting for domestic jobs and the other side is taking them away. Both ends of the left-right --spectrum have their own varieties of this narrative:

            The left is making the point that in the name of free trade the right cares about nothing else than maximizing profits and is thus helping companies take jobs away via trade-agreements and so on.
            The right is making the argument that the jobs are going because of high-taxation and leftist policies and to remain comptetitive the tax burden has to be cut so companies will bring jobs back.

            The thing to realize is both of these arguments are missing the point: the jobs are not going to come back for the simple reason that the standard of living in the west has risen so high that unskilled manufacturing labor is massively expensive (and hence, inefficient) in the west compared to outsourcing and automation. The people who think that there's some magical fix with which american or european workers will suddenly become cost-efficient compared to someone in China making less than 10 dollars a day, or an automated production line with an even lower cost, are deluded.

            The problem is jobs and employment have been at the core of politics and political debates for so long neither side can fess up and say we need to start to consider the rather unavoidable fact that full-employment in the 21st century does not seem like a reachable goal and we need to start talking about options to deal with that. But this inevitably means income-distribution policies like basic income, which if mentioned in the american landscape will brand you a communist and an 'enemy of free enterprise". This despite the fact that the current development of increasing automation and decreasing need for labor is itself a direct result of free enterprises and the market doing what the market does: favoring efficiency and cutting production costs.

            So there exists this negative feedback-loop in which both sides are continuing to talk about jobs and bringing back jobs because that's the mantra that they know will appeal to the voters most negatively affected by current ongoing trends but that doesn't mean the proposed solutions are actually going to work, and thus the politicians and the voters in tandem keep digging themselves into a deeper and deeper hole. Honest discussion is needed about the future modern automation means for us as a species. Currently the situation reminds me of a schizophrenic who at the same time wants cheap and powerful electronics and consumer goods and at the same time wants to be paid a lot for manufacturing said products. In other words our desires as consumers (cheap commodities and high pay) are in direct conflict with the current technological development that's pretty much unstoppable,

            We've created the economy to answer to our material needs and desires as efficiently as possible, and now that that efficiency means taking ourselves off the production line and letting machines do most of the work we recoil, because production is valued so much t

            • by DarkOx ( 621550 )

              The thing to realize is both of these arguments are missing the point: the jobs are not going to come back for the simple reason that the standard of living in the west has risen so high that unskilled manufacturing labor is massively expensive (and hence, inefficient) in the west compared to outsourcing and automation. The people who think that there's some magical fix with which american or european workers will suddenly become cost-efficient compared to someone in China making less than 10 dollars a day, or an automated production line with an even lower cost, are deluded.

              Which is exactly why we might have to acknowledge and accept what is good for the world isn't necessarily good for the country and make a choice. Yes in pure economic terms free trade might be more efficient, but the local wealth gap effects it create are undesirable. Maybe we should reject free trade on the grounds these are unacceptable to our democracy and return to a protectionist/mercantilist model.

              That leaves the AI/Automation problem where capital plays a larger and larger role in production as com

            • The people who think that there's some magical fix with which american or european workers will suddenly become cost-efficient compared to someone in China making less than 10 dollars a day, or an automated production line with an even lower cost, are deluded.

              There is a "magical" (read: effective) fix which absolutely no one is talking about instituting: tariffs on goods made with slave labor (whether effective or literal) which makes it unprofitable to enslave workers. Right now, our trade policies make slavery in other countries very profitable.

        • Wait, telling someone what they want to hear no matter how insane is now "adequately addressing a problem"?

          Wow, times sure are a-changing.

        • Germany started to have all these problems in the late 1980ies when mining and steelmaking in the Ruhr area crashed. That is when the North Rhine - Westphalia state government created a lot of subway projects so the miners could still have related jobs. The structural change still hurt a lot and NRW - that used to be one of the richest German states - is nowadays worse off than the former East German states which were rebuilt with the solidarity tax. I am originally from East Germany, but shortly after the

        • by AmiMoJo ( 196126 )

          Installing solar PV is something any moderately intelligent person can learn on the job. Most of it is basically construction work. Given time they could go to school and get the necessary skills to qualify as an electrician and do that part too.

          It's not zero effort and maybe the pay, at least at first, isn't the same as their old union job, but it's better than being unemployed and has a future of growth and security.

          This is how it's been for over a century. New technology and the inevitable rise of other

        • Nor do a I believe that Trump has any real solutions for the majority of blue color workers.

          Avatar was fiction, you know.

    • At best progressives will lecture them about how their jobs aren't coming back, they should learn to code, go to university, and move to the rich enclaves on the coasts.

      A) It's not "progressives" that said their jobs weren't coming back, it's the industry leaders.
      B) Anyone who says, "you should learn to code" to an adult doesn't have a fucking clue because programmers know it's not for everyone and they rather not have more competition.
      C) More people are finally realizing that universal basic income is where we need to go to help everyone out in this time of transition.

      conservatives figure out that it's better to pretend to listen, rather than to lecture those with less money, worse jobs and lower life expectancy on how they are all privileged transphobic racists and deserve their lot because of it.

      I would have thought the push to keep the ACA around would have made it clear that "progressives" want ev

    • by Solandri ( 704621 ) on Tuesday May 09, 2017 @02:40AM (#54382697)
      African Americans have the lowest life expectancy [kff.org], and vote overwhelmingly Democrat [factcheck.org].

      Something with as many subgroupings as life expectancy is going to be rife with Simpson's Paradox [wikipedia.org], so probably best not to read too much causality into these correlations.
    • by gtall ( 79522 )

      More likely, they are being lectured on getting a healthier living style and avoiding guns. Neither of these seems well received.

  • by vinn ( 4370 ) on Monday May 08, 2017 @11:25PM (#54382317) Homepage Journal
    Something doesn't seem right here. I live in Summit County, CO for 7 years and no one who lives in Summit County is actually from Summit County, or really even Colorado. Furthermore, even fewer are even year round residents. There's almost no one over the 65 there, the vast majority of the population are younger to early middle age ski bums. The same goes for Eagle County and to some degree Pitkin. Something about the ski bum population is skewing those results. (On a side note, a former Air Force general, Don Kutyna, who ran the US Space Command for a bit skied nearly every day and he was 70+ at the time. Over at Copper Mountain we had Frank Walters who was 80+ and skied hundreds of days a year.)
    • Something doesn't seem right here. I live in Summit County, CO for 7 years and no one who lives in Summit County is actually from Summit County, or really even Colorado. Furthermore, even fewer are even year round residents. There's almost no one over the 65 there, the vast majority of the population are younger to early middle age ski bums. The same goes for Eagle County and to some degree Pitkin. Something about the ski bum population is skewing those results.

      Of course not, they all died.

  • Oglala Lakota Nation (Score:5, Interesting)

    by Zibodiz ( 2160038 ) on Monday May 08, 2017 @11:36PM (#54382345) Homepage
    I live adjacent to the Oglala Lakota Reservation. It's a massive ghetto. I'm not surprised in the least that the expected lifespan is so short -- in fact, I'm kinda surprised it's that long. The poverty here is worse than most people realize exists in America. The hardest part is that there's literally no industry for these people to use as a means to climb out of poverty. They receive enough allowance from the government to stay alive -- and that's it.
    I'm not a native (heck, my dad wasn't even born in this country), but I feel deeply for our fellow men & women on the res. The USA forced them to live there, forced them into the ghetto -- and now they're too impoverished to ever leave. There's no work, no hope -- the res is the most depressing place imaginable. The lifespan information should be used as an indicator of how badly communities need help.
    • by phantomfive ( 622387 ) on Tuesday May 09, 2017 @12:50AM (#54382497) Journal

      They receive enough allowance from the government to stay alive -- and that's it.

      Sounds like a good basic income experiment right there.

      • Sounds like a good basic income experiment right there.

        Well, I can't speak for any other tribes, but my locals have been fucked over by poor governance. The members themselves would be okay (their spending habits are not so poor, individually) but letting some middleman who is sometimes corrupt control the disbursements doesn't work. The casino was deliberately mismanaged for embezzlement and they actually removed people from the tribe so that they wouldn't have to give them any money. Most of those people have since been reinstated.

        There was a time when the tr

    • Re: (Score:2, Informative)

      by ooloorie ( 4394035 )

      The USA forced them to live there, forced them into the ghetto -- and now they're too impoverished to ever leave.

      They are US citizens and they can leave anytime. Furthermore, poverty is not a barrier to picking up and leaving. What's actually going on is that people with initiative and skills do leave the reservations and join mainstream society. That leaves behind the people who are incapable of leaving because they lack the skills, intelligence, or initiative. And that's what you're seeing.

      The lifespan in

      • by Zibodiz ( 2160038 ) on Tuesday May 09, 2017 @04:11AM (#54382919) Homepage

        They are US citizens and they can leave anytime. Furthermore, poverty is not a barrier to picking up and leaving.

        I'm guessing you're not part of a minority.
        They could, technically, 'leave anytime,' sure. And be homeless somewhere. Most of them are unemployable; after all, they have a big black mark on their resumes: they've been living all their lives, unemployed, on the most high-crime res in the region. Would you hire someone with that resume?
        It's very hard to get out of a ghetto situation. Not only are they undereducated, but they have no opportunity to find work. It's hard to get a new home elsewhere when you've only ever known the res, and don't have the opportunity for work elsewhere. It's a rotten situation up one side, and down the other.

        These communities are already getting massive amounts of help.

        First off, you're wrong. They receive very little (a couple hundred/month if they enroll in a special welfare program. That's it.) In the 90s, the government built a bunch of houses, and moved everyone into odd little communities. Those have seen fallen into states of disrepair, as nobody could afford to live in them; lipstick on a pig and all that. They need education above all else.
        But more to the point, I never said they needed Federal aid. As a libertarian, I believe strongly in private aid organizations (my favorite charity is a particular homeless shelter which is completely privately funded.)
        Have you ever been on the Pine Ridge Res? If not, you have no idea what life there is like. I have traveled the western half of the USA, and have never seen a res as depressing and dismal as this. Even the Rosebud reservation, just a couple hours to the East, is substantially better. But if you recall in your history books, the Sioux, specifically the Oglala Lakota, were despised for their refusal to surrender to the USA. They're the tribe that ambushed Gen. Custer. They've never been seen as equals with the rest of America, and the bad situation 100 years ago has lead to the bad situation they live in today.

        • Even the Rosebud reservation, just a couple hours to the East, is substantially better.

          Wow that is saying something. I've never seen the Pine Ridge Reservation but I have seen the Rosebud one but Rosebud is a very low bar.

        • I'm guessing you're not part of a minority.

          Does being a gay immigrant count?

          They could, technically, 'leave anytime,' sure. And be homeless somewhere. Most of them are unemployable

          They are perfectly employable, for example in construction and agriculture. That doesn't require much education.

          First off, you're wrong. They receive very little (a couple hundred/month if they enroll in a special welfare program.

          I didn't say that they received large cash benefits, I said that they "are getting massive amounts of

      • Furthermore, poverty is not a barrier to picking up and leaving.

        What? Who told you that? Of course it is, we still live in a capitalist society. You can't just go places without money any more. It's getting to be like Europe where every square inch is owned. Trump and his ilk would like to see our public lands sold off to private interests to make this situation even worse. As it is, you already have to pay a lot of money to camp on most so-called public lands, which are really private lands owned by a state or federal government which reserves the right to tell you tha

        • What? Who told you that?

          Family and personal experience.

          • Family and personal experience.

            If you don't think it's harder for people with less money to move out, then you're not thinking at all. It doesn't mean it's impossible. It's still a barrier.

      • by serviscope_minor ( 664417 ) on Tuesday May 09, 2017 @08:17AM (#54383643) Journal

        They are US citizens and they can leave anytime. Furthermore, poverty is not a barrier to picking up and leaving. What's actually going on is that people with initiative and skills do leave the reservations and join mainstream society. That leaves behind the people who are incapable of leaving because they lack the skills, intelligence, or initiative. And that's what you're seeing.

        The trouble is, you've described about 95% of all humans. Forcibly dumping people into a shithole and then expecting them to show levels of initiative and risk taking well above what's average is going to leave you with an awful lot of people in a shithole.

        And blaming them is simply trying to absolve responsibility from the people who did the dumping.

        Instructing a group of people to be better humans than average is not a thing that will solve any problems.

        • And blaming them is simply trying to absolve responsibility from the people who did the dumping.

          I didn't "blame them", I simply explained why you're seeing what you're seeing. And the people who "did the dumping" are long dead. The sorry state of reservations is due to current policies adopted by current administrations and politicians.

          Instructing a group of people to be better humans than average is not a thing that will solve any problems.

          I'm not "instructing" Native Americans to do anything. What I am sa

  • by Billly Gates ( 198444 ) on Tuesday May 09, 2017 @12:40AM (#54382461) Journal

    So if you live in a city with higher income and job opportunities you live longer. Live in a poor rural area and you deserve to die. Nice system

    Ironic is these bozos who live in these regions are the most adamant on making sure they do not have healthcare so they can get healthcare in their mind as them having it is communism so give it to others who are rich and it will trickle back???!

    I don't get the thought process

    • I've struggled to find the logic as well in that thinking and I realized I was incorrectly using logic to solve an emotional problem. I think the reason they vote against their interests has more to do with pride than any real fear of socialism. By getting government backed healthcare, it's an admission that they aren't succeeding at life and are just like any other welfare recipient. I also suspect that many going on "disability" to collect a monthly check is a way to save face for many people.

      Now do you v

    • by DarkOx ( 621550 )

      Ironic is these bozos who live in these regions are the most adamant on making sure they do not have healthcare

      You are calling them bozos, which marks you as a prejudiced asshole! Let me explain the reality of the (un)Affordable Care Act for them to you. Before they did not have access to 'quality' healthcare, insurance that covered basics like antibiotics and such was priced out of the market for them. Conditions like diabetes were badly managed or not managed. So they got sick and stayed sicker longer leading to shorter lives, they often watched friends and family die for diseases that if caught sooner from

    • by moeinvt ( 851793 )

      If arrogant urban leftists would stop making assumptions and creating negative stereotypes about rural white voters (deplorable racist bozos who are afraid of communism, believe in trickle down economics etc. etc.) it would be rather easy to build a platform, even one including socialized medicine, that would be appealing to them.

      Why would the rural poor support Democrat plans for healthcare? Many of them earn just enough to be disqualified from Medicaid but too little to be able to afford good insurance.

  • The U.S. counties with the longest life expectancy are places like Marin County, Calif., and Summit County, Colo. -- communities that are well-off and more highly educated. Counties with the shortest life expectancy tend to have communities that are poorer and less educated. The lowest is in Oglala Lakota County, S.D., which includes the Pine Ridge Native American reservation.

    Simplistic discussions based on observing relationships between poverty, education, and life expectancy are not helpful in addressing

  • by ruir ( 2709173 ) on Tuesday May 09, 2017 @03:59AM (#54382887)
    Racism card to come in 3...2...1
  • Many of the other counties with the lowest life expectancy are clustered along the lower Mississippi River Valley as well as parts of West Virginia and Kentucky, according to the analysis.

    I wonder if genetic diversity - or rather the lack of it - is part of the equation.

  • Trump voters live in 3rd world counties, we just have to wait until they die out.
    Trumpcare will hasten that up quite a bit.

  • Okay, it's kind of obvious if you live in a place like a slum, with more disease, more violence and more temptation to use dangerous recreational (or medical drugs for recreational) drug, not to mention more junk food (through lack of education/knowledge + lack of availability of fresh produce), well, duh. Of course people on average will live less. Oh, let's not forget, lower availability of health care services due to lack of money/insurance or even lack nearby hospitals which is also a part of this. The

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