As a cause of excess mortality, socioeconomic disadvantage rivals smoking, hypertension, cancer, and cardiovascular disease. At age 40 years, the poorest US women can expect to die about a decade sooner than the richest; for men the gap is 15 years.¹ Socioeconomic inequalities are so pervasive that it is easy to assume they are immutable. Historical evidence demonstrates that tremendous progress toward narrowing inequalities is possible. Unfortunately, recent trends in the United States indicate that it is also possible to exacerbate inequalities: gaps in adult life expectancy have grown ever-larger since the 1980s.² Declines in life expectancy for disadvantaged individuals have increased so much that they outweigh small improvements among advantaged groups, and the United States has recently experienced overall declines in average life expectancy.³ This decline interrupts a century of life expectancy gains and is primarily owing to changes in adult rather than child mortality rates. The excess adult mortality reflects both “deaths of despair” linked to substance use and suicide, and the flattening of progress on cardiovascular disease among those without high school education.⁴

由于过高的死亡率，社会经济劣势可与吸烟，高血压，癌症和心血管疾病相抗衡。在40岁时，美国最贫穷的妇女可能比最富有的妇女早死十年。对于男人来说，差距是15年。¹社会经济不平等现象如此普遍，以至于很容易认为它们是不可变的。历史证据表明，缩小不平等现象的巨大进步是可能的。不幸的是，美国最近的趋势表明，也有可能加剧不平等现象：自1980年代以来，成人预期寿命的差距越来越大。²处境不利的人的预期寿命下降得如此之快，以至于超过了处于优势地位的群体中的小幅改善，而且美国最近平均寿命也出现了总体下降。³这种下降中断了一个世纪的预期寿命增长，主要是由于成人死亡率的变化，而不是儿童死亡率的变化。成人过高的死亡率既反映了与吸毒和自杀有关的“绝望之死”，也反映了未受过高中教育的人的心血管疾病进展趋于平缓。⁴