We are approaching the end of 2023. I could say it is the best of times and the worst of times. That, however, would be engaging in hyperbole, and we have enough of that going in these days. No, this past year has been fine for the most part. People are working, wages are up, and inflation shows signs of abating. It is the future that remains murky.

I am not going to comment on the overall state of the world. That would be above my pay range. But some things do bother me, and you few who read my scribbling are less expensive than a therapist. So, you are stuck listening to my ramblings. Aren’t you the fortunate ones?

I’m struck by the fact that so few comment on the fact that life expectancy in the U.S. has fallen recently, the drop being more dramatic than any others seen in a century. Sure, Covid deserves blame, but we have not rebounded as robistly as others have. Robert Califf, Commissioner of the Federal Drug Administration, warned his colleagues as follows:

America’s life expectancy is going the wrong way. We are the top health officials in the country. If we don’t fix this, who will?

The numbers are sad, that is for sure. The life expectancy for males in the U.S. is 73.5 years. That may sound okay, but it puts us in 43rd place among countries where such things are accurately measured. A number of our peer nations have life expectancy rates north of the 80-year mark.

Still, I wonder just how much blame, or responsibility, can be assigned specifically to public health officials. Yes, we have the most expensive health care delivery system in the world, by far. It is also true that our health outcomes are mediocre at best. And yes, our system is overly siloed, focuses on care by specialists, and treats prevention as being of secondary importance. All true. In many ways, our approach to health reflects our national obsession overall … which approaches and arrangements will generate the most remunerative bottom lines. A healthy population does not lead to high profit margins. Am I being too cynical here?

I recall my brief conversation with the young surgeon who replaced my former ear doctor, an eminent surgeon who retired. (I have one ear that doesn’t work because of a tumor that has been removed.) I touched on these matters since I like chatting with professionals. He quickly dismissed my concerns with one observation. ‘Americans make poor lifestyle decisions.’ Of course, he was in a hurry (one must push the medical assembly line along after all). Thus, there was no time to explore what I thought was a convenient rationalization for our poor national health performance … blame the customer. But it got me thinking.

Are there not other likely suspects to at least consider for our lower life expectancy rate. What about our insane gun policies? Our misreading (in my opinion) of the 2nd amendment has led us to become a carnage-ridden shooting gallery. We have 37,000 gun related deaths per year, just about as many American soldiers as were killed in the Korean conflict. The sop of guns saving lives doesn’t hold up to even a cursory scrutiny. The gun-related death rate in the U.S. is 4.52 (per 100,000). In Canada to our north, it is 0.62; In Germany it is 0.06; In Japan, it is virtually zero. Why the difference. In part, they have more sensible gun control laws while we are drowning in instruments of death.

Our suicide rate is also high. By one measure, we rank 2nd only to Greenland on that score. But the numbers are fuzzy. Intentional opioid (and other drug-related) deaths are difficult to sort out from those that are accidental. Some, however, lump such intentional exits from life into a category of deaths due to despair. As we sink into our national abyss of anger and hopelessness, we tend to strike out … at ourselves and others. Remember that many of our political disputes are based on sheer anger, at one another, and at those forces we barely comprehend.

Let’s back up further for a moment. What happens when a society becomes highly unequal, when more and more of the goodies are accumulated in the hands of fewer and fewer. That is where we are now. America has become the poster child for unequal economic outcomes. How many times have I pointed out that the share of income going to the top sliver of society has risen from less than 10 percent of the pie in the late 1970s to almost one quarter in recent years. This massive shift in wealth and power has become an axiomatic truth, something accepted as natural and fair even among many of the losers. How many struggling working class folk voted for Trump? They are angry and resentful, yet unclear about whom to blame. Republicans are most happy to provide convenient targets for their wrath.

Of course, it doesn’t have to be that way. Public policies can address our fondness for dying early and our apparent willingness to push policies designed to make the filthy rich even richer. Only Americans would think this is a good idea. One example … our tax system reduces the gini- coefficient (the standard measure of inequality) by some 27 percent.

You might think that is pretty good. But it is a rather weak performance when viewed globally. In terms of addressing the inequality issue (through taxes and transfers), we ranked 35th out of 44 countries. We barely beat out Russia. Greater concentration gives those at the top more power to control the rules that permit even greater inequality. Where does that end?

Public spending in general can help equalize economic outcomes, especially if those outlays are for human capital (e.g., education and research) and infrastructure improvements. Again, we rank poorly on this measure. Some 37 percent of all our spending is for public purposes. In France, that rate is 58 percent. In Belgium, it is 54 percent. Again, it depends on how the money is spent but public expenditures in preventative health, in early childhood development, in quality childcare and education, and in labor market programs can do wonders in correcting our highly unequal outcomes which, in turn, threatens our cohesive social fabric.

Let us face it. Inequality tears at our social fabric. It fosters suspicion and jealousies. It makes it easier for demagogues to play the divide and conquer game. The desperate losers fight with ever more conviction, if not desperation, over the remaining scraps.

And that is what I fear looking forward. We won’t be addressing the real issues … premature deaths, unequal opportunities, a poverty of public investments in the future, climate change, and so forth. We merely will continue to fight among ourselves for meager advantages in a stacked game while the big issues and challenges remain untouched.

I hope I’m wrong, but I doubt it. So, let me end with a hope that we work on getting the questions right. That would be my new year’s resolution … that we think hard and honestly about what we want to be as a society.