Skip to content
Spiral Staircase
Buy the book
Menu

Reference topic 36: Why We Die the Way We Do

Leading causes of death, and how long people are ill first

StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.12 sources0 graded recommendationsTopic hub: Aging

Published Updated

In December 2024, four statisticians at the National Center for Health Statistics published a short document with no argument in it. "Mortality in the United States, 2023" makes no case and names no villain. It reports what the death certificates said. That year just over three million people died in the United States, and each certificate was coded to one underlying cause.1

There are thousands of ways for a human body to stop. More than seven Americans in ten left by one of ten doors.1

Mismatch card

The system

All of them, counted at the end: what people die of, and how long they are unwell first.

What it expects

A body that moves, eats, defends, senses and socializes in the conditions of Parts Two to Seven, with death arriving mostly from outside (infection, accident, violence) after a modal age in the seventies.

What it gets

Those conditions removed one at a time, with medical treatment supplied for each resulting failure.

What happens in the gap

Ten causes take 70.9% of US deaths, six of them substantially modifiable, and the United States carries the world's widest healthspan-lifespan gap at 12.4 years.

The handrail

Topics 40 to 42, system by system; nothing new is prescribed here (●●○)

Strength of evidence

●●● for the mortality counts themselves (a full census of US death certificates) and ●●○ for the attribution of that pattern to environmental mismatch, which is an argument assembled across chapters rather than a single tested finding.

What this topic covers

  • ·The Number That Hides the Bodies
  • ·Omran's Three Ages
  • ·Reading the 2023 Ledger
  • ·Fries's Bet
  • ·The Gap That Is Opening

The practical version is in the book: Chapter 16, Aging Well.

The skeptic's corner

The case against this topic, from the research itself.

Fries's compression hypothesis is still a hypothesis. Has illness across whole populations been compressed, expanded, or settled into what demographers call a dynamic equilibrium, worse health but slower dying? That remains an open argument in the field, not a settled result in Fries's favor.12 The Garmany and Terzic data point toward expansion. But they are national, ecological figures, averages for whole countries rather than individuals followed through life. And health-adjusted life expectancy is itself a modeled quantity, built on disability weights (scores for how far each illness falls short of full health) that reasonable people dispute. A widening gap measured this way is a real signal. It is not a verdict.

Omran's three ages are a framework, not a law, proposed as theory in 1971 and patched since.57 Countries have moved through the stages at different speeds and in different orders, and some have moved backward.

The gains of modern medicine are real. Nine of the ten leading causes fell in a single year, as life expectancy rose almost a full year.1 The honest claim is narrower. Medicine has become good at postponing death from diseases whose environmental causes remain untouched, and that is one reason the years it adds are not always well ones.

Finally, a genuine complication cuts against the whole framing. Part of the modern cause-of-death profile is a byproduct of survival itself. People who no longer die at 30 of infection or injury live long enough to develop cancer, Alzheimer's and heart disease, and long enough to be scanned, screened and diagnosed with them. Some of what looks like a sicker population is an older and better-examined one. That effect is real and not small, but it does not account for a 12.4-year gap on its own.

Terms this topic defines

Related topics

Sources cited above

  1. 1.Murphy, S.L., Kochanek, K.D., Xu, J., and Arias, E. (2024). "Mortality in the United States, 2023." NCHS Data Brief, no. 521. Hyattsville, MD: National Center for Health Statistics. https://doi.org/10.15620/cdc/170564 (total deaths, the 70.9% share, life expectancy and age-adjusted rates from the brief's summary and tables; the ranked causes and their 2022 comparisons from Figure 4. The cancer change from 142.3 to 141.8 was not statistically significant.) (3,090,964 deaths in 2023, 70.9% of them from the ten leading causes. Age-adjusted death rates per 100,000 in 2023: heart disease 162.1, down from 167.2 in 2022; cancer 141.8, from 142.3; unintentional injuries 62.3; stroke 39.0, from 39.5; chronic lower respiratory diseases 33.4; Alzheimer's disease 27.7, from 28.9; diabetes 22.4, from 24.1; kidney disease 13.1, from 13.8; chronic liver disease and cirrhosis 13.0; COVID-19 11.9, a fall of 73.3%. Life expectancy at birth rose 0.9 year, from 77.5 to 78.4, and stood at 75.8 for men and 81.1 for women; the age-adjusted death rate for all causes fell from 798.8 to 750.5 per 100,000.)
  2. 12.Crimmins, E.M. (2021). "Trends in Morbidity, Healthy Life Expectancy, and the Compression of Morbidity." In Handbook of the Biology of Aging, 9th ed., 405-414. Academic Press. https://doi.org/10.1016/B978-0-12-815962-0.00019-6
  3. 5.Omran, A.R. (1971). "The Epidemiologic Transition: A Theory of the Epidemiology of Population Change." The Milbank Memorial Fund Quarterly, 49(4), 509-538. https://doi.org/10.2307/3349375 (a theoretical paper; the stage names and life-expectancy figures are Omran's own, checked against the open-access reprint in The Milbank Quarterly, 83(4), 731-757, 2005)
  4. 7.Barrett, R., Kuzawa, C.W., McDade, T., and Armelagos, G.J. (1998). "Emerging and Re-emerging Infectious Diseases: The Third Epidemiologic Transition." Annual Review of Anthropology, 27, 247-271. https://doi.org/10.1146/annurev.anthro.27.1.247

This topic carries 12 notes in the research manuscript; the 4 above are those behind the material on this page. Full source register.