The average life expectancy for residents of the 30 developed countries that comprise the Organization for Economic and Community Development (OECD) is 80.3 years. The life expectancy for a U.S. citizen is 78.7 years and falling.

U.S. life expectancy began dropping in the 1980s and fell below the OECD average in 1998. After reaching 78.7 years in 2012, U.S. life expectancy has not changed.

The report was published Wednesday in the British medical journal “the BMJ” based on an investigation by the National Research Council and the Institute of Medicine in a commissioned (not peer-reviewed) article that reviewed the results of recent studies.

The authors found that Americans had poorer health in many areas, including birth outcomes, injuries, homicides, adolescent pregnancies, HIV/AIDS, obesity, diabetes and heart disease. But there’s more, and it’s worse.

The rate of fatal drug overdoses rose by 137% between 2000 and 2014, driven by the epidemic in opioid use. In 2015, more than 64,000 Americans died of drug overdoses, a total greater than all U.S. military personnel killed during the Vietnam war.

The U.S. suicide rate rose 24% between 1999 and 2014, and the increase disproportionately affected white American adults between the ages of 25 and 59, those with limited education, and women. According to the report, the sharpest increases came in rural counties, especially from those regions with “longstanding social and economic challenges.”

What explains the decline in life expectancy? According to the authors there are many possibilities:

Why white Americans are dying at higher rates from drugs, alcohol, and suicides is unclear, complex, and not explained by opioids alone. The answer—likely some combination of factors in American life—must explain why the rise in mortality is greatest in white, middle aged adults and certain rural communities. Possibilities include the collapse of industries and the local economies they supported, the erosion of social cohesion and greater social isolation, economic hardship, and distress among white workers over losing the security their parents once enjoyed.

One source of the BMJ article is a study published last October in the American Journal of Public Health titled “The Epidemic of Despair Among White Americans: Trends in the Leading Causes of Premature Death, 1999–2015.” Based on that research, the BMJ authors note:

By contrast [to the experience of white Americans], greater resilience might explain why black Americans—who have contended with longstanding structural disadvantages, discrimination, and higher all cause mortality—have not experienced a surge in drug deaths or suicides.

BMJ authors also noted that “the US is rich, but its wealth is not inclusive” and that the American dream is “increasingly out of reach, as social mobility declines and fewer children face a better future than their parents.”

U.S. policymakers are taken to task:

In theory, policy makers jolted by the shortening lifespan of Americans would hasten to correct these conditions. They would promote education, boost support for children and families, increase wages and economic opportunity for the working class, invest in distressed communities, and strengthen healthcare and behavioral health systems. But the pro-business policy agenda favored by elected officials rarely prioritizes these needs. On the contrary, recent legislation and regulations may prolong or intensify the economic burden on the middle class and weaken access to healthcare and safety net programs.

The BMJ article contains a list of references to relevant articles and studies.

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