Deaths of Despair: Mortality in America
The CDC has reported that 2018 saw a rise in American life expectancy. This would not be big news, life expectancy has been rising in the developed world for almost a century, except the United States has been in a mortality slump. Between the years 2015 to 2017 the US life expectancy has declined year over year. It is really hard to overstate how devastating this turn is. Bill Gardner in his blog The Incidental Economist describes it as losing 400,000 human life years per cohort. That is a larger loss of life than the American soldiers sacrifice in the Iraq War.
This public health crisis is unique to the United States. A survey of OECD nations had the US life expectancy trends at the bottom of the pack already, before the recent downturn. Every other surveyed country having multiple different private and public healthcare systems out-performed the US on the life-expectancy metric before the dip in US life expectancy.
The good news follows a the first decline in drug overdose deaths since 1990. The spike in opioid deaths drove most (but not all) of the mortality crisis in America. The last time life expectancy stalled in America, the AIDS epidemic hit its peak killing 50,877 people in 1995. In 2018 there were 68,557 deaths to drug overdoses.
There has been a narrative, especially after 2016 surprise win in midwest states that these deaths represented a white working class “deaths of despair”. There are many white supremacist sites that will trumpet this narrative and perversions of it that I won’t get into here, but the original research was done by Anne Case and Angus Deaton and is collected in their book Deaths of Despair and the Future of Capitalism. In it they make the case that the white non-college cohort of Americans are experiencing a deep cohort wide anxiety and depression that is literally killing them early.
Angus Deaton is a Nobel laureate and along with his wife Anne Case are emeritus Princeton economists. Together they paint a picture of despair in America that is leading to the shocking rise in mortality. The largest driver of it is the opioid crisis. Prescription opioids were marketed to individuals unscrupulously, and the effect was an addiction that was devastating on Americans’ health, job prospects and social relations. As doctors became aware of the risks, they have stopped prescribing opioids which have lead addicts to seek out more dangerous drugs like synthetic fentanyl and heroin. It is not just opioids however, the researchers also found increases in deaths to gun violence particularly suicides. They show that if you single out non-college whites and compare them to them to their college educated and minority peers, the trend of deaths becomes more pronounced and has much earlier roots going back to the 1970s.
Using the data they paint a picture of self medicating to stave off despair in the middle of the country. While being jobless or having a much shrunken wage from previous years may be an economic issue, the effects on people’s psyche is detrimental and is showing up in the mortality data as an epidemic of drug abuse and suicide that we are only now getting under control.
So have we defeated the “deaths of despair”? Conservative media’s read of this new evidence of rising life expectancy is that the economy is great again, optimism has returned to the land of Middle America and with the extra wealth from the Trump tax cuts and cuts to Medicaid shutting down supplies of easy opioids, Americans have kicked their drug habit, stopped killing themselves and gotten back to work. That read is both naive and dangerous. The 2019 drug death estimates look in line with 2018 which means we are not actually making progress in saving people. We’ve just stopped the bleeding. We’re actually on the precipice of helping or worsening the “deaths of despair” epidemic and it will depend on what we do in the coming years.
First, I want to dispel some myths and misreadings of the original pairs work, and there are a lot of them.
- It’s not the economy.
For white non-college Americans the trend of more mortality due to suicide, alcohol, and drugs has been a long term trend going back to the 1970’s. It’s been consistent through recessions and recoveries. A paper by Christopher J. Ruhm found that economic factors account for less than 10 percent of the rise in drug and opioid-involved mortality rates. And other countries had the Great Recession too without killing tens of thousands of people in their prime.
- It’s not a rural vs urban issue.
Opioid deaths have often been attributed to over-prescriptions in rural America but deaths to opioids has been on the rise in a diverse range of counties. It’s not just opioids. Suicides have also risen across the United States. No one has been spared.
3. None of these maladies are limited to non-college whites inherently. African-Americans as a group have always had higher than average mortality. In a way, the African-American community has always been suffering from “deaths of despair” that has been undiagnosed as such. The authors do speculate on possible reasons the trend among non-college African-Americans has not following the same path; these include closer community ties, and the importance of the black church. There has also been a troubling development among African-Americans as a group seeing an opioid driven surge in deaths in the last few years.
Likewise college educated whites are not immune from the systemic deaths. As a group it hasn’t affected them nearly as dramatically as non-college whites.
4. It is a uniquely American phenomenon.
The authors note that the trend might just not be showing up in European countries because it’s too early, most other countries have already heavily regulated their opioid markets after the American experience. Calls to pull Medicaid from Americans suffering from this epidemic or put work requirements to access Medicaid are also counter-productive in the authors’ opinion pointing out the robust safety net in other countries have not lead to a similar rash of self-medicating despair.
I have a lot of issues with this study and the way that it’s presented, but I wanted to put the best possible argument for “deaths of despair.” I think it is a real phenomenon, but I question the focus of study and the weight of the available evidence for this narrative. It has done a lot of good to shine a light on the troubles of non-college whites and the local and national focus on arresting the rise of opioids is finally producing results. This study saved lives, and that is only good news.