It’s not often that economics research makes national headlines the way a paper in Proceedings of the National Academy of Sciences did last week. But most papers don’t posit, as this one did, that America is in the midst of a decades-long wave of sickness and death with little comparison in its modern history.
For the paper, the Princeton University wife-and-husband team of Anne Case and Angus Deaton examined mortality and morbidity (illness) data from 1999 to 2013. What they found was shocking: While middle-aged people in rich countries all over the world have been getting healthier, for white Americans — and no other subgroup in this country — rates of death and illness have actually gone up.
Since then, the statistician Andrew Gelman has pointed out that it’s probably more accurate to say that the death rate for white Americans has flattened since 1999. But the result is still staggering: While everyone else in wealthy countries has gotten healthier and less likely to fall ill or die, middle-aged white Americans haven’t. This could translate to tens of thousands of deaths that “shouldn’t” have happened, were it not for whatever dark aberration this population is experiencing. The authors believe that this mortality increase “was largely accounted for by increasing death rates from drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis.” It’s a public-health crisis that quickly drew comparison to the demographic catastrophe that ravished Russia after the fall of the Berlin Wall.
Naturally, the next question is: Why? And here’s where things get fuzzy. Based as it was on a zoomed-out view of the data, the paper could offer only speculation as to the root causes of all these unexpected deaths and illnesses. The authors note that their discovery “is only partly understood,” before mentioning the possibility that the “increased availability of opioid prescriptions for pain” over the last two decades could be part of what’s happening, and that the widening of income inequality over the last three decades could also be linked to the “epidemic of pain, suicide, and drug overdoses” among low-education white people who bore the brunt of the suffering documented in their paper.
While the well-documented economic problems of the past several decades — stagnant or declining real wages for middle- and lower-income Americans, reduced socioeconomic mobility, and cuts to public services as states scramble to balance their budgets — surely led to negative outcomes, the exact pathways via which this occurs are extremely complicated, and researchers are only starting to understand them.
Case and Deaton’s results offered an important, dramatic finding, but it brings with it an endless array of questions. To wit: Why was it white people, rather than black people and Latinos, who suffered the increase in mortality and morbidity? Why was it middle-aged people? What role has the fuzzy concept of hope, or its absence, played in determining health outcomes during a period when so many Americans saw their socioeconomic opportunities contract? And why does gender — an important variable in almost every conceivable circumstance — not appear to play much of a role here?
Answering these questions will be a key part of the national conversation on inequality and health in the months and years ahead, and will require studying the populations in question not just at the zoomed-out level of national data, but at every other level, too, all the way down to the way small-town residents access — or don’t access — physical- and mental-health services, and how they respond to stress and chronic pain. It’s a giant, tangled problem that can only be solved painstakingly, one study at a time. In short, “It’s going to take a lot of peeling back the onion before figuring out how to address this,” said Dr. Kathryn Paez, a principal researcher at the American Institutes for Research who studies chronic conditions and disparities in access to health care, and whose work Case and Deaton cited in their paper.
I asked Dr. Julie Phillips, a Rutgers sociologist who studies the effects of inequality, about the race issue. Could it be the case that they were exposed to senses of socioeconomic stability and hopes for upward mobility that black and Latino people never had in the first place? That white people, in other words, started at a higher point and therefore had a longer way to fall? She said this was likely part of the equation: “Rates of suicide have always been lower among blacks,” she pointed out. But “in terms of why the current rise in suicide is occurring only among whites, absolutely, what you describe is one of my working hypotheses.”
She also said that the specific structure of the economic downturn can explain why it was middle-aged people, rather than those in other cohorts, who are suffering the most. “In terms of the Great Recession, we know that the downturn disproportionately affected the middle-aged in terms of house values, household finances, and hits to retirement accounts,” she said. The problem is that numbers — evictions or drops in housing prices or whatever else — can’t entirely capture what these epochal forces do to individual lives. “I think the argument can be made that for those in midlife, the hardship and feelings of failure or hopelessness associated with worsening economic conditions are compounded by the fact that middle-aged adults are more likely than others to be family breadwinners and supporting dependents,” said Phillips, citing the results of some of her own research.
This connection between hopelessness, morbidity, and death is important and little understood, partly because hope is an impossible thing to quantify. To Paez, pain is an important part of the equation, since it’s likely the case that one’s perception of it is affected by their economic prospects — if you’re hopeful about things in general, you’re less likely to let pain get you down. A key question is “How do these factors cluster together?” she said. “For example, is death more likely if you have both economic challenges and pain, but if you have pain alone, there is not much of an increase?”
Overall, “We’re not really great about managing chronic pain,” she explained. “Our health-care system is geared toward either giving people drugs or doing procedures on them. Chronic pain is really about teaching people how to self-manage — how to cope with the pain and manage it by making lifestyle changes and thinking about it differently. Some of the things that seem to work for chronic pain are things like meditation, retaining an exercise program even though you hurt, getting adequate sleep, having adequate social support.” The problem is that people experiencing financial duress — particularly those with lower education levels — are much less likely to have access to these services. And when poor people suffer from chronic, untreated pain, she explained, the results can be disastrous. “People get into a pain cycle,” she said, “where if they weren’t under such financial pain their physical pain wouldn’t be so bad, but their emotional health contributes to their perception of their pain, and it’s a downward spiral, and they often have depression on top of it.”
In addition to all the other mysteries at work here, Paez also highlighted a confusing gender element: Case and Deaton didn’t find any meaningful gender differences in the mortality and illness rates, despite the fact that men have been much harder hit by the economic turbulence that occurred over the period they studied. “I had thought it would impact more men than women, because women weren’t affected by the downturn, I believe, as much as men were,” she said. “So why wasn’t there a gender difference here? … If [the increased mortality and illness] is related to men doing heavy labor and then losing their jobs, that wouldn’t be the case as much with women.”
One possibility, she thinks — and researchers would have to study this to know if it’s actually the case — is that in many cases women are bearing at least part of the physical and psychological brunt of their husbands losing their jobs. The effects of economic opportunities withering away may be contagious within households, in other words. But she emphasized that this was speculation on her part: “It’s a total mystery to me,” she said — one of many, many unanswered questions provoked by this depressing paper.