Deaths of Despair

https://www.theguardian.com/us-news/2017/mar/28/deaths-of-despair-us-jobs-drugs-alcohol-suicide

Is the US facing an epidemic of 'deaths of despair'? These researchers say yes

Anne Case and Angus Deaton’s findings on mortality rates have made waves. A new paper looks deeper at a divided America – and its crisis of suicide, overdoses, and drug- and alcohol-fueled diseases

Michael Bible


‘There appear to be two Americas: one for people who got a four-year college degree, and one for people who didn’t.’

In 2015, the Princeton economists Anne Case and Angus Deaton’s groundbreaking paper in the National Academy of Science’s magazine reported that mortality rates among a section of Americans were suddenly surging – something unheard of in previous decades. Mortality was only rising in a certain group: middle-aged non-Hispanic whites without a college degree.
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Case and Deaton have returned with a new paper published last week by the Brookings Institute. It paints a grim picture of two Americas, in which one has recovered from the 2008 economic crisis and the other hasn’t. The latter, once called “blue-collar aristocrats”, consists of families who were previously able to get by with jobs not requiring college degrees. The disappearance of those jobs has been accompanied by an alarming rate of suicides, overdoses, and diseases caused by drugs and alcohol.

Case and Deaton call these “deaths of despair” – and argue they have recently reached disturbing levels. While opioids account for many of the deaths, drug abuse may only be a symptom of a larger, unseen epidemic of despair.

Dr Anne Case answered questions over email.

Could you briefly describe your original research and what this new follow-up paper adds to it?

Our 2015 paper documented a set of facts: that after a century of almost uninterrupted progress on mortality, US white non-Hispanics (WNH) in midlife were experiencing a sustained period in which mortality rates stopped falling and rose instead. This stands in contrast to the continued declines in midlife mortality in other rich countries, and to progress being made in the US by black non-Hispanics, and Hispanics, who are on average poorer than whites.

Our 2015 paper highlighted the role played by suicide, alcohol-related liver mortality, and accidental drug overdoses in pushing mortality rates higher for WNH Americans. Our latest paper allowed us to take a deeper dive, looking at mortality and morbidity in much broader perspective. We found the mortality increases are in sync with the distress midlife WNHs face in many dimensions: poorer health and mental health, social isolation, obesity, marriage (or lack of marriage), poorer labor market opportunities, and weaker attachment to the labor market.
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Two additional findings stand out: using these outcomes as measures of wellbeing, there appear to be two Americas: one for people who got a four-year college degree, and one for people who didn’t. In addition, these poorer outcomes for those without a college degree become more and more pronounced the later in the 20th century.

You use the term “deaths of despair”. I’m wondering how you would define “despair” in this context?

We think of drug, alcohol and suicide deaths. In a sense, they are all suicide – either carried out quickly (for example, with a gun) or slowly, with drugs and alcohol.

How do you see religion and marriage as factors in the rise of mortality rates among WNH Americans?

There hasn’t been a decline in religion, but it appears there has been a change in the type of churches to which people report an affiliation. “Legacy” churches (eg Catholic, mainline Protestant) have given way to “seeking” churches, in which there is less structure.

I’m not sure traditional ideas of marriage have changed, but later-born birth cohorts of WNH without a college degree are substantially less likely to get married, or stay married. To be concrete, almost three-quarters of WNH men and women with less than a BA born in 1950 were married when observed at age 30; that fell to two-thirds for the cohort born in 1960 seen at age 30; and to half for the cohort born in 1980.

Scholars in sociology tell us this is closely connected to the fact that men in later-born cohorts can’t marry if they don’t have “a good job”. Those jobs – jobs with on-the-job training, jobs with benefits, jobs where, if you work hard, you can expect to move up – are harder and harder to come by now. While marriage rates fell, rates of cohabitation rose. However, unlike what one sees in many European countries, these cohabitations are fragile in the US. Taken together, this leaves less structure (in religion, in jobs, in marriage). If things go well, this is fine, but if things go poorly, this can lead to suicide.

You write that the recent decline in incomes does not completely explain the rise in “deaths of despair” among white non-Hispanics without a college degree; they also face a “cumulative disadvantage” over the course of their lives. How do you explain this?

Current household income per person doesn’t explain why those without a BA have rising mortality rates. For both those with and without a college degree, incomes rose in the 1990s and fell with the great recession. But those with a BA saw mortality rates fall throughout this period, while those without a BA saw mortality rates rise throughout.

We are working with a model of “cumulative disadvantage” to help us make sense of the rise in despair. You can think of everyone born in a given year (say, 1960 or 1970) as being handed a weight that they have to carry with them. The heavier the weight, the harder it is to carry, and the longer you carry it, the worse things become. That weight may be the kinds of jobs a person can get with a high school degree (measured in wages and opportunities for advancement), and it appears that weight is heavier for each successive birth cohort. The quality of the labor market may affect whether a person marries, and the stability of their personal lives, and whether they risk their health at work.
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What current policies, if enacted, could prolong or deepen or halt the epidemic?

Addiction and mental health programs are essential. Working to stop the over-prescription of opioids is essential. Policies that make available educational opportunities for people who don’t want a college degree – that allow people to develop the skills that will be rewarded in the 21st-century economy – would make a big difference.

You suggest that Europeans don’t see the same rise in death rates due in part to a stronger social safety net. Could you see an argument for such a social safety net in America?

This might be more difficult than it sounds. Americans like to think of themselves as individuals who can look after themselves and their families, and expect the same of their neighbors. A stronger safety net may not be politically feasible. The difference between a “helping hand” and a “handout” may be in the eye of the beholder.

In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In the UK, the Samaritans can be contacted on 116 123. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found here.