The Haas Institute hosted Anne Case on March 1 for a talk that looked at the opioid epidemic in the United States which has caused the deaths through overdose or suicide of hundreds of thousands of people, mostly white, in recent years. Case, who is Director of the Research Program in Development Studies at Princeton University, noted that these "deaths of despair" did not directly correlate with the state of the economy at any particular downturn, but were rather due to a long process that saw people's quality of life decrease. "Inadequate access to job networks and employment, lack of access to quality schools, decreasing availability of suitable marriage partners, lack of exposure to conventional role models, those actually would be good descriptors of what's happening to the white working class now," she said.
Her presentation was followed by responses from Mahasin Mujahid, who is a Professor of Public Health and Associate Professor of Epidemiology at UC Berkeley, and Ronald Lee, who is the Associate Director for the Center for the Economics and Demography of Aging at UC Berkeley.
This talk was moderated by Hilary Hoynes, Professor of Economics and Public Policy at UC Berkeley.
Check below for a transcript of the event.
Hilary Hoynes: My name is Hilary Hoynes; I'm a professor here in economics and public policy, and I also head up the HAAS Institute Economic Disparities Cluster, so I want to thank the HAAS Institute for a fair and inclusive society for sponsoring the activities of our cluster. This event is also sort of cosponsored by the Health Disparities Cluster here on campus. And as in Anne's slides here, this event is part of a recurring set of events on campus organized by the HAAS Institute around issues in the translation of research to impact. So the plan for today is we're gonna have three speakers here today, and I'm gonna introduce all the speakers now so that we can then go directly to the presentations. And then after the presentations, the speakers and I will come back to the stage, and we'll have some time for Q&A from the audience.
Hilary Hoynes: So before moving on, I want to make sure that I thank Takiyah Franklin, who helped out in organizing this event; there she is, in the front, sorry. Thank you so much, and our faculty advisor of the HAAS Institute is also here, Denise Heard, so I want to again welcome you all.
Hilary Hoynes: So I'm really delighted to introduce Anne Case, who's going to be our primary speaker at the event today. Anne is the Alexander Stewart 1886 Professor of Economics and Public Affairs Emeritus at Princeton University. Anne, over her career, has written extensively on health over the life's course. She's been awarded the Ken J. Arrow Prize in Health Economics, as well as the Cozzarelli Prize from the proceedings of the National Academy of Sciences for her research on midlife morbidity and mortality, the subject of today's talk. She's a member of the American Academy of Arts and Sciences, the National Academy of Medicine, the American Philosophical Society, and a fellow of the Econometrics Society. She's currently on the committee on national statistics, and the President's committee on the National Medal of Science.
Hilary Hoynes: So after Anne speaks, I'm really delighted to have two of my Berkeley colleagues who will be providing a commentary on Anne's talk. And our first speaker is gonna be Mahasin Mujahid, who's up here. And Mahasin is the Chancellor's Professor of Public Health, an associate professor of epidemiology at the School of Public Health. Mahasin got her master's in biostatistics and PhD in epidemiological sciences, both from the University of Michigan. She joined the faculty at Berkeley in 2009, after two years as a Robert Wood Johnson Health and Society scholar at Harvard School of Public Health. Mahasin's research examines how features of neighborhood environments impact health and health disparities. She's particularly interested in issues around cardiovascular health, and the relationship of neighborhood physical and social environments, and the relationship to cardiovascular risk factors. And racial ethnic minorities, and the consequences of this clustering on longterm cardiovascular health of these groups. Mahasin is a member of the Health Disparities cluster of the HAAS Institute, and a fellow of the American Heart Association.
Hilary Hoynes: Our second speaker, commentator, will be Ron Lee, who's the Edward G. And Nancy S. Jordan Family Professor Emeritus of economics, and professor emeritus of demography. And Ron is also the founding director of the Center for the Economics and Demography of Aging here at Berkeley. Ron's current research focuses on the macroeconomic consequences of the changing population age distributions, and on intergenerational transfers and population aging. He co-directs with Andrew Mason the National Transfer Accounts Project. Notably, for what we're talking about today, from 2010 to 2015 he co-chaired a National Academy of Sciences Committee on the long run macroeconomic effects of an aging U.S. population. He's an elected member of the National Academy of Sciences, the American Association for the Advancement of Science, American Academy of Arts and Sciences, and the American Philosophical Society. He's a former president of the Population Association of America, and I just want to have us all welcome our three speakers, and I look forward to the event.
Anne Case: So thank you so much, Hilary, it's such a pleasure to be here today. I'm gonna talk about a book that I've been writing with my co-author Angus Steeton, and the title is Deaths of Despair and the Future of Capitalism. It should be out in early 2020, as you could imagine, it would make a great holiday present, right? For that hard to buy for someone. So be looking for it early next year. The book, I can't possibly summarize in a short period of time, so I'm going to talk about a few bits of it. I want to talk a little bit about things coming apart in the last part of the 20th century for working class people. I'm going to compare what the black experience and the white experience over that period as well. And then I'm going to turn a little bit to why capitalism is failing so many people, and given this is research to impact, I'm gonna end with a list of things that the book talks about that we think might make a difference in helping people.
Anne Case: Just to set the stage here, the 20th century was really good for health outcomes in the U.S. so what you're looking at here is just mortality rates from men and women in midlife, 45 to 54. And we're looking at deaths per 100,000, which is all the death rates I'll be showing you today is per 100,000 people at risk. And what you can see is over the course of the 20th century, mortality rates for whites and middle age went from 1,500 to 400 per 100,000. So you can see just to give you a little bit of background here, you can see the 1918 flu epidemic, right? So that caused this big spike up here. And you can see a plateau around 1960, which was caused by the fact that people then in their 40s and 50s had smoked like chimneys in their 20s and 30s, and were dying of lung cancer and heart disease. But people stopped smoking, people started taking their antihypertensives, and progress continued.
Anne Case: So this is going to look different, and we'll return to this for African Americans. We have death records going back to 1968. Before that, they're divided into white, non-white. But if you look just from 1968 on toward the present, in 1968, black mortality rates in mid-life were twice as high as whites. So that gap has closed enormously, but it's still there, and it's still a persistent problem. So you can see that the trends are different though, that blacks were making more progress; the rate of decline is faster for blacks, than it was for whites. And we'll come back to that as well.
Anne Case: But if you look at what happened going forward, we got used to this idea that mortality was just going to keep falling. But what happened was if you go forward into the 21st century, and the countries that sort of, kind of look like the U.S., right, all the other rich countries, mortality rates continued to decline at 2% per year for people age 45 to 54. But the U.S. could have left the heard, right? So for U.S. whites, mortality stopped falling, and actually started to rise in the 21st century. So that a big gap has opened up between outcomes for whites and outcomes for rich countries elsewhere in the world, other English speaking countries and countries in Europe. For Hispanics, Hispanics look a lot like the line for the UK. They'd be basically on top of each other. For black non-Hispanics, starting at a higher mortality rate, but falling at a faster rate. So a 2.6% per year decline, as opposed as a two percent decline for these other countries.
Anne Case: What's caused this? Well, when we saw this, we were sort of surprised because we thought people must already know this. Right? So we spent a lot of time going around seeing our friends at medical schools, and asking whether or not this was something, it must be out there. People must know this, but it sort of came as a surprise when we started to show it around. And when we dug deeper, it turns out the three things that were actually increasing over this period of time were deaths from drug overdose, from alcohol/liver disease, and from suicide. And we started just as a shorthand, we started calling those deaths of despair. And that name kind of stuck with it. It's just a shorthand to describe these mortality rates, it doesn't say anything about causes. But it's just to say that that's been increasing all the way up, and continues to increase. And in fact, for whites 45 to 54, it overtook heart disease, and now it's reached the cancer, which is the biggest killer for people in middle age.
Anne Case: We took this around to, we speak on a regular basis to people at SAMSA, which is the Substance Abuse and Mental Health Services Administration in Rockville, Maryland, and to people at the NIH. And they agreed with our assessment that you might think of all of these as being a form of suicide. Right? So somebody's killing themselves quickly with a gun, or more slowly with alcohol or with drugs. It's often times hard for the coroner to know which box to check. So there's actually for drug overdose, there's drug overdose, intent undetermined. Where they don't know whether it was an intentional suicide or it was an accident. And in fact, in Flint, Michigan, there was a new study done in an emergency department in Flint, Michigan, where people were brought in having overdosed, given the Naloxone, so being brought back from that. But then when surveyed, 20% of them didn't know whether they were trying to kill themselves or not. Right? So it makes sense that it would be hard for the coroner to know what to check when the person, him or herself, doesn't even know exactly what's going on.
Anne Case: So we put these all in the same bin, and we call these deaths of despair. And most of what I show you today, but not all, will combine the three of them. There's something else that's going on though; all cause mortality would not have gone up for this group if it weren't for the fact that we stopped making progress on heart disease. And people aren't really talking about that very much in Washington. It's sort of a mystery why this has happened. But our progress flatlined on heart disease, which is one of the big killer where in the countries that look like the U.S., even countries that started with lower levels of heart disease, they've fallen faster, or have continued to fall.
Anne Case: I'm going to spend quite a lot of time looking at this by birth cohort, because the longer we thought about it, the more we thought, this is really something where looking at birth cohorts makes a difference. So this purple line are people born in 1935, and you can see the risk of dying one of these deaths of despair at the ages that we see them, and when we see them in the vital statistics. Pretty flat, same for the birth cohort of 1940, 45. But by the time you get to the birth cohort of 1950, at any given age, people born in 1950 are at higher risk of dying of one of these deaths than people born in earlier birth cohorts. And then 55 higher risk, 60 higher still, and it's not just that it's a shift up; there seems to be almost like a rotation here, so that the younger people are even at higher risk than the cohorts that came before.
Anne Case: So this is all of these; so we think of this as something that, whatever is happening, it's worse for people the later they were born. So we don't think that this is really just sort of like, middle age white people dying, right? Although sometimes as a joke to my friends, I'll just say, "White people dying, that's what I'm working on." It's actually worse for the young people than it is for the people who came before. And that's true; this is the slide you just saw. If you divide it up into drugs, which is the upper right, suicide, or alcohol/liver disease, you see the same thing in each of the component parts. Alcohol/liver disease is a little trickier; I used to think it was because until you got to about age 45, the liver's a really robust organ, right? It can cause a lot of ... You can do a lot of heavy drinking and still it doesn't necessarily come back to haunt you. But beyond age 45, that that's where we saw the rotation.
Anne Case: But most recently, in the most recent years of data, which we have now through 2017, even in these younger cohorts, you're beginning to see increases in alcohol/liver disease. And that's caused by the fact that people, oh and I should have mentioned, these are people without a bachelor's degree that we're looking at here. And that will become salient in a minute. People with a bachelor's degree, richer people, are more likely to drink, and they drink more often conditional on drinking, but people who are less well educated, people without a bachelor's degree, on the days that they drink, they drink a lot more. And it's binge drinking, it turns out is especially damaging to the liver. And that might be what we're seeing here.
Anne Case: If you compare people without a BA to people with a BA, it looks like they live in different universes. Right? It's sort of stunning. It looks like two entirely different countries. So these are all the book cohorts for people with college degree. I should also mention that between the cohort born in 1945 and the cohort born in 1965, the same fraction of them got a bachelor's degree. So it's not really that you have to worry as much about selection, that maybe there's a change in the kind of people who are getting this degree. Then there was an increase in college attainment between the cohort of 65 and 70. And then not much between 70 and 80, and it's going up again some. So if you wanna worry about selection, you could figure it in here a little bit, but that's really what we think is driving the results.
Anne Case: And we think that if you look at say, suicide against drug and alcohol overdoses, you want to say, where are we relative to the rest of the world? There's a really strong correlation between deaths from suicide and deaths from alcohol and drugs. The correlation coefficient, for those of you who are interested, is like, .5. and what you can see is that the countries where the suicide rates are the highest, South Korea aside, are all countries from the former Soviet Union. Slovenia, Poland, Estonia, Latvia, Lithuania. And the countries where especially for alcoholism, the deaths are highest, Finland aside, are also FSU countries. And where does the U.S. whites fit in to this? They fit right into the former Soviet Union. Right? Which is what it is. The only difference being, in the countries of the FSU, suicide rates are falling; in the U.S., suicide rates are rising. So they look similar, but they're moving in different directions.
Anne Case: So this all sort of by way of [inaudible 00:17:31] clear, and I want to clear up just a couple of things that the press sometimes gets wrong. We think this is very much something, we have education on the death records. We don't have income; we don't have how much a mother loved you; we have education, and we use education as best we can. We don't think it's necessary education per se, but that it's a marker for a bunch of other things, possibly. And if you divide this into people with and without a bachelor's degree, and you look at men and women, you see a trend that's incredibly similar between men and women. Some news reports, even if they write up the word correctly, the headline will read, white men dying. Now, white men are dying, and they're more likely to kill themselves by any of these means than are women, but the trend here is identical between men and women.
Anne Case: There was a newspaper - Washington Post - that wanted to make this a story just about women. Right? So it was about ... And it is sort of stunning, if you take this further back, if you take this back to 1990, very few women killed themselves in these ways. But the increase for women without a bachelor's degree has kept pace with, for men without a bachelor's degree. And you can see, sort of, that there's been an acceleration after about 2013. This is the arrival of fentanyl, right? So that it turns out that there have been three epidemics. There was a prescription opioid epidemic, where doctors were handing out jelly jam jars full of Oxycontin, which is basically heroin with an FDA label on it, that comes in pill form. That was the first epidemic. That gave way to a second epidemic of heroin, black tar heroin coming in from Mexico. Cheap, pure. People tell me it was cheaper than pot, what my generation would have called pot. And that gave way to this second epidemic. And the third one now is that fentanyl, which comes as a powder from China, and is incredibly deadly. And we'll see more of that to come.
Anne Case: Oh, I've wanted to remember to ask you, where is the Great Recession? Right? This is a very smooth upward trend, and so this is sort of the first sign that the immediate economic circumstances aren't necessarily the ones that are causing this to happen. Maybe it's deeper than this or older than this. For lack of time, I'm gonna skip this. Another thing that the press often gets wrong is they want to make it just into a rural crisis. Right? So reporter will call and say, "I really want to cover this; tell me where in rural Kentucky I should go." And [inaudible 00:20:44] are like, why don't you go to Baltimore City, you know, it's closer to where you live; and you can just do the work. So the rural line is the red line, and you can see it certainly has increased, but it's increased more or less in parallel with all other levels of urbanization.
Anne Case: I don't know how well this shows, but this is from ... If you divide the country into a thousand small regions, with at least 100,000 people in them, you can see where the increases in deaths have taken place, and the areas that have been hardest hit; the Northwest, the South Appalachia, but also Maine. And if you do this for deaths of despair, you get this. And then, if you want to point out where is it bad now, you more or less want to say, where isn't it bad now? Right? So the north central part of the country has not been hit very hard, but the rest of the country has certainly seen a lot of damage done.
Anne Case: They correlate very strongly with pain maps, actually, so Gallup every night asks people about the pain that they experience the day before, and there was quite an increase in pain, with a few exceptions. Where we are right now, not much pain; the I90 corridor between Washington and Boston, also has been exempt. That's where also people though with more education tend to live.
Anne Case: Okay, how does this compare to the black experience, which usually when something goes badly wrong in the U.S., it goes badly wrong for people who have experienced a lot more discrimination, a lot more oppression for their entire lives; and this one crisis where, until fentanyl hit the markets, black mortality was falling really nicely. So, how could it possibly have something to do with economics, if it's not something that hits blacks harder?
Anne Case: And there was this cartoon, Doonesbury cartoon where BD and Ray are talking to each other. And Ray says, "Nice day, easy for you to say." "But not you?" "No, my kind is dying off." "Man, my peer group sure is getting hammered lately." "What peer group's that?" "Middle aged whites, mortality rates soaring. They're called deaths of despair from drugs, alcohol, or suicide, driven by economic or social distress. Oddly, it doesn't seem to affect blacks and Latinos." "Nothing odd about that, man. We've always lived distressed lives; we're used to it." "So, black privilege, right?" So there's privilege, indeed; it's still the case that even as far out as the early 2000s, black mortality on average had only fallen to where white mortality had been 50 years earlier. Right? So it's hard to say that's much privilege at all.
Anne Case: Well, one thing that seemed odd to me, at least, was that if you looked at mortalities - now, this is all cause morality - blacks and whites with a high school degree or less, what you see is a convergence of mortality rates. Black rates fell nicely until the arrival of fentanyl, and then started to rise; white rates have been rising, so what you see is actually these rates coming together. Every year the CDC puts out a big, thick book about the size of what we used to call a phone book, if that's a familiar term of anyone here. And they always celebrate the fact that the black/white mortality gap is falling.
Anne Case: Well, it's great if the gap is falling because black progress has been fairly dramatic over part of this period. It's not so great if it's happening because white mortality is rising. It also seems to me to do a real disservice to compare blacks with whites, because whites are doing so badly; if you want to see how well blacks are doing, compare them to a European country, where real progress continues to be made. This doesn't really help much, I don't think.If you look at drug and alcohol and suicide mortality, though, by five year birth cohort, what you can see is that until the arrival of fentanyl, in several of these age groups, mortality rate for African Americans were falling, while they were rising for whites.
Anne Case: So in the book, what we do is, we argue that in many respects, what's happening to the white working class mirrors what happens to African Americans beginning in the 1970s. And that we could see, the book, this, what's happened to white working class is just another chapter of the saga of American labor. And William Julius Wilson's words describes a lot of what's happening to whites now. So he wrote in The Truly Disadvantaged, the problem exists mainly because of the large scale and harmful changes in labor market, and it's resulting spatial concentration. As well as the isolation of such areas from the more affluent parts of the black community. Inadequate access to job networks and employment, lack of access to quality schools, decreasing availability of suitable marriage partners, lack of exposure to conventional role models, those actually would be good descriptors of what's happening to the white working class now.
Anne Case: Many of the same arguments that were made about quote, unquote, black culture, going back to the Moyhnihan Report ... And I pulled out just this little piece from the Moyhnihan Report. At the center of the tangle of pathology is the weakness of the family structure. Those are exactly the arguments that are being made today about white working class culture. So just for you, on the plane, I actually opened, we opened up Charles Murray's book, Coming Apart. Right? Which I recommend to all of you until you break out into a rash. So, he talks about white males of the 2000s were less industrious, which is for him, the most important virtue is being industrious. White males of the 2000s were less industrious than they had been 20, 30, or 50 years ago. The Decay in industriousness occurred overwhelmingly in Fishtown.
Anne Case: So that's one thing. I think that actually, if we could stop talking, if we could just focus on class, we might make a lot more progress. But you cannot deny that part of this also has a racial component to it. Martin Luke King summarized, the southern aristocracy took the world and gave the poor white man Jim Crow, so that when he had no money for food, he ate Jim Crow, a psychological bird that told him that no matter how bad off he was, at least he was a white man, better than a black man.
Anne Case: Andrew Cherlin, a great sociologist, writes that, whites did not consider their status until their whiteness premium was lessened by legislation in the last few daces of the twentieth century. At that late date, the old, whiteness-based system had been ein place so long as to be invisible to them, and the new equal opportunity laws seemed to white workers less like the removal of racial privilege, and more like the imposition of reverse discrimination.Some of that might be going on underneath. The historian Carol Anderson writes, if you've always been privileged, equality begins to look like oppression. So we think that may have something to ... It's hard not to think that there's some of that going on underneath the surface as well when people are having a very hard time of it. Doesn't make it right, it's just ... I'm not advocating it, I'm just saying, I think that might be what's going on.
Anne Case: I had the misfortune of sitting next to Steve Mnuchen at a dinner; I think you might have heard of him. I really don't name drop unless I have to say something nasty about somebody who did something bad. So, sit down next to him at the dinner; Angus is at the other side of the table, between Christy LeGuard and Jenny Allen, and they're laughing, and they're having a great time; I'm sitting next to Steven Mnuchin. He said "What do you work on?" I said, "Well, I've been working on these deaths of despair." And he said, pause, two, three, four. "We have an opioid crisis in America?"
Speaker 3: Wow.
Anne Case: And before I could close my mouth, he said, "What does that have to do with economics?" Right. So what does this have to do with economics? Well, it's actually not a bad question. Poverty, what we find is that poverty doesn't correlate well with deaths of despair. The timing doesn't match, the geography doesn't match, and the deaths are too white. The people who are dying are not the poorest people in America by a long shot.
Anne Case: Inequality? We think inequality plays a role, but not directly, not the kind of inequality makes all of sick kind of way, but the fact that as the rich in the U.S. get richer at the expense of the less well educated, kind of a reverse Robin Hood going on, that that is possibly one of the drivers here.
Anne Case: Great recession? The patterns of income don't match the deaths. Unemployment? The rates are low now, right? Bad jobs are still counted as jobs. Right? So that's part of what's goin on that you can't really tell. We think a lot of this, though, does have to do with the labor market. I'm going to skip that. Here's what happened to the employment population ratio for white men and women, aged 25 to 54. We have the dashed lines are women, and the solid lines are men. Hard to tell, if you can tell the gray from the black, but the gray are people with a college degree, and the black are people without. And you can see that, we've heard about the fact that, well, forced participation among men has been falling. But it's been falling more for men without a BA. And what tends to happen is there's a recession; these are these dots here. So there were two recessions in the early 80s; one in 1990, one in 2001.
Anne Case: At the recession, men without a college degree left the labor force, then they would come back, but they would never come back quite as high as they had been before. Then there's another recession, and it ratchets down. So we see that, either the jobs disappeared, or the good jobs disappeared, and men left the labor force, to the point now where women with a BA are more likely to be in the labor force than men without a BA. And women with less than a BA hit a high mark right around 2001, and their participation has been falling as well. Now why is it falling? I'm going to skip that. I think largely because the jobs are crummy. Right? So that if you have a BA or more, birth cohort of 1940 to 1955 to 1975, the cohort of 1990 struggled a little bit because they were coming out during the great recession. What you see is that the later born birth cohorts with a BA are earning more, whereas the later birth cohorts, without a BA are earning less. And they may never earn as much as the blue collar aristocrats who are now all exiting the labor market.
Anne Case: So they're not earning as much, the jobs they have may not have a ladder up; the jobs they have may be service jobs that don't have any benefits, and we think that that has a lot to do with what's happened to this group. Our friends in sociology - and I have friends in sociology - our friends in sociology had been telling us for a really long time that if you don't have a good job, you can't get married. Right? Because she doesn't want to marry you unless you're a good prospect. So that as the good jobs disappeared, marriage disappeared as well. And if you look at the fraction of the birth cohorts where people have never married by a particular age, what you see is that for the cohorts without and with a BA, born in 1940, you know, some fraction of the population's just never gonna marry. But to cohort born 20 years later in 1960 without a BA is significantly higher and the cohort born in 1980 significantly higher than that.
Anne Case: So one of these things that has generally been thought of as a pillar that keeps people's lives together, which is having a stable home life, is missing now. As is a job where you felt, part of your status comes from your work, and that you have a job. So the labor market isn't working; the marriage market isn't working; that hasn't stopped people from having children; cohabitation increased dramatically. So I let him move in; we might even have a kid together, but I'm keeping my options open, and then he leaves, and another man enters. And the first guy may not even see the kids. So the sort of family life that often times is thought to bring stability to people is disappearing at the same time.
Anne Case: People without a bachelor's degree may feel disenfranchised in the political system. This is just the fraction of blacks and whites who voted in presidential election years. And you can see that aside from the Obama elections, where there was quite dramatically high turnout for black non-Hispanics, in general, for both blacks and whites there's a sense without a BA, that voting doesn't matter; these parties don't represent me, and I stay home.
Anne Case: Church has changed a lot too. So it turns out that for 18 to 29 year old white working class young adults, 50% of them don't affiliate with any church whatsoever. The ones who affiliate with church, a lot of them have left; kind of what you might think of as mainline churches. And gone to evangelical churches, and a lot of them became disillusioned with evangelical churches, and are out seeking, putting together spiritual program for themselves. But again, that leaves them without the kind of frame in which they can think about a stable life.
Anne Case: So I don't have time to tell you about a lot of these things, and I knew I wouldn't. So I just put them all up here. For people born in 1950 who would have entered the labor market around 1970. For those without a bachelor's degree, higher suicide, drug mortality; pain, which I haven't really talked about. Difficulty socializing; difficulty relaxing, which are triggers for suicide. Mental distress; heavy drinking. Body mass index. So I think in the end of the day, we're gonna think about obesity the way we think about the deaths of despair. The people need to soothe the beast somehow. And some people choose to soothe it with food. That's kind of outside of the talk, but I think in the end of the day we may think that. Marriage, changing; labor force attachment changing. Real wages changing, religious affiliation changing; the sort of upheaval that [inaudible 00:38:22] said was a perfect recipe for suicide.
Anne Case: What do we do about it? Well, in the book we talk about various things that we might think about doing that might make a difference. I'm just gonna point a couple of them here. One is opioids while we like to think we've turned off the tap on prescription opioid abuse, we've gone from prescribing enough opioids so that every adult in America would have a month's supply a year, to having now just a three week supply a year. So it is progress, but it's not exactly the kind of progress that we think might actually stop this cold.
Anne Case: Health care is huge; I mean, now there is, we're hopefully entering a period where we can have a serious debate about health care. Which we see as being an industry that is sucking money up, to people who are very wealthy, and it's making them wealthier. And that there are a lot of people who don't understand that part of the reason that median wages have been flat for 50 years, just part of the reason, is because if employers are paying your healthcare benefits, and those benefits are getting more and more expensive, part of your compensation is going straight up into the healthcare industry.
Anne Case: A couple of other things I wanted to mention; one is just minimum wages. That I think that at the federal minimum wage right now, a person working full time is basically just above the poverty threshold. Right? If we could do something that could take in the $15 an hour and do something about that, that would be huge.
Anne Case: I'm happy during the Q&A to talk about any of these things you want to talk about, or drill down into any of these. But we think that all of these, some are heavier lifts than others. But all of these should be part of the discussion. So that's what I brought. Thanks.
Mahasin Mujahid: Good Afternoon. Can everyone here me okay? Great. So I appreciate the invitation to give some comments on a wonderful presentation, which I did not have access to ahead of time. And so all I had to go on was your 2017 Brookings Report, and so I was very pleased to see some of the themes that you have extended your conversation to, and I'll just try to reiterate some of those things.
Mahasin Mujahid: When I initially thought about my comments, I was tempted to serve as the epidemiologist on the panel, and have the fun conversations that we love to have as we debate who handles bias better, around selection issues, and age/period cohort effects, and endogeneity, or residual confounding. But instead, I want to represent the skin that I am as a black woman who happens to study why black people live sicker and die younger in this country. And sort of reiterate the idea that inequality might actually be making us all sick.
Mahasin Mujahid: Okay. So we're in a period right now where we have established a health equity agenda for this country; and this is a very important agenda. It's this idea that everyone has a fair and just opportunity to be healthier. And that this really requires us to remove obstacles to health, and these obstacles related to poverty and to discrimination, as well as their consequences; also obstacles related to powerlessness, and lack of access to good jobs with fair pay; and also in relation to quality education and housing, as well as safe environments and healthcare. And so it's this health equity agenda that I always want us to remind us of, because it really helps us understand this debate that we're having right now around what health equity actually is. And it's this idea that we may need to invest more in some people, in some communities, because of the reality that we're faced with.
Mahasin Mujahid: And the reality is that we have such an unfair distribution of resources and opportunities, that we have some communities with an overabundance of resources, and others that are starting 10 feet under. And so this is the time to think about how your findings, Anne, can contribute to our need to sort of motivate ourselves around this health equity agenda.
Mahasin Mujahid: So the first thing that I want to emphasize from your talk is that the critical importance of surveillance. And not just for disease, morbidity, and mortality, but also for inequities in health. So I was a part of a recent meeting at the American Heart Association, and the meeting was designed to take place around this issue of the declines in heart disease and stroke, as you mentioned earlier. And so there was a 1978 convening around the time when there was a steep decline in heart disease and stroke, and so that meeting was really trying to see what was responsible for that; was it real? And how we could continue to move with that decline.
Mahasin Mujahid: And so this meeting was to actually celebrate this idea that there were more declines; so we've had over 40 years of decline in heart disease and stroke; and you can see here that in 1958, 56 per 10,000 people were dying from heart disease, versus 2010, where that has gone down to 18 per 10,000. And as was alluded to earlier, we are now in a period of stagnation, where we no longer are seeing those declines in heart disease and stroke; and so I was very pleased when the director of cardiovascular sciences at National Heart, Lung, and Blood Institute, David Goff, asked me to be a a part of this session to really emphasize that there was never a good news story to begin with in terms of what we've done in relation to heart disease and stroke.
Mahasin Mujahid: So this is data looking from 1965 to 2015, at black/white differences in cardiovascular disease, and what we can see is that although yes, there have been declines, that when you look at the differences between heart disease and stroke, between blacks and whites, you can see that there was never a decrease in disparities; in fact, they were increasing for some time before they're decreasing. And so we have had this persistence of differences in heart disease and stroke by race in this country.
Mahasin Mujahid: We also know that there are geographic differences responsible, and underlying these disparities; you can see here in 1968 that we had few states that had the kinds of black/white mortality ratios that were above 1 in this case, and now more states in 2015 are experiencing these larger numbers of disparities over time.
Mahasin Mujahid: The second point I want to emphasize is that when we do this deeper examination of mortality trends by race, what we see is this enduring story of inequities. And so this is data from the CDC at MMWR, that has highlighted differences in all cause mortality; in this case, within a specific age group. So you can see here that the cut point does matter; slightly different from yours, where we're looking at individuals 18-34; 35 to 49; and 50 to 64 years of age. But the idea is that even though, yes, in terms of all causes of death, you've seen declines from 1999 to 2015 for blacks, and in some cases you've seen increases in whites, that this disparity has persisted over time for all age groups, except for now some evidence suggesting that we don't see it in individuals over the age of 65.
Mahasin Mujahid: And then also, if we think really about what we mean by deaths of despair, then we have to highlight the problems of homicide, and look at conditions such as HIV, where you can see that not only have the disparities been persistent, but they are pervasive; where you can see that, for example, here, in 1999, of all ages; there are 20.1 per 100,000 homicides. Among blacks, which did not decrease at all; and among whites, only 3.8 per 100,000. And so really pervasive disparities in homicide, as well as HIV; and this is some indication of deaths of despair that is happening in marginalized communities.
Mahasin Mujahid: I also just want to emphasize that the lead investigator of this particular MMWR, Timothy Cunningham, was an African American man, age of 35, who died, and based on all indication, that was from suicide. And so you are seeing more increases in suicide, and other forms of deaths of despair, excuse me, in African Americans.
Mahasin Mujahid: And then the last point that I really want to conclude with is this idea of achieving health equity is not the same as reducing disparities. And this particular set of figures that you showed earlier, Anne, really highlights this idea that what we're seeing here in terms of meeting in the middle among individuals with less than a high school diploma or high school diploma and less, is the same thing as meeting at the bottom. So we can't actually make our goal to reduce health disparities by making things worse for everyone; this is not the goal that we should be reaching.
Mahasin Mujahid: And there's another example of this with some data from Tom Leviste, who's the Dean of the School of Public Health at Tulane University; and what he wanted to do with his exploring health disparities and integrated community study was to see if he could identify places in the country, integrated communities in the country; and these are communities where there are comparable numbers of blacks and whites, and there was also a comparable distribution of education income within those areas, what disparities looked like within these integrated communities.
Mahasin Mujahid: And the first important point from this work was that there was only .6% of the country that actually met this criteria. So he was defining communities as census tracks; and he only found .6% of census tracks in which that criteria could be met in the United States. And within those areas, yes, there was less pronounced disparities in those areas in relation to a number of outcomes: diabetes, hypertension, obesity, some healthcare utilization outcomes. But when do a deeper dive into those communities, these were the worst possible communities, where income levels were lower, education levels were lower, so you found this kind of equal outcomes only in the worst conditions.
Mahasin Mujahid: So I'd like to conclude my comments with a call to action, because at the rate that we're going, we're only going to eliminate health disparities by making things worse for everyone, and this should not be our goal. And so I want to reintroduce our idea of health equity. And the idea that we actually work towards achieving health equity or attaining the highest level of health for all Americans. Thank you.
Ronald Lee: Well, I'd like to thank Anne for a great talk. I hadn't seen or heard this presentation before either, so I'll be talking about some of the earlier work I guess, and general points in relation to this. The first paper by Case and Deaton came out on this topic, came out in 2015. And it was really a bombshell. It was shocking, and it seemed unbelievable, really, at first that mortality could be rising across a broad range of ages in the U.S.; no one had been talking about this; no one seemed to have notice it before, and then that this could be due to rising deaths from drug overdoses and suicide, and alcohol poisoning seemed equally impossible; those were surely small causes of death that couldn't possibly be moving the total in that way.
Ronald Lee: And then when further, this was linked to rising depression, and increased self reported pain and such things; it really ... It struck people, not just experts in the field, but it struck just the general population, I think, 'cause this was widely publicized. Just very saddening and discouraging and upsetting news that made these statistic, which are very abstract in themselves, extremely concrete. And so we got a lot of the flavor of that here.
Ronald Lee: I thought what I would do is, I'll race some, just ask some questions, and make a comment or two, maybe put this in the context of some other research on mortality, and things that have been happening to mortality in the U.S. so first of all, how are deaths of despair related to the general widening of differences in mortality by socioeconomic status? This in itself is a big and disturbing trend in the U.S., which I personally found unbelievable at first also. So there's been, actually there have been now, a number of decades of research on widening differences when you look at it by education, between high education people and low education people, and those differences now are around, they can be as big as 10 or 14 years of life expectancy; life expectancy at birth. It's just shocking and stunning.
Ronald Lee: There's a more recent literature over the last 10 years or so, that uses social security earnings histories and looks at the relationship between these sort of lifetime earnings history data and mortality outcomes. What Hillary Waldren, I think was the first to start this, and there have been others. And so I'm gonna show some of that stuff in a moment. But in the 2017 paper, Case and Deaton make, you know, some cogent arguments against Steven in association of mortality with income, or of mortality change with income change, and it's all sort of puzzling. So I'm interested in, what is the relationship between these widening differences by SES and the deaths of despair.
Ronald Lee: Now this is from the paper by Waldren, that sort of opened this up in terms of income. We're looking at different life expectancy at age 65 for different birth cohorts, starting in 1912, and going up to 1941. And the black squares here are life expectancy for people in the bottom half of this lifetime earnings distribution. And the white ones are for people in the top half. And what you see is that over 30 generations, almost all of the gains in life expectancy, older age, have accrued to the top half of the earnings distribution, and it's essentially been flat or very modestly increasing for the bottom half. Well, that was very striking.
Ronald Lee: And Dan, one of the really good studies, is by Bosworth, Burtless, and Zhang. I've just taken something out of their appendix here. So this is mortality at age 60, or the ratio of mortality to age 60 of the bottom 30th, well, 0 to 30% of the earnings distribution to the top 70%. And you see that for people born in, from people born in 1950, up to 35 years later, those born in 1950, that ratio for men has more than doubled, and for women it's almost doubled. So there's been this striking and I think, rather puzzling widening of these social economic differentials. Both by education, and by income. And if you put them both in the equation, you see a powerful effect of both. So how is this related to the deaths of despair?
Ronald Lee: Second point, I suppose that's just related to the first, is that changes like those I just described for the U.S., are taking place in many OECD countries; in Europe, North America, and also in Latin America, in many countries, although not all countries. I think everywhere people have been able to look, and it's not a simple thing to do datawise, but every region which people have been able to look, it's turned out to be happening in many countries.
Ronald Lee: So we just saw that this first statement is wrong; the scale of mortality from deaths of despair isn't unique to the U.S., we see it sort of in the former Soviet Union category. But among, I'd say, western Europe, and so on, I think it's unusual. And despite the fact that the deaths of despair a not, I believe it's correct, aren't the driver in Europe and elsewhere that they are in the U.S.; nonetheless we see these widening trends, and I wonder what that's about. And of course, a leading thought, the first thought many people have is that the widening of the income distribution, which is happening in the U.S., and is also happening in many other countries, is causing the widening of the mortality distribution. But, we don't even know if that's true in the U.S., I think, when you come right down to it. Because of the way the analyses have been done. So this isn't, I think, an interesting question.
Ronald Lee: Now, there's also have been a shocking reversal in life expectancy in the U.S. And I wonder how deaths of despair are related to that. And so here we see life expectancy in the U.S. from 1933, this is life expectancy at birth, through 2017. And so if we look at this, well, that's, okay there's a straight line. But there was a slowdown between 2010 and 2014. And then after 2014, there's actually been an absolute decline. Now, it's not huge, but it's by maybe .3 or .4 years in total. And the thing is, if we were to measure that gap relative to the trend, or what we'd have expected to happen, we'd have expected life expectancy to rise about half a year over those three years. Instead, it's declined by [inaudible 00:59:11] .3 or .4. So effectively, we've lost close to a year of life just in the last three years; we don't yet know what 2018 looks like in terms of the data. So I'm wondering, how this change also is related to deaths of despair.
Ronald Lee: Okay, a fourth point is that Currie and Schwandt, in an article a few years ago, found that if you looked at mortality by county in the U.S., and you ranked the counties according to the level of poverty in them and used that as your measure of, say, economic status, or the bottom of the income distribution, then it looked like mortality for children, up to the age of 20, that mortality was actually becoming more equal rather than less equal, in contrast to what has been found at older ages. And so I just extracted this from science article; this is one line of a figure. So here we have infant mortality, the blue line is ... Here's the poverty from 0 to 100. This is mortality at age 0; the blue lien is in 1990, 2000, 2010; and you can see that it's rotated down. And the same thing is true at all these ages. Now if they do the same thing at older ages, they see it getting steeper, rather than getting flatter.
Ronald Lee: They think of this, they attribute it, I don't think they've actually done an analysis, but what they speculate is that this is reflecting successful public policies to support health and nutrition of lower income kids. And then an important question is whether these more equal circumstances are going to persist as these generations grow older. Will there be more equal mortality when they get into their 30s and 60s and 70s and 80s, or is this going to sort of wear off and the patterns, the unfortunate patterns we're seeing now, are they going to continue? So that's another question. Of course, nobody knows.
Ronald Lee: I guess the last thing, 'cause I've run out of time; the last thing I'll talk about is this one; what is the role of geography and local policy? And how might a state and county policies interact with changing economic fortunes and workers and different economic fortunes of workers? So we heard a little bit about this, I think Anne Case maybe mentioned that a little, and maybe you did as well. In any event, so there are two papers I think of here. One is Jennifer Montez and her collaborators. They've been working along these lines at earlier publications. But they find a lot of variation across states in the extent of the mortality differences by education. So in some states, low education people only have slightly higher mortality; in others they have greatly higher mortality.
Ronald Lee: And there're also differences across states in how much that difference has increased or not increased or decreased. And they suggest, they find that those with increases are concentrated in that southern and Midwestern states, mostly, but also somewhat oddly, I would have thought, California and Maine are in there. And they think, they suggest, that it is the policy context varying by state that is leading to these differences, at least that's a working hypothesis, let's say. Things like the earned income tax credit, tobacco taxes, minimum wages, and so on. But these are substantially determined by state policy, and that that will influence how people with different levels of education, their health, their behavior, their longevity.
Ronald Lee: And then Rhum, oh about a year ago, did an analysis by county; this was by state; this was by county. He concluded that economic change had little role in terms of the drug related mortality, and he thought it had more to do with availability and cost of drugs, and maybe public health conditions, and so on. And questioned whether these things should really be called deaths of despair. I'm not really sure that any of this is inconsistent with what we heard from Professor Case earlier or is in the 2017 paper, but I think it's a rich area for discussion. And yeah, so I guess, I will finish by wondering ... There were very plausible suggestions made about what is underlying this, a list of factors, and so on. And we saw, sort of aggregate trends that seemed consistent with those ideas, but I'm not sure whether there's really any more detailed analysis that shows covariation at a location, time, context. And that's what'd I really like to see. Thank you very much.
Hilary Hoynes: So I want to open it up to the crowd. We've got a little over 10 minutes left here, and why don't we get started with that. I'm gonna start with Denise up here. I think that's on.
Denise: Thank you all for a wonderful panel. I just wanted to make a comment about the last point made by Ruhm. And that is that I think looking at alcohol policies, taxation policies, drug policies, really critical because some of this could be death by partying, and if we look over time, alcohol taxes, they don't, they haven't kept pace with the economy, so that means they're much more cheap. And I think the accessibility of drugs of all kinds has changed dramatically, along with the public health environment for some of those things. So I think these are corporations we're dealing with, the alcohol industry, the drug industries, the pharmaceutical industries, and I think look at those relationships may also be beneficial.
Hilary Hoynes: You go, and then hand it to Michael.
Speaker 7: Yeah, I thought you were all very clear in describing how these deaths of despair have evolved, and how they might comove with economic and social conditions. But I don't think I really got much on the second half of the title. And I just wanted you to speak a little bit more on that. How do these trends relate to the future of capitalism, and what are you suggesting on their relationship between our economic system, and how, or if it needs to change? 'Cause, it was the second half of the title.
Anne Case: Yeah. That's really good; that's what I really wanted to do was lock the doors to make you guys stay for about eight hours so we could have done the whole thing. Just very quickly, I think that corporate power has become much stronger. Unions used to play a much bigger role; they gave labor a seat at the table when profits were being distributed. Those, labor no longer has a voice at the table. When it comes to lobbying in Washington, none of the lobbyist represent labor. Right? So every corporation, they are something like five lobbyists for every member of Congress. From just the pharmaceutical industry. Right? So lobbying has gotten out of control as well.
Anne Case: None of that, no one is lobbying on behalf of workers. It's a case that the Supreme Court has become very anti-labor as well. But they've passed, they've actually voted that workers cannot band together to bring class action lawsuits in some cases, and that they would have to bring those cases one at a time; and that stops workers from getting back pay or from getting things that they've been actually contractually promised to get. So that in many dimensions, corporate power has gotten to the point where they're grinding labor to the ... What in economics we would call their participation constraint. Right? That beyond that, they're not going to be able to survive. So we're going to have to do something, I think, to reign in the power, more antitrust, more eyes on antitrust as well. More eyes on whether employers can have noncompete clauses, right?
Anne Case: So that one in five blue collar workers is working under a noncompete clause. Well, that can make sense if I have trade secrets. But if I'm flipping burgers, it's really hard to believe that I have some sort of great skill set, so that if I'm offered another job with better wages for me, that I shouldn't be able to go and take it. But to the extent that corporate corporations have been able to, they have no interest in stakeholders; they have only interest in shareholders. I think Elizabeth Warren's book is very good on this. So I think that it doesn't necessarily ... I believe in capitalism, I think actually for the last 250 years it has done an amazing thing to pull people out of horrible poverty. But I think that we need to realize that if we don't reign it in, it's going to kill the golden goose. So.
Hilary Hoynes: If I could just add one thing, and then I'll turn over to the next questioner. One of the things I was sort of staring at when you were going through the basic facts, is that you know, we know that the trends and wages for less skilled women is not quite as discouraging as the trends and wages for less skilled men. And we know that the declines in employment are also not as extreme, and so there's a way in which the fact that the patterns are similar for men and women I realize is a very simplistic lens to look at it with. Kind of creates another puzzle point for me of trying to understand the connection between the kind of fundamental drivers in the labor market, and the outcomes that you're focusing on. I mean, it's like a little bit of another angle on the, you know, what is the connection in the economy that then would help to point to the solutions, the right policies.
Anne Case: I think that's a really good point. I think, let me see if I understand what you're saying, that women's wages have not suffered the same way that men's wages have suffered, yet we see that women without a bachelor's degree, that their labor force participation since 2000 has fallen fairly dramatically.
Hilary Hoynes: What I was saying is that the deaths of despair are rising for that group in a way that seems to be inconsistent with the wage story.
Anne Case: Oh, just the wage, no, indeed. And which is why we think it's not just about the labor market, but the knock on effects, the idea that marriages have stopped taking place, that women are also living in these unstable relationships. They're trying to raise kids with getting some child support from somebody who's not even on the scene. That also we're hoping for a better future that's not coming to them either. So we think that it's more than just what happens, it's more than income. I mean, that's the ... And we have no, I think Chris Ruhm tried to make there to be a debate where there really wasn't one. And that there was, it's more than an income story. It's really about loss of status, and also an unstable environment caused by the upheaval that was caused by globalization and AI. With a large emphasis on AI.
Anne Case: And can I just say also, I agree entirely. I think that meeting in the middle is a horrible way for us to reach an equitable society. And that the kinds of things that have befallen the white working class look so much like what happened to the black working class, and that was like, part one, and this is part two. And that those stories go together.
Speaker 8: This is a great panel, a great talk. I wanted to encourage you, Dr. Case, to lengthen that list of things that we could do. And you already touched on one, unionization, not because just because of the outcome, but because of the process of collective mobilization is one of the greatest antidotes to being in despair, that I know about, anyway, in my lifetime. And the other kind of collective action we've seen recently is the fight for $15 minimum wage, which I think, I'll talk about this later in the day, has had some effect on these deaths of despair. But also, maybe this to echo Denise Heard, you mentioned three epidemics.
Speaker 8: Opioid, heroin, and fentanyl. And you don't, your list of what to do only talked about opioids, which we can control more through prescription drug controls. But it seems from what you're saying, and from the data say, that the heroin and fentanyl problem is really taking that over. And so I encourage you to add that to the list too. How to control those substances. 'Cause if you don't, you're gonna get criticized for not having them on there.
Anne Case: That's great; I want to say there was a parallel as well between the crack epidemic that hit the inner cities starting in the mid 1980s, and the heroin epidemic, or the fentanyl epidemic. One of the injustice, one of the many injustices is when it was a crack epidemic, it was a criminal act. When it's an opioid epidemic, it's a medical problem. And that has just, it incenses people, rightly so, that that's the case, that when the face of the drug changed from black to white, now suddenly it's a medical problem. But the crack epidemic burned itself out in two ways. One, people aged out of it, and two, the next generation coming of age were disgusted, and that's one of the words that gets used, and when you read this literature, they were disgusted by what they saw, and they moved away from it. And it was a community effort as well to stop the crack epidemic.
Anne Case: Fentanyl will burn itself out; we don't know how yet. But these sorts of really deadly epidemics do tend to burn themselves out. But that would still leave heroin, which is why I think we need to focus the roots underneath that, why are people turning to drugs? No one wakes up at age 16 or 17 or 18 and says, my goal in life is to be a heroin user, or a heroin addict. So I think that's where the, going to the deeper roots comes in.
Hilary Hoynes: In the back.
Speaker 9: I appreciated Dr. Case, how you talked about some of the narratives about rise in white mortality have kind of been misrepresented in the media, and my question is, what kind of headlines can we put out there to bring clarity to the rising white mortality phenomenon, along with persistent, ongoing racial inequities. Like, what would those headlines look like so that we can make sense of both the phenomenons that you and Mahasin spoke of.
Anne Case: That's a really good question. I think we need to, I would be really curious what you have to say as well on this, I would think if we could talk more about class, and the fact that there's an entire, it's 67% of the adult population who don't have a college degree that are getting ground down. And if we could talk about class, rather than race, it might be easier to make progress on this. But you, I don't know ...
Mahasin Mujahid: I think we have to talk about class and race because I think that we're still in a situation where the effects of the crack epidemic, as you mentioned, are real, because we have mass incarcerations; we have not only incarcerated individuals from sort of that time, but also more feeding into that particular epidemic; and we're actually working on identifying that as a major public health crisis of the moment. As well as things like police violence, the American Heart Association just came out with a statement on that, that police violence should also be considered a major predictor, and important sort of underlying factor in relation to health disparities, and so I think it's race and class, in that within race, you see extreme class differences, and those differences lend to differential health outcomes.
Mahasin Mujahid: But we also know that race is also a powerful predictor of status in this country, and differential treatment in this country. So somehow that has to be a big part of the story as well.
Anne Case: I don't think we have an easy answer for you.