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.
So before moving on, I want to make sure that
I thank Takia 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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 opiod 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.
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.
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.
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.
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?
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.
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.
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.
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.
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.
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.
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.
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 opiod crisis in America?"
Wow.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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 opiod 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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?
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
You go, and then hand it to Michael.
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.
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.
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?
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
In the back.
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.
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 ...
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.
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.
I don't think we have an easy answer for you.
