Rising death rates among non-Hispanic whites ages 45 – 54 were reported in early November in Proceedings of the National Academy of Sciences of the United States of America, the prestigious journal usually known in the scientific community as PNAS. The authors of the report, Anne Case and Angus Deaton, are well-known economists from Princeton who have made important empirical contributions in the areas of demography and public health. A few weeks earlier, Angus Deaton had received the 2015 Nobel Memorial Prize in Economic Science.
The major finding of Case and Deaton is a rising trend of mortality and morbidity—i.e., increasing frequency of death and disease—among non-Hispanic whites between ages 45 and 54. Their paper is titled “Rising morbidity and mortality in midlife among white non-Hispanic Americans,” and the text refers repeatedly to “midlife mortality,” and “midlife morbidity;” perhaps an editor at PNAS should have suggested to Case and Deaton that “midlife mortality” is a contradictio in terminis, as mortality is always an end-of-life event. But such minutiae must be put aside, as there is no question that the paper is an important one that, for good reason, has been the object of much commentary and debate in the media.
The detailed analyses reported by Case and Deaton show that rising mortality in the demographic group called “non-Hispanic whites” aged 45 – 54 is confined to those with a high school education or less. Within this group, death rates rose by a remarkable 22.3% between 1998 and 2013. Non-Hispanic whites ages 45 – 54 with a college education experienced a decline in death rates in the same period. It is also worth noting that, as the graph shows, death rates for blacks ages 45 – 54 , although visibly declining over the entire period, remained substantially higher than death rates for non-Hispanic whites, a fact Case’s and Deaton’s paper mentions only in passing.
The fact that mortality is rising in not-so-old whites is shocking because it implies a reversal, occurring around the turn of the century, of a previously declining trend. It is also shocking because it contrasts with the declining trend of mortality in that same age group in all other demographic groups of the U.S. population, Hispanic Whites, African American, Asian Americans, and American Indians. In other high- or medium-income nations such as France, the United Kingdom, Spain, and Portugal, mortality at ages 45 – 54 has been declining for many decades, without any substantial departure from the general falling trend in any age group. (Though we do not know what is happening in these countries in particular demographic groups, say Asians in the U.K. or citizens of African descent in Portugal.)
Social researchers agree that mortality is a key indicator of the level of health in a society or a social group; indeed health, as measured by mortality-based indicators, particularly life expectancy at birth, is one of the three sets of numbers—the other two are education and income—systematically used by United Nations agencies to measure the level of social development and the progress of human societies. Countries like Japan, Spain, France, South Korea, Norway, Canada, and Cuba, all of which have lower mortality rates than the U.S., are considered to be at the top in regard to population health. Inversely, countries like Sierra Leone, Côte d’Ivoire, and South Africa, with the highest levels of mortality, are considered to be at the bottom in the world rankings of population health.
Declining mortality at all ages has been quite a general phenomenon of human societies in the past two centuries as part of the so-called demographic transition, but when the process begins, and the rates of mortality decline, have been different among nations and have sometimes changed, coinciding with periods of reversal during major social and economic disruptions such as epidemics, famines, and wars, which fortunately have been rather rare in the last half century. In recent decades, mortality rates have also increased but at particular places and periods because of specific diseases such as HIV/AIDS, or periods of socioeconomic and political turmoil like that which followed the end of communism in the countries of the old Soviet bloc during the 1990s.
Why is mortality increasing among U.S. whites around age 50, particularly those with low levels of education? Data shows that the rise of death rates in this group is due to increases in suicides, drug poisoning, and alcohol-related disease, such as liver cirrhosis. Adult mortality from these causes has been rising in all demographic groups in the U.S. population, but only in whites around 50 has its rise overcome the reduction of mortality due to other causes of death (such as cardiovascular disease). Case’s and Deaton’s paper shows that the rising mortality rate of white non-Hispanics at ages 45 – 54 is paralleled by a rise in morbidity, that is, rates of disease. In surveys of self-reported health, asking questions about symptoms of mental distress, ability to conduct activities of daily living, and increases in chronic pain and inability to work, non-Hispanic whites at ages 45 – 54 provide answers revealing growing levels of psychological distress, disability, and pain. Higher frequency of disease is also revealed by measured deteriorations in liver function, which strongly correlates with liver damage due to alcohol, and perhaps other toxic substances. Also, the increase in death rates in whites 45 – 54 of low education is matched by a decline in inflation–adjusted income. But presumably trends in income can be similar for other demographic groups—say, African Americans—which are suffering high but declining mortality (see figure).
Some researchers have speculated that, because of deterioration in socioeconomic conditions, mortality in recent years could be rising in European countries with high levels of unemployment, such as Greece, Spain, or Portugal. However, statistics show that mortality has continued falling for basically all age groups and all causes of death in these countries. Suicide may be an exception: it has slightly risen in recent years in Spain and Greece, but in both countries suicide rates remain much lower than the European average. At any rate, Case’s and Deaton’s findings show that, in an specific demographic group, an effect may appear that does not seem determined by a mere addition of the specific components that seem to contribute to it. This is another way to say that, to a considerable extent, the final causes contributing to the rise in mortality of less-educated whites aged 45 – 54 are obscure. Indeed, an extra layer of complexity has been added to the issue by analyses authored by Andrew Gelman, a professor of statistics and political science at Columbia University. Gelman reanalyzed Case’s and Denton’s data, publishing his conclusions online in Slate. He says that, while Case’s and Deaton’s conclusions are correct, a closer look at their data reveals that the rising trend of mortality of non-Hispanic whites ages 45 – 54 is concentrated in females, whose death rate increased steadily between 1999 and 2013. In males of the same demographic group mortality rose in 1999 – 2006, but then dropped. Gelman’s results have not been published in a peer-reviewed journal, but they seem to be based on solid evidence and sound analysis.
The rising mortality among 50-something U.S. whites detected by Case and Deaton has been compared with the increase in adult mortality that took place in the early 1990s in the countries of the old Soviet bloc, particularly those that had been part of the USSR. What the two cases have in common is an increase in adult mortality, but the analogy does not go much beyond this. In the Soviet case the mortality increase basically affected the whole adult population, and especially males, while in the U.S. the mortality upturn affects a specific demographic group, non-Hispanic whites ages 45 – 54—and only females in this group, if Gelman’s analysis is correct. However, another parallel between the increase in mortality of adults in Eastern Europe in the 1990s and in the U.S. in the 2000s is the role that psychosocial factors might play. In Eastern Europe, increases in adult mortality were mostly connected with extra numbers of heart attacks, traffic injuries, suicides, and homicides, to a large extent linked to increased levels of alcohol consumption. These phenomena coincided with a political and socioeconomic transition during which societal norms were drastically changed at the same time when large sections of society suffered major blows to their standard of living, with rising levels of joblessness, losses of access to social services, and major cuts in household income and wealth due to heavy devaluations of the currency. It seems logical to think that these developments led to acute hopelessness for many people in Eastern Europe. In the case of the United States, the epidemic of pain, suicide, and drug overdoses in not-very-old individuals has been linked to economic insecurity; as in the view of Case and Deaton, for example, that “many of the baby-boom generation are the first to find, in midlife, that they will not be better off than were their parents.” In the past, public health researchers paid much more attention than they do today to what Aaron Antonovsky called the “sense of coherence,” which is strongly related with factors associated with mental health, such as optimism, hardiness, learned resourcefulness, sense of control, mastery, self-esteem and self-efficacy, acceptance of disability, and social skills. Studies have shown that a diminished sense of coherence is strongly associated with anxiety, burnout, hostility, hopelessness, and depression. Abuse of alcohol and consumption of prescription drugs to fight physical and mental distress may, today, be playing the same role among not-so-old, less-educated U.S. whites that binge drinking of vodka had in the old Soviet bloc in the early 1990s. It is not unreasonable to speculate that the sense of coherence may have been at low levels in both contexts.
Case and Deaton comment that if white mortality rates for ages 45 − 54 had held at 1998 values, 96,000 deaths would have been avoided between 1999 and 2013. Furthermore, if mortality in this demographic group had continued to decline as it had been declining during 1979 ‒ 1998, half a million deaths would have been avoided in the period 1999 ‒ 2013; this is comparable to the number of lives lost in the entire U.S. AIDS epidemic, down to the present. These are sobering figures that make clear that there is something rotten in the Republic.
In the short-run, it is difficult to be optimistic about these gloomy trends, which appear rooted in obscure processes and do not seem as though they will be susceptible to easy remedies. The expansion of access to health care, if that is actually the effect of the Affordable Care Act, could be even stoking the trend to be fought, which to a large extent seems iatrogenic, connected with the use of prescription drugs. With perspectives of economic prosperity for the U.S. population rather dubious in the short and medium term, with a society in which isolation and loneliness are common in the living arrangements of major sections of the white population, and with a blooming medicalization of American society, in which millions of pills for hundreds of diseases and newly discovered “disorders” are consumed daily, it is not difficult to understand why mortality is rising in particular demographic groups. Case’s and Deaton’s findings could even be the harbinger of worse things to come. At any rate, given the role of prescription drugs in this epidemics of deaths among white Americans with low levels of education, it might be proper to mention the motto attributed to one of the fathers of modern medicine, William Osler, who said that the first duty of the doctor is to teach the patient not to take medicines.
Sources and additional readings
Allen F. Saving Normal: An Insider’s Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. (New York: William Morrow), 2013.
Cornia, G.A. & Paniccià, R., eds. The Mortality Crisis in Transitional Economies. (New York: Oxford University Press), 2000.
Case, A. & Deaton, A. “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century.” Proceedings of the National Academy of Sciences of the United States if America, Early edition, November, 2015.
Eriksson, M. & Lindström, B. “Antonovsky’s sense of coherence scale and the relation with health: a systematic review.” Journal of Epidemiology and Community Health 60(5): 376 ‒ 381, 2006.
Gelman, A. “Is the Death Rate Really Increasing for Middle-Aged White Americans?” Slate. November, 2015.
Tapia Granados, J.A., & J.M. Rodriguez. “Health, economic crisis, and austerity: A comparison of Greece, Finland and Iceland.” Health Policy 119(7): 941 ‒ 953, 2015.
Toffolutti V. & M. Suhrcke. “Assessing the short term health impact of the Great Recession in the European Union: a cross-country panel analysis.” Preventive Medicine 64: 54 ‒ 62, 2014.
ContributorJose A. Tapia
JOSE A. TAPIA is an Associate Professor of Politics at Drexel University, Philadelphia. His research has been published in Journal of Health Economics, the American Journal of Epidemiology, Social Science & Medicine, PNAS, and other journals.