The forces driving middle-aged white people's 'deaths of despair'

In 2015, when researchers Ann Case and Angus Deaton discovered that death rates had been rising dramatically since 1999 among middle-aged white Americans, they weren't sure why people were dying younger, reversing decades of longer life expectancy.

Now the husband-and-wife economists say they have a better understanding of what's causing these "deaths of despair" by suicide, drugs and alcohol.

In a follow-up to their groundbreaking 2015 work, they say that a lack of steady, well-paying jobs for whites without college degrees has caused pain, distress and social dysfunction to build up over time. The mortality rate for that group, ages 45 to 54, increased by a half-percent each year from 1999 to 2013.

But whites with college degrees haven't suffered the same lack of economic opportunity, and haven't seen the same loss of life expectancy. The study was published Thursday in Brookings Papers on Economic Activity.

Case and Deaton, who are both at Princeton University, spoke with NPR's David Greene about what's driving these trends. The interview has been edited for brevity and clarity.

On the original discovery of rising mortality rates for middle-aged whites

Deaton: Mortality rates have been going down forever. There's been a huge increase in life expectancy and reduction in mortality over 100 years or more, and then for all of this to suddenly go into reverse [for whites aged 45 to 54], we thought it must be wrong. We spent weeks checking out numbers because we just couldn't believe that this could have happened, or that if it had, someone else must have already noticed. It seems like we were right and that no one else had picked it up.

We knew the proximate causes — we know what they were dying from. We knew suicides were going up rapidly, and that overdoses mostly from prescription drugs were going up, and that alcoholic liver disease was going up. The deeper questions were why those were happening — there's obviously some underlying malaise, reasons for which we [didn't] know.

On what's driving these early deaths

Case: These deaths of despair have been accompanied by reduced labor force participation, reduced marriage rates, increases in reports of poor health and poor mental health. So we are beginning to thread a story in that it's possible that [the trend is] consistent with the labor market collapsing for people with less than a college degree. In turn, those people are being less able to form stable marriages, and in turn that has effects on the kind of economic and social supports that people need in order to thrive.

In general, the longer you're in the labor force, the more you earn — in part because you understand your job better and you're more efficient at your job, you've had on-the-job training, you belong to a union, and so your wages go up with age. That's happened less and less the later and later you've been born and the later you enter this labor market.

Deaton: We're thinking of this in terms of something that's been going on for a long time, something that's emerged as the iceberg has risen out of the water. We think of this as part of the decline of the white working class. If you go back to the early '70s when you had the so-called blue-collar aristocrats, those jobs have slowly crumbled away and many more men are finding themselves in a much more hostile labor market with lower wages, lower quality and less permanent jobs. That's made it harder for them to get married. They don't get to know their own kids. There's a lot of social dysfunction building up over time. There's a sense that these people have lost this sense of status and belonging. And these are classic preconditions for suicide.

Case: The rates of suicide are much higher among men [than women]. And drug overdoses and alcohol-related liver death are higher among men, too. But the [mortality] trends are identical for men and women with a high school degree or less. So we think of this as people, either quickly with a gun or slowly with drugs and alcohol, are killing themselves. Under that body count there's a lot of social dysfunction that we think ultimately we may be able to pin to poor job prospects over the life course.

On how mortality rates differ among races

Deaton: Hispanics [have always had lower mortality rates] than whites. It's a bit of a puzzle that's not fully resolved, to put it mildly. It's always been true that mortality rates have been higher and life expectancy shorter for African Americans than for whites. What is happening now is that gap is closing and, for some groups, it's actually crossed. What we see in the new work is if you compare whites with a high school degree or less, at least their mortality rates are now higher than mortality rates for African Americans as a whole. If you compare whites with a high school degree or less with blacks with a high school degree or less, their mortality rates have converged. It's as if poorly educated whites have now taken over from blacks as the lowest rung of society in terms of mortality rates.

On the geography of mortality rates

Case: There's not a part of the country that has not been touched by this. We like to make the comparison between Nevada and Utah to look at the extent to which good health behaviors lead to longer life. Two-thirds of Utahans are Mormons. They don't drink, they don't smoke, and they don't drink tea or coffee. Two-thirds of Nevadans live in Las Vegas paradise, where there is a little more of everything, so the heart disease mortality rates are twice as high in Nevada as they are in Utah.

But both states are [in the] top 10 for deaths of despair. Utah has had a terrifically hard time dealing with the opioid crisis, and suicide rates [are] going up as well. There's a lot of surprise here in parts of the country that we weren't really expecting to see.