This is the kind of study every public health student should read. It highlights the astounding upturn of death and disability rates in a very particular group: white, mostly middle-aged Americans, from a very particular cause: drugs and alcohol. There are so many deaths in this particular category that it has managed to reverse the gains in all-cause mortality made in this group in recent decades. Reverse. Not just level off, but send back up.
Here’s the mortality graph that’s all over the media. Note that red line (white Americans age 45-54) that increases while all the other lines decrease:
As you can see, these deaths are unique to the United States. They are also unique to whites. Hispanics had falling mortality rates over these 15 years (1.8% a year); rates for African Americans dropped even more (2.6% a year). (The mortality rate for middle-aged blacks is still higher than that for whites, 582 per 100,000 compared to 415 per 100,000 in 2013, but the gap is narrowing.)
The up-tick began around 1999, which is another weird bit of data. Usually these things happen slowly. If there’s something unhealthy in the environment, say we’re smoking more, the fall in death rates levels off and over time might start to slope upward. This here is like a pinpoint reversal.
This next graph shows the causes of death that the authors say largely account for the increase in mortality among white Americans age 45-54:
- Drug and alcohol poisonings
- Liver diseases and cirrhosis
For context, they drew dotted lines for mortality from lung cancer and diabetes. While diabetes is a problem in this group, it is neither killing as many people nor are their deaths on the increase. THAT is striking.
All educational groups saw increases in mortality from suicides and poisonings, but the increases were largest in those with least education.
Both genders are affected:
Patterns are similar for men and women when analyzed separately.
While news reports focused on the 45-to-54 age group, in reality all age groups from 30 to 64 were on an upward death trend (if you’re over 65, your rates are still falling).
As Fig. 4 makes clear, all 5-y age groups between 30–34 and 60–64 have witnessed marked and similar increases in mortality from the sum of drug and alcohol poisoning, suicide, and chronic liver disease and cirrhosis over the period 1999–2013; the midlife group is different only in that the sum of these deaths is large enough that the common growth rate changes the direction of all-cause mortality.
None of these lines should being going up! From now on, every time you hear diabetes being discussed in the news, remember that deaths from drugs is far-and-away the worst scourge. It is, to use Case and Deaton’s term, an epidemic. Close to 500,000 deaths could have been avoided in these mere 15 years if the trend line followed that of every other rich country, or even middle-aged people 15 years ago (a decrease of 1.8% a year).
All of the graphs above show mortality or deaths. But there is a lot of disability in the base of this iceberg. Table 2. shows a decline in self-reported physical and mental health, and, “this deterioration … is observed in each US state analyzed separately.” It’s everywhere. There is a lot of pain – neck, face, joint, back; there is increased anxiety and depression; there is increased difficulty performing the activities of daily life (ADLs). It’s worth noting that they found deterioration in both obese and non-obese.
Our findings may also help us understand recent large increases in Americans on disability.
That there is rising death and disability in this group does not address why there is rising death and disability. Case and Deaton took a stab at this in their Discussion. This next excerpt, to me, explains why both the Journal of the American Medical Association (JAMA) and the New England Journal of Medicine (NEJM) rejected their study for publication (Prestigious Medical Journals Rejected Stunning Study On Deaths Among Middle-Aged Whites. The journals’ sponsors, the drug companies, would have had a conniption:
The increased availability of opioid prescriptions for pain that began in the late 1990s has been widely noted, as has the associated mortality.
Painkillers for pain are good. Not so good when the drugs are abused:
The CDC estimates that for each prescription painkiller death in 2008, there were 10 treatment admissions for abuse, 32 emergency department visits for misuse or abuse, 130 people who were abusers or dependent, and 825 nonmedical users. Tighter controls on opioid prescription brought some substitution into heroin and, in this period, the US saw falling prices and rising quality of heroin, as well as availability in areas where heroin had been previously largely unknown.
Finally, they address economics, noting the wide, and widening, income gap in this country; and financial insecurity, which may be worse in the US than other developed countries:
The United States has moved primarily to defined-contribution pension plans with associated stock market risk, whereas, in Europe, defined-benefit pensions are still the norm. Future financial insecurity may weigh more heavily on US workers, if they perceive stock market risk harder to manage than earnings risk, or if they have contributed inadequately to defined-contribution plans.
Jonathan Skinner, professor of economics at Dartmouth College, said:
An increasingly pessimistic view of their financial future combined with the increased availability of opioid drugs has created this kind of perfect storm of adverse outcomes.
We have to care. We have to care that half a million people died needlessly. In public health, you learn not to blame the individual. You learn to blame the institutions at the root of the problem, that foster individuals’ behavior. We have to fix the institutions, provide more affordable education and healthcare, tackle the stigma attached to addiction, rehab instead of incarcerate, provide more sources of employment that offer a living wage, remove the worry that when someone’s working years are over, their income is not. These are just my non-expert guesses.
A serious concern is that those currently in midlife will age into Medicare in worse health than the currently elderly. This is not automatic; if the epidemic is brought under control, its survivors may have a healthy old age. However, addictions are hard to treat and pain is hard to control, so those currently in midlife may be a “lost generation” whose future is less bright than those who preceded them.
News stories with good perspective:
Death Rates Rising for Middle-Aged White Americans, Study Finds, New York Times, Gina Kolata, 2 November 2015
In Reversal, Death Rates Rise For Middle-Aged Whites, NPR, 2 November 2015
A Group Of Middle-aged Whites In The U.s. Is Dying At A Startling Rate, Washington Post, 2 November 2015