Abstract and Introduction
Although recent declines in life expectancy among non-Hispanic Whites, coined "deaths of despair," grabbed the headlines of most major media outlets, this is neither a recent problem nor is it confined to Whites. The decline in America's health has been described in the public health literature for decades and has long been hypothesized to be attributable to an array of worsening psychosocial problems that are not specific to Whites.
To test some of the dominant hypotheses, we show how various measures of despair have been increasing in the United States since 1980 and how these trends relate to changes in health and longevity. We show that mortality increases among Whites caused by the opioid epidemic come on the heels of the crack and HIV syndemic among Blacks. Both occurred on top of already higher mortality rates among all Americans relative to people in other nations, and both occurred among declines in measures of well-being.
We believe that the attention given to Whites is distracting researchers and policymakers from much more serious, longer-term structural problems that affect all Americans.
It is an axiom in demography and public health that life expectancy increases over time. In nations that are free of war, famine, and disease outbreaks, the increase in life expectancy over time has been described as "so extraordinarily linear that it may be the most remarkable regularity of mass endeavor ever observed." (p1029) However, in the 1990s, public health researchers began sounding an alarm about some disturbing changes observed in the United States. In particular, researchers observed 3 aberrant trends: the self-rated health of Americans had leveled off and started to take a downward turn;[2–4] life expectancy growth in the United States was slowing relative to other nations, even for socioeconomically advantaged White subpopulations; and absolute survival rates were declining for socioeconomically disadvantaged White women.[4–10]
By the turn of the millennium, the United States had become a curious outlier among its peers. Health system costs per capita rose to twice that of the next highest country, but overall survival was barely budging and was falling year-on-year for segments of the White population and for Native Americans overall.[5,9] As a result, the long-term relative decline in life expectancy culminated in a multiyear absolute decline in life expectancy in the United States in 2015 and 2016.[11–14] One of the drivers of this absolute decline in life expectancy is an ongoing opioid-related mortality epidemic, which contributed to more than 60 000 lives lost in 2016. However, absolute declines in life expectancy were observed for some groups and localities starting at least as early as 1980—decades before the opioid epidemic began.
In 2015, Princeton researchers Case and Deaton documented a recent spike in mortality rates among less-educated non-Hispanic Whites. Although mortality increases among those with declining socioeconomic mobility, particularly in Southern "stroke belt" counties and among White women, had been previously noted, Case and Deaton provided a narrative with media resonance. They termed this excess mortality "deaths of despair," on the basis of their finding that mortality increases were largely driven by suicide, cirrhosis of the liver, and fatal opioid-related overdoses—causes that suggest victims are likely to be suffering from psychological distress.[16,17] Linking these trends to deaths that can be traced back to psychological despair allowed a clear story to be distilled from a mass of data. The identification of increasing mortality rates among middle-aged non-Hispanic Whites (generally referred to as "Whites" here for ease) was particularly shocking for the lay press. The hypothesis received headline coverage on the major networks and newspapers, with Bloomberg News labeling the term "deaths of despair" a "part of the American lexicon."
We believe that Case and Deaton observed an epidemic of opioid-related deaths superimposed on longer-term trends toward worsening health and declining longevity in the United States. We argue that these deaths represent an uptick in a much broader trend and that declines in survival and life expectancy would not have been possible without the long-term malaise seen in the United States. This is important to highlight because the broader story of America's decline has been told by many different research teams in many different ways but has not been given much of a powerful voice. Case and Deaton found that voice, but they may have overlooked the longer-term trends and the overall malaise described by sociologists, demographers, health services researchers, epidemiologists, and economists over the past 3 decades.
Am J Public Health. 2018;108(12):1626-1631. © 2018 American Public Health Association