America's Declining Well-Being, Health, and Life Expectancy: Not Just a White Problem

Peter A. Muennig, MD, MPH; Megan Reynolds, PhD; David S. Fink, MPH; Zafar Zafari, PhD; Arline T. Geronimus, ScD

Disclosures

Am J Public Health. 2018;108(12):1626-1631. 

In This Article

The True Deaths of Despair

We argue that "despair," which we define broadly as a decline in measures of psychosocial well-being over time, is a core public health problem in the United States. However, we believe that despair plays only 1 role in the opioid epidemic. Moreover, we posit that increases in despair over time have produced a broad effect among all groups in the United States, not just less-educated Whites. In fact, declines in the relative life expectancy of Americans relative to other nations has occurred across most groups since at least 1980.[5]

The Effects of Epidemics Are Time Limited

When looking at longer-term trends, a fuller picture of American health emerges. Since publication of the original Case and Deaton report, efforts have been made to specify how the patterns observed vary across race, age, and gender.[18,19] When one looks at the big picture—with data spanning decades—we see that suicide rates are barely higher than they were in 1980 (Figure 1). We also see that deaths from alcoholic cirrhosis have increased only mildly since then. However, we do see that there is a shorter-term opioid epidemic that is predominantly affecting Whites.[19]

Figure 1.

All-Cause and Cause-Specific Percentage Changes in Mortality Rates Attributable to Drugs, Suicides, or Alcohol Among White 45- to 54-Year-Old (a) Women and (b) Men: United States, 1980–2013
Note. Drug and all-cause series: double line (=) indicates a negative correlation over time; solid line (–) within-man opioid deaths indicates a positive or null correlation over time.
Source. Data provided by Ryan Masters.

This opioid epidemic, although extremely severe and alarming, has been relatively recent and has predominantly affected men.[16,20] The absolute increases in mortality among Whites that grabbed the attention of public health officials are seen only among women (Figure 1). Rather than driving the decline in life expectancy among White women, opioid-associated deaths have merely accelerated the manifestation of a trend that was already well under way.[5] This trend toward an increase in mortality among White women began at least as early as 1980.

In Figure 2, we see that Black–White disparities in mortality were generally parallel or converging through the early 1980s. This convergence was interrupted in the mid-1980s through the mid-1990s by the HIV/AIDS and crack epidemics, which predominantly affected Blacks.[21,22] In this figure, we see that health disparities by race increased greatly during the epidemics. However, once the epidemics ended, reductions in mortality rates for Blacks relative to Whites resumed. Although the proximate cause of such epidemics is relatively straightforward, factors such as despair are plausible contributors.

Figure 2.

Black and White Mortality Rates per 100 000 Standard Population: United States, 1970–2015
Note. Mortality disparities by race largely converged until the mid-1980s with the onset of HIV/AIDS. They then widened and narrowed again with the introduction of protease inhibitors.
Source. National Center for Health Statistics death rates and life expectancy at birth. Available at: https://data.cdc.gov/NCHS/NCHS-Death-rates-and-life-expectancy-at-birth/w9j2-ggv5. Analyses by author.

Despair Has Been Rising for a Long Time

Sociologists have observed the decline in various measures of psychosocial well-being in the United States for some time. Alarming declines in measures such as trust have been documented for decades.[23] But is the United States different from other nations? Australia serves as an apt comparator nation because it has seen some of the most rapid declines in mortality rates in the world over the past 40 years and because it has a colonial history and a population composition similar to those of the United States.[5] Some semblance of historical and demographic similarity is important because survey responses are patterned by these factors as well as by cultural orientations. Australians consume goods and services from the United States, including its media.

Using the General Social Survey, we plotted trends in self-reported happiness and self-reported trust in others from a survey that is administered in both the United States and Australia (Figure 3). Self-reported happiness serves as a generic but powerful measure of psychological well-being. Self-reported trust is a widely used measure of social capital. In both instances, the United States is declining relative to Australia. In Figure 3, we have also included a number of other measures that were available only for the United States. (Comparable measures were not available for Australia.) Over time, Americans are less likely to see others as fair, to believe their standard of living was as good as their parents, and to have recreational sex.

Figure 3.

Long-Term Trends in Selected Measures of Well-Being in the United States and Australia: 1983–2012.
Note. Australia is a world leader in life expectancy gains. All figures are presented as cumulative percentage change in the outcome of interest so that they can be more easily compared and are limited to Whites. The overall trends in the United States for these measures are declining. However, the 2 available comparison trends—happiness and trust in others—are increasing in Australia over time.
Source. Analyses by Boshen Jiao using data from the General Social Survey—National Death Index and the National Center for Health Statistics.

When one steps outside the sociological literature and examines the health literature, a similar picture of despair emerges. In the Behavioral Risk Factor Surveillance Survey, respondents are asked, "Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?" A similar question is asked about physical health. On both measures of physical and mental health, declines are evident in the United States.[3] Although these questions are not meant to measure rates of clinical disease, such as depression, they have been extensively validated (including among low-income subgroups)[24] for general reliability and validity. Unfortunately, data on objective measures of depression prevalence in the US population or elsewhere are thin.[25] Over the relatively near term, clinical depression is worsening in the United States, albeit mostly among younger people.

It is difficult to make statements about despair trends with any certainty because of the lack of a validated despair measure or systematic meta-analyses of analogous concepts. Nevertheless, both our exploratory analyses and the broader literature portend worsening mistrust, loneliness, mental health, and health across all ages, races, ethnicities, and quartiles of socioeconomic status where measured.[26,27] The literature previously cited and in Case and Deaton's report does suggest that there is period- and cohort-based deterioration in many measures of well-being over time in the United States. Likewise, the public health literature we cited suggests a deterioration in health and longevity over the same period.

We provide an overview of disturbing trends toward both increasing despair and declining health observed among a broad array of groups in the United States. We also note that there have been other deadly drug epidemics among different groups over time, most notably among Blacks in the mid-1980s. Emotional pain can logically lead one to use and become addicted to drugs. But can we say that these epidemics were driven by despair?

Opioid Death Causes Are Fairly Well Understood

Numerous accounts have chronicled the machinations of a pharmaceutical industry capitalizing on a well-intended surgeon general who regarded pain as undertreated in the United States.[15,16] Prescriptions for opioids have increased 4-fold since 1995. Deaths have increased steadily since, mainly among Whites in lower-income communities.[15,28]

It is hardly a mystery that less-educated Whites are disproportionately affected by the opioid crisis.[20] The opioid crisis is believed to have some roots in prescription opiates. Whites have better access to health care—and, thus, prescription pain medications—than do Hispanics or Blacks. Even among those who do access care, Whites are much more likely to be treated for pain with opioids than are Blacks or Hispanics.[29] Older, blue-collar Whites have high levels of disability relative to their better-off peers, so their need for pain relief is higher.[15,30] Another factor implicated in increasing opioid overdose deaths is that powerful synthetic opioids (e.g., fentanyl) are cheap to smuggle into the United States in smaller quantities than are traditional heroin and, even when consumed in small quantities, increase the likelihood of drug overdoses compared with heroin, leading to higher mortality rates.

Finally, deaths attributable to opioid use shifted from baby boomers to millennial men, a group that is healthier and, by definition, younger than are most Americans.[11] Together, this suggests that White mortality and the deaths of despair are actually a spike in opioid-related deaths that are occurring in addition to long-term trends in declining health and well-being in the United States.

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