Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century
By Anne Case and Angus Deaton
Proceedings of the National Academy of Sciences, published online before print on November 2, 2015
Abstract
This paper documents a marked increase in the all-cause mortality of middle-aged white non-Hispanic men and women in the United States between 1999 and 2013. This change reversed decades of progress in mortality and was unique to the United States; no other rich country saw a similar turnaround. The midlife mortality reversal was confined to white non-Hispanics; black non-Hispanics and Hispanics at midlife, and those aged 65 and above in every racial and ethnic group, continued to see mortality rates fall. This increase for whites was largely accounted for by increasing death rates from drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis. Although all education groups saw increases in mortality from suicide and poisonings, and an overall increase in external cause mortality, those with less education saw the most marked increases. Rising midlife mortality rates of white non-Hispanics were paralleled by increases in midlife morbidity. Self-reported declines in health, mental health, and ability to conduct activities of daily living, and increases in chronic pain and inability to work, as well as clinically measured deteriorations in liver function, all point to growing distress in this population. We comment on potential economic causes and consequences of this deterioration.
From the Discussion
Although the epidemic of pain, suicide, and drug overdoses preceded the financial crisis, ties to economic insecurity are possible. After the productivity slowdown in the early 1970s, and with widening income inequality, many of the baby-boom generation are the first to find, in midlife, that they will not be better off than were their parents. Growth in real median earnings has been slow for this group, especially those with only a high school education. However, the productivity slowdown is common to many rich countries, some of which have seen even slower growth in median earnings than the United States, yet none have had the same mortality experience. 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.
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.
Significance
Midlife increases in suicides and drug poisonings have been previously noted. However, that these upward trends were persistent and large enough to drive up all-cause midlife mortality has, to our knowledge, been overlooked. If the white mortality rate for ages 45−54 had held at their 1998 value, 96,000 deaths would have been avoided from 1999–2013, 7,000 in 2013 alone. If it had continued to decline at its previous (1979‒1998) rate, half a million deaths would have been avoided in the period 1999‒2013, comparable to lives lost in the US AIDS epidemic through mid-2015. Concurrent declines in self-reported health, mental health, and ability to work, increased reports of pain, and deteriorating measures of liver function all point to increasing midlife distress.
http://www.pnas.org/content/early/2015/10/29/1518393112.full.pdf
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Comment:
By Don McCanne, M.D.
In recent years concerns have been raised about the increases in death rates from prescription pain medications, but the magnitude of the problem was not recognized until this landmark study was released yesterday. Midlife deaths from poisonings with alcohol and drugs or from suicide of white, non-Hispanic men and women in the United States have skyrocketed since 1999. Morbidity likewise has increased in this group.
The intensity of the problem can be easily visualized by clicking on the link above and looking at Figure 1. The mortality curve of US white non-Hispanics, ages 45-54, is moving upward as the curves for US Hispanics and for residents of six other wealthy industrialized nations are continuing downward.
Although the other nations have more egalitarian, accessible and affordable health care systems, that alone cannot explain the differences since Hispanics in the United States have not seen this same isolated increase in mortality.
The authors suggest that the decline in economic security that began in the early 1970s may be an important factor. Not only have wages stagnated, but retirement security has diminished with a shift from defined benefit to defined contribution pension plans. Lack of higher education has been especially associated with this phenomenon of higher mid-life morbidity and mortality.
A single payer system would help by improving access to preventive health, mental health, and drug treatment services. But we need to do more. We need public policies that distribute the gains in productivity to the workers rather than to the rentiers, plus tax policies that reduce the injustices of income and wealth inequality. We need to ensure adequate education opportunities for all, including industrial arts and training for the service industries, along with assurances of adequate incomes in those fields. In general, we need policies that serve the social good.
To do that we need political leaders who are dedicated to the health and welfare of the people and who would enact policies to ensure that. We need to displace our current political leaders who have dedicated themselves to supporting the military-industrial complex (through more warfare), the medical-industrial complex (through prioritizing support of insurers and pharmaceutical firms above the interests of patients), and the rentiers of Wall Street who are redistributing wealth from the masses to the magnates.
