Deaths of despair

Glyn Davis
G'day, I'm Glyn Davis and welcome to The Policy Shop, a place where we think about policy choices.

Trae Crowder
So when I see poorer voters come out in droves for this guy in places like my home town, where the unemployment rate's been double digits for 20 years and you're considered a rich kid if your daddy carried the mail, it blows me away. When the rest of Liberal America's asked to explain it, they just go well, they're a bunch of ignorant bigots, Trump's the king bigot. Who wants kombucha? Well it ain't that simple, [Tristan].

Glyn Davis
That was the voice of US comedian, Trae Crowder, six months prior to the US presidential election, highlighting a surge in support for Donald Trump from America's white working class. The shock election of America's 45th president has placed a focus on this white working class, often typified in popular culture as trailer park trash. A media narrative has developed that an angry white rural coal-loving trailer park country provided crucial support for team Trump in securing 1600 Pennsylvania Avenue.

But as a bunch of sharp comedians and evocative writers questioned this narrative and challenged common assumptions, a husband and wife economist team has been researching these questions deeply.

In 2015, Professor Sir Angus Deaton and Professor Anne Case reported that working class middle-aged white Americans were killing themselves in large numbers. An epidemic of overdoses, suicides and alcohol-related illnesses had caused a surge in deaths since 1999.

Unlike every other age group, unlike every other racial and ethnic group, unlike every other rich country, death rates for middle-aged white Americas have been rising. This research illustrates a sharp stark social divide in the world's most developed nation. To discuss this research, we're honoured to be joined by Professor Sir Angus Deaton, noble laureate, senior scholar in the Woodrow Wilson School at Princeton.

Angus, can I invite you to describe what your research found, the scale of these deaths and why you were surprised?

Angus Deaton
We originally were working on suicides and I'd long been interested in suicides and measures of happiness. I was looking into suicides as a way of perhaps validating or perhaps invalidating measures of happiness. Anne and I were writing a paper for a conference that looked at that and we discovered - and this was the first part of the puzzle - we discovered that there was quite an upsurge in suicides in middle-age in the United States among white non-Hispanics, both men and women. Women don't kill themselves nearly as often as men, but both were rising in parallel.

So we thought it would be good for the presentation of the paper to have a slide showing how this rise in suicide merged into what was happening to other causes of mortality at the same time. So then we went to the CDC data, that's the Center for Disease Control, where you get all the data from. We pulled down the numbers on the deaths and the mortality rates of people, white non-Hispanics in middle age from all causes together. That was when we thought we must have made a mistake, because the numbers were so astonishing that we really couldn’t believe what we were seeing.

If you look at mortality rate for that age group, middle-aged white non-Hispanics, it's been falling basically for 100 years from 1900 through to - which is when the data start - to the end of the century. But around 1998 it stops falling and it's flat or rising after that. First of all, it's just extraordinary that a trend like this, which is so long established and which is so much the foundation of social progress, that mortality rates are going down, should suddenly have stopped going down.

So that was a major puzzle and surprise by itself, but also we thought it couldn’t be right because if it had happened, other people would have noticed it, including all the government statisticians and other people who were working on this data. But it turned out it was there and we were right.

So that was the first surprise, was just discovering this rise in mortality, which is really basically unprecedented.

Glyn Davis
So what is the scale we're talking about?

Angus Deaton
In 2015 there's about 52,000 people who died from drug overdoses, that's from legal and illegal drugs, in the United States. But there's then a slightly smaller number who died by killing themselves and a similar number who died from alcoholic liver disease. So you're talking about maybe 120,000 people.

Glyn Davis
So what causes these deaths? What is the driving motivation that pushes people to these desperate measures?

Angus Deaton
Our belief is that it's despair and it's living this life that's come apart. It's not better than your parents, your marriage is not any good anymore, you don't really know your kids. There's been a huge upsurge in pain in spite of all this treatment and so I think a lot more people are in pain, or at least conscious of being in pain. But these things seemed to us then and they seem to us now to be all something that you could sensibly regard as suicides in one form or another.

People are killing themselves very rapidly, or they're killing themselves more slowly, so alcoholic liver disease, obviously you've got to go at it for a while before your liver is shot. Whereas if you pick up a gun or you swallow some pills, you could go very quickly. The drugs are accidental, they're not suicides, the coroner, whoever, has decided that this was accidental death. So the question is why are they taking the drugs in the first place and of course, there's the whole story of the opioid epidemic and why that happened and how it relates with heroin and illegal drugs.

Glyn Davis
Perhaps we could pursue that, because you've written very powerfully about the opioid and prescription painkillers and their effect and in particular, the role of OxyContin and other prescription drugs. Can you say a little about how that came into the picture?

Angus Deaton
Yes, well these opioids started out being used more heavily around 1990 and then OxyContin was approved, I think, 1997. OxyContin is a very popular one of the opioids. I've often described it as heroin with an official label on it. Some people say it's even more effective at binding to the receptors in the brain than heroin is. So you don't want to think of it as a weak form of heroin; you might want to think of it as a strong form of heroin. Then there are drugs now like fentanyl which has become very important. They're supposed to be about 100 times more powerful than heroin.

The prescription drug thing is both interesting and horrifying. There's a long and very interesting issue of pain in the United States and in other rich countries, sort of oscillating between the treatment which says buck up and the pain will go away, go for a long walk, or this is a symptom that really needs to be treated as some sort of disease. So there's been a lot of pressure around the time that the opioids became available to classify pain as a disease. It's often called the fifth vital sign, that doctors are supposed to ask you when you go in there; are you breathing, what's your blood pressure, et cetera. They also ask you pain and you do indeed often see in doctors' offices, in the US at least, big pain charts which says here's zero, you have no pain at all and there's a smiley face. Then there's a horrible grimacing demon at the other end where it's at 10.

So doctors were asking people and they were treating pain and certainly the pharma companies pushed very hard for those painkillers to be prescribed. The FDA in 1997 or 1998 approved OxyContin, which became one of the very popular ones of these drugs. The problem with it, it was always known there was some potential for addiction because this is basically think of it like heroin.

Somehow the FDA and the docs thought that they could tell in advance who had addictive personalities and who didn't, so that we could avoid addiction by only giving it to people who were not at risk of addiction, which I don't think they really know how to do. It's probably true that if people are dying of terminal cancer, for instance, prescribing it is fine, but otherwise I don't think they really know. Then the other part of that is that once you're addicted, it's incredibly hard to get un-addicted. So some people will challenge that, but I don't think anyone who's worked in the field will argue that it's easy to un-addict someone, whether it's from alcohol or drugs or whatever.

These things are being handed by the bottleful by dentists, for example. You have a tooth out and then you go home with 100 of these and if you resist this temptation to sell them in the open market, which there is a big open market in these things, a big old market, you can take these and you can find yourself seriously addicted, even if you know the risks.

Glyn Davis
So you've written very powerfully about rent-seeking by those in the production chain of those who are selling these and you've just mentioned the range of players. Have we set up an economy where these sorts of prescription painkillers become integral to a whole set of industries?

Angus Deaton
Until the next administration, there were not very many lobbyists in Washington and the trade associations are mostly in New York. So this organised lobbying on behalf of business and writing laws and having congressmen read the scripts is a relatively new, very aggressive selling campaign by the pharmaceutical firms, the physicians, that pain as the fifth final sign is very much a part of that.

We haven't done as much work in other countries as we intend to, but I know for instance in Britain, where they're worried about it, opioids tend to be prescribed in hospital. So if you have a hip replaced, for example, when you wake up from surgery and the anaesthetic wears off, they'll give you OxyContin or something to contain the pain for a couple of days. But you're in bed in a hospital and they're watching you and they can take this away from you before anything really bad begins to happen. That seems to be true within Europe. I've forgotten the percentage, but an astonishing amount, it's like 90 per cent of all the world's supply is consumed in the United States.

Glyn Davis
Indeed, there's a calculation that your partner, Anne Case, did that said there's enough prescriptions written for heavy-duty painkillers in America to feed every adult in America around the clock for a month.

Just following up on that, she was also quoted as saying there was something rotten going on even before OxyContin. People want to feed the beast of despair, they may do that with drugs, they may do that with alcohol, they may do it with food. So what role alcohol, obesity and other forms of addiction in the pattern of white male deaths that you're describing in America?

Angus Deaton
When you quote her, I think you should talk to her. She's so much more eloquent than I am.

Glyn Davis
We'll try to do that.

Angus Deaton
Yes, well we're not necessarily talking about addiction. You can drink a lot of alcohol and get alcoholic liver disease without being addicted. Also suicide is certainly connected with addiction, but you can decide to kill yourself without being addicted to anything. Also addiction to opioids doesn't necessarily kill you.

What seems to happen is that people break the habit, they go cold turkey, they get clean, they're sober, as it were, then when they've been taking it, you have to keep increasing the dose to have the same effect on the pain. So by the time you quit, your dose is much heavier than it was when you started.

So if you quit and you're off for a month and then you relapse and you take the dose you were taking on the day you quit, that's when you die, because your body doesn't have the tolerance of that anymore.

What Anne was talking about is this sense that we think the opioids were what she calls an accelerant. It was like adding fuel to the flames and that there was something deeply wrong in the state of Denmark before this started happening. This just made it so much worse. You can think of suicides and alcohol as an escape from unhappiness and an escape from despair.

We don't really know about obesity, but obesity would be another part of that story. You just eat yourself to being sick. In the US - and I was just looking before I talked to you at the Australian numbers - but in the US, the decline in heart disease mortality, which has driven a lot of the life expectancy improvement over the last 40 years, has slowed down and actually stopped, so it's going up. In Australia, it went down and now it's slowing down. It's still decreasing, but it's decreasing at a lower rate than it was. So you may have some of the same thing too. We don't know that this is obesity, but it's plausible.

Glyn Davis
You mentioned earlier that it's not the same rate of suicides or mortality between men and women from these causes, but can you say a little about the difference between outcomes for men and women in American white working class families?

Angus Deaton
Well we've been up and down on this several times and I have a view, but let me tell you the other view too. The baseline for all of these things is that men do more of it than women do. So I think suicides for women are about a fifth of suicides for men. But if you look at what's happened since all this started in the late '90s and you look at all these things, they've gone up like tramlines for men and women. But then people say well, but the percentage increase for women has been much larger than for men.

That seems to be the wrong way of thinking about it. It's sort of like if someone gives you a dollar and me a dollar, then they say they actually gave more to you because you had less money to start with, well that's not what we're really talking about here; we're talking about the increase. So the increase has been, we think, parallel tramlines.

Glyn Davis
Pursuing that a bit further, the comparison between the death rates for say white, Hispanic and African Americans, are there noticeable differences?

Angus Deaton
Yes, very noticeable differences. This is one of the puzzles, so what we've been talking about is happening for white non-Hispanic men and women in the United States. It's not happening for Hispanics. If you look at Hispanic death rates, they look like British death rates or Australian death rates or something, they just look like what's happening elsewhere, so they're just fine. If you look at African American death rates, they're still higher than white non-Hispanic death rates.

Historically that's been true for a very long time and it's one of the things that people rightly worry enormously about.

One of the many characteristics in which African Americans do worse than whites, but the mortality rate for African Americans has been falling more rapidly than even Hispanics. So they're closing in on whites. Actually we have a graph which some people don't like very much, but it's always been the case that African Americans have been regarded as if you want a social group that's discriminated against, that's doing really badly, they're the ones. But if you take white non-Hispanics without a university degree, they're now doing worse on mortality than all blacks, which is, if you like, not a fair comparison, but it was all blacks that were always used as the terrible group. Now the terrible group is these whites without a university degree.

Glyn Davis
It's a pretty appalling set of outcomes across every criteria and one of the things you linked them to is education outcomes. You've said that America's not a great place for people who only have a high school degree.

Angus Deaton
These negatives outcomes, these mortality rates are doing much, much worse among people who do not have a four-year BA, from those who do have a university degree. That seems to be the dividing line. Even some people who have some college are more likely than people who have none than the people who actually have a degree.

The rest of us who have s college degree are not doing great; we're doing about the same as the European average. But the people who are really suffering are these people without a university degree.

Glyn Davis
How significant is this in a public policy sense?

Angus Deaton
From your discussion in Australia, there's real concern as to whether you're next. That's one of the - what used to be a $64,000 question, I guess, it's the $64 billion question now. There's no lack of candidates for horrible things happening to people who don't have a university degree. Of course, it's in all the rich countries in the world. Globalisation and technical change is making life very hard for people.

You could think of someone who got a high school degree, graduated in 1970, went to work for General Motors - or as someone said the other day, went to work for Generous Motors - they got a really pretty good salary, they got an increase every year and they belonged to the unions. The union may not have been the most pleasant bunch of guys in the world, but they gave some real political power to the working class.

Glyn Davis
And job security.

Angus Deaton
And job security and pay rises year after year. So these people could hope for a real middle class life and that has gone. Jobs don't last as long, they're not as good jobs, they often don't have health insurance. The commitment by both the employee and the employer to these jobs has diminished.

People don't seem to accumulate the same amount of skill on the job as they used to do. Of course, it's not a black and white thing, it's just that all these good things seem to be having diminished over time and they're linked up with social outcomes, which I think we think are the key, which is because of social changes, what Charles and Mary would call a loss of virtue.

People live with their girlfriends instead of getting married with them. They have children out of wedlock on a large scale. So now in the US, the average white mum has had at least one child out of wedlock, which just did not use to be the case. So in the US, unlike Europe - and I don't know the Australian situation - these cohabitations, as they call them, don't last nearly as long as marriages last.

So you might move in with your girlfriend, you have a kid, she finds someone who's a little better on the ladder than you are, kicks you out, has another guy, kicks him out. You get these kids who are 11 years old and they've had three dads, dads in heavy quotes. That's not a way to bring up a child.

Then you get to age 50, you've just lost the last in a series of short-term not very good jobs. You've got three kids but you never see them because they're living with other guys. You can see how in a world like that…

Glyn Davis
Despair sets in, yes.

Angus Deaton
…despair sets in. So that's the sort of story we've been telling to ourselves and it's a very preliminary sort of story. It matches up with what the sociologists and other people are saying, but we've got five years' work ahead of us.

Glyn Davis
In 1931, the historian, James Truslow defined or described the American dream as a dream of a land in which life should be better and richer and fuller for everyone, with opportunity for each according to ability or achievement. But that's not the America you're describing.

Angus Deaton
It's America that a lot of people seek to believe still exists, but the data don't really support it very well. If you were born when I was born, 1945, by the time you were 30 - I was not born in the US, but if I'd been born in…

Glyn Davis
Edinburgh, if memory serves me.

Angus Deaton
That's right, from which half my relatives went to Australia because we were so poor, but anyway.

Glyn Davis
I read an address you gave to the Royal Society of Edinburgh, which was just fabulous, remembering your time there.

Angus Deaton
Yes, so to go back to the American cohort born in 1945, by the time they were 30, something like 90 per cent of them were better off than their parents had been when they were 30. Then if you go to the cohort that was born 20 years later, in 1965 or 1970, only about 60 per cent of them were better off than their parents. That's just because economic growth sort of stopped, or it didn't stop but it really slowed down. The trouble, of course, with that story is that's happening elsewhere too and they're not all killing themselves.

Glyn Davis
Since the election of Donald Trump, as you say, there's been a big public conversation about the role of America's white working class and things that are afflicting them. There are clear narratives being developed to explain the election of the US president and narratives that new writers, including many from working class communities, are challenging. Let's listen to one.

Sarah Smarsh is a writer with Harper's online, The New Yorker and others and this is Sarah speaking recently on Harvard's Shorenstein Center podcast, about the narrative being used to explain the shock election of Donald Trump.

Sarah Smarsh
The Trump train was a white phenomenon, not a poor white phenomenon. At every economic level, white people - including almost by the same margin, college educated white people - came out for Trump at the same rate. I don't see any news stories or media narratives examining the great mystery of why middle class suburban white men with golf clubs in tidy garages voted for him. But there are a lot of obsessive reports going on about why coal country did.

Glyn Davis
Angus, misconceptions around America's white working class seem to be at large. Can you describe the experience you and Anne have had with conducting your research and your interaction with these communities that you are studying and reporting on?

Angus Deaton
What Sarah said is quite interesting. If you look at the white non-Hispanics without a university degree and compare them with black non-Hispanics without a university degree, the black non-Hispanics, I think about 28 per cent of them are poor, meaning they're below the poverty line. About seven per cent of the white non-Hispanics without a college degree are below the poverty line.

So one of the things that comes through from the ethnographic research very clearly - and it's sort of consistent with what she said, but I'm not sure about the college educated - is that there are a lot of white people who are incredibly resentful of the welfare benefits they see being handed out to people who they don't think deserve them. You could argue that it's racism in disguise, but you could argue it's just they don't like handouts and they don't like them to be given to white people either.

Gyn Davis
I'd like to take you to that point about welfare benefits and anger at that, because presumably one of the arguments that could be pursued is that Australia and Europe have quite good social safety networks and that is possibly why we're not seeing the outcomes in these countries to the same extent as you're describing.

America's social safety network is relatively recent, it's certainly tenuous in the current political climate and it's opposed by many of those who might be the beneficiaries. Is this a fundamental cultural difference? Or how do we explain the failure, in a sense, to produce long-term policies that ensure that not so many people end up in difficult circumstances?

Angus Deaton
I wish I knew the answer to that. I think it's a leading hypothesis that the superior welfare states in these other rich countries stopped this from happening in a way that it did happen in America. But there's the question that doesn't take us all that far, because why don't Americans have this welfare state? Why don't they want it?

One of the arguments often comes back to race, that most of the other western countries were much more racially homogeneous, at least at the time that they instituted those welfare policies. In America those welfare policies perhaps did not develop, because it was seen as transfers from whites to blacks.

The other issue that I think has been very important is this huge mistrust of government in the United States. So many Americans believe that the capitalist system is inherently fair, which to me is an odd belief, having grown up in Britain. But there's a sense that it's an anonymous market that produces these outcomes. Whereas they would contrast that with what the government does, which they see as arbitrary and unfair.

So the government's always doing bad things to some people and bringing some other people forward, like a sort of drunken god somehow that's making arbitrary distinctions between people, that people see as massively unfair. They don't see the capitalist system as being unfair. That's one of the reasons I've been focusing a lot on rent-seeking recently, because that sort of bridges that gap. The government is responsible for rent-seeking, it makes it happen, it's the target of it too, of course. So you could imagine someone on the left and someone on the right hating rent-seeking just about as much as one another.

Glyn Davis
In a recent speech you stated that one would be better off living below the World Bank's extreme poverty line in a country like Bangladesh than in the United States. There are figures showing life expectancy in at least one US county is now less than Sudan. I'm just fascinated as an outsider who's come to America, how Americans explain to themselves these outcomes.

Angus Deaton
By saying those things about Bangladesh, I made a lot of people very upset and not everybody agrees with the analogy. Though it's also true that calculation makes no allowance for the fact that even if after adjusting for prices you might be able to live on $2 a day in India, but in India they don't have to buy any housing, they don't have to pay for transport, they don't have to pay for healthcare, there's just lots.

So it might be that you should be using $4 a day in Australia or in the US or something, in which case there'd be even more. But there is this very long tail of really poor people in the US and I don't know how they justify it. If you're on the right, if you read Milton Friedman, Milton Friedman thought that poverty was created by governments trying to help it.

Glyn Davis
In your view, what sort of policy responses make sense, given the circumstances you're describing? Are you seeing any signs that people are not just talking about the problem, but have some ideas about how to respond?

Angus Deaton
Well there are people, yes, for sure. I'm not sure we have an operating government right now in Washington [laughs] and so the question is to - it's very, very hard to predict what's going to happen. We have been talking to some of the people in the Senate who are writing - or Anne has - to some of the people in the Senate who are trying to write the healthcare bill.

But here's one policy which people, I don't think, usually associate with in this way. I think this could happen, not deliberately but almost by accident, which is we spend about $3 trillion a year in the United States on healthcare.

It's about 18 per cent of GDP and the next most expensive country spends about 12 per cent. So a third, that's 12 versus 18, six per cent is a third. So we could save $1 trillion a year if we went to the second most expensive way of delivering healthcare. Remember our healthcare, if you think of the opioids, the family that owns OxyContin is a family health firm, according to the Los Angeles Times, has made $30-something million out of it.

So here this system is making these people incredibly rich and it's killing people and life expectancy is going down. So we run an incredibly expensive healthcare system that's delivering a lousy healthcare outcome. So if you take that $1 trillion and divide it by the number of families in the United States, you get about $8000 per family per year. So if we could get that back, this would stop the steady deterioration in earnings that's been happening since 1970.

People don't understand that the employer-based healthcare system, someone has to pay for it and a lot of it comes out of wages. So that's been a major factor in holding down wages in the United States. The businesses complain about it holding down profits, but most of the studies show that it comes out of wages. So if we went to a single parent healthcare system, not only would we have as good or perhaps better health, but the major bit about it is it would stop this vicious decline in earnings at the bottom of the income distribution. I think that would do a lot.

Glyn Davis
It's a fascinating concept, given Congress's desire to turn back even the Obama healthcare initiatives. However, you'd have to be an optimist, wouldn’t you?

Angus Deaton
Well I think what might happen is there's a huge amount of uncertainty out there right now. So one of the things we could do is screw up so badly that there'd be a huge political backlash which would lead to something like this. That's how it might happen.

Glyn Davis
As the rest of the world looks to American experience - and we do, we follow it closely and American models of economic development are powerful around the planet - what lessons should we draw from the American experience that you're describing?

Angus Deaton
Well I think you want to be pretty careful about opioids first of all and actually I was looking at this before I talked to you. In one of our papers we show that Australia is one of these places where the same classification that we call depths of despair have actually not been doing so well.

You can see that Australia and I think Scotland - we've been meaning to go back and look at Scotland - has a problem. I don't know exactly what that problem is. If you put it on the same graph as what's been happening in America, there's sort of nothing there. But as you say, these health trends in America have a habit of popping up in other countries, five or 10 years later. So I think one of the policy prescriptions for other countries is look what happened and be very, very careful of those things.

Glyn Davis
It's been a great pleasure speaking to Professor Sir Angus Deaton, the Noble Laureate and senior scholar at the Woodrow Wilson School at Princeton. You can hear how important this research is. Angus, thank you for taking time to talk to the audience here today on The Policy Shop.

Angus Deaton
Thank you, it's been a real pleasure talking to you.

Voiceover
The Policy Shop would like to thank the Liberal Redneck, Trae Crowder; author and journalist, Sarah Smarsh and Harvard's Shorenstein Center podcast. The Policy Shop is produced by Eoin Hahessy, researched by Paul Gray and Ruby Schwartz. Audio engineering is by Gavin Nebauer. Licensed under creative comments. Copyright, the University of Melbourne 2017.