Daniel H Simon, Andrea M Tilstra and Ryan K Masters
Rising mortality among young and middle-aged White Americans has alarmed researchers, public health professionals and the broader public. These concerns were amplified by a 2015 study in which the authors attributed rising mortality rates among White Americans to increases in deaths from chronic liver disease, suicide and drug overdoses. The authors argued that increased mortality from these causes of death is likely a result of the “same underlying epidemic” that is affecting a “lost generation” of Americans. The underlying epidemic was said to be “deaths of despair”, originating from rising distress, economic insecurity and chronic pain.
Media outlets covered this narrative extensively, with several commenting on the struggles and decline of White America that enabled this trend in rising mortality. The 2016 Presidential election also brought speculation that the success of Donald Trump was due in part to the social breakdown and economic challenges afflicting poor, rural, White Americans.
The evidence supporting deaths of despair, however, is quite weak. The study that pushed this narrative was met with scepticism about its methods and interpretation, with some arguing that the findings were misleading due to “age-aggregation bias”. It was correctly pointed out that between 1999 and 2013, the average age of people in the 45–54-years age group increased considerably. With more people in this age group being in their 50s, the mortality rate might naturally increase, as mortality is more common at older ages. In fact, adjusting for the age composition of the population could account for a large percentage of the reported mortality increases.
In our study recently published in the IJE, we find little empirical support for the pain- and distress-based narratives. We show that mortality increases have likely been shaped by the US opiate epidemic and stalled progress in reducing deaths related to metabolic diseases. While we do not question the severe public health consequences of economic insecurity or the harsh realities of chronic pain and addiction, existing research and media reports have advanced a narrative that is simply not supported by the data.
The foundation of the deaths of despair explanation was a study that analysed a small age group (45–54 years), during a select period of time (1999–2013), while combining deaths from separate causes for men and women. In our study, we analysed women and men separately for cause-specific mortality from suicides, alcohol poisonings, drug poisonings, metabolic diseases and causes external to the body (such as complications from childbirth or pregnancy, nutritional deficiencies and accidents other than drug or alcohol poisonings). Further, we extended the analysis to mortality rates between 1980 and 2014, for both younger (25–34 years) and middle-aged (35–54 years) White Americans.
We grouped our findings into four main points, each of which are relevant to mortality research and public health policy. First, there are considerable gender differences in White American mortality trends, which are reflected in all-cause mortality rates and cause-specific trends. Notably, to some extent, the gender differences in mortality from external causes of death reflect HIV/AIDS-related deaths that plagued middle-aged men in the 1990s but which continued to shape White men’s mortality well into the 2000s. Additionally, while men and women both experienced increased drug-related mortality, there are differences in the onset, level and ages most affected. We would expect to find similar trends for men and women if the increases in White mortality had been driven by the “same underlying epidemic”.
Second, and most importantly, we found that mortality trends are not consistent for the despair-related causes. For example, we found that the relative contribution to overall mortality from drug-related deaths increased dramatically in the 1990s and continued through the 2010s, but we observed no sizeable increases in suicide or alcohol-related deaths for White men or women. This would imply that the underlying causes driving these mortality trends are likely different.
Third, rising drug-related mortality does not reflect rising mortality among a “lost generation” of White Americans, as increases in drug-related deaths were not confined to mid-life ages. Given that we found that all ages (25–54 years) experienced similar rapid increases in drug-related mortality, we find this inconsistent with a narrative of increasing pain and despair plaguing a single generation. Instead, the timing of the increases coincides with the rising availability, over-prescription and misuse of opioid-based painkillers, such as oxycodone, which increased addiction and heroin use.
Fourth, successes in reducing mortality from metabolic diseases (i.e., heart disease, obesity, hypertension) have slowed among White men and stalled among White women. This important point is missed in the despair narrative, as overall mortality rates would likely not have increased for middle-aged Americans without this slowed progress. Further, while drug-related mortality increases reflect a period-based phenomenon affecting multiple generations of Americans, we found evidence to suggest that mortality risk from metabolic disease is rising substantially across cohorts and affecting younger Americans more strongly than previous generations. These results likely represent the onset of health consequences related to the US obesity epidemic.
To conclude, our findings do not support the deaths of despair narrative, which argues that a generation of middle-aged White Americans is suffering from an underlying epidemic of distress, uncertainty and pain. If this were the case, we would expect to observe similar increases in mortality from all three causes for both men and women. Our findings illustrate that mortality increases for White Americans have largely been driven by period-based increases in drug poisoning deaths and cohort-based increases in metabolic disease deaths, related to the US opioid epidemic and the US obesity epidemic, respectively.
Read more:
Masters RK, Tilstra AM, Simon DH. Explaining recent mortality trends among younger and middle-aged White Americans. International Journal of Epidemiology, dyx127, https://doi.org/10.1093/ije/dyx127.
Daniel Simon is a PhD student in the Department of Sociology at the University of Colorado Boulder and is affiliated with the CU Population Center at the Institute of Behavioral Science. His research focuses on population–environment interactions in Mexico and recent trends in US mortality and is funded by the National Science Foundation through a Graduate Research Fellowship award (Twitter: @SimonSOCY).
Andrea Tilstra is a PhD student in the Department of Sociology at the University of Colorado Boulder and a graduate research assistant for the CU Population Center at the Institute of Behavioral Science. Her research interests are primarily in the areas of social demography and population health, and she is particularly interested in how US mortality and fertility vary across time and space, and how these variations align with changes in public policy (Twitter: @Andrea_Tilstra).
Ryan Masters is an assistant professor of sociology and a faculty associate in the Population Program and Health & Society Program in the Institute of Behavioral Science at the University of Colorado Boulder. His work examines social differences in US health and mortality trends.
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