Saving Willy Loman

The focus on the increase in death rates for white Americans between ages 45-54 in the media obscures equally troubling results in Anne Case and Angus Deaton’s recent study published in the Proceedings of the National Academy of Sciences, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21^st Century.”

Case and Deaton highlight the finding that overall mortality rates for middle-aged white Americans have increased in recent years due to deaths from self-destructive behavior: suicide, drug and alcohol overdose, and disease resulting from long-term alcohol abuse. In contrast, overall death rates have continued to decline for middle-aged folk in industrialized Europe, and among African Americans and Hispanics in the U.S.

Focus on the overall death rate in the article and in media reports, however, blurs the breadth of the bad news reported in the article in at least two ways. First, the data show death by self-destruction has increased for all white Americans between the ages of 30 and 64. Death by suicide, drug and alcohol poisoning, chronic liver disease and cirrhosis roughly doubled in the fifteen-year period between 2000 and 2015 for 30-34 year olds and 50-54 year olds. It increased by around 1.75 times for others between the ages of 35 and 50, and for those 55 and older.

Secondly, while attention has been understandably focused on the result that the greatest increase in overall mortality occurred among white Americans with a high school degree or less, Case and Deaton's results show that death from suicide and drug poisoning for white Americans with BA degrees or some college also increased for the middle-aged, 45-54 category.

But back to the data showing an increase in deaths by self-destruction for white Americans between the larger set of ages, ages 30 through 64. The focus on overall mortality in the data obscures that there has been a redistribution in the proportion of deaths among adult white Americans over the age of 30 caused by drugs, alcohol, and suicide.

This is notable news no matter whether the overall death rate for this age group goes up or down. To wit, if a new cancer treatment reduces cancer mortality for a group by ten percent, but death from suicide and drug and alcohol abuse increases, say, by eight percent, then the overall death rate for the group goes down by two percent. But if the cancer treatment reduces cancer mortality by six percent, but the increase in death from suicide and drug and alcohol poisoning stays the same, then the overall death rate increases by two percent. An eight percent increase in death from self-destructive behavior in this group is no less disturbing because of the offsetting effect of a decline elsewhere happens to be larger or smaller than the increase in death by self-destruction.

A significant increase in death by self-destruction demands attention whether it affects the overall death rate of a population or not.

The big puzzle left unanswered by Case and Deaton is the “why” question: Why have the rates of these types of death increased for this age group of white Americans, but have continued to decline for Hispanics and African Americans (although the absolute death rate for African Americans remains shockingly high even as overall death rates decline), and have continued to decline for Europeans?

There may be a significant economic component. But as Case and Deaton point out, there have been similar economic slowdowns in European countries, but without the same impact on mortality.

Also, while the incomes of white American men have basically stayed the same since the 1970s (in constant dollars), the incomes of white American women increased dramatically through about 1990. If economic stagnation were the cause of the increase in death rates, then one would expect that self-destructive death rates for women should have continued to decline while the death rates for men increased.

Yet Case and Deaton report that the increase in mortality for white middle-aged Americans is (roughly) the same for both men and women. To be sure, women’s income gains plateaued around 1990, which is when the mortality statistics began to turn upward. But, presumably, there is a lag of some years, perhaps even decades, between the plateauing of one’s economic prospects and an increased inclination to self-destruction. Cirrhosis of the liver, after all, does not develop overnight.

Case and Deaton speculate that the shift from defined-benefit pension plans in the U.S. to defined-contribution plans (such as the 401(k)) may have caused the upward shift in mortality rates. But this makes little sense given the data they present: U.S. workers with less than a high-school degree had relatively little access to traditional pensions before the shift away from pensions to defined-contribution plans. If the shift away from defined-benefit pension plans caused the increase in mortality, then one would expect to see the opposite relationship between education and mortality: there would presumably be an increase in mortality among the more-educated in this group of Americans than among the less-educated, given that it is the more-educated who have disproportionately lost defined-benefit retirement pensions.

Something that Case and Deaton do not consider is the increase in drug abuse in rural America. With wide tracts of space and few people in rural areas, law enforcement has a more-difficult task monitoring and enforcing drug laws relative to urban areas. The decreasing cost of meth and heroin, and their increasing availability in rural areas, has seemingly lead to increased use in those areas.

But it would be a mistake, I think, to focus solely on material causes. As with Willy Loman, the benighted suicide in Death of a Salesmen, the interaction of material and spiritual conditions is complicated. Indeed, that the data show the increase in death by self-destruction is not limited to whites with low educational achievement suggests that something else is at work—or at least something more complicated than lower economic achievement or increasing inequality.

That said, it would be a mistake to ignore the much-greater impact of increased death rates on lower-achieving whites (and the even yet higher, although still decreasing, absolute death rates among African-Americans) as though changing death rates matter all of a sudden because they also affect more highly-educated whites. Nonetheless, the changing rates does press the question: Why do members of any group in the U.S. increasingly numb themselves to death by drug or alcohol poisoning, or even take the more-direct path of suicide? The answer cannot be pretty.

James R. Rogers is Associate Professor of Political Science at Texas A&M University.