By Dr. Geoffrey Modest
The NY Times had a striking article from 2 Princeton economists (including Angus Deaton, who just won the Nobel Prize in Economics) finding that white Americans aged 45-54 with no more than a high school education had an increase in death rates, largely attributed to suicides and substance abuse from alcohol and prescription opiates. In terms of racial comparisons, white Americans have a mortality rate of 415/100K, African-Americans are at 581/100K (though the gap is closing), and Hispanics have a much lower rate of 262/100K. For the NY Times article, see http://www.nytimes.com/2015/11/03/health/death-rates-rising-for-middle-aged-white-americans-study-finds.html?emc=edit_th_20151103&nl=todaysheadlines&nlid=67866768&_r=0 . The full article is also freely available (see doi: 10.1073/pnas.1518393112).
Will summarize the article in more detail:
- If the white mortality rate in those 45-54 had continued to decline at the rate it was from 1979-1998, 488,500 deaths would have been avoided in the period 1999-2013. This loss of life is comparable to lives lost during the AIDS epidemic though mid-2015.
- Between 1970 and 2013, there was a 44% overall decrease in mortality for those 45-54 yo, attributed to behavioral change, prevention and treatment. Similar changes were seen in other wealthy countries. In the US, this was a decrease of 2%/year. But after 1998, in contrast to other rich countries’ mortality rates which continued to decline at 2%/yr, the mortality rates for US non-Hispanic whites rose by 0.5%/yr. See the first graph below: all groups (including US Hispanic) are trending down, with the solitary exception of US whites (in graph, USW=US whites, USH=US Hispanics).
- The increases in mortality were largely in US whites with high school degree or less (37% increased mortality over 1999-2013, with an increase of 134/100K) and less so for those with some college but no BA (31%) and those with BA or more (32%).
- In those 45-54 group, mortality was dramatically increased for drug and alcohol poisonings, but also for suicides and chronic liver diseases, with not much change for diabetes and decreased mortality from lung cancer (see 2nd graph below). In 2013, drug overdoses were highest in white non-Hispanic, and death from cirrhosis and chronic liver disease fell for blacks and rose for whites.
- The increased mortality in white non-Hispanics increased for each 5 year grouping from age 30 to 64, but the increases were most dramatic in the 45-54 groupings (see last graph on below). Not shown was those 65-74, who continued to have decreased mortality at 2%/yr.
- Morbidity increased in parallel to mortality: overall, comparing data from 1997-99 to 2011-13, there were significant changes in self-assessed health status, pain, psychological distress, difficulties with activities of daily living, and alcohol use. For example, one in three white non-Hispanics aged 45-54 reported chronic joint pain in 2011-13. The Kessler six questionnaire, which assessed serious mental illness, increased from 3.9% to 4.8% of respondants. There were significant decreases (2-3% range) in walking 1/4-mile, climbing 10 steps, standing or sitting for 2h, shopping, and socializing with friends; and the activities overall were limited by physical and mental health issues. Of note, though obesity played a role, increases in midlife morbidity increased both in those with BMI >30 and those <30.
- “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.”
So, pretty impressive/depressing. The CDC estimates that for each prescription pain killer death in 2008, there were 10 admissions for abuse, 32 ER visits for misuse/abuse, 130 people who were abusers or dependent, and 825 nonmedical opiate prescription users (so, mortality is really just the tip of the iceberg in terms of the full societal effects). One aspect in the current discourse not really addressed is the effects of economic insecurity and lack of adequate social supports in the US (it is notable that the economic downturn was worldwide over the past 7-8 years, but the increases in mortality were confined to the US). And the greatest change was in non-Hispanic whites with little education (unclear why US Hispanics did relatively better, but there may have been less of a dramatic change in their economic and social well-being during the downturn, as well as differences in social/community supports. International surveys indicate that overall Latin Americans have higher subjective well-being, despite lower incomes). Just raises yet again the 1879 Virchow quote: “Don’t crowd diseases (epidemics) point everywhere to deficiencies of society?”