Anne Case

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The narrative of the recent election is that Trump won over “forgotten Americans,” though Hillary Clinton received the most votes from households making under $50k. The MAGA voters who were fetishized in the Election Day post-mortem were white, and somehow their struggles were awarded greater currency than people who had less. Part of that is because they tipped a vital election by being located in certain states which gave them a certain political capital, but the truth is their skin color fit into the noxious demagoguery of the campaign season. 

I’ve published a couple of posts about the new Case-Deaton paper about morbidity and mortality, which tries to divine the reason for middle-aged Caucasians enduring a “great die-off.” The report has not yet been peer-reviewed, and in Pacific·Standard, Mark Harris pushes back at the findings, arguing the research is marked by suspect methodology (above my head) but also that it misleadingly fixates on white Americans who still enjoy healthier and wealthier lives across the board than, say, African-Americans. The latter group has a significantly shorter lifespan than their white counterparts.

If the trend lines truly show one race making progress and another faltering, even if the declining group is richer, it’s certainly valuable to report as much so that we can attempt to stem a serious problem. The danger, however, is that attention will be pulled from those who need it most because of a compelling story line. 

From Harris:

Dubious methodology aside, there is still some useful information in the Case and Deaton report. America does seem to have a serious problem ensuring longevity for its population as compared to its peer nations. But, though the international perspective is the strongest part in their paper, it’s not what the researchers or the newspapers led with. Why put the statistical alchemy in front? Why is the story more dramatic or attractive when it’s about white people?

Mistakes and missteps also propel social science forward, as the Olshansky paper did. Still, Case and Deaton didn’t publish their findings in a peer-reviewed public-health journal, at least not first. Brookings is a center of political influence in Washington, and I have no doubt that Capitol Hill staffers have already written up their briefs on the report and passed them to their bosses — that is, if they work half as fast as Internet journalists do.

By the time it makes its way to the top of the policymaker food chain, how will this report be understood? I’d wager it’s something like the Brookings blog headline: “Working Class White Americans Are Now Dying in Middle Age at Faster Rates Than Minority Groups.” I asked [Arline] Geronimus if that was, to her understanding, a true statement: “I think that’s misleading, I really do. Oh boy,” she laughs, “there’s so much wrong with that. That headline makes it sound like problems are worse for white Americans than black Americans.” The narrative is wrong, but it’s not the first time Geronimus has heard it since the election. The Case and Deaton paper, she says, fits conveniently in this story, and it’s one she fears Americans are primed to believe.•

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Recently, I posted about Jack Healy’s excellent New York Times article about the Winemiller farming family in Ohio’s Clermont County, which boasts a low 4.1% unemployment rate. The parents have already lost two of three adult children to heroin overdoses, with the third one battling to beat the same poison. The father is a staunch Trump supporter, drawn by his tough-on-crime talk, hoping someone, anyone, can capture and kill the demons that has run over his life. The faith is misplaced, but grief can sometimes harden into vengeance.

Such demises can be categorized in Case-Deaton terms as “deaths of despair.” The husband-and-wife economists offered, in 2015, a shocking report about the sharp spike in mortality for white, middle-aged Americans, especially those who possess a high-school-or-less education. The epidemic seems driven by suicide, alcohol, opioids and obesity, self-destructive behaviors associated with hopelessness, dysfunction and poor childhood training. Deaton even compared the findings to the scourge of AIDS. The paper was published, appropriately, on December 8, the anniversary of Pearl Harbor.

Economics is certainly partly to blame for the steep decline of those in this demographic, though the full picture is far more complicated. In a follow-up paper, the economists write that the “story is rooted in the labor market, but involves many aspects of life, including health in childhood, marriage, child rearing, and religion.” The duo stresses the importance of dealing with the opioid problem but promise no quick fix for what’s a deeply entrenched disaster. Somehow we need to break free from our often-myopic politics to address these troubles, staying the course over long term. As Case and Deaton write: “The epidemic will not be easily or quickly reversed by policy.”

An excerpt: 

Taking all of the evidence together, we find it hard to sustain the income-based explanation. For white non-Hispanics, the story can be told, especially for those aged 50–54, and for the difference between them and the elderly, but we are left with no explanation for why Blacks and Hispanics are doing so well, nor for the divergence in mortality between college and high-school graduates, whose mortality rates are not just diverging, but going in opposite directions. Nor does the European experience provide support, because the mortality trends show no signs of the Great Recession in spite of its marked effects on household median incomes in some countries but not in others.

It is possible that it is not the last 20 years that matters, but rather that the long-run stagnation in wages and in incomes has bred a sense of hopelessness. But Figure 2.4 shows that, even if we go back to the late 1960s, the ethnic and racial patterns of median family incomes are similar for whites, blacks, and Hispanics, and so can provide no basis for their sharply different mortality outcomes after 1998.

There is a microeconomic literature on health determinants that shows that those with higher incomes have lower mortality rates and higher life expectancy, see National Academy of Sciences (2015) and Chetty et al (2016) for a recent large-scale study for the US. Income is correlated with many other relevant outcomes, particularly education, though there are careful studies, such as Elo and Preston (1996), that find separately protective effects of income and education, even when both are allowed for together with controls for age, geography, and ethnicity. These studies attempt to control for the obviously  important reverse effect of health on income by excluding those who are not in the labor force due to long-term physical or mental illness, or by not using income in the period(s) prior to death. Even so, there are likely also effects that are not eliminated in this way, for example, that operate through insults in childhood that impair both adult earnings and adult health. Nevertheless, it seems likely that income is protective of health, at least to some extent, even if it is overstated in the literature that does not allow for other factors.•

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Angus Deaton is cognizant that it’s absurd for a Princeton economist who’s been knighted by the Queen of England to lecture the “elites,” but he can’t help himself. Hardly anyone can these days.

Over several courses of fine food, he tells Shawn Donnan of the Financial Times about spending his summers trout fishing in Montana, retiring on Nobel Prize money and, oh, about those damned elites!

Okay, I’ll now stop being a smart ass. Deaton seems like a lovely, concerned person as does his wife and fellow economist, Anne Case. The couple famously collaborated on 2015 paper which revealed a shocking spike in the mortality rate of middle-aged white Americans. In my original post about the findings, I wondered how significant a role the opioid epidemic played in this stunning development. During his interview with Donnan, Deaton considers the same question.

An excerpt:

Deaton retired from his position at Princeton in the spring but he and Case are continuing to dig into the data. Since the election others have seized on the correlation between places with high white mortality rates and votes for Trump. But the link to those who report suffering from physical pain is even greater, Deaton says. He sees an epidemic of pain and a related flood of opioids into communities over the past decade as being, more than globalisation or economic dislocation, the real cause of rising mortality among middle-aged white Americans.

With Gallup’s help he has been collecting data on how many people report having felt physical pain in the past 24 hours and says the numbers are staggering in the US. What is causing that epidemic — and its links to Trump’s rise — remains unclear, he says. He seems more willing to blame pharmaceutical companies and doctors for overprescribing opioids. A surge in addiction (drug overdoses caused more deaths in the US last year than auto accidents) has, he argues, proved far more fatal than globalisation.


Deaton’s 2013 book The Great Escape argued that the world we live in today is healthier and wealthier than it would otherwise have been, thanks to centuries of economic integration. He sees efforts to blame globalisation for woes in the US Rust Belt or Britain’s beleaguered industrial areas as a mistake.

“Globalisation for me seems to be not first-order harm and I find it very hard not to think about the billion people who have been dragged out of poverty as a result,” he says. “I don’t think that globalisation is anywhere near the threat that robots are.” …

In his book, Deaton argues there is an inextricable link between progress and inequality and his views on wealth and innovation are complicated by that. “It’s hard to think that Mark Zuckerberg is actually impoverishing anyone by getting rich with Facebook,” he tells me. “But driverless cars are another matter entirely,” with millions of truck and other drivers likely to lose jobs.•

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The best follow-up reporting I’ve read about the eye-popping Anne Case-Angus Deaton study on the shocking spike in mortality among white American adults (which I blogged about here) is Julia Belluz’s Vox piece. It’s clear that oxycodone and the like are contributing furiously to the early deaths, but the question is why the usage has become so widespread. What is the void this group of people is trying to fill? Deaton discusses his theory with Belluz, though such overarching narratives are always somewhat slippery. An excerpt:

2) Deaton thinks middle-aged white Americans have “lost the narrative of their lives”

But what’s behind the substance abuse? One possible factor here: This demographic group has faced a rise in economic insecurity over the past decade, driven by things like the financial crisis and the collapse of manufacturing.

Still, it’s difficult to put together a full story of what’s going on. After all, if the recession or decline of manufacturing was the only factor, we might expect to see a similar uptick in mortality rates among middle-aged people in places such as Europe. But America seems to be unique in this regard.

“An anthropologist friend here says that [white, middle-age Americans] have lost the narrative of their lives — meaning something like a loss of hope, a loss of expectations of progress,” he explained.

Though African Americans as a group are still worse off overall, Deaton added, their quality of life has improved over the past several decades. “And when Hispanics look back, they may look back to where they came from, or what their parents or grandparents had,” he continued.

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Some people aren’t polite about their drug addictions, and some of us are rude in return. They’re called names, like “crackheads.” How messy that such substances are purchased on streets. When these folks are minorities, the meanest among us assign blame to them based on race. It’s appalling and counterproductive. 

I’ve thought for the past decade that white Americans of what used to be called the middle class have a very polite and well-mannered drug epidemic in oxycodone and the like. The whole undertaking is as neat and clean as a prescription pad. Reports of a spiked usage would regularly be published, but I worried that maybe I suffered from confirmation bias because I’ve spent so much time visiting relatives in hospitals the last few years. In these facilities, it’s easy to assume an oxy epidemic. The same goes for other self-destructive behaviors (obesity, alcoholism, etc.) appearing to be rampant.

It’s worth wondering how much opioid use is causing the alarming trend in the U.S. of the increasing deaths in white, middle-aged citizens, which has just been reported in a stunning paper by Anne Case and Angus Deaton. Why are people in this group drugging, eating and drinking themselves to death? Why have they become the walking dead? Some of it is overt suicide, some buried in risky behaviors.

From Gina Kolata of the New York Times:

The mortality rate for whites 45 to 54 years old with no more than a high school education increased by 134 deaths per 100,000 people from 1999 to 2014.

“It is difficult to find modern settings with survival losses of this magnitude,” wrote two Dartmouth economists, Ellen Meara and Jonathan S. Skinner, in a commentary to the Deaton-Case analysis to be published in Proceedings of the National Academy of Sciences.

“Wow,” said Samuel Preston, a professor of sociology at the University of Pennsylvania and an expert on mortality trends and the health of populations, who was not involved in the research. “This is a vivid indication that something is awry in these American households.”

Dr. [Angus] Deaton had but one parallel. “Only H.I.V./AIDS in contemporary times has done anything like this,” he said. …

David M. Cutler, a Harvard health care economist, said that although it was known that people were dying from causes like opioid addiction, the thought was that those deaths were just blips in the health care statistics and that over all everyone’s health was improving. The new paper, he said, “shows those blips are more like incoming missiles.”•

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