What Reports About White #Students People Dying Missed

By now even casual observers of the news know that the rate of death among white, middle-aged Americans is rising – a trend that isn’t seen in similar countries. The news followed a widely circulated paper published online Nov. 2, and members of the media were quick to attribute the trend to several factors, from despair to a lack of social services to economic opportunity.

Pundits on both sides of the political aisle used the study to further their own narratives. From the left came the cry that this was a result of pro-business policies that have engendered a new era of income inequality. The right used the study to repeat the mantra that the decline of the prototypical, husband-wife, two-child family was to blame.

But it’s hardly that simple or singular. A closer look at the study and other surrounding data on mortality show that initial reports may have missed the mark on identifying which people are most affected by rising death rates, and that extenuating factors such as gender, educational attainment or geography may offer additional context to the headline-grabbing report.

Written by Princeton economists Anne Case and Angus Deaton, the report found mortality rates for whites began rising in 1999 and continued to do so through 2013. The rise was driven by drug and alcohol overdoses, suicide, chronic liver disease and cirrhosis.

“A serious concern is that those currently in midlife will age into Medicare in worse health than the current elderly,” Case and Deaton wrote in the paper, published in the Proceedings of the National Academy of Sciences.

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The authors presented their data without directly stating the root cause for the destructive behaviors they identified as driving the trend, though they noted the prevalence of opioid use the U.S. has seen. They noted as well that a large group of people report difficulties with pain, which can lead them to take prescription painkillers or place them at risk of suicide. Prescription drugs, conversely, can make pain worse as their effects begin to diminish, and also have the potential to invoke suicidal thoughts. They additionally can be a gateway to illegal drugs such as heroin.

“These are really important public health problems someone should look at tackling,” says Dr. Kathleen Fairfield, a clinical scientist at the Center for Outcomes Research at Maine Medical Center. “They weren’t on everyone’s radar screen.”

Case and Deaton, who are married, used self-assessment data from the National Comorbidity Survey and from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System to look at physical health, mental health, activities of daily living – like walking, socializing and standing – and alcohol consumption among middle-aged white Americans. They compared results between 1997 to 1999 and 2011 to 2013.

“Addictions are hard to treat and pain is hard to control, so those currently in midlife may be a ‘lost generation’ whose future is less bright than those who preceded them,” Case and Deaton wrote.

This quote in part led to a media narrative that white Americans’ inner turmoil was leading to negative, fatal health outcomes.

While the authors speculated that economic difficulties may have played into these attitudes, as the country was recovering from a damaging recession during some of this time, they stated the rest of the world faced similar economic conditions and other countries did not see the same trend in death rates.

Also worth noting within the recession narrative is that black Americans still have a higher death rate than whites, but death rates for blacks – and Hispanics, who have far lower mortality rates than whites – declined during the period studied. Death rates for younger and older adults of all races and ethnicities did the same. Presumably, these groups also suffered during the financial crisis.

Case and Deaton encouraged others to more fully explore the data, which some critics have already done.

In Looking at Death Rates, Women Cannot Be Ignored

Case and Deaton’s paper did not specify whether middle-aged white men or women were seeing increasing mortality rates. Still, several news outlets misreported that the trend was occurring among only men.

In fact, women are arguably driving the trend. “I think by not looking separately at men and women that they missed an important story and piece of the puzzle,” says Laudy Aron, a senior fellow at the Urban Institute’s Center on Labor, Human Services and Population.

Aron responded to the report in an analysis she co-authored with other fellows from the Urban Institute on the Health Affairs blog, in which they made the case that rising mortality is especially pronounced among middle-aged women, given other recent studies on the subject.

The Urban Institute’s analysis of the same data showed that the average increase in age-specific mortality rates for whites ages 45 to 54 was more than three times higher for women than men. The mortality rate among women increased by 26.8 deaths per 100,000 people, while the rate for men increased by 7.7 deaths.

So although men still have higher mortality rates and tend to die at a younger age than women, the rates of increase are lower for the male gender. “Women are starting to look more like men in terms of their survival and underlying mortality patterns,” Laudy tells U.S. News.

The Urban Institute authors concluded that Case and Deaton’s discussion of their findings was too narrow. “They identify what they call ‘an epidemic of pain’ as the most likely cause of greater drug use, alcohol abuse and suicides, and only name growing disability rolls as a consequence,” the authors said, going on to argue that social support systems are necessary to reverse the trend.

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Andrew Gelman, a statistics and political science professor at Columbia University, wrote a similar analysis. “We’re so used to the narrative that things are getting worse for men, it’s so hard to be a guy in the modern era, etc.,” he wrote, noting that while mortality rates continued to increase among women after 2005, they decreased for men after that year.

The Princeton researchers also did not break down the causes of death that more commonly occur among women. Data have shown that women have far lower suicide rates than men, and that men drink more than women. In January, the CDC reported that each day from 2010 to 2012, an average of six people in the U.S. died from alcohol poisoning. About three-quarters were middle-aged men.

But another factor that has not made its way into the conversation is the alarming, rising rate of heavy drinking among women.

County-by-county data compiled by the Institute for Health Metrics and Evaluation at the University of Washington, covering 2002 to 2012, found that Americans are drinking more than ever and that women, in particular, are drinking at higher rates.

Women saw a rise in binge drinking – defined as having four drinks or more on a single occasion, such as over dinner or at a party – of 17.5 percent from 2005 to 2012. Men saw an increase of just 4.9 percent.

“Men start bad behaviors and women take up after them,” says Ali Mokdad, lead author of the study and a professor of global health and epidemiology at the University of Washington, about trends like this seen in public health. A similar trend was seen in smoking rates, he says.

The Case-Deaton report did not break down data geographically, but when looking only at drinking rates, the largest concentrations of heavy drinking and binge drinking have been found in the Midwest and the West.

Poisonings Rose for All Education Levels

The report from Case and Deaton found that people with only a high school degree and those who never graduated from high school saw death rates from poisonings – including drug overdoses and alcohol poisonings – increase fourfold between 1999 and 2013.

Though death rates from all causes increased by 22 percent in that lowest educational group, they fell slightly among those who dropped out of college or who earned a certificate or associate degree. Death rates fell by about 24 percent among people who attended a four-year college or went on to receive higher degrees.

Those with the lowest educational attainment also comprised a greater share of the middle-aged population than might be assumed. According to the Case-Deaton report, 37 percent of whites in the group had no more than a high school education. This was higher than the percentage of people in the age group who went on to a four-year college or attained additional degrees, which was 32 percent.

But groups who had higher educational attainment than a high school diploma were not immune, particularly when it came to drug and alcohol poisonings. Among people who dropped out of college or earned a certificate or associate degree, poisonings rose by 14.6 per 100,000 people, and they rose slightly by 4.64 per 100,000 people for people who graduated from college or went on to receive a master’s, professional or doctorate degree.

In an email, Deaton tells U.S. News it’s important to note that the proportions of people in the three education groups are very nearly constant over the period he and Case studied.

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Ben Miller, senior director for postsecondary education at the Center for American Progress, says there’s a perception in the U.S. that many more people have bachelor’s degrees than actually do. Though the majority of people try college, many drop out or go on to attain a certificate or associate degree.

The report did not break down people of middle age by economic status, though generally disparities in health care are in part explained by educational attainment, as well as other factors including quality of medical care received and insurance coverage, says Mokdad, from the University of Washington.

Still, those who haven’t gone beyond high school tend to have lower incomes than the general population, although a four-year college isn’t necessarily the ticket to higher pay. Miller explains that while those who attain a four-year degree are more likely to attain middle-class status, an associate degree is more variable. “It can be way better [in salary] than a BA, or it can be way worse,” he says.

Drawing conclusions without breaking down the study by income can lead to generalizations. For instance, alcohol was one of several factors that contributed to health risks identified in the study, and that in turn appeared to feed into a misperception that people of lower educational attainment drink more.

Dr. George Koob, director of the National Institutes of Health’s National Institute of Alcohol Abuse and Alcoholism, says identifying drinking patterns according to educational attainment or class is an oversimplification. “Alcoholism is not exclusive to anyone,” he says. “There are just as many deans in academic universities that are alcoholics or CEOs of businesses as there are people on the street.” He also notes that someone does not need to have alcoholism to face the health care difficulties cited in the paper.

Samuel Ball, president and CEO of the National Center on Addiction and Substance Abuse at Columbia University, says in an email that a more detailed analysis of the data is needed for recommendations to be made that could reverse the dire trend put forward by the paper.

“Baby boomers who did not attend college are an extraordinarily diverse group in the U.S. More research is needed to understand what are the specific health risks, stressors and behaviors within this group that accounts for this worsening of morbidity and mortality trends,” he says. “Fewer years of education may be a marker, but by itself cannot be an explanatory factor for why this age/race group has disproportionately higher death rates from overdose, suicide and liver disease.”

The study also did not distinguish between health insurance status, an additional factor that could help public health officials target communities for intervention. Neither did it identify what changed in 1999 to spur the sudden uptick in mortality rates that continued over a decade and a half. OxyContin, a prescription painkiller whose overuse can cause addiction and death, hit the market in 1996 and its use quickly spread by 2000, and though whites have better access to prescriptions, this fact alone wasn’t the only driver of mortality rates.

Fairfield, from the Center for Outcomes Research at Maine Medical Center, concludes that to determine the exact causes of the rise in mortality rates, someone would need to conduct more data analysis.

“It really does highlight a problem that I think we didn’t realize was going on among people that otherwise should have been enjoying reasonable health,” she says.

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