The news that mortality is increasing among middle-aged white Americans spread like wildfire last week (see here and here and here) thanks to a study by Anne Case and Angus Deaton, who recently won the Nobel Prize in Economics. As researchers who study the social determinants of health, we were very pleased to see such widespread interest in this urgent national problem. Unfortunately, there are a couple of pieces of the puzzle that we think the Case and Deaton study missed.
By not looking at men and women separately, Case and Deaton failed to see that rising mortality is especially pronounced among women. The authors parenthetically note that “patterns are similar for men and women when analyzed separately,” but several recent studies have shown otherwise.
Two studies from the National Academy of Sciences (NAS) and the Institute of Medicine (one of which was directed by the first author of this post) have shown that Americans are slipping behind other high-income countries when it comes to mortality and survival, and that this “US health disadvantage” has been growing particularly among women. Another study by researchers at the University of Wisconsin–Madison shows that in the decade between 1992-96 and 2002-06, female mortality rates increased in 42.8 percent of US counties. Only 3.4 percent of counties, by comparison, saw an increase in male mortality rates.
Furthermore, our own analysis of the same data used by Case and Deaton shows that the average increase in age-specific mortality rates for whites age 45-54 was more than three times higher for women than men. More specifically, between 1999 and 2013, age-specific mortality rates for US white women age 45-54 increased by 26.8 deaths per 100,000 population, while the corresponding increase for men was 7.7 deaths.
By lumping women and men together, the study also missed the important point that the increases in mortality are affecting women of reproductive and childrearing ages, a finding that has huge implications for children, families, and communities.
We blogged about this nearly two years ago in January 2014 and recently updated the original NAS cross-national comparisons. Here is our updated figure showing the probability of women surviving to age 50 in the United States and in other high-income countries, including western European countries, Canada, Australia, and Japan. There is simply no mistaking the reality that American women are currently dying much earlier than their counterparts in other advanced nations.
The data are from the Human Mortality Database (at University of California, Berkeley and the Max Planck Institute for Demographic Research) and cannot support analyses by race or ethnicity. However, we know from the NAS reports that the US health disadvantage affects all races and ethnicities.
Case and Deaton identify suicide, drug and alcohol poisoning, and chronic liver diseases and cirrhosis as the main causes behind the rising mortality rates among white Americans in mid-life. Our recent analysis of causes of death among American women confirmed increasing death rates among non-Hispanic white women ages 15 to 54 specifically. Like Case and Deaton, we found accidental poisonings (linked to prescription opioid and heroin use) and suicides to be among the biggest drivers of this increase.
Accidental poisonings increased more than all the other causes combined, but they still explain only half of the total increase in deaths among white women at these ages. In addition to suicide, obesity- and smoking-related diseases are driving these mortality increases. Our findings clearly point to the need for a stronger public health focus on the misuse of prescription opioid drugs, as well as more prevention and treatment of tobacco, alcohol, and other drug use; mental illness; and obesity-related illnesses.
Finally, Case and Deaton’s discussion of their findings is too narrow in our view. 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. They consider the possibility that economic insecurity may help explain these trends, but then dismiss this factor by noting that other countries have had similar economic downturns without corresponding mortality increases. In the end they come back to the epidemic of pain, suicide, and drug overdoses and conclude: “if the epidemic is brought under control, its survivors may have a healthy old age. However, addictions are hard to treat and pain is hard to control, so those currently in midlife may be a lost generation.”
The causes and consequences of the US health disadvantage, especially among women, are much more complex and serious than this analysis suggests. We should not be prepared to write-off any generation as lost. In order to tackle the underlying causes of rising mortality among women of reproductive age, the nation needs to take a much broader perspective on health and survival, one that encompasses the social determinants of health of all women because women’s health and survival have profound implications for the health and wellbeing of children, families, and entire communities.
Men and women have different experiences in the labor market, different responsibilities for caring for children and aging parents, and different economic realities. Improving the conditions of life that shape the health of women and their families and social networks and that are contributing to the “epidemic of pain” is critical. Many systemic and environmental factors are likely at work behind these mortality trends, including unstable and low-paying jobs, a fraying social safety net, and other stressors. When life conditions undermine health or one’s ability to make healthy choices, we all suffer.
Editor’s note: Watch for more on US mortality trends in the upcoming December issue of Health Affairs.