'Deaths of despair': a tale of two countries Episode 4 of the Health Foundation podcast

Jennifer: Life expectancy is a totemic measure of our health and well-being but across most developed countries in the last 10 years, it's been stalling. Stalling most noticeably in the US and the UK. Last March, Anne Case and Angus Deaton, two distinguished economists from Princeton University, published what became the must-read book of the year called Deaths of Despair and The Future of Capitalism.

It shows that health has deteriorated fastest in middle-aged White Americans and in particular because of premature deaths due to suicide, drugs and alcohol, the so-called Deaths of Despair.

In the meantime, here in the UK The Marmot Review: Ten Years On was published last February looking at national health trends in England. This review revealed stalling growth in life expectancy nationally across England and an actual shortening of life expectancy among the people living in the poorest areas, in particular, women.

What is going on here? Is this simply a short-run issue due to public spending cuts or is it a long-term structural trend? What needs to be done? Might the pandemic accelerate solutions? To discuss these important issues today, I'm really delighted to welcome two outstanding guests.

Professor Angus Deaton was awarded the Nobel Prize for Economics in 2015. With Professor Anne Case, he co-authored Deaths of Despair and he's Emeritus Professor of Economics at Princeton University.

Angus: You get a situation which would certainly drive me to consider whether my life was worth it or not which is, ‘You're a 50-year-old man. You've had two or three sets of children. You don't know any of them and you've reached this time in middle-age when you look back and say, ‘What have I done?’ You have very little.

Jennifer: Sarah O'Connor is an employment columnist for the Financial Times and regularly highlights the conditions of low paid workers in the UK.

Sarah: Unemployment is definitely terrible for your health but really bad quality jobs, the evidence suggest are just as bad, actually. We've had a real growth in bad quality jobs here in the UK.

Jennifer: In 2016, Sarah won the Orwell Prize for her vivid reporting of life on the margin in the left behind coastal town of Blackpool, whose population has the lowest life expectancy in England.

Welcome to you both. Say first, Angus, your book is full of absolutely wonderful analyses with lots of graphs. Can you paint us a picture, please, of the long-run health trends in the US and why are you focused on white people aged 45 to 54?

Angus: Well, history is the way things happen and that affects the way you go. Anne and I were originally working on pain and on suicide. We had discovered there was this group of middle-aged white, non-Hispanic Americans whose suicide rates were rising very rapidly. This is a time in which most of the world's suicide rates are falling. US suicide rates are now up near those countries of the former Soviet Union, were the suicide capitals of the world.

Then, we looked behind that and we wanted to look at how the suicide was doing along with other deaths in that group. That was when we discovered that if you took those 45–54-year-old white age group, that all deaths were increasing. Not by very much but these deaths had been decreasing for the best part of the century. Even a stalling and a slight rise was just an appalling thing.

Then, we dug into what else was going on. We did what I think most people would have done, which is to dig and see what other causes were rising very rapidly. The first of those was accidental poisonings, which turns out to be what the officials call drug overdoses. Mostly opioid epidemic. Then, there was a large rise in deaths from alcoholic liver disease.

There was this sense that people were killing themselves quickly or slowly and those became the Deaths of Despair, a phrase that I think Anne coined, which really captured the public imagination.

Jennifer: You also wrote about morbidity as well. Pain and poor mental health. Does that map of illness map on to the Deaths of Despair?

Angus: Let me say something about the mapping question. Mapping suggests geography and I don't really want to push that very much in the United States. I think it's incredibly important in Britain, but the way it really maps-- and this is a big clue to the whole analysis in the United States and which cannot be replicated in Britain is that these people who are dying are all people who do not have a four-year college degree.

Remember, a standard university degree here takes four years, not three. People with a college degree are largely exempt from the suicides, the drug addiction, the alcoholic liver disease and they're exempt from these incredible increases in morbidity that are going on too.

That really matches in that way. The increase in deaths of despair is happening all over the United States.

Jennifer: Just remind us, what quantum of the increased deaths of despair is due to the opioid crisis? Can you quantify that?

Angus: The opioids, if you take the total deaths of despair, which are currently running at about 165,000 deaths a year, the biggest single one of those are opioid deaths but they're a bit less than half. Suicide and alcohol deaths make up the rest.

It's not just opioids, though, if you took the increase since the mid-90s, given that maybe 60,000 people in the mid-80s, 90s die of deaths of despair in what you might call ‘normal’ times, there are always going to be suicides and drug overdoses.

Most of that increase of 100,000 deaths a year, which should absolutely not be happening-- I don't have the precise figures for the increase, but the majority of that would be opioids, yes.

Jennifer: The situation in England is, of course, stalling life expectancy and our analysis takes much more of a geographic focus than probably has been the case in the US, but, of course, one of the areas in England with the lowest life expectancy from men and women is, in fact, Blackpool.

Sarah, can you summarise what you saw in this community and what you thought might be leading to some of the early health problems and early death?

Sarah: The genesis of that piece was a conversation I had with a friend who was training to be a GP in the northeast of England, actually, and she just mentioned that there was this term that GPs used among themselves to describe the elements of some of their patients, which was shit-life syndrome and that basically, there was a feeling that a lot of the people that they were seeing that it's not that they weren't genuinely unwell, they were, they were suffering psychological and physical pain, but that their sense was--

The cause of this was social and economic issues rather than something that the GP could easily fix. I became very interested in this and I looked at antidepressant prescription rates by geography and that sort of thing to try and get a sense of whether this was real and where it was happening.

That led me to Blackpool only because at that time, it was the place with the highest antidepressant prescription rates in the country. I just thought I'll go there and talk to people and try and see what's happening with as few preconceptions as possible, really.

What I found most interesting there was that I think there's a narrative, particularly in the UK, but probably in the US as well that some places have been left behind, that their economies have suffered some terrible shock, whether that's through globalisation or automation. In the case of Blackpool, it used to be a thriving place where people went on holiday and then, of course, the low-cost airlines came along and Blackpool's economic reason for being disappeared or if not disappeared, it certainly weakened and changed.

What's happening in Blackpool is more complicated than that. It's not the people that are leaving and the only ones who can't leave are getting depressed. It's that, actually, people are going to Blackpool. Blackpool is sucking people in from around the country, who feel like they've got nowhere else to go. People who need cheap accommodation and maybe are feeling sad or depressed or in pain end up gravitating to places like Blackpool partly because there's lots of very, very cheap accommodation there and partly because I think the seaside just attracts people who want to feel better in a strange way.

That was definitely what a lot of people in Blackpool told me. You'll see people getting off the trains in Blackpool with binbags with all of their stuff just going to look for a bedsit to live in. I found it really interesting corrective to my thinking on the economic geography of ill health, that actually it's not just that healthy people leave and then a place declines.

That sometimes, actually a place can suck people in and then you have a huge concentration of people with problems in one place that doesn't necessarily have the funding or the equipment to deal with it.

Jennifer: I think some of the data in your Blackpool piece that I think your colleague produced, I think was really telling about the extent of which the population flowed into and out of Blackpool.

Sarah: Yes, it's one of the most densely populated places outside of London. It's the transience that's what's so notable, the number of people coming in and going out and coming and going, and the impact that that has on all kinds of things, not least a sense of community, which is something I know Anne Case and Angus wrote about in their book.

Jennifer: Let's lead on, then, to some of the factors underpinning what we're seeing in terms of these health trends. I thought if we could probably take them in turn and maybe clump them up. I think the first clump for me is economics and employment.

Angus, I wonder if you can just talk about the changing nature of employment, the extent to which you think these long-run structural trends are a factor underpinning what you saw? Working conditions, de-industrialisation that actually you've written about but also many others, Amy Goldstein, for example in Janesville, Hillbilly Elegy to an extent, some of the iconic literature of the last few years.

Angus: I liked the idea of long-run structural. That's the thing to focus on. Let me come back to that. In contrast there, let me say that for instance, during the Great Recession in 2008, when the unemployment rate doubled pretty much overnight and where we had many years where we came out of that very, very slowly, deaths of despair were rising before that, they were rising during the Great Recession and they were rising afterwards.

We have a plot in the book where it's just a straight line upwards. I know when Ann likes to present that graph, she says, where's the Great Recession in this graph? The answer is: you can't see it at all. We don't believe there's a short-run tie between the business cycle or maybe even austerity and the deaths.

What we think is happening is the sort of thing you were talking about with those books, which is that there's been almost 70 years now of decline in real wages for people who do not have a college degree. Remember, two-thirds of the population in America do not have a college degree.

That two-thirds of the population, if you look at their wages over the last 70 years or the last 50 years since 1970 or so, those wages have-- There's the bounce around a bit with the business cycle, but basically there's a long-run downward trend.

That downward trend has been associated with the downward trend in the ratio of people who are in the labour force at all for men, a trend, which was different for women, but since 2000 has been the same for women. Again, for men and women without a BA and not for people with a BA.

We think that it's those disintegrations of labour market destroy the social life. They destroy the communities, they destroy marriages. They give rise to a phenomenon you don't really have in Britain, which is very short-term unstable cohabitations in which people produce children, but then pass on after a few years to someone else.

You get a situation which would certainly drive me to consider whether my life was worth it or not, which is you're a 50-year-old man, you've had two or three sets of children. You don't know any of them because they're living with other men or with your ex and you've never been married and you reach this time in middle-age when you look back and say, what have I done? You have very little.

Religion is faltering, especially among working-class less-educated Americans. There's been this huge rise in pain among these younger cohorts to the point where we have an absurd thing, which is not true in Britain at all, which is that people in middle-age are now reporting more pain than the elderly. I think those of us who are elderly can tell you that pain rises with age.

This is because terrible things are happening to those people in middle age, who've been in more pain throughout their lives than the older people. Again, it's only people who don't have a BA.

Jennifer: To what extent can you tease out or is it sensible to tease out what might be economic effects, long-run from long-run other effects? Are they just so intertwined in your view?

Angus: Well, there's a time sequence. You do see all of these things happening to this group and not to other groups. There has to be something peculiarly American about this too, because as you say the deaths of despair are much lower in Britain. Not so much lower in Scotland, for example.

All of these countries are facing these challenges to their labour markets for less skilled workers.

Unfortunately, in Britain, because you don't collect, not only, you do not collect ethnicity on the death certificates, but you don't collect education on the death certificates we just can't track this through in Britain, at home.

Jennifer: Sarah, in your analysis of Blackpool, did you think that unemployment and benefits were an issue more than precarious or low-quality jobs or are the two things again so closely entwined?

Sarah: Yes, I think they really go hand in hand. One of the fascinating differences between the US and the UK is that while in the US a lot of people have dropped out of the labour market altogether, that hasn't happened at all in the UK. People have remained engaged in the labour market and unemployment has been really low. As we know, until COVID happened, we were at record low unemployment rates.

Actually, unemployment wasn't the major problem in the UK and yet we were seeing these signs of something going awry, and health is a great place to notice that that's happening. I think unemployment is definitely terrible for your health, but really bad-quality jobs, the evidence suggests are just as bad actually.

We've had a real growth in bad-quality jobs here in the UK, particularly very, very insecure jobs where you don't know from one day to the next if you'll be going to work, where you wait for a text message at 10:00 PM to tell you if you need to get on the bus at 9:00 AM. You might get on the bus at 9:00 AM, arrive in the factory to be told that actually you're not needed. You have to sit in the canteen until the next person, then go home again all at your own expense.

Those sorts of jobs are actually pretty ruinous for your stress levels, your ability to look after your children. All of those I think can be really bad for your health.

Jennifer: You've written, I think about increased routinisation of work.

Sarah: In certain parts of the labour market, you'll find it a lot in places like warehouses for online retailers. There'll be people who are wearing headsets and a voice tells them go to aisle 23, you go to aisle 23, pick five objects, you pick five objects, go to aisle 22 pick six objects.

You really are just following these rote instructions and your productivity is measured in real time. There's lots of research to suggest that a lack of any autonomy in your job is really bad for your health levels.

Jennifer: Which leads me on to the, just unpacking a little bit more some of the non-economic factors that Angus you began to touch upon. You talked really cogently with Anne Case about the long-term loss of a way of life, which you began to describe.

Why is that such a US phenomenon when it's also happened to an extent elsewhere?

Angus: The stories you've been telling about this non-meaningful work, that's happening here on a large scale too. It's quite difficult to get hard data, but it's clear that a number of occupations, a number of jobs that used to be within large firms are no longer within large firms.

For instance, there are very few American corporations who have their own security staff, who have their own cleaners, who have their own catering staff, who have their own drivers, who have all those sorts of tasks which were good jobs, meaning you worked for a large employer.

I remember when I was a kid in Edinburgh, if you got a job with say ICI or something, you thought you had it made, and it didn't matter if you were just operating the lift. You were part of an ongoing, worthy meaningful enterprise in which there was dignity and in which you could build a career. You might even get promoted if you were good and you might finish up in a management job even if you start--

All of that has gone. Instead, what Sarah said is people are working in Amazon warehouses watching this device in their hand, which is ordering them around or watching the clock in McDonald's.

There's a parallel literature here. A book by someone called Emily Guendelsberger, which is excellent paralleling similar books in the UK.

I think it's not in one of the Goodheart books, but there's this wonderful quote, which we use when someone in an ex-mining area says, when you ask people what they do, they say, ‘I'm with Amazon.’ No one would ever have said, ‘I was with the National Coal Board,’ they would say, ‘I was a collier.’ Those jobs were dangerous. My grandfather died in the pit in Thurcroft in Yorkshire. There was a society attached to that, there was meaning in life and it might not have been very good life, but it was not devoid of meaning in the way that working in an Amazon warehouse or all these outsourced jobs.

Jennifer: And Sarah, just turning now to perhaps a more British phenomenon, which is the erosion of the safety net. To what extend this is a welfare issue as opposed to a wider economic issue?

Sarah: Well, I think it is a wider economic issue, but I definitely think that there's a connection with the welfare state in the way that some of these things interact with each can be really quite damaging and Blackpool really opened my eyes on that. I spoke earlier about how we have had very low unemployment, but what we have had is a growth in the number of people who are too unwell to work, but the nature of those people has changed over time.

It used to be that it was former coalminers, people who had done very manual jobs who then their bodies were destroyed by that manual work and so would go onto incapacity benefits. Now in the UK, the most common reason that you go onto incapacity benefits is if you're in mental distress, if you're suffering from depression and anxiety.

There's been various attempts to do something about this in the UK on the part of the government. They've tried various welfare reforms, all with the idea that what we want to do is to try and get these people back into work if we possibly can. But the way it's played out in the UK over the last 10 years has turned out to be quite cruel, really, because we decided that we needed to give people regular assessments on whether they really were too sick to work or not. People would have to go and meet someone who tries to decide if their illness is genuine and how genuine it is. If it isn't, then they would have to go and look for work, under pain of sanction if they didn't.

Obviously, you can push people into work in a vibrant economy with lots of good quality stable jobs that have the flexibility to work around your illness but in an economy like Blackpool, you have a lot of very low-paid hospitality jobs, which are both inflexible and often short-term because of the tourism season. You're trying to push people off incapacity and into a type of work that actually isn't good for your health anyway.

I think various attempts at welfare reform in the UK haven't been particularly effective in the last 10 years.

Jennifer: I think we all know that the pandemic is having a deteriorating effect on health, but I think the question really on the table here is the pandemic going to be an inflection point for policy or are we going to snap back to business as usual? Angus, do you think that this is a turning point?

Angus: No, I don't-- Well, there's somewhere in between those two things. I mean a turning point suggests everything is going to turn around and we go back to what I think is called in Britain ‘the sunny uplands’ a somewhat different context.

I don't think we'll ever go back to where we were before. I think the pandemic will have permanent long-lasting effects, many of which we know but many, many more people will work from home.

That will have very serious effects on cities, on transportation, on jobs within cities, just to name a few.

It's also the case that it might be a turning point in the sense that Anne and I have written about how we hope-- not hope because there'll be a lot of suffering to get there but when we come out of this, the American healthcare system will have been seen to be so deficient that the pressure for change, which has been there for a long time will become irresistible.

The other thing that's happening here that's not happening there is that the stock market ended the year on the highest level it's ever been. We had this enormous increase in the stock market, which has made some of us quite wealthy, right?

You have a situation in which 300,000 have died, a lot of people have lost their livelihoods, many are in some distress. They're in long lines outside food banks. The top 10 people have made about a trillion dollars between them out of this pandemic.

Now whether that's sustainable I don't know. My ability to predict the horrors of American life has been tested and failed before.

Jennifer: Sarah, can I ask you the same question? I mean it's a bit depressing, isn't it? There isn't that much sign of serious economic strategy and we've got the Brexit medicine as well to take as well as the pandemic.

What are your thoughts about whether the pandemic is really going to kickstart something serious about levelling up?

Sarah: I think the optimistic part of me would say that I think the pandemic made people think quite hard about essential workers, the fact that actually the people who have to keep working in order to keep the rest of us going as we worked from home, who were deemed to be essential to the national life and health of the country are actually the ones who are often the worst paid and are in the kinds of insecure jobs that we've just been discussing. I think it has brought about a sort of realisation that actually maybe we need to change the way we value some of those jobs and that could be positive if it could filter through into policy.

The other thing I think is as exposed to some of the problems with our welfare state, particularly around punitively low levels of sick pay, for example. Frankly just the low level of welfare benefits in general. I think a lot of people are finding that out because they're having to turn to the welfare state, not having had to before.

Maybe there'll be a general sense that something can and should be done. The other thing is of course the government has suddenly discovered that it has a lot more money to spend than it thought it did. I think it will be really hard to sell another story of austerity any time soon.

Angus: That would be great.

Jennifer: Sorry-- where--?

Angus: Well, it's just that I'm really worried that both here and in Britain the austerity hawks are always there. I don't believe that austerity is responsible for what's happening to a large expectancy. I think austerity is a horrible policy and it's a terrible policy and it hurts people and people really need this public services.

What will happen is the hard right on this that pretends to hate debt when it's not being used for things that they approve of will turn on this and there will be enormous forces pushing for more austerity for cuts in public services.

Sarah: That's definitely what happened last time.

Jennifer: Angus in your book, there's a chapter at the end on places to start when thinking about solutions and you have special words for the healthcare system. What is your approach? Is it to tackle some big discrete areas of the type that you mention or is it to try to go for wiser economic strategy that tries to encompass this for the longer term?

Or is that just pie in the sky with respect to US politics and what's practical?

Angus: Well, I think what needs to be done can be done at the micro level and ought to be done anyway. For instance, we ought to stop making it hard for unions to organise because that is really hurting working class people.

You mentioned the healthcare, which is not such a problem. I mean, healthcare is a problem everywhere. It costs a huge sum of money. You can spend almost any amount of money on it, but the US is in a class by itself of spending one in every $5 in GDP on this and not getting anything for it.

This is a huge drain.

It's like a metastasized cancer on our economy and if we could do anything about that, that would be incredibly helpful. We've got to take on anti-trust seriously because it's not clear that big tech is anymore helping in the public interest.

Jennifer: Sarah, I mean you obviously have written a lot about unemployment and having greater work as protection. There are also words to be said about welfare policy but also, I was struck about your piece about Blackpool, where you talked also about maybe a more regional approach to regeneration and whether not that would be a bigger feature in the future of a kind of economic policy that we haven't seen before.

Sarah: Yes, there's been a lot of talk about devolution of power to the lower level and I think that's definitely a good idea. There's a tendency in the UK for central government to hand out pots of money to places that are struggling. Often ask them to compete for it and I think that that's not the right way to go, that more power in local hands definitely would be a help. I actually really wanted to ask Angus something if that's okay?

Jennifer: Yes, go ahead.

Sarah: I just wanted to ask about the non-graduate versus graduate split in the data. I wondered whether you think there's a risk that some of the trends of increased levels of pain and mental distress and deaths of despair that we've seen among non-graduates might start to creep into this youngest generation of graduates?

Angus: It's entirely possible and given the story we tell, if you think of what happened to the blacks in the '60s and '70s as being the first wave. What happened to less-skilled whites being the second wave then they're coming for all of us. The next wave will be a lot of jobs that currently go to people with BAs.

I don't think there's any expectation that any group is exempt from this. It could certainly move up the chain.

Jennifer: Really interesting.

Sarah: I definitely get the sense-- I mean it's all anecdotal but just from talking to young people, and I mean people about 10 years younger than me who are graduates or who are studying now, there seems to be a really acute sense of anxiety and stress and worry about the future, which definitely, I don't think my generation felt at the same stage in their lives.

Angus: I think that's right. One of the things that would be really useful is a few people who have some play there would help press the ONS to merge the death data into the census, so we know who these people are who die.

Sarah: Who the people are.

Angus: This business of relying on these deprivation indices has lots and lots of problems with this.

Jennifer: Yes. I think that's on the cards actually, Angus. I just wanted to finish by asking you both what your personal plans are to push this forwards?

Sarah: I don't have too grandiose a sense of my own job. I'm not a policymaker, but I see my job as really going out and shining a light on what's happening. One of the great joys and privileges of writing for the FT is that the people who read it are often the people who actually have the power to do something about whatever it is that you're putting in front of them.

For example, after the Blackpool piece was written, I had a long conversation with Andy Haldane about it, who's the chief economist at the Bank of England. He then subsequently went to Blackpool himself and met with a lot of charity groups and people dealing with depression and alcoholism, and that sort of thing. I'll just keep doing that and hope for the best, I think.

Jennifer: Angus?

Angus: For me, that's common with Sarah, is that the most effect I think I can have is writing about these things, and it gets a fair amount of attention. I don't have the sense that no one's listening, so all of that is good.

More seriously though, I haven't seen my grandchildren in nine months, and that's my first order of priority if they ever manage to stop bungling the distribution of the vaccine.

Jennifer: We're going to leave it there. Thank you so much to Professor Angus Deaton and Sarah O'Connor for their very thoughtful analysis today.

Thanks also to you both for suggesting solutions that could have a good impact on health and reduce inequalities.

Angus: Thank you.

Sarah: Thanks for having me.

Jennifer: I'd strongly encourage everyone to read Deaths of Despair. It really was the must-read book of last year. Also, Sarah’s always informed and thoughtful weekly column in the FT.

Later this year, look out for the Deaton IFS inquiry, which reports in June, and the Health Foundation's very own COVID inquiry, reporting later on in the summer on the impact of the pandemic, specifically on health inequalities.

As always, you will find all the excellent books, reports and briefings we've mentioned and more in the show notes. Next month, we'll be returning to a theme we mentioned today, ‘Why don't we care enough?’ Asking why some types of work, often carried out by women, often in health and social care, are persistently undervalued, and what can we do about it?

Until then, thank you for listening. Most importantly, stay well.

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Goldstein A. Janesville: An American story. Simon & Schuster; 2017.

Goodheart D. The road to somewhere. The new tribes shaping British politics. Penguin; 2017.

McGreal C. American Overdose. The opioid tragedy in three acts. Faber and Faber; 2018.

Sandel M. The tyranny of merit. Why the promise of moving up is pulling America apart. Macmillan USA; 2020.

Vance JD. Hillbilly elegy: A memoir of a family and culture in crisis. Harper Collins USA; 2016.

Williams J. White working class: Overcoming class clueslessness in America. Harvard Business Review Press; 2017.