Rising Morbidity and Mortality in Midlife Among White Non-Hispanic Americans in the 21st Century

There has been an alarming increase in the all-cause mortality of middle-aged white non-Hispanic men and women in the United States between 1999 and 2013. This change reversed decades of progress in mortality and was unique to the United States; no other rich country saw a similar turnaround. The midlife mortality reversal was confined to white non-Hispanics; black non-Hispanics and Hispanics at midlife, and those aged 65 and above in every racial and ethnic group, continued to see mortality rates fall.

There has been a remarkable long-term decline in mortality rates in the United States, a decline in which middle-aged and older adults have fully participated. Between 1970 and 2013, a combination of behavioral change, prevention, and treatment brought down mortality rates for those aged 45–54 by 44%. Parallel improvements were seen in other rich countries. Improvements in health also brought declines in morbidity, even among the increasingly long-lived elderly. These reductions in mortality and morbidity have made lives longer and better, and there is a general and well-based presumption that these improvements will continue.

Increasing mortality in middle-aged whites was matched by increasing morbidity. When seen side by side with the mortality increase, declines in self-reported health and mental health, increased reports of pain, and greater difficulties with daily living show increasing distress among whites in midlife after the late 1990s.

Despite advances in health care and quality of life, white middle-aged Americans have seen overall mortality rates increase over the past 15 years, representing an overlooked "epidemic" with deaths comparable to the number of Americans who have died of AIDS.

This increase for whites was largely accounted for by increasing death rates from drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis. Although all education groups saw increases in mortality from suicide and poisonings, and an overall increase in external cause mortality, those with less education saw the most marked increases. Rising midlife mortality rates of white non-Hispanics were paralleled by increases in midlife morbidity. Self-reported declines in health, mental health, and ability to conduct activities of daily living, and increases in chronic pain and inability to work, as well as clinically measured deteriorations in liver function, all point to growing distress in this population.

For those with a high school degree or less, deaths caused by drug and alcohol poisoning rose fourfold; suicides rose by 81 percent; and deaths caused by liver disease and cirrhosis rose by 50 percent.

All-cause mortality rose by 22 percent for this least-educated group. Those with some college education saw little change in overall death rates, and those with a bachelor's degree or higher actually saw death rates decline.

In terms of lives lost, had the white mortality rate held at its 1998 value, 96,000 lives would have been saved between 1998 and 2013. If it had continued to fall at the rate of decline seen from 1978-1998, 488,500 deaths would have been avoided between 1999 and 2013. This figure is comparable to the number of deaths caused by the AIDS epidemic in America.

Fig. 1 shows age 45–54 mortality rates for US white non-Hispanics (USW, in red), US Hispanics (USH, in blue), and six rich industrialized comparison countries: France (FRA), Germany (GER), the United Kingdom (UK), Canada (CAN), Australia (AUS), and Sweden (SWE). The comparison is similar for other Organisation for Economic Co-operation and Development countries.

Fig. 1 shows a cessation and reversal of the decline in midlife mortality for US white non-Hispanics after 1998. From 1978 to 1998, the mortality rate for US whites aged 45–54 fell by 2% per year on average, which matched the average rate of decline in the six coun- tries shown, and the average over all other industrialized countries. After 1998, other rich countries’ mortality rates continued to decline by 2% a year. In contrast, US white non-Hispanic mortality rose by half a percent a year. No other rich country saw a similar turnaround. The mortality reversal was confined to white non-Hispanics; Hispanic Americans had mortality declines indistinguishable from the British (1.8% per year), and black non-Hispanic mortality for ages 45–54 declined by 2.6% per year over the period.

Midlife increases in suicides and drug poisonings have been persistent and large enough to drive up all-cause midlife.  If the white mortality rate for ages 45−54 had held at their 1998 value, 96,000 deaths would have been avoided from 1999–2013, 7,000 in 2013 alone. If it had continued to decline at its previous (1979‒1998) rate, half a million deaths would have been avoided in the period 1999‒2013, comparable to lives lost in the US AIDS epidemic through mid-2015. 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.

For deaths before 1989, information on Hispanic origin is not available, but we can calculate lives lost among all whites. For those aged 45–54, if the white mortality rate had held at its 1998 value, 96,000 deaths would have been avoided from 1999 to 2013, 7,000 in 2013 alone. If it had continued to fall at its previous (1979‒1998) rate of decline of 1.8% per year, 488,500 deaths would have been avoided in the period 1999‒2013, 54,000 in 2013.

This turnaround, as of 2014, is specific to midlife. All-cause mortality rates for white non-Hispanics aged 65–74 continued to fall at 2% per year from 1999 to 2013; there were similar declines in all other racial and ethnic groups aged 65–74. However, the mortality decline for white non-Hispanics aged 55–59 also slowed, declining only 0.5% per year over this period.

Americans born between 1945 and 1965 did not have particularly high mortality rates before midlife.

Fig. 2 presents the three causes of death that account for the mortality reversal among white non-Hispanics, namely suicide, drug and alcohol poisoning (accidental and intent undetermined), and chronic liver diseases and cirrhosis. All three increased year-on-year after 1998:

Fig. 2 also presents mortality from lung cancer and diabetes. The obesity epidemic has (rightly) made diabetes a major concern for midlife Americans; yet, in recent history, death from diabetes has not been an increasing threat. Poisonings overtook lung cancer as a cause of death in 2011 in this age group; suicide appears poised to do so.

The change in all-cause mortality for white non-Hispanics 45–54 is largely accounted for by an increasing death rate from external causes, mostly increases in drug and alcohol poisonings and in suicide. (Patterns are similar for men and women when analyzed separately.) In contrast to earlier years, drug overdoses were not concentrated among minorities. In 1999, poisoning mortality for ages 45–54 was 10.2 per 100,000 higher for black non-Hispanics than white non-Hispanics; by 2013, poisoning mortality was 8.4 per 100,000 higher for whites. Death from cirrhosis and chronic liver diseases fell for blacks and rose for whites. After 2006, death rates from alcohol and drug-induced causes for white non-Hispanics exceeded those for black non-Hispanics; in 2013, rates for white non- Hispanic exceeded those for black non-Hispanics by 19 per 100,000.

The increased availability of opioid prescriptions for pain that began in the late 1990s has been widely noted, as has the associated mortality.

Okie S (2010) A flood of opioids, a rising tide of deaths. N Engl J Med 363(21): 1981–1985.

Centers for Disease Control and Prevention (CDC) (2013) Vital signs: Overdoses of prescription opioid pain relievers and other drugs among women—United States, 1999−2010. MMWR Morb Mortal Wkly Rep 62(26):537–542.

Volkow ND, Frieden TR, Hyde PS, Cha SS (2014) Medication-assisted therapies— Tackling the opioid-overdose epidemic. N Engl J Med 370(22):2063–2066.

Beauchamp GA, Winstanley EL, Ryan SA, Lyons MS (2014) Moving beyond misuse and diversion: The urgent need to consider the role of iatrogenic addiction in the current opioid epidemic. Am J Public Health 104(11):2023–2029.

The CDC estimates that for each prescription painkiller death in 2008, there were 10 treatment admissions for abuse, 32 emergency department visits for misuse or abuse, 130 people who were abusers or dependent, and 825 nonmedical users (23). Tighter controls on opioid prescription brought some substitution into heroin and, in this period, the US saw falling prices and rising quality of heroin, as well as availability in areas where heroin had been previously largely unknown.

Quinones S (2015) Dreamland: the True Tale of America’s Opiate Epidemic (Blooms- bury Press, New York).

Cicero TJ, Ellis MS, Surratt HL, Kurtz SP (2014) The changing face of heroin use in the United States: A retrospective analysis of the past 50 years. JAMA Psychiatry 71(7): 821–826.

The epidemic of pain which the opioids were designed to treat is real enough, although the data here cannot establish whether the increase in opioid use or the increase in pain came first. Both increased rapidly after the mid-1990s. Pain prevalence might have been even higher without the drugs, although long-term opioid use may exacerbate pain for some (26), and consensus on the effectiveness and risks of long-term opioid use has been hampered by lack of research evidence. Pain is also a risk factor for suicide. Increased alcohol abuse and suicides are likely symptoms of the same underlying epidemic, and have increased alongside it, both temporally and spatially.

Although the epidemic of pain, suicide, and drug overdoses preceded the financial crisis, ties to economic insecurity are possible. After the productivity slowdown in the early 1970s, and with widening income inequality, many of the baby-boom generation are the first to find, in midlife, that they will not be better off than were their parents. Growth in real median earnings has been slow for this group, especially those with only a high school education. However, the productivity slowdown is common to many rich countries, some of which have seen even slower growth in median earnings than the United States, yet none have had the same mortality experience.

The United States has moved primarily to defined-contribution pension plans with associated stock market risk, whereas, in Europe, defined-benefit pensions are still the norm. Future financial insecurity may weigh more heavily on US workers, if they perceive stock market risk harder to manage than earnings risk, or if they have contributed inadequately to defined-contribution plans.

A serious concern is that those currently in midlife will age into Medicare in worse health than the currently elderly. This is not automatic; if the epidemic is brought under control, its sur- vivors 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” whose future is less bright than those who preceded them.

And what is the lesson? Why, that poor whites are moral failures, and they should move to where there are opportunities (where?). 

t’s surely worth noting that other advanced countries, with much more generous welfare states, aren’t showing anything like the kind of social collapse we’re seeing in the U.S. heartland. 

Why, it’s almost as if having a strong safety net leads to better, not worse, social health. Culture still matters: US Hispanics do a lot better than one might have expected. But the idea that somehow food stamps are why we’re breaking bad is utterly at odds with the evidence.  All of those other advanced economies are just as open to trade as we are — so whatever you think of free trade, it doesn’t necessarily cause social collapse.

Anyway, the right’s inability to face up to the evidence on this front is … just like its inability to face up to evidence on any other front.