Douglas Clement has published an \”Interview with Anne Case,\” subtitled \”Princeton economist on the cost of AIDS in South Africa, `deaths of despair\’ in the U.S. and women in economics,\” in The Region (from the Minneapolis Federal Reserve, December 12, 2017)
On \”deaths of despair\” and rising mortality of middle-aged US whites:
\”We found that suicide rates were rising. That opened another door: What about mortality in general? That’s when we found that mortality among whites in middle age was actually increasing. That came as a surprise to us, so we tried it out on friends of ours at medical schools. We thought this result must be known to them, or others, but it came as a surprise to basically everyone we showed these results to.
\”So we drilled into it and found it wasn’t that heart disease was increasing, it wasn’t that cancers were increasing. It turned out that the largest increases were for suicide, alcohol-related liver mortality and drug overdose, which we combined into what we called “deaths of despair.” Because to us it all seems like suicide; it’s either quickly with a gun or it’s slowly with drugs and alcohol. … [This is a] narrow demographic in terms of being white, non-Hispanic, yes, but it is throughout middle age. It’s happening for people in their 20s and their 30s, 40s and 50s. … The group that’s being hammered is people with less than a bachelor’s degree, more specifically, people with a high school degree or less. Those groups are at highest risk of those deaths.
\”None of that would’ve come to light if we had continued to make progress against heart disease in the U.S. Unlike other rich countries where mortality rates from heart disease are falling, they flat-lined in the U.S. We don’t really understand why. Some people are saying, `We’ve been telling you for two decades that you’re all getting fat and that eventually obesity will catch up with you.\’ But that’s a little bit premature, we think, because in Britain, the obesity rates are almost as high as they are in the U.S., and yet their heart disease rates continue to fall. So it’s something of a mystery. If heart disease progress had continued, it would’ve overwhelmed the increases we’ve seen in drugs and alcohol and suicide. But given that it’s flat-lined, it’s allowed those deaths to actually cause mortality rates to rise. We don’t fully have a picture of why this has happened even though the National Institutes of Health are spending $30 billion annually on health research and as a country we are spending $3 trillion a year on health care.
We decided that part of the mortality turnaround was probably due to the circumstances into which people in the U.S. without a B.A. were finding themselves. … We don’t think people abuse alcohol or drugs, or pick up a gun, if their lives are going well. We think that to understand what actually happened, we’re going to have to reach back in time to the 1970s. It was the early 1970s when it became less and less the case that people with just a high school degree could get on a job ladder that had on-the-job training and benefits, and the potential to make a middle-class life. We think it’s not a coincidence that the median wages for men in the U.S. have not grown since 1972. The opportunities available became less and less good, which meant men became less marriageable. …
\”So you’ve got a fragile home life, a job without prospects, and you put those together with a change that also happened in the U.S. where people, though they don’t report themselves to be less religious, are less likely to report belonging to the “legacy” churches of our youth, and instead they’re moving to more evangelical churches, which are much more individual-oriented. The kinds of pillars that used to help people in community are absent. It can be a perfect recipe for suicide. …
\”Coming to the policy part of this, we think that, while it’s not an easy thing to do, it’s relatively easy to turn off the taps for the prescription opioids, which are out of control. I think that a consensus is building for this, despite a lot of push-back from medical doctors who will say, `You come to my clinic, you look at these people who are in horrible pain and you tell me not to prescribe them something that can actually relieve their pain.\’ Well, we understand there’s a place for prescription opioids, but we think that they’re not currently being prescribed at an appropriate level. The fact that at current levels, every adult in the U.S. could be taking opioids around the clock for three weeks is more than probably makes any sense at all.
\”But when prescription opioids become too expensive or when the tap is turned off, that won’t entirely solve it. The same receptors in the brain respond to heroin, which is now coming in from Mexico, and it’s pure and cheap. Dealers don’t want to have to tangle with gangs in the inner cities, but they will deliver it to rural Maine and to Indiana, and that has made the illegal opioid crisis much worse as well. Talking about drugs is like trying to shoot at a moving target. In 2010, it was the prescription opioids; now it’s heroin and fentanyl.\”
When South African Families Impoverish Themselves with Funeral Expenses
\”In this part of KwaZulu-Natal and also in the Cape Flats outside of Cape Town, where we also had a field site, funerals are extremely expensive. … In this part of Zululand, probably the only business that was thriving was the funeral business. … When a baby dies, or a child at a very young age, there would be a traditional funeral. You would wrap them in a blanket and put them in the ground, and there’d be cookies and tea. When poor people died in old age, they would have an old-age funeral policy that would pay for their funerals; they pay in every month a little bit of money, and that takes care of funeral expenses.
\”But when people started to die in middle age, from AIDS, they didn’t have funeral policies to cover expenses. But the household felt compelled to bury them according to whatever their station was. For men, you would slaughter a cow. That’s a very expensive proposition. For women, you would slaughter a goat—less expensive but still a big chunk of change. There would be food for the extended family, who would come from far and wide, and stay as long as they wanted to stay. And you would have to feed them for as long as they wanted to stay.
\”It was also impossible for local areas to say, `OK, we’re going to make a pact in this local area: No one has an expensive funeral,\’ because your family who is coming all the way from Johannesburg, they didn’t buy into that. They wanted to come and have this enormous party. It was very important to be able to do that. … And if you couldn’t afford to bury your dead according to the status of that person, you would borrow money, and as a last resort you would borrow from a money lender at uxorious rates.
\”So then these households would fall into a deep hole because they couldn’t get out of the loan they had taken out to pay for the funeral. We were able to document the extent to which further bad things happened in those households, whether or not children went hungry, whether or not children got to school, whether or not people reported more psychological stress than would’ve been caused just by the death of someone in the household. In those households that borrowed money, things got worse very quickly.\”
Underrepresentation of Women in Academic Economics and the Sharp Elbows Issue
\”When I go to seminars in other disciplines, the tenor of the seminars tends to be a lot less about scoring points and a lot less about trying to nail the speaker to the blackboard. I think that women oftentimes don’t respond as well to that as men do. Now, some women do, obviously. There’s a distribution to both genders. …
\”I think that women in economics oftentimes find that government work is one in which there’s more teamwork and their skills are fully recognized. A lot of women go into government instead of academia because when they look around they think, this is actually an environment that seems pretty healthy. And I think that it’s not the case that economics is altogether a healthy discipline for women.
\”My first graduate degree was in public policy, and all during my undergraduate years where I studied math and economics, and in public policy school, I never felt one whit of discrimination. But the minute I started a Ph.D. in economics, it was apparent. That was a long time ago now, but from that day until today, I have felt that if I want to be heard, I have to be willing to come in and be ready to fight, with sharp elbows.\”