In the 1960s, Americans had among the highest life expectancy on the planet. The United States was the country pushing the boundaries of longevity and setting an example for the rest of the world.Today, the U.S. ranks at the bottom of major developed nations. We are currently 43rd in the world when it comes to life expectancy and predicted to be 64th by the year 2040. Despite spending more on healthcare per capita than anywhere else, the fact is we are living shorter lives and in poorer health.It was two economists at Princeton who first noted this uniquely American phenomenon, the husband and wife team of Anne Case, PhD, and Angus Deaton, PhD. It was right around the recent turn of the century that death rates for middle-aged whites stopped falling in the United States, abruptly turned course, and started rising for the first time in nearly a hundred years. At first, Case and Deaton thought they had their numbers wrong. They spent weeks confirming their findings, believing surely someone else would’ve noticed the unfolding calamity. In the end, they realized they were right and no one else had picked it up.The next question was, “Why?”It is true that advances in the treatment of heart disease and cancer — the two biggest killers in middle age — continued to cut death rates through this time. Those advances were eroded, however, by the staggering increase in opioid drug overdoses, suicides, and alcoholic liver disease. Case calls those “deaths of despair.”
For 3 years in a row, the U.S. has dropped in life expectancy, something that had only previously happened 100 years ago during World War I and the 1918 global flu pandemic.
The underlying reasons for this current increase in mortality are more of a mystery. That’s the subject of our new HBO film, One Nation Under Stress.
To start, we established that what was happening in the U.S. was globally distinctive. While the poor nearly always fare worse regardless of where they live, we learned this is not a story solely rooted in the economy. Other wealthy, developed nations continued to experience falling death rates among the middle aged over this same time period despite having similar ups and downs, including periods of significant economic decline.
Importantly, within the U.S., African-Americans and Hispanics had similar decreases in death rates as the rest of the developed world. African-Americans, while still having death rates higher than whites, have seen those numbers drop almost every year since 1999. Hispanics, who already had lower death rates than whites, have seen a drop as well. It was only U.S. whites, aged 45 to 54, commonly with a high school education or less, who have seen increasing death rates. And they are the only population of people in the developed world to do so.After spending time with pathologists, evolutionary biologists, primatologists, and scores of people emblematic of these tragic statistics, a fascinating explanation started to emerge: the uniquely toxic stress of dashed expectations.You see, the demographic initially most affected were the sons and daughters of the Greatest Generation.They were supposed to inherit the earth (or at least the United States). That didn’t happen, and we subsequently learned those dashed expectations can be a remarkably toxic stressor to individuals and the society in which they live. It is far worse to have expected and not received, than simply to have not received.Another toxic stressor for a society is blatant income inequality. It is measured using the Gini coefficient. While countries in Africa and Latin America have the highest income inequality, the United States leads the way among wealthy countries.
In the HBO film, we showcase the work of Frans de Waal, PhD, to visualize the impact of this sort of conspicuous income inequality. We show two capuchin monkeys performing a repetitive task for reward, in this case a piece of cucumber. The monkeys, in separate cages side by side, perform the same task easily 20 times in a row. Then, one of the monkeys starts receiving a grape (a more desirable treat). As you might imagine, the cucumber-receiving monkey starts rattling the cage and experiences escalating stress levels. Perhaps that is not a surprise, but subsequent studies show the stress levels of the grape-receiving monkey shoot up as well. It seems no matter where on the spectrum you lie, glaring income inequality causes stress to individuals and can make an entire society start to crack.
For 20 years, we have witnessed the symptoms of these stressors on American society: drug overdoses, suicides, and liver disease. But, as any good doctor should, we also wanted to identify some of the root causes of the problem. There are many factors, including a gradual loss of community, loneliness, and evaporating social cohesion. It is also in part the story of people working hard and being rewarded very differently, and the crushed dreams of a generation who believed they would inherit an even better life than their parents.We know there is a price to pay for unjust income inequality and dashed expectations. Understanding this may help guide our best strategies forward and help the U.S. reverse the current spiral of self-destruction.