thank you good evening and welcome welcome to our very special meeting it is special because we're going to address a topic which is hopelessness death that is suicides as well as death because of drug abuse or alcohol abuse specifically this kind of events in the american province and the most desolate american province when we hear about the american province we immediately think about the people who have elected trump and most likely there is a coincidence between these two phenomena we're going to talk about this together with mrs chen on monad a researcher and professor at the university of pennsylvania who has focused her research exactly on these topics crossing through different disciplines public health sociology demography data about suicide and death out of despair of the hopelessness pretty terrifying since 99 after present time in less than 20 years almost 2 million american citizens have died for causes related to drug alcohol and suicide this is a very high number and i imagine you know that there are many worldwide statistics on suicides i believe that the world health organization states that worldwide there are approximately eight hundred thousand eight hundred thousand suicides per year however the incidence in the usa is particularly high and there are statistic indicators if you're interested in this italy is one of the country with the lowest suicide rate the more you move towards the south the lower the suicide rate so maybe this is not necessarily linked to economic wealth maybe it is related to a different type of well-being and maybe you remember that in 2011 2012 in italy we had a surge of so-called economic suicides in the first quarter 2012 38 to 40 entrepreneurs committed suicide because of failures at work um a high number of workers who had lost their jobs also committed suicide the suicide rate is not usually regarded as economic as an economic indicator it doesn't rank like the gdp however this is a sign of the health of the given country and you know at that time about so many economic suicides in italy i investigated the metra and i found some very interesting data it is true that the economic suicide the suicide of despair so to say uh it's something that is increasing we already had a peak in the first half of the 90s because um we all know that this crisis is a very long one but already in the 90s italy went through a very strong economic crisis then the figures went down and after 2009 they went up again and investigating individual stories because i always try to see what is behind the figures so i investigated the story of all these economic suicides and as a matter of fact there was not a true catastrophe i mean we had cases of individuals who committed suicide for amounts of money that were not that overwhelming something that could have been sold one way or the other but most likely what was missing and what is actually the cause for people deciding to put an end to their life was a lack of prospects the fact that there was no a horizon ahead of them in 2011 there was a lot of talk about the fact that a greek man a retired man killed himself in the sigma square leaving a note stating that the economic crisis in greece had affected him and he wanted to conclude his life with dignity before having to go through the rubbish to find something to eat as a matter of fact in my research i have actually found and i don't know whether this is good news or not i found that according to statistics um twice as many people kill themselves because of love reasons this seems significant for me maybe i'm romantic and i keep thinking that um maybe there are some sort of news which if they're not good at least they're not as bad as the others anyway i do not want to steal time away from shannon i'm looking forward to listening to her presentation and at the end of the presentation you're free to ask questions so shannon you have the floor thank you for that introduction and thank you all for coming it's a real pleasure to be here in this beautiful city i've never been before this is my first time so it's really wonderful to be here today i'm going to be talking about a major public health issue in the united states and that's what are commonly referred to as deaths of despair deaths from drug alcohol and suicide mortality before i get started i'd just like to thank my funders and others who have supported this research including the institute for new economic thinking who brought me here today very exciting i appreciate that my objectives during this talk are going to be three parts first i want to describe demographic and spatial trends in u.s drug alcohol and suicide mortality rates these deaths of despair second i want to identify the demographic economic and social factors that are associated with spatial differences specifically differences across u.s counties in these deaths of despair and then third i'll wrap up by describing how these deaths of despair were related to the u.s 2016 presidential election and specifically trump's over-performance and clinton's underperformance in certain parts of the united states during the most recent election so part one this chart shows the increase in the mortality rate from drugs from 1999 through 2015. what we see is that unintended drug-induced deaths in the u.s have more than tripled since 1999 with nearly 50 000 deaths due to drugs in 2015 alone the death rate from drugs has increased at a much faster pace than death rates from other causes in the united states and in fact the growth trend now is very similar to the growth trend of deaths from the hiv aids epidemic in the late 80s and early 90s suicides have also increased by over 50 percent since 1999 and alcohol-induced deaths have increased in the u.s by about 70 since 1999 with cirrhosis of the liver being the major contributor to the increase in these types of deaths so together drugs alcohol and suicide are responsible for over 1.5 million deaths in the u.s since 1999. we can also break these deaths down like this where we see unintended drug deaths are in green the alcohol deaths are in purple and suicides are broken down by whether they're drug-related gun related or by some other cause and what's interesting here is that gun suicides make up the largest contribution to suicide deaths in the united states and suicides by drugs are actually a very low percentage of suicides in the united states now when we add deaths where drugs or alcohol were not the underlying or the direct cause of death but that contributed to the death in some way we see that from 1999 to 2015 drugs alcohol and suicide contributed to about 2 million deaths in the us this breaks down drug deaths over this period by whether they were caused by a specific type of drug and what we see here is that most drug deaths the medical examiner is unable to identify the specific drug that was involved but in cases where the medical examiner can identify the drug we see that opioids are the primary cause of drug-related deaths opioids of course include heroin prescription opioid pain relievers like oxycodone and hydrocodone and synthetic opioids like fentanyl the us makes up less than five percent of the world's population and yet we consume the overwhelming majority of the world's prescription opioid pain relievers we see there's been a major increase in deaths involving heroin since 2010 a major increase in synthetic opioid related deaths since 2013. synthetic opioids include fentanyl it's an incredibly potent opioid 50 to 100 times more potent than morphine and it's often mixed into heroin with or opioid pain reliever pills without the users knowing that it's mixed in there benzodiazepines get less attention from the u.s media or from politicians as a contributing cause but as a contributing cause of death they have been increasing benzodiazepines are sedatives they're commonly used to treat anxiety or panic disorders or to help with sleep and i would suggest we need to watch out for those as the next opioid now the countervailing message in the u.s media has been that addiction does not discriminate though that's technically true it's also true that certain demographic groups have much higher addiction rates and have much higher mortality rates from drugs alcohol and suicide and it's also true that mortality rates from drugs alcohol and suicide are much higher in certain parts of the u.s than in other parts of the u.s and this is important because it has implications for how we think about the causes of these deaths and how we should think about prevention and treatment so here i show increases in mortality rates from drugs alcohol and suicide by 10-year age groups i'm going to show you these individually drug mortality rates are the lowest for age 15 to 24 and they've leveled off for that group since the mid-2000s rates are the highest for the 54 a 45 to 54 age group but they're quickly catching up for the 25 to 34 and 35 to 44 age groups for alcohol age 55 to 64 has the highest mortality rates and that really makes sense because the majority of alcohol-related deaths are due to cirrhosis of the liver and risk of cirrhosis increases with years of heavy drinking it's noteworthy how much of an increase there has been in alcohol-related deaths since 2008. suicide rates are highest among the 45 to 54 age group followed closely by the 55 to 64 age group so this is not a young adult problem right this is a middle age adult problem in the us here i break down drug overdoses by age group and when we do that and we examine the drugs involved we see that heroin is present in a larger percentage of young adult overdose deaths whereas prescription opioid pain relievers are present in a larger percentage of middle age and older adult deaths so heroin use is much more common among young adults than among middle age and older adults and despite more liberal prescribing practices over the past 20 years or so in the united states many physicians are still hesitant to prescribe prescription opioids long term to young adults especially able-bodied young adults so what happens is in some cases young adults may receive an opioid prescription from a doctor or a pharmacist for a surgery or injury or wisdom tooth extraction and when they may have only needed a one-week supply of this drug they may have received a month supply they took them all and their bodies became dependent on on this drug that's one way that folks sometimes transition from prescription pain relievers to heroin but another way is that some young people uh get addicted simply by experimenting with their friends their friend has some pills um the person takes some and after a while they get they get hooked but prescription pain relievers are very expensive in the united states and heroin is very cheap in the u.s in most places heroin is cheaper than a six-pack of beer it was very cheap easy to access and so some young people turn to that there is significant racial ethnic and sex variation in drug alcohol and suicide mortality rates rates are much higher among men than among women and they're much higher among whites than among blacks or hispanics not only are mortality rates higher among whites than blacks and hispanics but they've increased among whites well they've actually dropped they've declined among black and hispanic males this is really a demographic and epidemiolog epidemiological conundrum it's a mystery given that blacks fare collectively worse on most u.s health measures and they face considerable economic disadvantage in the u.s so this is really an unprecedented trend in the u.s and it's unlike trends that we see for any other major cause of death in their recent research the economist case in deaton highlight these rising mortality and morbidity rates among middle-aged whites in the u.s especially those without a four-year college degree and they attribute those increases mostly to drug overdoses but also to suicides and to cirrhosis of the liver case and deaton attribute this to a decline in wage returns to experience and to age the longer we work in our jobs the longer we're in the labor force the higher our incomes are supposed to go and that hasn't been happening in the u.s especially for whites without a four-year college degree case and deaton pay less attention to geographic variations in these rates in these deaths of despair and that's what i'm going to focus on today so here i show drug alcohol and suicide mortality rates separately by metropolitan status purple represents large urban orange represents small urban and green represents rural large urban counties in the u.s are those that are located in a metropolitan area with more than one million residents so those are places like new york los angeles san francisco washington d.c those are large metro areas small urban counties are those located in a metro area of fewer than 1 million residents smaller cities in rural are all of the other counties that are not located in a metropolitan area now suicide rates have historically been higher in rural versus urban areas but drug mortality rates were once higher in large urban areas than in small urban or rural areas but since the mid-2000s mortality rates have been higher in small cities in rural areas than in large urban areas this map shows the distribution of drug related mortality at the county level in the united states the red orange and red are the highest mortality rates and the blues are the lowest mortality rates and we can see here clear spatial clusters of high versus low mortality rates so addiction may not discriminate but this is also clearly not a universally national problem in the united states there are really high rates in places like appalachia this is coal mining country here oklahoma large american indian populations large indigenous populations northern california this is a very rural area of the country that has lost significant labor due to losses of jobs and forestry and then there are very low rates in other parts of the country including the great plains this is heavy farming area lots of farming dependent economies in that area and the rural south now this part of the country is fascinating because on any other health map you look at in the united states this part of the country would be bright red this is majority african-american majority black thank you majority black population down here and on any other type of mortality and i'm basically any health indicator they have the worst rates but when it comes to drug alcohol and suicide mortality rates among blacks are very low now when we combine drug alcohol and suicide mortality together and map those there are some similarities but we also add really high rates in the west okay these are very isolated areas very rural areas suicides are high here there's a heavy degree of gun ownership in that part of the country significant drinking in that part of the country and large spaces of isolation where your neighbor might be 10 20 30 miles away there isn't as much interaction in that part of the country so those were the trends now for part two i'm going to talk about spatial variation and some explanations for that spatial variation in these trends drug alcohol and suicide deaths are not some random collection they often derive from depression despair anxiety hopelessness chronic pain and they're occurring within a context of declining health and declining economic and social circumstances among non-college-educated whites but they're also increasing at a time of declining mortality from other causes including declines in mortality from heart disease from most cancers from motor vehicle accidents so while rates of those types of deaths have remained stable or decreased rates of drug alcohol and suicide deaths have increased so that suggests that it's possible that the factors that are associated with spatial variation in drug alcohol and suicide mortality rates may be different from the factors that are associated with spatial differences and other types of death in the united states so to put this into some context i want to talk a little bit about this book written by journalist sam quinones and he wrote about the opioid epidemic in the united states before anyone else picked up on it to many in the u.s this epidemic seems to have come out of nowhere sam quinones demonstrates that prescription opioids and heroin and the problems that contributed to their increase didn't just appear overnight instead the current u.s despair problem has really been driven by this complex interplay of globalization and industrial restructuring poverty inequality and policies that really favor the market over population well-being jd vance and sociologist arlie hoshide also get some of these ideas about economic decline cynicism anxiety stagnation slippage jd vance writes about how years of decline in the working class and blue collar economy led to this sort of collective community level downward mobility in ohio part of the industrial midwest formerly strong area of the u.s with lots of manufacturing jobs a place that used to make things and now doesn't make things much anymore arlie hoshide wrote about how her respondents felt like they were on shaky grounds the shaky and uncertain labor market led to a sense of unfairness for them and anxiety and that was an area that was dependent on natural resource extraction consistent across all of these books that i just summarized is a feeling of loss a feeling of anxiety frustration despair specifically among whites and even more specifically among whites without a four-year college degree so what's going on with whites whites especially without a four-year college degree are very pessimistic about their prospects and their position in u.s society and we need to think about this from the a position of reference group many non-college educated whites are comparing themselves to previous generations their parents and their grandparents where economic prospects were better where job security was stronger where wages were even higher so when they compare themselves to groups that we're doing better it makes them feel worse about their life chances blacks and hispanics in the us are also comparing themselves to previous generations their parents and grandparents and though things may not be great for blacks and hispanics in the u.s they still have higher poverty rates they still earn lower wages than whites it feels like progress has been made among those groups their mortality rates are down life expectancy is up college graduation rates are up wages are increasing and so there's a sense that progress is being made when they compare themselves to previous generations they're comparing themselves to a reference group that makes them feel better and optimistic about their life chances now we can also apply this at the place level this is really a story from my perspective about group level place level downward mobility that residents of once economically strong manufacturing communities strong extraction communities they've seen jobs dry up they've seen wages decline they've seen social conditions decline including increased divorce rates increased rates of single parent families shutdowns of community centers very few opportunities for interacting with their neighbors and that has led to frustration anxiety stress pessimism and that makes those places vulnerable to drugs to alcohol abuse and to mental health problems that can lead to suicide so when i think about all of this i think about it from the perspective of landscapes of despair that's the framing socioeconomic status as anyone who studies health knows is a fundamental cause of poor health and health disparities sociological research shows us that socioeconomic disadvantage increases risk of mortality from preventable causes at least in part due to distress hopelessness lack of control over one's life now add on to that that for the past 40 years globalization automation and u.s policies that favor the market over collective well-being have led to the replacement of good paying manufacturing jobs and good paying natural resource jobs with lower paying and more unstable service work these macro economic changes have led to place level downward mobility in many places in the us not every place but in many places and that's most clearly observed through declining wages and declining household income but it's also observed from people moving away out migrating from places that were once strong economies that place level downward mobility then leads to enemy community breakdowns declines in social trust and selective out migration where those who have the resources to leave are the ones who leave leaving behind a larger concentration of the least resource and the most vulnerable groups these processes then all work together to contribute to growing distress despair and hopelessness that can make people vulnerable to engaging in harmful health behaviors important to all of this is that these processes have been spatially uneven they have not occurred equally across the united states they haven't occurred equally even within states so some counties within states are doing much better than other counties within states and the fact is that many small cities in rural areas have been left behind the most they've been left behind by a changing economic system that values corporate profits in rising stock prices over population well-being so i can't test these specific causal pathways that i show in this framework but what i can do is show whether there are associations between collective and contextual economic conditions social conditions and spatial variation in drug alcohol and suicide mortality rates so i conducted an ecological analysis using county level data the dependent variable is the age adjusted drug alcohol and suicide mortality rate among u.s counties pooled across a 10-year period 2006 to 2015. data suppression does not allow me to break down annually so i cannot assess change over that time too many counties have suppressed information the u.s centers for disease control suppresses mortality rates and death counts for counties with fewer than 10 deaths of any cause independent variables include a number of county level demographic socioeconomic labor market social and healthcare infrastructure data that come from a variety of us government sources i use regression models where i log the mortality rate because the mortality rate is skewed as you can imagine so that reduces the skew and i use state level fixed effects to account for the fact that counties are clustered within states but by doing that it also controls for differences across states differences state-level policies for drug-related policies or alcohol-related policies for instance okay here we go i recoded the continuous variables into quartiles to deal with multi-collinearity issues but also to enable comparisons of the magnitudes of the coefficients so what these bars do is compare the percentage difference in drug mortality rates between counties in the top quartile the highest quartile of each of these indicators and counties in the bottom quartile of each of these indicators the red bars indicate higher mortality rates for the top quartile of that particular indicator and the blue bars represent lower mortality rates four counties in the top quartile of that particular indicator so what i'm showing you right now are unadjusted they don't control for anything except for state fixed effects i'll show you the controlled models in a minute so here we see in terms of population characteristics drug alcohol and suicide mortality rates are higher in counties with a larger share of military people who are in the military or veterans a larger share of elderly people aged 65 and older they're higher in counties with a higher share of indigenous population american indians and they're higher in counties with higher shares of whites they're lower in counties with higher shares of hispanics and blacks so those are the population level differences when we look at socioeconomic disadvantage across all indicators of socioeconomic disadvantage we see that drug alcohol and suicide mortality rates are higher in counties where socioeconomic disadvantage is higher and these are sorted by magnitude so percent without health insurance is the largest effect percent unemployed and not in the labor force percent with a work disability percent receiving supplemental security income which is a u.s public assistance program for non-elderly who are poor and often disabled the poverty rate percent single-parent families percent receiving public assistance and percent without a four-year college degree across all of these indicators drug alcohol and suicide mortality rates are higher in places with higher economic distress we look at labor market characteristics there are some interesting things happening here we see that mortality rates are higher in counties that have a higher percentage of workers in blue collar manual labor jobs these are jobs like construction manufacturing extraction jobs where people work with their bodies or their hands physically demanding jobs they're also higher in counties with larger presence of sales and service occupations those tend to be lower paying more unstable they don't come with benefits no retirement hours are unknown inconsistent they're lower in places with a larger percentage of workers employed in professional occupations white collar jobs you go into the office or you're a college professor a doctor a lawyer those types of jobs in the u.s we have this measurement created by our united states department of agriculture that measures economic dependency across counties and identifies the major type of industry employer in a county and counties can be broken down by whether they're dependent on mining services manufacturing farming the public sector which is government work or whether they're non-specialized and what we see is that mortality rates are highest in counties that are mining dependent and they're much lower in counties that are public sector or farming dependent income inequality is associated with higher mortality rates so counties with higher income inequality have higher drug alcohol and suicide mortality rates but they're lower in counties where a larger percentage of residents are considered middle income and middle income means that they're between percent and sixty percent of the total u.s income distribution this shows differences across social capital measures social association measures and health care infrastructure so drug alcohol and suicide mortality rates are higher in places that have more membership associations these are like professional political civic associations and those sometimes come with fees for entry so they can be exclusionary there are times that that they also advocate for the interests of business which is sometimes not beneficial to lower income residents mortality rates are higher in places that are mental health care shortage areas primary health care shortage areas places that have experienced persistent population loss and they're higher in places with more nonprofit organizations they're lower mortality rates are lower in places with more sports and recreation establishments these are places where people have opportunities to interact with their neighbors get out and meet people not feel isolated and they're lower in places in the u.s with higher voter turnout voter turnout is a really good measure of social trust and cohesion and self-efficacy the feeling that you actually matter in your community so places with higher voter turnout have lower mortality rates finally mortality rates are higher in small urban micropolitan and rural counties versus large urban counties so those are the unadjusted when you run models that control for all of those variables together these are the variables that remain as statistically significant all of those socioeconomic disadvantage indicators i create i created an index for because they're so strongly correlated that they can't be included in the same models so we created this socioeconomic disadvantage index counties in the top quartile of socioeconomic disadvantage have mortality rates that are about 40 percent higher than counties that are in the bottom quartile of socioeconomic disadvantage and that is controlling for all of the other variables i just showed you in addition to that counties that are mining industry dependent counties with larger shares of military and veterans counties with larger percentage of people working in sales and service occupations counties with a higher share of elderly higher share of american indians and counties with persistent population loss all have significantly higher drug alcohol and suicide mortality rates conversely mortality rates are lower in places with a larger share of hispanics larger presence of sports and recreation establishments counties that are public sector dependent those are government jobs local state federal government counties with more religious establishments and counties with a larger percentage of blacks it's also interesting to consider the role of change in the labor market and so what this shows is that mortality rates are higher among counties that were dependent on natural resource extraction jobs and manufacturing jobs in the 1980s and 1990s but then lost experienced declines in those types of jobs by 2014 so in model one which is unadjusted it doesn't include any controls we see that counties that were dependent on manufacturing but lost jobs between 1980 to 2014 have mortality rates are about 6.7 percent higher than counties that were not manufacturing dependent and did not lose jobs that's not that big of an effect right and it's explained away by adding demographic controls and specifically it's explained away by accounting for the percentage of the population that's white because the majority of manufacturing loss has been in places that have large white populations versus large black and hispanic populations on the other hand compared to counties that are not natural resource industry dependent counties that were dependent on natural resource industry jobs but then lost those jobs have mortality rates that are about 28.5 higher and that significant effect remains through all controls even in fully adjusted models in addition counties that experience median household income decline about half of counties in the united states experience median household income decline counties where income declined they have about 10.2 percent higher mortality rates and that effect remains significant despite controls so there are some limitations to those data i'm going to move on to part three here in a minute but the limitations are that because this is an ecological analysis that uses county level data i can't account for the characteristics of the individuals who died within each county i don't know their race their sex their age and i'm not able to to figure that out with the data that are available to us i mentioned data suppression earlier the fact that the cdc suppresses rates for counties with too few deaths and what that means is that i can't disaggregate rates by race or sex or age another problem with that is that i can't assess change over time in mortality rates and what has caused change over time what i can tell you is that mortality rates have increased in almost all u.s counties very few where they've decreased and where they've decreased are places large urban areas that used to have really really high drug mortality rates like baltimore that still have moderately high rates but not nearly as high as they used to okay so part three this is the real exciting stuff so after the election um there was a lot of attention to what the heck happened all of the polls showed that hillary clinton should have won they showed her up by a pretty wide margin and so it was surprising to a lot of folks when she lost and it turns out that despite the fact that she won the u.s popular vote by nearly 2.9 million votes she lost three key states perhaps four key states depending upon how you want to count it and so i was curious i'm a demographer people were frustrated and scared and didn't know what to do and when i get that way i just start doing data analysis because that's that's my way of dealing with stress so hillary's last as i mentioned really came down to a particular region in the country where democrats have historically done pretty well it's a region that we refer to as the industrial midwest also referred to as the rust belt that region once had a really strong economy a detroit was once among the richest cities in the whole country at a time when new york city was among the poorest country counties in the whole city or cities in the whole but since the 1970s manufacturing jobs have declined in that part of the country in fact everywhere but really in that part of the country unemployment has increased wages have declined or they they've remained stagnant and health has been in decline and that wasn't just a recession effect that's been happening for 30 to 40 years the recession exacerbated it but it's been a long-term process and donald trump performed quite well in that part of the country or you could interpret it as hillary clinton performed quite poorly in that part of the country and trump won the election really based on that region the industrial midwest because of the way our electoral college system works so this is a scatter plot from a study i did shortly after the election and what that study showed is that nationally but especially in the industrial midwest there was a positive relationship between drug alcohol and suicide mortality rates and trump's over performance he did better in places with higher mortality rates and it wasn't just that he got a higher share of votes republicans tend to do well in places that have worse health worse economies but it was that he performed even better than mitt romney the 2012 republican candidate so when you hold that at baseline and you take the difference between romney's performance and trump's performance you get this measure of trump over performance and trump over performed the most in places with the highest drug alcohol and suicide mortality rates now when you dig deeper into that you see that it's not just deaths of despair but he did better along all kinds of measures of despair including economic distress poor health overall low educational attainment and percent separated and divorced on each of these measures trump performed better over performed mitt romney the most in the most distressed places if you break down a whole litany of variables and examine trump's over performance across all of these indicators these are ranked in order of importance magnitude of coefficient or standardized coefficients we see that he over performed the most in lower educated places places where fewer people have a four-year college degree but in addition to that we see that there are multiple measures of economic social and health well-being that were very important including disabilities he performed better in places where a larger share of the working age population have some functional disability he performed better where there's a larger share of vacant housing units he performed better in places with a higher percentage of the population is separated or divorced measures of isolation distress despair perform better in places that are more reliant on disability income where poverty is higher where unemployment and not in the labor force rates are higher but he performed less well performed worse than romney in places with more religious affiliations uh and of course places with larger shares of non-hispanic blacks hispanics and foreign-born those places just weren't going to vote for him i don't know if you guys saw any of the media around him but he um was not the nicest to racial minority populations in the u.s and his policies were certainly not going to be popular with them so let's consider just one county as an example that represents these larger patterns this is sort of a case study example it's really a symbol of what's happened in formerly strong manufacturing areas in the united states this is luzerne county pennsylvania in lazern county manufacturing jobs declined from over 42 000 in 1980 to fewer than 19 000 now and the types of jobs that are available there now simply don't pay as much as the jobs that were around forty years ago and they're more unstable they don't come with benefits including health insurance often the poverty rate is not the highest in the state or in the country but it's been difficult it's been increasing median household income there has remained stagnant since 1980 so incomes are staying the same but cost of living is increasing over a quarter of the 25 to 59 age group are either unemployed or not in the labor force at all that's remarkable because i just heard alan krueger say that in the united states as a whole that rate is 11 so in the united states the percentage of age 25 to 54 who are out of the labor market is 11 percent and in lazarn counties 25 they deal with chronic out migration of young adults young adults are moving and those who are most likely to move are those who have the resources to move and that leaves behind larger concentrations of the most vulnerable and the most disadvantaged drug overdose deaths have tripled in luzerne county in the past 15 years but it's not just drugs suicides have doubled there as well what's going on here is really bigger than drugs people in places like lizard county places like there have not felt like america was great for quite some time when you're driving by old shutdown factories with boarded up windows and you're watching nightly news reports about drug overdoses and you're seeing more of your neighbors sign up for disability instead of looking for work the message that america is great already simply doesn't match with your reality and that was the message the clinton campaign was using america is already great and of course trump's message was make america great again so one interpretation is that trump capitalized on and exploited those frustrations and anxieties in these landscapes of despair his anti-free trade message for example likely resonated with voters who saw manufacturing plans shut down and saw decent paying jobs that their parents and grandparents have be replaced by less well-paying more unstable service jobs and then growing racial and ethnic diversity in some of these same places likely contributed to the interpretation even if it was of a false interpretation that immigration was partly to blame for the woes in these places but an equally likely interpretation goes the other direction and that's about antipathy dislike ambivalence about hillary clinton that dislike or antipathy or the lack of connection that hillary clinton had with the industrial midwest may have led some potential voters who may have voted for another democratic candidate with a stronger working-class message may have led those people to just stay home in fact the data showed that voter turnout for democrats was down in a large part of the industrial midwest so it wasn't just enthusiasm for trump it wasn't just trump over performance it was also clinton's underperformance that that led to to his victory so i think about it like this just as decades of decline in secure and livable wage jobs resource disinvestment social decay just like those things have made some places in the u.s vulnerable to opioids and other drugs those same forces made those same places vulnerable to a candidate like donald trump who proposed a quick fixed message and in the us we love quick fixes it's part of the issue of our medical system it's part of why the opioid epidemic became so big because we try to fix everything quickly in the case of opioids we try to fix it with pills one of the things that we have to remember about all of this is that drug alcohol and suicide deaths represent only a very small fraction of people who are suffering from substance abuse and mental health diseases and disorders and the effects ripple beyond those who die or who are addicted to include family friends first responders service providers employers i have a picture here from from a facebook not a friend but a friend of a friend and this was being shared a couple of of uh months ago and what it says is i watched as my husband carefully and gently carried him out of the funeral home this is my son and this is what heroin did and it's a baggie of ashes and this is a funeral home and what struck me about this picture is that this is a funeral home near my hometown where my grandmother had her funeral and so it just it sort of hit home and so the point is that it's not like drug addicts were the ones who were going out and voting for trump right that opioids these deaths of despair are sort of canary in the coal mine there's some they're symptoms and symbols of much larger problems and in these places drugs and the related despair are affecting everybody we are seeing increases in children who are being removed from their homes and placed into foster care the foster care system is now overburdened in the u.s because parents are addicted or they're overdosing on drugs workplace productivity suffers when people are addicted to drugs or are abusing alcohol first responders and emergency department personnel are overwhelmed by overdose calls that they're getting and so those are costs to us all as i said these deaths are symptoms of much larger social and economic problems that go well beyond drugs in the u.s they're a symbol of our crisis in population health this is a country that tends to emphasize quick fixes to really complex problems rather than address the underlying social and economic issues that cause the problem so to summarize deaths of despair are not distributed equally across the u.s this is not a uniformly national crisis and the message that it is risks that resources will not be appropriately distributed to the places that need them most deaths of despair are occurring within larger landscapes of despair characterized by distress along multiple indicators of well-being including economic well-being social well-being and health well-being and the same factors that help to explain spatial variation in deaths of despair help explain spatial variation in trump's performance or clinton's underperformance so moving forward we have to come to grips with the fact that in the us our problem is bigger than opioids it's even bigger than donald trump all of our institutions have contributed to getting us into this mess deaths of despair are occurring within larger landscapes of despair characterized by distress across all these measures our individualistic go it alone attitude john wayne anybody heard of john wayne a very individualistic meritocratic attitude whites in particular in the u.s embrace this ethos of individualism and that might partly explain such high rates of deaths of despair among that group when things start to fall apart when you lose your job or your wages decline or you go through a divorce going through all that alone is not all that successful it contributes to isolation and depression so this idea that we're all in it by ourselves and only the strongest survive contributes to isolation and despair in the us i especially like this cartoon which is a rowboat where the people up here at this top part of the rowboat are saying thank goodness the hole is at their end well the people in the bottom are bailing it out we have a habit of that kind of thing in the u.s the reality is the consequences of deaths of despair and of trump affect us all whether we personally know someone who's dealing with addiction or mental illness this is a population health issue and until we are willing to invest the time and energy and resources into addressing the underlying economic and social causes of these issues i am afraid that these death rates are going to continue to increase so now i'm happy to take questions any question well while we wait for the audience to make questions i'd like to ask you a question well i took a message from your presentation and i don't know if it is correct can we say that it is impoverishment that kills more than poverty because i was very much struck by the fact that well we in italy think that blacks and hispanics in the u.s are the most devastated categories but in fact you told us that the dna's mortality rates are lower for them that perhaps means that they have a strong identity a sense of belonging they know what they are perhaps unlike the working white class but then if we look at suicide rates at a world level we see that the poorer the country i mean very poor countries well there there are the lowest suicide rates so perhaps people kill themselves either directly or indirectly because they fear to lose something while those who have nothing to lose can find a balance do you think that this can be a possible message that we can draw from your research work and then another question in these first months of trump administration has something changed perhaps the rate of suicide has increased so do you have any news any data please this is a multi-part question so i'm going to repeat the question for the english speakers in the audience or try to summarize that question so part one of the question was about um whether these rates are higher in higher poverty places and the seeming disconnects between the fact that blacks and hispanics are economically disadvantaged in the united states but they have low rates of deaths of despair so i'll answer that part first i want to be clear that blacks and his blacks in particular have higher rates of mortality from all other causes so it's just drug alcohol and suicide mortality rates that are lower among blacks than among whites i think there are multiple explanations for this some studies show that physicians are less likely to prescribe opioids to black patients than to white patients because they perceive black patients as being dealers or addicts or users but from my perspective that can't be the whole explanation because blacks also have higher lower mortality rates from alcohol and suicide so it can't just be prescribing differences i think another part of it is that blacks are less likely to do the drugs that kill you blacks in the u.s are more likely to smoke marijuana and as far as i know nobody has died of a marijuana overdose yeah um i think a third factor is that blacks and hispanics have been living an economic disadvantage for several generations there's nothing new about that for that group and they've learned how to cope with it in some way and part of that coping is this community collective level support that you mentioned blacks and hispanics tend to have stronger kinship networks than whites have they have more social support whereas this group of non-college educated whites are really coming to grips for the first time really with the fact that not working hard is isn't enough working hard isn't enough to to achieve the american dream and this is really the first time that's happened to that demographic group so that's why for me it's a story of downward mobility it's a story of loss compared to what life used to be like the second part of the question was about whether suicide rates have increased since trump took office we don't have the data to know that yet but i'm certain that will be on our radar to look at um the most recent publicly available data are from 2015 so i'm afraid we're going to have to wait a couple of years to see the trump effect but i will say speaking to doctors anecdotally what they consistently say is that they have more people coming in to see them for anxiety and depression since trump was elected uh and that was especially prevalent very recent after the election well very interesting presentation um i had a question uh that was when i saw the it's me i'm oh i just didn't want to stand up but um i when i saw the high mortality rates of whites versus uh blacks and hispanics i think maybe there's a couple factors that maybe looking into would be part of the the reason um first of all if you look at gun ownership of whites versus blacks and non-hispanics it's nearly double so you put a gun is more likely to be in the house of a white uh whites are 50 more likely to have insurance medical insurance coverage which means that they have access to go to the doctors and get opioid medication to start this spiral you know you take the opioids you have a gun in the house and then finally the uh the really high incarceration rates of of blacks and uh hispanics takes away a percentage of the population that potentially could be at risk and puts them in a jail where actually you know less likely they would they would be able to overdose uh and and shoot themselves and do all those kind of things so i think those are three factors i know they weren't part of your demographic study but would you agree that maybe those uh those are contributing factors to why there was such a higher number of of white mortality through uh deaths of despair versus uh blacks and non-whites yeah thank you for that question um let me start with the um the part about incarceration so i initially thought of this uh but it turns out that drug overdose rates are incredibly high in prisons um in a california prison that i had in my notes but now i don't i can't remember which one the drug overdose rate is two times higher than the rate in other counties in california so i i don't think the incarceration component would have much of an effect on that because it turns out that drugs are really easily accessible in prison and you have lots of reasons to want to kill yourself in there the gun ownership issue i definitely agree with and you can see by looking at the map that the part of the country that is incredibly white and vast and rural is the part that has very high suicide rates and as we know the majority of suicides are gun related suicides the challenge with that is finding county level data to be able to incorporate into the into the analysis might be able to get gun sales data but as we well know sales do not always occur where the actual ownership occurs especially in the u.s where people want to hoard as many guns as possible and so they go to gun shows in different states and they might live two or three states away and then the third was about access to health insurance access to health care so i think that's a possibility for opioid related deaths but as i mentioned this group also has higher rates of alcohol-related deaths and suicides so presumably if they have that access to health care then they should be using that for alcohol-related problems or for mental health problems and if we're also being we're also thinking about that as a cause then blacks in particular have high rates of medicaid use and that would mean that they would have sort of equal access to health care i'm i'm a little bit frustrated with the health care variables that are available at the county level there aren't a lot and the ones that are available i tend to find very little effect they tend to not be significant a lot of the time and so it's it's hard to really say what's going on with the health care infrastructure variables thank you for my question hi um thank you very much for your lecture it was really interesting and quite insightful you obviously put a lot of emphasis on socioeconomic factors and how they influence everything that's happening to what extent do you think that the focus that um healthcare has in general in the sense that it's mostly acute medical care rather than preventive preventive care and and concentration in public health care things like that also influences all the results that you just showed us because from what i saw um areas where there's ngos who i assume engage in preventive and public community activities and also places where you have religious communities or whatever this communal feeling that also brings to a more extensive care rather than just medical care show lower levels of mortality so my question i guess is if let's say the u.s and other western countries that i assume have very similar results move towards a more people-centered healthcare as who has been suggesting do you think that this could actually lead to a change to an improvement i would suggest that it couldn't hurt it couldn't make the problem worse um we as i mentioned we are a very quick fix country and and that's certainly the case with our our medical system um where instead of trying to address the upstream causes of health problems we tend to treat them at the bottom end and so what we do in the us is let's use the analogy of a stream and you're at the bottom of the stream and you see all this trash and you're spending all of your time pulling the trash out of the stream because it's polluting the stream and you do all that where what you should really be doing is going to the top of the stream to figure out who keeps putting the trash in there to begin with well we take the the first approach and despite the fact that we spend more money on health care than any other advanced nation but we have worse health than most nations suggests to me that something is going wrong our health care is incredibly expensive it's based on fixing the immediate problem instead of preventing problems from the start and it's incredibly segmented so instead of having a place or a physician or a group of physicians where we deal with physical health problems and mental health problems altogether we send people to different specialists different locations for every separate problem that we have and we try to address it with pills instead of with different types of interventions so to somewhat answer your question i i think that a more person inclusive approach a more coordinated collective approach and certainly in a pr approach where we integrate social capital institutions into what it means to be a healthful and successful society those approaches i think could have some merit considering the the low voter turnout rate in the united states does all these people that you study these categories did they all go out and vote for trump uh could you be more specific which which people well no you're the the alcohol opioid categories that you studied no so what i'm not saying is that addicts and alcoholics are the ones who went out and voted for trump what i can't see in the data is in the counties which people voted for trump what i can see is that counties that have more despair collectively are counties where trump overperformed the most and that's because drug alcohol and suicide deaths are really a symptom of much bigger problems right there they're one type of despair and if that if those types of things are happening in a county they're not the only things that are happening in that place right those places are suffering from a lot of problems that everybody within them are experiencing and so it's less clear whether it's actually the people who are experiencing despair and anxiety and frustration and job loss and wage reduction and disability whether they're the ones who voted for trump or didn't vote for clinton or whether it's the people around them who are frustrated with seeing all of the poverty and unemployment and disability and they're just fed up with people who they they perceive as leeching off the system i have a question do you think bernie sanders would have won the election against donald trump i'm so glad that you asked that um i keep trying to put that out there as a hypothesis and of course i have no empirical support other than to say that the places where bernie sanders won the primary against hillary clinton are the same places donald trump won and wasn't supposed to win and bernie sanders certainly expressed a pro-working-class message one that emphasized trying to reduce income inequality increase wages it was as angry as trump's message but in a more progressive way so and given so he probably bernie sanders probably wouldn't have won some of the places hillary clinton did but that might not have mattered because if the democrat had won pennsylvania wisconsin michigan ohio which are places that bernie sanders did really well in the primary then that's what would have won the election so i think so but it's it's just conjecture ten more minutes so if you have a couple more questions or maybe one last question intuition was very interesting um i find i find your story of the quick of the the fact that the u.s like likes quick fixes more than other countries uh incredibly diplomatic um i would formulate it a bit differently that there are concrete political interests in the u.s congress uh that essentially prevents the us from having a universal prayer health care and like all like reform the health care system in such a way that you don't get this drug use and that you get better health care for everyone um so i would i would encourage you to although i guess that doesn't help with getting research money but i would encourage you to be a little bit more straightforward and aggressive in your policy conclusions yeah i would agree um especially since the citizens united supreme court decision where anybody can give as much money as they want to political campaigns and they don't have to tell anybody who they are it's pretty clear well it's been clear for a while that corporations run politics in the united states and big pharma plays a major role in politics the united states one of the things i didn't talk about but that is important to the whole opioid epidemic was the role of big pharma in pushing prescription opioid pain relievers on populations and in fact told their drug reps to heavily market oxycontin which was an extended release highly potent oxycodone pill to heavily market that drug in places that had a high concentration of manual laborers places like extraction industry towns and manufacturing towns and so those are the places where you see the first pill mills pop up these pill mills are places where doctors would prescribe oxycontin and other opioids with little diagnosis little follow-up you come in with a few hundred dollars in cash and the doctor would give you 360 oxycontin pills and that's really where the the problem began and it was in those parts of the country with large concentrations of manual laborers and so now several states have sued purdue pharmaceutical company which was the creator of oxycontin for their misleading marketing practices because purdue pharma said the oxycotin wasn't as addictive as other opioid pain relievers because it was extended release version of the pill but in fact users quickly learned that they could crush up the pill they could snort it they could inject it and oxycotin was really the the driver of the surge in opioid related deaths so they're being sued but but not to worry because the sackler family who owns purdue pharma is the 19th richest family in america so they're not hurting too bad but yes you're correct corporate interests are they created the quick fix mentality because it's in their best interests very last question because we do not have more time playing off the last gentleman's question i use the words cause and effect a dysfunctional health care system may have exacerbated the effect you're describing but the causes which may have produced that health care system are much deeper and economic we didn't take care of our economy and the people and the employment structure in transition and these things are all a follow-on from that that's absolutely right and in other presentations i've given about this i've used the analogy of spark and kindling opioids were the spark we would have seen increases in other drug related mortality alcohol mortality suicide mortality even without the the massive opioid problem that we have now that made it worse but the killing the the factors that set the conditions for vulnerability to these drugs were economic and social decline macroeconomic issues which were connected to social decay and decline so yes thank you for that question because i wanted to say that well very well i believe we have to close now i would spend the whole evening listening to professor monarch so thank you very much for being here congratulations your presentation was really very very interesting thank you very much thank you very much to all of you thank you very much also from the interpreters you