A fascinating and disturbing paper from Princeton social scientists Anne Case and Angus Deaton reveals a shocking deterioration of health among what can be called, to echo Michael Harrington’s famous 1962 book on poverty, the Other White America.
The Other White America is made up of the approximately 55 million white non-Hispanic American adults who have no formal education beyond high school. This group compromises a little more than one third of all white non-Hispanics, and includes more than one in every five American adults. If it were an independent nation, the population of the OWA would be larger than the adult population of every European country other than Germany.
The deteriorating health of the Other White America is seen most clearly among its middle-aged residents. In a development that has almost no precedent in the public health statistics of advanced economies, the mortality rate for middle-aged whites with no more than a high school education actually increased by 22.3 percent between 1999 and 2013. This increase correlates closely with educational levels: Over this same time, the mortality rate of middle-aged whites with at least a BA degree fell by 24 percent, which is consistent with the rate of decline in mortality in the rest of the population, both in the United States and in other developed nations.
One aspect of the Case-Deaton study that has gone largely unnoticed is the extent to which it reveals an ongoing intensification of the so-called “Hispanic paradox.” The paradox is this: Normally, socio-economic status, as reflected in education levels and income, correlates well with health outcomes, as indeed it does among the whites in their study. American Hispanics have far less formal education, and make considerably less money, on average, than white Americans. Middle-aged white Americans are three times more likely to have college degrees than middle-aged Hispanics, and are 55 percent more likely to have graduated from high school. Median household income for whites is 46 percent higher than it is for Hispanics.
Despite these differences, which would ordinarily produce far better health outcomes for the more educated and wealthier group, American Hispanics now have longer life expectancies than whites. Indeed, the Case-Deaton study found that, among middle-aged Americans, this gap is growing at a fast pace, as mortality rates among Hispanics continue to drop rapidly, while they are actually rising among whites. The result is that mortality rates for middle-aged whites are now 54 percent higher than for Hispanics.
An even more startling contrast can be found between the mortality rates of Hispanics, and of whites with no more than a high school education. Since approximately 80 percent of middle-aged Hispanics never went to college, the educational credentials of this group largely overlap with those of white Americans with high school degrees or less. Yet the middle-aged members of the Other White America now have a mortality rate that is an astonishing 173 percent higher than that of their Hispanic peers.
What could account for such astounding disparities? Case and Deaton found that most of the increased mortality rates among middle-aged residents of the Other White America could be accounted for by just three interrelated factors: drug and alcohol overdoses, suicide, and chronic liver diseases that are usually a product of long-term alcohol abuse. (These factors are closely related in that the line between deaths formally classified as suicide and other forms of self-destruction can be quite fuzzy).
Middle-aged whites are now more than twice as likely to die of drug and alcohol overdoses than are Hispanics of the same age. This is in large part because middle-aged residents of the Other White America are four times more likely than Hispanics to overdose on legal and illegal drugs, including alcohol. The suicide rate among middle-aged whites is three and half times higher than the rate among middle-aged Hispanics. Among less educated whites it is five and a half times higher.
Case and Deaton have generously shared more of their data regarding this subject with me, and examining it reveals that patterns they have discovered are also becoming pronounced among younger Americans. For example, while 20 years ago the mortality rate of 35- to 44-year-old Hispanics was approximately 15 percent higher than that of white non-Hispanics of the same age, today white non-Hispanics in that age range have a mortality rate nearly 60 percent higher than same-age Hispanics.
Many explanations have been offered for the Hispanic paradox, including lower levels of smoking, stronger community networks, and the purportedly better health habits of less acculturated recent immigrants to America. Here I will offer another, which seems especially applicable to the data Case and Deaton present.
The Hispanic paradox is essentially a paradox about social class. Why are Hispanics now enjoying better health outcomes than whites, and in particular drastically better health outcomes than whites of the same education and income levels? The answer, I suggest, has much to do with the very different social trajectories of the white and Hispanic working classes.
While it is always dangerous to generalize about as diverse a group as American Hispanics, it is safe to say that much of the Hispanic working class in America is made up of families that immigrated relatively recently from Mexico and Central America. For these people, the United States is still a land of remarkable opportunity: a place where it is likely that they, and their children, will end up much better off than their families were in their countries of origin.
For working class whites, by contrast, the situation is almost precisely the opposite. The members of the Other White America live in a world that, by most standard economic and cultural measures, has gotten worse for them than it was for their parents and grandparents. Working class whites and Hispanics may have similar income and education levels, but they are communities moving in starkly different directions. The starkly different direction the literal health of these two groups is taking is, it seems, a reflection of these larger patterns.