"One Nation Under Stress" (Courtesy of HBO)

Dr. Sanjay Gupta on how income inequality is making us stressed out

Dr. Sanjay Gupta talks about his new film, "One Nation Under Stress," and how income inequality creates anxiety


Alli Joseph
March 24, 2019 11:30PM (UTC)

Americans are dying sooner, increasingly self-medicating with drugs and alcohol, and committing suicide at alarming rates. The unifying factor for all of these conditions? Stress. These growing public health epidemics prompted CNN’s Emmy Award-winning chief medical correspondent Dr. Sanjay Gupta to take a closer look a the big contributing factor —constant daily stress — to understand how a loss of predictability and control are having detrimental effects on Americans' health.

His new documentary, “One Nation Under Stress,” which premieres Monday, March 25 on HBO, investigates the causes, the depressing trends and how we can better handle stress. Appearing on “Salon Talks” earlier this week, Dr. Gupta discussed why these self-inflicted deaths are happening in the United States at a uniquely higher rates than in the rest of the world.

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Gupta admits that we all need some level of stress to thrive and survive, and that stress itself is not the problem. Rather, it's the constant nature of the stress that is killing us. In the film, he takes a close look at how animals employ stress and why humans have over-exerted the stress response so much that we've actually changed the composition of the brain.

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There is good news, though, and Gupta offers strategies on regaining control and managing stress and anxiety.

Watch my "Salon Talks" episode with Dr. Sanjay Gupta here, or read the Q&A of our conversation below.

Stress is something that I imagine you've seen a lot in your own life. When did it cross over to your medical work and press you to take a harder look?

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Dr. Sanjay Gupta: It sort of came about in a backwards way, and what I mean by that is, I think like a lot of people hear the term stress and think it's a rather nebulous term. I don't quite know how to define it. We probably overuse it. "I'm so stressed," whatever it might be. What sort of got me on this was that I was looking at this and what was happening in the United States generally, and realizing that we were the only country in the developed world where life expectancy was falling. Kind of an extraordinary thing, right?

We spend way more on healthcare than anybody else. Our life expectancy is falling, mortality was going up, and then when you really started to dig down into what was happening, even within the United States, you saw that it was, you have these different demographics, African Americans mortality, while it's higher than whites, was falling. Hispanics have lower mortality rates, they're still falling.

Whites, and particularly working class whites, [mortality] was going up. They're the only population of people in the developed world where that's happening. It’s not the economy, because other countries have gone through economic forces, labor force changes, all these types of things. So what was so particularly unique to the white working class at this time in our history that was causing life expectancy to drop? That's where stress started coming into the equation. Could the stress be the underlying force and why is it so specific to this group of people? That's how it sort of hit my radar.

And when you say stress, as you just mentioned, it seems kind of nebulous, right? People use the term in a lot of different ways, but when you went to Princeton University, as you made this film and spoke with several economists, they came up with a specific term “deaths of despair,” to describe the stress that we're talking about here—the stress that is life ending that contributes to these changing mortality rates. What does this term exactly mean?

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 It’s an awful term, right? But it basically means that the spikes that we're seeing in terms of what's actually leading to the people ending their lives is drug overdoses, suicides and alcoholism. Those were the deaths of despair. What are those all have in common? I mean suicide I guess is when someone dies by suicide, it's the most obvious that's a self-inflicted death, but drug overdoses and alcoholism, do they also have some component of being self-inflicted as well?

I think that's what the economists from Princeton were really driving at was that in some ways they're all part of the same toxic mix, and they're happening in this country at higher rates than anywhere else in the world.

Suicides have gone up 30 percent over the last 20 years. There's plenty of coverage on drug overdoses and opioid overdoses. Everyone's heard about this now, but ever wonder why? Other countries have opioids as well. Why do we take so many opioids in this country? Why are we drinking ourselves to death in this country? That was the question that Angus Deaton, who won the Nobel Prize, and his wife Anne Case, that's the question they were really asking. What is fundamentally different about America right now? That was the question they really want it to get at.

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What was the granulated answer?

Well you'll have to watch the film, but you want me to take a stab at it?

Yes, do take a quick stab.

Let me put it this way. Nothing is obviously just one answer for medicine, as in journalism, right? There's always going to be different factors that come into play. We know the symptoms of the problem, the things that we just talked about, but the cause of those symptoms, the underlying cause, really seems to be this idea in some ways that, we're talking about the sons and daughters of the greatest generation, right? This population of people, their parents went off and won the world war.

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They came back, and they built America. Veterans came back, and they built America. You see veterans come home today, and you imagine they may be broken or hurt in some way. At that time, the greatest generation came back and built America after winning the world war.

Their kids were supposed to inherit the earth. Their kids were supposed to inherit the United States at a minimum, and that didn't happen right? Jobs left because of outsourcing and automation. Wages went down, and now they find themselves dying at a faster rate than any other population in the developed world. Those dashed expectations, the idea of having expected something and not received it turns out to be incredibly toxic stressor, much worse than simply not receiving something.

Dashed expectations, broken dreams, unrealistic expectations, whatever it might be, seems to cause this relentless stress that is almost existential in nature. It's not just about, “I got a meeting today, I'm busy. I've got to do a presentation.” It is about who you are, your identity, your value, who you represent to your parents, and your grandparents and everything. So it's the notion of dashed expectations being really toxic, that was one of the factors that we really zeroed in on.

It is actually a good segue into the noise, the distractions and our engagement with media. I think at least for the younger generations, that's a really core piece of some of the things you just describe. I realize we can't stop time and progress, but these constant push notifications, this has to affect our stress levels.

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Absolutely, and what you learn and we talked to developmental biologists about this and the primatologists. The thing is that as much as we'd like to be Pollyannaish about this and say we'd like to just get rid of stress, we don't want to not have stress. That is neither possible, nor is it probably a good idea, right? Because we do need some level of stress, we need some level of stress to survive and to thrive.

But to your point, I think if stress itself is not the problem, then it's the constant nature of stress, the constant nature of the stress that we're being exposed to in a country like the United States. And yes, I have my phone, I do social [media], I do all those things as well, but the idea that you can't get a break from it now, everyone knows that that's a problem.

Right? I don't think anyone says, “Yes, that's a great idea that I never get a break from it.” But I think what we're now seeing is the objective impact of this, and it's pretty tragic. When you talk about life expectancy dropping and trying to find the unifying factor and realizing that it's just this constant stress that you feel like you can never get out of, that that's your life. All these things play a role in it. If you can just not make it constant, you can go a long way towards reducing the impact of the stress.

You study animals a bit in the film and make some correlations between all mammal species, humans included, as far as the response to stress, the fact that animals, who do not speak also experience stress and raise cortisol levels. What can we learn from other animals about managing stress? Fight or flight?

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Fight or flight is a good example of why we do need stress sometimes, right? So there are times when you do have to take flight or fight. One of the guys that we interviewed, Robert Sapolsky.

I loved him.

He writes this great book, it's called “Why Zebras Don't Get Ulcers.” Zebras get chased — something wants to eat that zebra. At that time, the zebra has incredibly high levels of stress. As soon as they're safe, they're grazing, they're happy, stress levels come way back down. That is how we should be behaving. We need the stress to peak at the right time and then to come back down, we don't have that.

With the monkeys — I found this so interesting — there was an experiment done with what are called skinner cages. So two cages side by side, capuchin monkeys, those are the organ grinder monkeys, very smart monkeys, and they have to do a task, and the task is to give a rock to the examiner. If they give a rock to the examiner, they get a treat, and it's a piece of cucumber. And these monkeys sitting side by side in separate cages, they can see each other. They do this over and over again for 20 times. At some point we start giving the monkey on the right a piece of grape instead. That's a more desirable treat. 

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The monkey on the left sees this a couple times, kind of then gets the cucumbers still and looks at it, some point throws the cucumber back at the examiner. Okay? That's how primal this is, literally throws it back. Was perfectly happy with that cucumber 20 times in a row. Now that the monkey sees the other monkey getting a grape, he's very upset. Starts literally rattling the cage. Stress levels go through the roof. Perhaps that's not surprising. What was surprising though a little bit was that the monkey who was receiving the grape, their stress levels also went through the roof, just by being in this sort of unequal, inequitable situation.

And the point is, and I think you know there's been plenty of data on this, but if you live in a society that has blatant inequality... I'm doing the exact same task as the next person and for whatever reason, we're no longer being rewarded the same. We're no longer being compensated the same. Something is unfair and unjust about this. No matter where you are on that spectrum if you're the one benefiting from that, or you're the one who's not benefiting from that, it raises stress levels.

Simply being in a society where there's blatant, glaring inequality tends to be a very highly stressful situation, and we see that very visually with the monkeys, because it's so primal, so reflexive, it really captures your attention. But you know what? We're living that. That's what we're seeing in terms of the chronic nature of stress. There's a thing called the Gini Coefficient, which basically measures how much inequity there is in a society. Among wealthy nations, the United States is the highest. Our inequity is similar to countries like Sudan, which are known to have high very unequal distribution of wealth. In the United States, we have that as well, and it's very glaring in people's face. And that is probably what is in part driving the stress levels as well.

Would that mean that the wealthy feel stress because of the inequality?

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I think that it's unsettling and unstable to live in a society [with] glaring inequality, conspicuous wealth... I think that you have plenty of examples around the world of truly capitalistic societies that do not suffer the way the United States is suffering right now. They continue to have increasing life expectancy, they continue to have decreasing mortality and decreasing levels of stress.

The United States is unique in this regard and that's the part that fascinated me the most, because you could easily lay the story at the feet of the economy or labor forces or capitalism or the need for socialism or whatever. It's really not about those things. It is more about when things just seem unjust.

If people work hard and earn more as a result of that, that doesn't seem to cause the same problems as we're doing the exact same thing here and for whatever reason, for unfair reasons, somebody is being rewarded and treated differently than I am. That's the real problem.

And that goes back to your thesis of dashed expectations. Can you tie them together?

You can tie them. I think that the glaring inequality, plus the dashed expectations on top of that, end up being the two primary drivers that we really zeroed in on. I mean there's other things as well. We've lost social fabric in this country, social structures aren't as strong as they used to be. Our belief systems aren't what they used to be in this country. We've espoused this idea of rugged individualism, but if you have to look at what's unique about America and what's probably driving these drops in life expectancy, dashed expectations, blatant glaring inequality, those two things in combination seem to be a big part of it.

I want to drill down a little bit more into your analysis of race, class, ethnicity and these rising mortality rates. You make an interesting distinction between race, ethnicity and class in terms of mortality rates. And part of this is that narrowing of percentages between middle class African Americans and middle class whites, which was historically never comparable. So why do you think that is?

Well, we're not entirely sure. Some of this data that we're looking at is, I mean, it’s literally being uncovered now for the first time. We know what the data shows. It shows that African Americans still have higher mortality rates than whites, but they've been steadily coming down, half a percent to a percent a year, whereas white mortality rates have been going up, and the white mortality rates have been going up so significantly that in the United States as a whole life expectancy is dropping.

Why is that? I mean, in part I think when you think about the underlying causes of the stress, the dashed expectations for African Americans, they've been living that life for decades. For many of the working class whites, this is the first time they're really now, over the last few years now the first time they're really being exposed to these toxic levels of stress with this — the impact of these dashed expectations. 

The sense of, "we were supposed to inherit the earth, we're not going to inherit the earth," that is becoming more real now at this point. I think for African Americans, there was never any expectation of African Americans living in the United States that they were going to inherit the United States. So it's a totally different expectation there, and that could be in part why you're starting to see the numbers start to intersect. Interestingly, Hispanics have lower mortality rates than whites and they continue to drop. It's called the Hispanic paradox. We're not entirely sure why that is, but in their case it probably is because they tend to be have much tighter social structures.

It's the community. 

Yes, the community and the social cohesion. I mean people think of those as sort of euphemisms, nice things to add to an academic paper, but frankly you find societies all over the world that suffer from some of the same problems we do, and yet because of their social cohesion, they appear to be fairly protected. We don't have that. We don't have systems in place to nurture and foster social cohesion. If anything, it's becoming more fragmented, more individualistic, more siloed off than before, and we're seeing the impact of that.

This is obviously not a political film, but it is interesting that it's a story about how we manage our fragile emotional state, and one could argue that the charged state of affairs here in this country and Trump's rash approach to governance has a lot to do with that. Did you make a conscious choice to keep him out of the narrative?

When we started this, it was before the election, so I think when we started really figuring out the story that we are going to tell, and the experts we're going to talk to, it wasn't really about Trump at that point. We certainly saw what was happening certainly as we were making this documentary. I think there's definitely real relevance to what's happening now that wasn't intentional.

We didn't know where the world was going to be when we started making this film, but I think the idea that it is supercharged, and I work in the news business, you cannot get away from it. Besides whether or not you even agree with policies or don't agree with policies, I think the thing that was really striking to us as we talked to scientists about this was it's a lack of control.

The lack of predictability that seems to be the biggest drivers of that sort of toxic stress that people feel. Even if you agree with what's happening or you think that there should be deregulation with regard to energy policy, whatever it might be, the fact that it can change on a dime day to day that you don't know what tomorrow will bring is probably a big factor for everyone.

It's not just people who are voters, I mean young people as well are feeling this, that was surprising as well, that they would just be as equally affected by this unpredictable nature of the news cycle, and what was happening in the country. Loss of control, loss of predictability, deriving from what's happening at the White House, deriving from what's happening with this president, I think ended up being a big predictor.

As a doctor do you feel that opioids have been over-prescribed, and what is your stance for marijuana for pain management?

There’s no question these medications, opioids have been over-prescribed in the United States. I mean, you look at some of the classes of opioids, we consume 80 to 90 percent of the world's supply. We're not even 5 percent of the world's population. How do we consume 80 to 90 percent of the world's supply of some classes of opioids?

It doesn't make sense, and there's a lot of blame to go around, including to the doctors who probably bought this notion that, yeah, these aren't addictive, they're not problematic. "Why should anyone have pain? Prescribe these at will." That was sort of the message I received when I was a medical student. We should have asked more questions. We've certainly paid the price with people's lives, it’s the number one cause of unintentional death in America today.

Can you believe that? Drug overdoses, primarily opioid overdoses, more than car accidents, it just doesn't make any sense. But I think, and we need to do things about that and decrease prescribing [opioids], come up with different ways to treat pain.

The luxury of being able to make this sort of documentary, and for you I'm sure it's the same thing when you make documentaries, is we got to dig deep. In some ways the opioid crisis is a metaphor for the whole thing because it is the pain, right? I can treat pain in a patient, no problem. What caused that pain? Where did that pain really come from? Someone's having chest pain and I give him opioid and I miss a heart attack, that's a big problem. I've missed something really serious.

You could make that sort of analogy for what's happening in the country now. We're treating the symptoms, we've missed the root cause, now we can identify the root cause. Let's figure out how to treat that, because if you treat that, all the other things will, will be much more easily treated and go away.

In doing all of this research on stress in America and how it has negatively impacted pretty much everyone's lives in some way, what was your personal "a-ha" moment? Have you made any changes in your own life to better accommodate stress?

There were a lot of a-ha moments, but I think one of the big ones was how quickly stress can change your brain. On a day-to-day basis, on a moment-to-moment basis, when you are experiencing stress, you actually start to turn off areas of the brain that are responsible for your judgment. So what does stress lead to besides increasing your blood pressure, your heart rate? It can lead to poor decisions later on that day, later on that hour, later on that week, whatever it might be. That becomes this sort of self-fulfilling problem. The flip side of that is that even with relatively short times of really truly decreasing your stress, you can grow those areas of the brain back.

If you give yourself 10 to 12 minutes, and I call it a time where you take control, more than calling it mindfulness or meditation or yoga, people have their thing, you do you, but whatever it is, if you can take control for that period of time, we can physically see the changes in the brain in a good way. Things actually start to come back.

That was a big aha moment and I'm a guy, probably not different than you in some ways, I'm always going, and I don't have enough time, but I realized that I was so inefficient if I didn't take the 10 to 12, 15 whatever minutes a day, I accomplished so much more because I had that control. It changed my brain. I made better decisions and I think I benefited because of that.

I definitely think of my kids. I have three kids and if unrealistic expectations can cause a psychic stress so powerful that they can start to lead to decrease life expectancy, I will not do the same thing to my kids. I will not place unrealistic expectations on a generation having no knowledge of what the world's going to be like when they become adults.

We live under this belief that the next generation should do better than us, that we're going to leave the world better than we found it, and that our kids' lives will be better than our lives. That's just not realistic in many places around the world, and by placing those expectations on people that can do a lot of damage, so there was a lesson for me and for everyone that I love in there as well.


Alli Joseph

Alli Joseph is a writer/producer and family historian; a Native New Yorker, she is a member of the Shinnecock Indian Nation.

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