A U.S. flag is stuck in the broken window of a building on the grounds of the now-closed Bethlehem Steel mill in Bethlehem, Pennsylvania on April 21, 2016. Brian Snyder/Reuters

Two Princeton economists elaborate on their work exploring rising mortality rates among certain demographics.

Two years ago, the Princeton economists Anne Case and Angus Deaton published an alarming revelation: Middle-aged white Americans without a college degree were dying in greater numbers, even as people in other developed countries were living longer. The husband-and-wife team argued, in a study in the Proceedings of the National Academy of Sciences, that these white Americans are facing“deaths of despair”—suicide, overdoses from alcohol and drug, and alcohol-related liver disease.

The paper caused a stir in academic circles and in the media, and has remained in the public discourse following Donald Trump’s win partly on the strength of his support from these same middle-aged white Americans (the alive ones, to be clear). The paper, however, couldn’t answer the question everyone had: Why was this demographic in particular struggling? It couldn’t be purely the economic pain they faced in the wake of globalization; after all, European countries are also affected by globalization, and their residents are getting healthier and living longer. And non-whites in the U.S. are living longer than they used to as well, and they are subject to the same economic forces as middle-age whites and are struggling, at least in economic terms, even more.

As I wrote yesterday, the poor health of middle-aged white Americans is having an impact on the labor force. Men aren’t working or looking for jobs because they’re sick, on pain pills, or abusing alcohol or drugs, research suggests. Just why they’re so sick was not something that Case and Deaton elaborated on in their 2015 paper.

Now, in a new paper, the economists explore try to pin down why this demographic is so unhealthy. They conclude it has something to do with a lifetime of eroding economic opportunities. This may seem like a circular argument, when put together with previous work: Middle-aged Americans aren’t working because they’re sick, and middle-aged Americans are sick because they’re not working. But Case and Deaton argue that it’s not just poor job opportunities that are affecting this demographic, but rather, that these economic misfortunes build up and bleed into other segments of people’s lives like marriage and mental health. This drives them to alcoholism, drug abuse, and even suicide, they say, in a new paper released Thursday in advance of a conference, the Brookings Panel on Economic Activity.

“As the labor market turns against them, and the kinds of jobs they find get worse and worse for people without a college degree, that affects them in other ways too,” Deaton told me.

What differentiates Case and Deaton’s paper is this idea that as people get older and their fates deviate more and more from those of their parents, they struggle to keep their lives together.  The very act of doing worse than their parents’ generation—what Case and Deaton call “cumulative disadvantage”—is killing them.

As my colleague Olga Khazan has written, there are other convincing theories about why this demographic may not be doing well health-wise. A study from the Commonwealth Fund released last year suggested that while suicide and substance abuse contributed to deaths of middle-aged white people, factors such as heart disease, diabetes, and respiratory disease also played a big role. These factors may themselves have causes, such as diet and lifestyle, that are independent of macro-economic changes.

Case and Deaton agree that deaths from those factors are important, but emphasize that they see a large uptick in deaths from suicides, poisonings, and alcoholic liver disease among whites with lowest levels of educational attainment. This is in contrast to Europe, where people of all educational backgrounds are living longer, which suggests that there’s something unique among middle-aged Americans without a college education that’s making them sicker. It’s also in contrast to other Americans. For instance, whites aged 50-54 with a high-school degree or less had been dying at a rate 30 percent lower than that of that of all blacks in the same age group in 1999, but by 2015, their mortality rate was 30 percent higher than that of all blacks in that age group. Between 1998 and 2013, death rates for Hispanics fell as well.

What makes this group unique? It’s not just that they don’t have the guarantee of good jobs that they once did, Deaton said. Life doesn’t turn out as this age group had hoped it would, creating a sense of hopelessness, and as a result, they turn to risky behaviors such as overeating, alcohol abuse, or drug use, the economists say. They divorce or have trouble finding a marriage partner because of their poor economic prospects. They no longer turn to social organizations like churches, which can provide important social support, the economists write. They don’t have structure in their lives, which in some cases makes them turn to suicide.

“We are trying to say that low income and low job opportunities, after a long period of time, tears at the social fabric,” Deaton told me. “It’s the social fabric that keeps you from killing yourself.”

There is other evidence that people who might have been on the brink of an unhealthy lifestyle are becoming less healthy. There has been an increase of emergency-room visits for alcohol consumption, between 2006 and 2010, suggesting that people who are binge drinking are going to greater extremes than they once did, according to Aaron White, senior scientific advisor to the director at the National Institute on Alcohol Abuse and Alcoholism. Per capita consumption of alcohol has increased about 10 percent since 2000.  

Over-prescription of opioids “pours fuel on the flames,” Deaton said, leading to more people addicted to drugs and more people dying because of lethal combinations of drugs and alcohol.

Case and Deaton theorize that this trend is not happening in Europe because of the social safety net there. While middle-aged whites in the United States are left adrift once economic opportunities go away; those in Europe are provided with financial support and health care that make it easier to be satisfied with life, Deaton believes. What’s more, Europeans enter into more stable cohabiting relationships than Americans do, providing a stronger support network than Americans have. This may also be linked to the safety net: Single parents in Britain don’t need to seek additional partners for financial stability because they receive child allowances, for example.

This is a “very pessimistic” paper, Deaton told me, in part because there are few policy prescriptions that could help slow the rising death rate of middle-aged white Americans. A European-style welfare state could help stabilize some people, but it’s an unlikely occurrence in the U.S.—indeed, the trend in the GOP-controlled Congress seems to be currently to roll back the welfare state. Reducing over-prescription of opioids could be helpful, but would just address a small part of the problem.

Donald Trump promised, on the campaign trail, a return to the heady days of manufacturing, in which middle-aged whites without a college education could make a good living, and this return to the past would seem to be one solution. It is, after all, the divergence between the past and today that is causing people such anguish. But it’s going to be difficult to bring back good manufacturing jobs, especially in the face of widespread automation. Few other solutions have been put forward, as I’ve written before. This new paper emphasizes a growing problem: For middle-aged whites without a college degree, the future continues to look bleak.

This story originally appeared on The Atlantic.

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