Re: "Places that adopt nanny state policies to improve public health get better public health." and "If you decide to implement paternalistic health policies, you get better health outcomes; if you don’t, you don’t.":
To belabor the obvious, there is a bit of a leadership vs. followership question here. A legislature that won't pass, eg, seat belt laws or motorcycle helmet laws probably has a constituency with an abundance of folks that don't like that sort of law. Sort of a bummer for the health conscious minority, although as libertarians will note, the absence of motorcycle helmet law is not an impediment to wearing a helmet (social pressure might be, since helmets are quite visible).
Things like second-hand smoke in restaurants and office buildings were a more dramatic battleground for years. "Ask me to stop smoking in a restaurant because it might harm other people?!? What's next, you're going to make me wear a mask during flu season?"
I’m not sure it is wrong as much as it is overstated. It one point the per capita fatal overdose rate was highest in WV.
Was that driven by higher opiate availability, eroding working class employment or something else?
The white male labor participation rate is down to more than 5 percentage points since November 2009 to 70 pct, part of that is college attendance, but not all of it. By comparison, the black male labor participation rate is flat at 69 pct over that period.
“The surge (and subsequent decline) of murders is about post-Floyd depolicing and people deciding that was a bad idea.”
My brain is screaming at me not to go there but damn the torpedos. This is being TOO POLITE to police in the summer of 2020. There were very few municipalities that explicitly instructed police to pull back patrols and enforcement. Many police forces pulled back out of fear/anger over criticism. This is a crucial distinction. I love MY but he needs to be a little more willing to punch at the cops from time to time.
To be less polite, if cops are too butt hurt to accept any criticism of their actions maybe they should stop being such wusses and crying for mommy that everything is unfair. Cowboy up and do your job.
We can criticize teachers and their unions in this space but somehow criticizing cops is too woke. Give me a break! I think there should be MORE cops but they should be more accountable and better trained as MY has argued in other (very well argued) columns.
Not all fault for all ills in America lies left of center. I’m fine with hippie punching but sometimes the self-flagellation gets a little out of hand, particularly on policing stuff.
Most cops are good public servants. There are also an unhealthy number of sociopathic pricks like Derek Chauvin. It’s OK to be loud about that. You can be so without trading in your anti-woke card.
Right, which I understand. But if the point of Matt's argument is "these are not deaths of despair" then I disagree with it. And, as I understand it, there are other trend-data that support the "people are despairing" argument, like stats on loneliness etc etc.
**Aside, have "deaths of despair" not increased inn Europe? I don't know one way or the other.
My concern here is just guarding against the type of argument that one dude was fighting on Twitter, that "the hard econ data is great! people shouldn't be bummed out!" That people are bummed out despite XYZ economic (or other) data is itself important.
A+ article, except for referring to the pseudo-scientific personality model of “conscientiousness.” Nothing you say backs this up, which is problematic in an article about shoddy research with leaps of logic.
But possibly the best piece I’ve ever read from Matt. Imagine how many Ohio diner articles we could have been spared if this paper had been properly scrutinized.
I think people love personality models so much they throw all skepticism out the window. I feel like it’s got the same clutch on the imagination as Freud, so it may take quite some time before people are willing to acknowledge how ridiculous it is.
It's easy to apply a morality weight to the results of the Big 5. Unlike say Myers-Briggs or Enneagram, there is not a continuum between different traits in the Big 5. It is either "high" or "low" trait and that's it.
That seems like a distinction without a difference to me--for example, low extroversion implies high introversion, and both the Big Five and Myers-Briggs use extroversion as a trait, even if only the latter explicitly mentions introversion.
Matt, no offense in the slightest, I love your smart takes, but also think you would be well served to spend more time in Trump country.
Its a disaster full of despair in the forgotten geographies of the USA. Come to Cumberland County New Jersey or deep Appalachia. Its a shit show and people are desperate.
Why are deaths related to drug addiction not in a category of despair? Perhaps this sentiment is biased by the notion that in wealthy circles, drug use is more often seen to be related to thrill seeking, morally bad stuff. In my experience, drug use is often an antidote for despair, and often causes individuals to fall into a trap of addiction.
If not related to “despair,” could we at least call opioid addiction a mental illness?
In any case, the pattern I see is individuals with little opportunity in rural south jersey get drug addicted and eventually then end up in tent cities near a safe injection site in Philadelphia.
It could be related to workplace injuries. Physical work is more likely to lead to an Oxy prescription than data analyst work. Red states also tend to be less well-insured, and so addiction treatment is harder to come by.
I think this thesis about prescriptions is bad. This was solved several years ago and yet at least around here, the problem continues to worsen. And I can’t get pain meds when I’ve needed them
I think the narrative is: pushing prescription opioids on too many people created a lot of new addicts, but now that addicted population has substantially turned toward heroin and fentanyl. That doesn't mean, of course, that every single addict in America started on that path via an MD's prescription (it just greatly expanded it).
It that view is correct (and we have in fact "solved" or at least substantially improved the prescription issue), we should see opioid addiction numbers, overdose deaths, etc begin to decline in the near future.
Its a good point and I’m sure that prescription policy difference played an important role in worsening the crisis. But pain scripts have been on lockdown for a long time. So long in fact that when I googled searching for dates on policy changes, I found the most recent 2022 CDC guidance was a *loosening* of pain prescription because the pendulum had swung too far restricting. This was after the 2016 CDC guidance to severely restrict - 7 years ago. We should have seen that decline by now
I hypothesize that the difference between US and Europe for this crisis is access to healthcare … and actual despair among the bottom 25%. Europe has a functional social safety net and universal access to healthcare, including mental healthcare, much more vacation sick and family leave, higher labor standards, better consumer protections etc
Well, different people have different intuitions, and I find your take deeply counter-intuitive. And I write this as a full-blooded Social Democrat who very much wants a kindler, gentler, and more European-style USA.
These things are seldom zero-100, of course, so, sure, it's unlikely America's less effective safety net plays literally zero role in all of this. But the data to my eyes simply don't suggest a generalized "Americans are miserable so they're self-medicating themselves to death" narrative as a satisfactory explanation. As far as I know there's plenty of smoking and alcoholism in Europe, for instance—and obesity has been rising just about everywhere. Also, while the gap-ridden US healthcare system undoubtedly accounts for a nontrivial degree in the mortality gap between the US and other rich countries, it doesn't explain why US life expectancy has actually been *declining*, especially given the fact these gaps have gotten smaller since the enactment of Obamacare. Moreover, it seems plausible the arrival of fentanyl has simply swamped (for now, at least) any public health benefits from the crackdown on prescription opioid abuse, and so there's a delayed effect (though it also should be pointed out that it appears Opioid-induced deaths in America *are* finally beginning to decline).
I realize this isn't how you view it, but to my mind, Occam's razor very strongly suggests differing standards with respect to opioid prescriptions are what created the surfeit of opioid-related deaths in the US, and that this factor more than any other has been the driving force behind the decline in US life expectancy in recent years.
Yep. but I don’t know if they would tell the whole story. Because all the services for the homeless and opioid addicted are in urban centers, which often act like a magnet. Meanwhile, rural communities generally try to ship off vagrants
Here in Philly at least, there have been efforts to provide safe injection sites and deprioritization law enforcement around drugs because of concerns over racial profiling.
If you’re a broke addict, you probably go to where there’s services set up and a whole vagrant community already
And so it seems to me this ugly ecosystem has developed. And no one is offering anything approaching decent solutions as far as I can tell.
The main explanation that they are currently advancing for different death rates between the US and Europe is that Europe has a much stronger social safety net. I like your takedown, but I do wish you'd addressed this point as well!
It really depends on where in Europe. The US spends around 19% of it's GDP on social welfare while Switzerland spends around 16%. I'm sure the specifics of what they spend their money on matters, along with a million other factors. I just don't think it's a good idea to take it at face value that all of Europe has better social welfare than we do.
My personal rebuttal is that access to a safety net in the US does not appear to be correlated, in either time or space or demographic, with overdoses or other deaths of despair, nor with changes to life expectancy. The labor market also does not exhibit any correlation.
I'll stress that I'm indifferent to changes in suicide rates (I think it's people's own business whether they kill themselves or not), but one thing I can't help but notice is that people who do express concern about increasing suicide rates, at least from a "left" perspective, all but completely ignore that, historically, suicide was severely stigmatized in Western cultures, both religiously and civilly, going back even to the pre-Christian era. Given that all forms of stigma around suicide have been substantially reduced, either directly (e.g., repeal of property forfeiture laws for suicide victims) or indirectly (e.g., general decline in religiosity), over the past century or so, how clear is it that we're genuinely seeing an increase in suicidality versus finding the "natural rate" of suicides in the absence of stigmatization?
Possibly not a real memory, but I'm pretty sure I was taught about suicide contagion in health class in 9th (?) grade. Seemed to check out to me, and a few years later I recall learning as an RA that the college paper had a policy of not running stories about the one or two people a year who would jump off the bridge in the middle of campus. Possibly apocryphal as well.
Fast forward to the present day, and there are suicide ads on the bus. So much of the conventional wisdom around mental health in this country seems so broken.
Yes. It’s also somewhat “contagious”-- suicides spike locally when someone in a community commits suicide, and then more broadly when a celebrity does.
A theoretical point rather than empirical (maybe someone could figure out away to look) that Angus Deaton make is that the strange US system of having employers purchase health insurance for their employees acts like a head tax on employment. And as head tax, it represents a higher portion of wages of low-income employees so employers naturally try to avoid it by job splitting and "contracting" instead of "employing" people and substituting away from low skill/low wage workers for higher skilled/higher paid workers.
I may be missing something, given folks' comments. If I can get a gun today because of some intervening regulatory change but couldn't last year and thus kill myself this year but not last year, it's a "death of despair" or whatever word one wants to use. It may also be a death of "bad regulatory state" or whatever, but happy people--again, with exceptions that prove the rule--don't due by suicide.
I think the thrust of Matt’s take was that the original Deaths of Despair concept came out of a paper that argued the despair was caused by economic troubles--that hit all of Europe too, but only Americans had such an uptick in mortality.
So of course suicide is motivated by despair--but the question is whether the despair is because of broad economic trends or something else.
I think you were sufficiently polite. :)
Re: "Places that adopt nanny state policies to improve public health get better public health." and "If you decide to implement paternalistic health policies, you get better health outcomes; if you don’t, you don’t.":
To belabor the obvious, there is a bit of a leadership vs. followership question here. A legislature that won't pass, eg, seat belt laws or motorcycle helmet laws probably has a constituency with an abundance of folks that don't like that sort of law. Sort of a bummer for the health conscious minority, although as libertarians will note, the absence of motorcycle helmet law is not an impediment to wearing a helmet (social pressure might be, since helmets are quite visible).
Things like second-hand smoke in restaurants and office buildings were a more dramatic battleground for years. "Ask me to stop smoking in a restaurant because it might harm other people?!? What's next, you're going to make me wear a mask during flu season?"
Academic reviews get much ruder than this.
I kinda suspect it’s cigarette bans doing most of the work.
Well said, Matt.
Masterful
I’m not sure it is wrong as much as it is overstated. It one point the per capita fatal overdose rate was highest in WV.
Was that driven by higher opiate availability, eroding working class employment or something else?
The white male labor participation rate is down to more than 5 percentage points since November 2009 to 70 pct, part of that is college attendance, but not all of it. By comparison, the black male labor participation rate is flat at 69 pct over that period.
“The surge (and subsequent decline) of murders is about post-Floyd depolicing and people deciding that was a bad idea.”
My brain is screaming at me not to go there but damn the torpedos. This is being TOO POLITE to police in the summer of 2020. There were very few municipalities that explicitly instructed police to pull back patrols and enforcement. Many police forces pulled back out of fear/anger over criticism. This is a crucial distinction. I love MY but he needs to be a little more willing to punch at the cops from time to time.
To be less polite, if cops are too butt hurt to accept any criticism of their actions maybe they should stop being such wusses and crying for mommy that everything is unfair. Cowboy up and do your job.
We can criticize teachers and their unions in this space but somehow criticizing cops is too woke. Give me a break! I think there should be MORE cops but they should be more accountable and better trained as MY has argued in other (very well argued) columns.
Not all fault for all ills in America lies left of center. I’m fine with hippie punching but sometimes the self-flagellation gets a little out of hand, particularly on policing stuff.
Most cops are good public servants. There are also an unhealthy number of sociopathic pricks like Derek Chauvin. It’s OK to be loud about that. You can be so without trading in your anti-woke card.
Rant over!
The discussion here is mainly another one of those “tell me how to ‘feel.’” What are the policy implications?
Right, which I understand. But if the point of Matt's argument is "these are not deaths of despair" then I disagree with it. And, as I understand it, there are other trend-data that support the "people are despairing" argument, like stats on loneliness etc etc.
**Aside, have "deaths of despair" not increased inn Europe? I don't know one way or the other.
My concern here is just guarding against the type of argument that one dude was fighting on Twitter, that "the hard econ data is great! people shouldn't be bummed out!" That people are bummed out despite XYZ economic (or other) data is itself important.
A+ article, except for referring to the pseudo-scientific personality model of “conscientiousness.” Nothing you say backs this up, which is problematic in an article about shoddy research with leaps of logic.
But possibly the best piece I’ve ever read from Matt. Imagine how many Ohio diner articles we could have been spared if this paper had been properly scrutinized.
The Big Five model weirdly seems to escape the scrutiny that other personality attribute models have received. Maybe it will eventually.
I think people love personality models so much they throw all skepticism out the window. I feel like it’s got the same clutch on the imagination as Freud, so it may take quite some time before people are willing to acknowledge how ridiculous it is.
It's easy to apply a morality weight to the results of the Big 5. Unlike say Myers-Briggs or Enneagram, there is not a continuum between different traits in the Big 5. It is either "high" or "low" trait and that's it.
That seems like a distinction without a difference to me--for example, low extroversion implies high introversion, and both the Big Five and Myers-Briggs use extroversion as a trait, even if only the latter explicitly mentions introversion.
Matt, no offense in the slightest, I love your smart takes, but also think you would be well served to spend more time in Trump country.
Its a disaster full of despair in the forgotten geographies of the USA. Come to Cumberland County New Jersey or deep Appalachia. Its a shit show and people are desperate.
Why are deaths related to drug addiction not in a category of despair? Perhaps this sentiment is biased by the notion that in wealthy circles, drug use is more often seen to be related to thrill seeking, morally bad stuff. In my experience, drug use is often an antidote for despair, and often causes individuals to fall into a trap of addiction.
If not related to “despair,” could we at least call opioid addiction a mental illness?
In any case, the pattern I see is individuals with little opportunity in rural south jersey get drug addicted and eventually then end up in tent cities near a safe injection site in Philadelphia.
It could be related to workplace injuries. Physical work is more likely to lead to an Oxy prescription than data analyst work. Red states also tend to be less well-insured, and so addiction treatment is harder to come by.
I think this thesis about prescriptions is bad. This was solved several years ago and yet at least around here, the problem continues to worsen. And I can’t get pain meds when I’ve needed them
I think the narrative is: pushing prescription opioids on too many people created a lot of new addicts, but now that addicted population has substantially turned toward heroin and fentanyl. That doesn't mean, of course, that every single addict in America started on that path via an MD's prescription (it just greatly expanded it).
It that view is correct (and we have in fact "solved" or at least substantially improved the prescription issue), we should see opioid addiction numbers, overdose deaths, etc begin to decline in the near future.
Its a good point and I’m sure that prescription policy difference played an important role in worsening the crisis. But pain scripts have been on lockdown for a long time. So long in fact that when I googled searching for dates on policy changes, I found the most recent 2022 CDC guidance was a *loosening* of pain prescription because the pendulum had swung too far restricting. This was after the 2016 CDC guidance to severely restrict - 7 years ago. We should have seen that decline by now
I hypothesize that the difference between US and Europe for this crisis is access to healthcare … and actual despair among the bottom 25%. Europe has a functional social safety net and universal access to healthcare, including mental healthcare, much more vacation sick and family leave, higher labor standards, better consumer protections etc
Well, different people have different intuitions, and I find your take deeply counter-intuitive. And I write this as a full-blooded Social Democrat who very much wants a kindler, gentler, and more European-style USA.
These things are seldom zero-100, of course, so, sure, it's unlikely America's less effective safety net plays literally zero role in all of this. But the data to my eyes simply don't suggest a generalized "Americans are miserable so they're self-medicating themselves to death" narrative as a satisfactory explanation. As far as I know there's plenty of smoking and alcoholism in Europe, for instance—and obesity has been rising just about everywhere. Also, while the gap-ridden US healthcare system undoubtedly accounts for a nontrivial degree in the mortality gap between the US and other rich countries, it doesn't explain why US life expectancy has actually been *declining*, especially given the fact these gaps have gotten smaller since the enactment of Obamacare. Moreover, it seems plausible the arrival of fentanyl has simply swamped (for now, at least) any public health benefits from the crackdown on prescription opioid abuse, and so there's a delayed effect (though it also should be pointed out that it appears Opioid-induced deaths in America *are* finally beginning to decline).
I realize this isn't how you view it, but to my mind, Occam's razor very strongly suggests differing standards with respect to opioid prescriptions are what created the surfeit of opioid-related deaths in the US, and that this factor more than any other has been the driving force behind the decline in US life expectancy in recent years.
I appreciate the civility of your disagreement! Thank you.
I doubt we’d move each other, but just so you don’t think my take is entirely based in intuition, some data…
https://www.thenationalcouncil.org/news/lack-of-access-root-cause-mental-health-crisis-in-america/
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2788767
Yeah. I’m interested in a comparison of rural suicide/OD fatality rates compared to urban rates.
Yep. but I don’t know if they would tell the whole story. Because all the services for the homeless and opioid addicted are in urban centers, which often act like a magnet. Meanwhile, rural communities generally try to ship off vagrants
Here in Philly at least, there have been efforts to provide safe injection sites and deprioritization law enforcement around drugs because of concerns over racial profiling.
If you’re a broke addict, you probably go to where there’s services set up and a whole vagrant community already
And so it seems to me this ugly ecosystem has developed. And no one is offering anything approaching decent solutions as far as I can tell.
The main explanation that they are currently advancing for different death rates between the US and Europe is that Europe has a much stronger social safety net. I like your takedown, but I do wish you'd addressed this point as well!
It really depends on where in Europe. The US spends around 19% of it's GDP on social welfare while Switzerland spends around 16%. I'm sure the specifics of what they spend their money on matters, along with a million other factors. I just don't think it's a good idea to take it at face value that all of Europe has better social welfare than we do.
My personal rebuttal is that access to a safety net in the US does not appear to be correlated, in either time or space or demographic, with overdoses or other deaths of despair, nor with changes to life expectancy. The labor market also does not exhibit any correlation.
I doubt that is completely accurate. There surely is a correlation, though we can argue about it's strength.
I'll stress that I'm indifferent to changes in suicide rates (I think it's people's own business whether they kill themselves or not), but one thing I can't help but notice is that people who do express concern about increasing suicide rates, at least from a "left" perspective, all but completely ignore that, historically, suicide was severely stigmatized in Western cultures, both religiously and civilly, going back even to the pre-Christian era. Given that all forms of stigma around suicide have been substantially reduced, either directly (e.g., repeal of property forfeiture laws for suicide victims) or indirectly (e.g., general decline in religiosity), over the past century or so, how clear is it that we're genuinely seeing an increase in suicidality versus finding the "natural rate" of suicides in the absence of stigmatization?
Possibly not a real memory, but I'm pretty sure I was taught about suicide contagion in health class in 9th (?) grade. Seemed to check out to me, and a few years later I recall learning as an RA that the college paper had a policy of not running stories about the one or two people a year who would jump off the bridge in the middle of campus. Possibly apocryphal as well.
Fast forward to the present day, and there are suicide ads on the bus. So much of the conventional wisdom around mental health in this country seems so broken.
Yes. It’s also somewhat “contagious”-- suicides spike locally when someone in a community commits suicide, and then more broadly when a celebrity does.
And back when there were local newspapers, the rule was not to report on suicides unless they happened in public.
For good reason.
A theoretical point rather than empirical (maybe someone could figure out away to look) that Angus Deaton make is that the strange US system of having employers purchase health insurance for their employees acts like a head tax on employment. And as head tax, it represents a higher portion of wages of low-income employees so employers naturally try to avoid it by job splitting and "contracting" instead of "employing" people and substituting away from low skill/low wage workers for higher skilled/higher paid workers.
I may be missing something, given folks' comments. If I can get a gun today because of some intervening regulatory change but couldn't last year and thus kill myself this year but not last year, it's a "death of despair" or whatever word one wants to use. It may also be a death of "bad regulatory state" or whatever, but happy people--again, with exceptions that prove the rule--don't due by suicide.
I think the thrust of Matt’s take was that the original Deaths of Despair concept came out of a paper that argued the despair was caused by economic troubles--that hit all of Europe too, but only Americans had such an uptick in mortality.
So of course suicide is motivated by despair--but the question is whether the despair is because of broad economic trends or something else.