Institutional Failures as Structural Determinants of Suicide: The Opioid Epidemic and the Great Recession in the United States.

We investigate recent trends in U.S. suicide mortality using a "structural determinants of health" framework. We access restricted-use multiple cause of death files to track suicide rates among U.S. Black, White, American Indian/Alaska Native, and Latino/a men and women between 1990 and 2017. We examine suicide deaths separately by poisonings and nonpoisonings to illustrate that (1) women's suicide rates from poisonings track strongly with increases in prescription drug availability and (2) nonpoisoning suicide rates among all adult Americans track strongly with worsening economic conditions coinciding with the financial crash and Great Recession. These findings suggest that institutional failures elevated U.S. suicide risk between 1990 and 2017 by increasing access to more lethal means of self-harm and by increasing both exposure and vulnerability to economic downturns. Together, these results support calls to scale up to focus on the structural determinants of U.S. suicide.

Life Expectancy Changes During the COVID-19 Pandemic, 2019-2021: Highly Racialized Deaths in Young and Middle Adulthood in the United States as Compared With Other High-Income Countries.

We estimated changes in life expectancy between 2019 and 2021 in the United States (in the total population and separately for 5 racial/ethnic groups) and 20 high-income peer countries. For each country's total population, we decomposed the 2019-2020 and 2020-2021 changes in life expectancy by age. For US populations, we also decomposed the life expectancy changes by age and number of coronavirus disease 2019 (COVID-19) deaths. Decreases in US life expectancy in 2020 (1.86 years) and 2021 (0.55 years) exceeded mean changes in peer countries (a 0.39-year decrease and a 0.23-year increase, respectively) and disproportionately involved COVID-19 deaths in midlife. In 2020, Native American, Hispanic, Black, and Asian-American populations experienced larger decreases in life expectancy and greater losses in midlife than did the White population. In 2021, the White population experienced the largest decrease in US life expectancy, although life expectancy in the Native American and Black populations remained much lower. US losses during the pandemic were more severe than in peer countries and disproportionately involved young and middle-aged adults, especially adults of this age in racialized populations. The mortality consequences of the COVID-19 pandemic deepened a US disadvantage in longevity that has been growing for decades and exacerbated long-standing racial inequities in US mortality.

Differences in Determinants: Racialized Obstetric Care and Increases in U.S. State Labor Induction Rates.

Induction of labor (IOL) rates in the United States have nearly tripled since 1990. We examine official U.S. birth records to document increases in states' IOL rates among pregnancies to Black, Latina, and White women. We test if the increases are associated with changes in demographic characteristics and risk factors among states' racial-ethnic childbearing populations. Among pregnancies to White women, increases in state IOL rates are strongly associated with changes in risk factors among White childbearing populations. However, the rising IOL rates among pregnancies to Black and Latina women are not due to changing factors in their own populations but are instead driven by changing factors among states' White childbearing populations. The results suggest systemic racism may be shaping U.S. obstetric care whereby care is not "centered at the margins" but is instead responsive to characteristics in states' White populations.

Increases in Obstetric Interventions and Changes in Gestational Age Distributions of U.S. Births.

Objective: To examine how changes in induction of labor (IOL) and cesarean deliveries between 1990 and 2017 affected gestational age distributions of births in the United States. Materials and Methods: Singleton first births were drawn from the National Vital Statistics System Birth Data for years 1990-2017. Separate analytic samples were created (1) by maternal race/ethnicity (Hispanic, non-Hispanic Black, non-Hispanic Asian, and non-Hispanic white), (2) by maternal age (15-19, 20-24, 25-29, 30-34, 35-39, 40-49), (3) by U.S. states, and (4) for women at low risk for obstetric interventions (e.g., age 20-34, no hypertension, no diabetes, no tobacco use). Gestational age was measured in weeks, and obstetric intervention status was measured as: (1) no IOL, vaginal delivery; (2) no IOL, cesarean delivery; and (3) IOL, all deliveries. The joint probabilities of birth at each gestational week by obstetric intervention status for years 1990-1991, 1998-1999, 2007-2008, and 2016-2017 were estimated. Results: Between 1990 and 2017, the percent of singleton first births occurring between 37 and 39 weeks of gestation increased from 38.5% to 49.5%. The changes were driven by increases in IOL and a shift in the use of cesarean deliveries toward earlier gestations. The changes were observed among all racial/ethnic groups and all maternal ages, and across all U.S. states. The same changes were also observed among U.S. women at low risk for interventions. Conclusion: Changes in gestational age distributions of U.S. births and their underlying causes are likely national-level phenomena and do not appear to be responding to increases in maternal risk for interventions.

Sources and severity of bias in estimates of the BMI-mortality association.

Estimates of mortality differences by body mass index (BMI) are likely biased by: (1) confounding bias from heterogeneity in body shape; (2) positive survival bias in high-BMI samples due to recent weight gain; and (3) negative survival bias in low-BMI samples due to recent weight loss. I investigate these sources of bias in the National Health and Nutrition Examination Survey (NHANES) 1988-94 and 1999-2006 linked to mortality up to 2015 (17,784 cases; 4,468 deaths). I use Cox survival models to estimate BMI differences in all-cause mortality risks among adults aged [45-85) in the United States. I test for age-based differences in BMI-mortality associations and estimate functional forms of the association using nine BMI levels. Estimates of the BMI-mortality association in NHANES data are significantly affected by all three biases, and obesity-mortality associations adjusted for bias are substantively strong at all ages. The mortality consequences of overweight and obesity have likely been underestimated, especially at older ages.

Changes in Life Expectancy Between 2019 and 2020 in the US and 21 Peer Countries.

Importance: Prior studies reported that US life expectancy decreased considerably in 2020 because of the COVID-19 pandemic, with estimates suggesting that the decreases were much larger among Hispanic and non-Hispanic Black populations than non-Hispanic White populations. Studies based on provisional data suggested that other high-income countries did not experience the large decrease in life expectancy observed in the US; this study sought to confirm these findings according to official death counts and to broaden the pool of comparison countries. Objective: To calculate changes in US life expectancy between 2019 and 2020 by sex, race, and ethnicity and to compare those outcomes with changes in other high-income countries. Design, Setting, and Participants: This cross-sectional study involved a simulation of life tables based on national death and population counts for the US and 21 other high-income countries in 2019 and 2020, by sex, including an analysis of US outcomes by race and ethnicity. Data were analyzed in January 2022. Exposures: Official death counts from the US and 21 peer countries. Main Outcomes and Measures: Life expectancy at birth and credible range (CR) based on 10% uncertainty. Results: Between 2019 and 2020, US life expectancy decreased by a mean of 1.87 years (CR, 1.70-2.03 years), with much larger decreases occurring in the Hispanic (3.70 years; CR, 3.53-3.87 years) and non-Hispanic Black (3.22 years; CR, 3.03-3.40 years) populations than in the non-Hispanic White population (1.38 years; CR, 1.21-1.54 years). The mean decrease in life expectancy among peer countries was 0.58 years (CR, 0.42-0.73 year) across all 21 countries. No peer country experienced decreases as large as those seen in the US. Conclusions and Relevance: Official death counts confirm that US life expectancy decreased between 2019 and 2020 on a scale not seen in 21 peer countries, substantially widening the preexisting gap in life expectancy between the US and peer countries. The decrease in US life expectancy was experienced disproportionately by Hispanic and non-Hispanic Black populations, consistent with a larger history of racial and ethnic health inequities resulting from policies of exclusion and systemic racism. Policies to address the systemic causes of the US health disadvantage relative to peer countries and persistent racial and ethnic inequities are essential.

Age-Specific Mortality During the 2020 COVID-19 Pandemic and Life Expectancy Changes in the United States and Peer Countries, 1980-2020.

OBJECTIVES: Since the 1980s, life expectancy at birth (e0) in the United States has fallen steadily behind that of other high-income countries, widening the U.S. e0 disadvantage. We estimate how that disadvantage was affected by high mortality rates in 2020, the first full year of the coronavirus disease 2019 pandemic. METHODS: We contrast male and female e0 in the United States and 18 peer countries for years 1980, 1995, 2010, 2019, and 2020. Using Arriaga decomposition, we show how differences in age-specific death rates have contributed to U.S. e0 disadvantages. RESULTS: In 2020, U.S. male and female e0 changed by -2.33 (-2.50, -2.15) and -1.69 (-1.85, -1.53) years, respectively, whereas corresponding changes in peer countries averaged -0.67 (-0.82, -0.51) and -0.50 (-0.65, -0.35) years, respectively. This accelerated a longstanding and widening U.S. e0 disadvantage relative to its peers, which increased from 3.49 to 5.15 years in males and from 2.78 to 3.97 years in females between 2019 and 2020. Whereas deaths before age 65 accounted for 55% and 40% of declines in U.S. male and female life expectancy, respectively, they accounted for only 24% and 11% of the respective declines in peer countries. DISCUSSION: U.S. life expectancy declines in 2020 were larger than in peer countries and involved deaths across a broader age range, particularly among young and middle-aged adults. Both the longstanding U.S. e0 disadvantage and acute losses of life in 2020 signal the need for systemic policy changes in the United States.

The National Death Index as a Source of Homicide Data: A Methodological Exposition of Promises and Pitfalls for Criminologists.

Criminologists largely rely on national de-identified data sources to study homicide in the United States. The National Death Index (NDI), a comprehensive and well-established database compiled by the National Center for Health Statistics, is an untapped source of homicide data that offers identifiable linkages to other data sources while retaining national coverage. This study's five aims follow. First, we review the data sources in articles published in Homicide Studies over the past decade. Second, we describe the NDI, including its origins, procedures, and uses. Third, we outline the procedures for linking a police gang intelligence database to the NDI. Fourth, we introduce the St. Louis Gang Member-Linked Mortality Files database, which is composed of 3,120 police-identified male gang members in the St. Louis area linked to NDI records. Finally, we report on preliminary cause-of-death findings. We conclude by outlining the benefits and drawbacks of the NDI as a source of homicide data for criminologists.

Effect of the covid-19 pandemic in 2020 on life expectancy across populations in the USA and other high income countries: simulations of provisional mortality data.

OBJECTIVE: To estimate changes in life expectancy in 2010-18 and during the covid-19 pandemic in 2020 across population groups in the United States and to compare outcomes with peer nations. DESIGN: Simulations of provisional mortality data. SETTING: US and 16 other high income countries in 2010-18 and 2020, by sex, including an analysis of US outcomes by race and ethnicity. POPULATION: Data for the US and for 16 other high income countries from the National Center for Health Statistics and the Human Mortality Database, respectively. MAIN OUTCOME MEASURES: Life expectancy at birth, and at ages 25 and 65, by sex, and, in the US only, by race and ethnicity. Analysis excluded 2019 because life table data were not available for many peer countries. Life expectancy in 2020 was estimated by simulating life tables from estimated age specific mortality rates in 2020 and allowing for 10% random error. Estimates for 2020 are reported as medians with fifth and 95th centiles. RESULTS: Between 2010 and 2018, the gap in life expectancy between the US and the peer country average increased from 1.88 years (78.66 v 80.54 years, respectively) to 3.05 years (78.74 v 81.78 years). Between 2018 and 2020, life expectancy in the US decreased by 1.87 years (to 76.87 years), 8.5 times the average decrease in peer countries (0.22 years), widening the gap to 4.69 years. Life expectancy in the US decreased disproportionately among racial and ethnic minority groups between 2018 and 2020, declining by 3.88, 3.25, and 1.36 years in Hispanic, non-Hispanic Black, and non-Hispanic White populations, respectively. In Hispanic and non-Hispanic Black populations, reductions in life expectancy were 18 and 15 times the average in peer countries, respectively. Progress since 2010 in reducing the gap in life expectancy in the US between Black and White people was erased in 2018-20; life expectancy in Black men reached its lowest level since 1998 (67.73 years), and the longstanding Hispanic life expectancy advantage almost disappeared. CONCLUSIONS: The US had a much larger decrease in life expectancy between 2018 and 2020 than other high income nations, with pronounced losses among the Hispanic and non-Hispanic Black populations. A longstanding and widening US health disadvantage, high death rates in 2020, and continued inequitable effects on racial and ethnic minority groups are likely the products of longstanding policy choices and systemic racism.

Trends in "Deaths of Despair" Among Working-Aged White and Black Americans, 1990-2017.

Life expectancy for US White men and women declined between 2013 and 2017. Initial explanations for the decline focused on increases in "deaths of despair" (i.e., deaths from suicide, drug use, and alcohol use), which have been interpreted as a cohort-based phenomenon afflicting middle-aged White Americans. There has been less attention on Black mortality trends from these same causes, and whether the trends are similar or different by cohort and period. We complement existing research and contend that recent mortality trends in both the US Black and White populations most likely reflect period-based exposures to 1) the US opioid epidemic and 2) the Great Recession. We analyzed cause-specific mortality trends in the United States for deaths from suicide, drug use, and alcohol use among non-Hispanic Black and non-Hispanic White Americans, aged 20-64 years, over 1990-2017. We employed sex-, race-, and cause-of-death-stratified Poisson rate models and age-period-cohort models to compare mortality trends. Results indicate that rising "deaths of despair" for both Black and White Americans are overwhelmingly driven by period-based increases in drug-related deaths since the late 1990s. Further, deaths related to alcohol use and suicide among both White and Black Americans changed during the Great Recession, despite some racial differences across cohorts.

Exceptional mortality risk among police-identified young black male gang members.

Gang membership is associated with many risky behaviors but is often overlooked as a source of mortality among young Americans. Gang Member-Linked Mortality Files (GM-LMFs) match St. Louis, Missouri gang members listed in a law enforcement gang database to mortality records in the National Death Index. We created three analytic samples composed of black males aged 15-35 years by merging cases of the GM-LMFs with National Vital Statistics System and Census data in years 1993-2016. Mortality rates standardized to the 15-35-year-old 2010 U.S. male population were estimated for all-cause (1477.4, 99% CI = 1451.5-1503.3), homicide (950.1, 99% CI = 932.2-967.9), non-homicide injury (314.0, 99% CI = 308.8-319.2), and non-injury (213.3, 99% CI = 202.3-224.4) deaths in the GM-LMFs. We fitted Poisson rate models to estimate mortality rate ratios (RR) between gang members and demographically-matched comparison groups. Black male gang members in St. Louis were at an elevated mortality risk from all causes of death, and homicides contributed substantially to this risk. Compared to black males in St. Louis, gang members experienced greater relative risk of all-cause (RR = 2.9, 99% CI = 2.4-3.5), homicide (RR = 3.2, 99% CI = 2.5-4.1), and non-homicide injury (RR = 4.0, 99% CI = 2.8-5.8) mortality between 1993 and 2016. Relative risk was greater when compared to black males in St. Louis MSA, Missouri, and the USA. These results identify a key source of excess mortality among young black Americans. Health policies and interventions may be most efficacious when they acknowledge, address, and incorporate information about and target high-risk populations, including gang members, that contribute to relatively high mortality risk in the USA.

Worth the Weight? Recent Trends in Obstetric Practices, Gestational Age, and Birth Weight in the United States.

Birth weight in the United States declined substantially during the 1990s and 2000s. We suggest that the declines were likely due to shifts in gestational age resulting from changes in obstetric practices. Using restricted National Vital Statistics System data linked birth/infant death data for 1990-2013, we analyze trends in obstetric practices, gestational age distributions, and birth weights among first-birth singletons born to U.S. non-Hispanic White, non-Hispanic Black, and Latina women. We use life table techniques to analyze the joint probabilities of gestational age-specific birth and gestational age-specific obstetric intervention (i.e., induced cesarean delivery, induced vaginal delivery, not-induced cesarean delivery, and not-induced vaginal delivery) to fully document trends in obstetric practices by gestational age. We use simulation techniques to estimate counterfactual changes in birth weight distributions if obstetric practices did not change between 1990 and 2013. Results show that between 1990 and 2013, the likelihood of induced labors and cesarean deliveries increased at all gestational ages, and the gestational age distribution of U.S. births significantly shifted. Births became much less likely to occur beyond gestational week 40 and much more likely to occur during weeks 37-39. Overall, nearly 18% of births from not-induced labor and vaginal delivery at later gestational ages were replaced with births occurring at earlier gestational ages from obstetric interventions. Results suggest that if rates of obstetric practices had not changed between 1990 and 2013, then the average U.S. birth weight would have increased over this time. Findings strongly indicate that recent declines in U.S. birth weight were due to increases in induced labor and cesarean delivery at select gestational ages.

Body size reference norms and subjective weight status: A gender and life course approach.

This paper uses data from The National Longitudinal Study of Adolescent to Adult Health (Add Health) to describe county-level variation in norms regarding physical weight among adolescents in the United States. We demonstrate that regardless of one's physical size, those residing in counties with a heavier weight norm are significantly less likely to see themselves as overweight than those residing in counties with a light weight norm. We further show that the local weight norm during adolescence (Wave 1) is associated with individuals' weight perceptions through adolescence and into young adulthood (Wave 4), though these associations attenuate in strength as respondents age. Our results suggest that weight norms have a stronger influence on weight perceptions among women compared to men and that the role of gender is particularly important during adolescence. We encourage life course researchers to consider the normative health environment during adolescence as an important context for understanding disparities in health and health lifestyles as people age.

Explaining recent mortality trends among younger and middle-aged White Americans.

Background: Recent research has suggested that increases in mortality among middle-aged US Whites are being driven by suicides and poisonings from alcohol and drug use. Increases in these 'despair' deaths have been argued to reflect a cohort-based epidemic of pain and distress among middle-aged US Whites. Methods: We examine trends in all-cause and cause-specific mortality rates among younger and middle-aged US White men and women between 1980 and 2014, using official US mortality data. We estimate trends in cause-specific mortality from suicides, alcohol-related deaths, drug-related deaths, 'metabolic diseases' (i.e. deaths from heart diseases, diabetes, obesity and/or hypertension), and residual deaths from extrinsic causes (i.e. causes external to the body). We examine variation in mortality trends by gender, age and cause of death, and decompose trends into period- and cohort-based variation. Results: Trends in middle-aged US White mortality vary considerably by cause and gender. The relative contribution to overall mortality rates from drug-related deaths has increased dramatically since the early 1990s, but the contributions from suicide and alcohol-related deaths have remained stable. Rising mortality from drug-related deaths exhibit strong period-based patterns. Declines in deaths from metabolic diseases have slowed for middle-aged White men and have stalled for middle-aged White women, and exhibit strong cohort-based patterns. Conclusions: We find little empirical support for the pain- and distress-based explanations for rising mortality in the US White population. Instead, recent mortality increases among younger and middle-aged US White men and women have likely been shaped by the US opiate epidemic and an expanding obesogenic environment.

Mortality from Suicide, Chronic Liver Disease, and Drug Poisonings among Middle-Aged U.S. White Men and Women, 1980-2013.

Recent increases in all-cause mortality rates among the middle-aged U.S. white population have been explained in terms of elevated levels of midlife distress. This brief report provides evidence against this explanation for recent mortality trends among U.S. white men and women. Official mortality rates for U.S. white men and women aged 45-54 from suicide, chronic liver disease, drug poisonings, and other "extrinsic" causes of death (i.e., causes external to the body) between 1980 and 2013 are examined. Results suggest that recent increases in extrinsic mortality among the middle-aged U.S. white population are overwhelmingly driven by rapid increases in drug-related mortality. The contributions of chronic liver disease and suicide to U.S. white men's and women's mortality levels have been fairly stable for the past 30 years. Further, large gender differences in extrinsic mortality trends are observed. These two findings are inconsistent with the explanation that distress among the middle-aged U.S. white population is a common cause driving trends in U.S. white mortality.

The relationship between education and health among incarcerated men and women in the United States.

BACKGROUND: This paper contributes to research on the education-health association by extending the scope of inquiry to adult inmates. Not only are inmates excluded from most nationally representative studies of health but they also represent a highly select group in terms of both education and health. As such, our study provides new information about the health of incarcerated populations and it extends the generalizability of the education-health association beyond the non-institutionalized population. METHODS: We use a prison-level fixed-effects regression model with the 2004 Survey of Inmates in State Correctional Facilities (n = 287 facilities) to evaluate the effects of education on a standardized morbidity scale of 11 lifetime and current health conditions among incarcerated men (n = 10,493) and women (n = 2,797). RESULTS: Education prior to incarceration is negatively associated with lifetime health problems for both women and men and the association is stronger among women. Among inmates who enter prison with less than a GED level of education, attaining a GED in prison is associated with better current health outcomes for men, but not women. CONCLUSIONS: The generalization of the education-health association among prisoners further highlights the fundamental nature of education as a health promotive resource. Discussed are the implications for the education-health literature in general and health promotion efforts among incarcerated adults specifically.