The Great Divide: Education, Despair, and Death.

Deaths of despair, morbidity and emotional distress continue to rise in the US, largely borne by those without a college degree, the majority of American adults, for many of whom the economy and society are no longer delivering. Concurrently, all-cause mortality in the US is diverging by education in a way not seen in other rich countries. We review the rising prevalence of pain, despair, and suicide among those without a BA. Pain and despair created a baseline demand for opioids, but the escalation of addiction came from pharma and its political enablers. We examine the "politics of despair," how less-educated people have abandoned and been abandoned by the Democratic Party. While healthier states once voted Republican in presidential elections, now the less-healthy states do. We review deaths during COVID, finding mortality in 2020 replicated existing relative mortality differences between those with and without college degrees.

GDP, wellbeing, and health: thoughts on the 2017 round of the International Comparison Program.

In March 2020, the International Comparison Project published its latest results, for the calendar year 2017. This round presents common-unit or purchasing-power-parity data for 176 countries on Gross Domestic Product and its components. We review a number of important issues, what is new, what is not new, and what the new data can and cannot do. Of great importance is the lack of news, that the results are broadly in line with earlier results from 2011. We consider the relationship between national accounts measures and health, particularly in light of the COVID-19 epidemic which may reduce global inequality, even as it increases inequality within countries. We emphasize things that GDP cannot do, some familiar-like its silence on distribution-and some less familiar-including its increasing detachment from national material wellbeing in a globalized world where international transfers of capital and property rights can have enormous effects on GDP, such as the 26 percent increase in Ireland's GDP in 2015.

COVID-19 and Global Income Inequality.

There is a widespread belief that the COVID-19 pandemic has increased global income inequality, reducing per capita incomes by more in poor countries than in rich. This supposition is reasonable but false. Rich countries have experienced more deaths per head than have poor countries, their better health systems, higher incomes, more capable governments and better preparedness notwithstanding. The US did worse than some rich countries but better than several others. Countries with more deaths saw larger declines in GDP per capita. At least after the fact, fewer deaths meant more income. As a result, per capita incomes fell by more in higher-income countries. Country by country, international income inequality decreased. When countries are weighted by population, international income inequality increased, in line with the original intuition. This was largely because Indian GDP fell and because the disequalizing effect of declining Indian incomes was not offset by rising incomes in China, which is no longer a globally poor country. That these findings are a result of the pandemic is supported by comparing global inequality using IMF forecasts in October 2019 and October 2020. These results concern GDP per capita and say little or nothing about the global distribution of living standards, let alone about the global distribution of suffering during the first year of the pandemic.

Life expectancy in adulthood is falling for those without a BA degree, but as educational gaps have widened, racial gaps have narrowed.

A 4-y college degree is increasingly the key to good jobs and, ultimately, to good lives in an ever-more meritocratic and unequal society. The bachelor's degree (BA) is increasingly dividing Americans; the one-third with a BA or more live longer and more prosperous lives, while the two-thirds without face rising mortality and declining prospects. We construct a time series, from 1990 to 2018, of a summary of each year's mortality rates and expected years lived from 25 to 75 at the fixed mortality rates of that year. Our measure excludes those over 75 who have done relatively well over the last three decades and focuses on the years when deaths rose rapidly through drug overdoses, suicides, and alcoholic liver disease and when the decline in mortality from cardiovascular disease slowed and reversed. The BA/no-BA gap in our measure widened steadily from 1990 to 2018. Beyond 2010, as those with a BA continued to see increases in our period measure of expected life, those without saw declines. This is true for the population as a whole, for men and for women, and for Black and White people. In contrast to growing education gaps, gaps between Black and White people diminished but did not vanish. By 2018, intraracial college divides were larger than interracial divides conditional on college; by our measure, those with a college diploma are more alike one another irrespective of race than they are like those of the same race who do not have a BA.

Decoding the mystery of American pain reveals a warning for the future.

There is an expectation that, on average, pain will increase with age, through accumulated injury, physical wear and tear, and an increasing burden of disease. Consistent with that expectation, pain rises with age into old age in other wealthy countries. However, in America today, the elderly report less pain than those in midlife. This is the mystery of American pain. Using multiple datasets and definitions of pain, we show today's midlife Americans have had more pain throughout adulthood than did today's elderly. Disaggregating the cross-section of ages by year of birth and completion of a bachelor's degree, we find, for those with less education, that each successive birth cohort has a higher prevalence of pain at each age-a result not found for those with a bachelor's degree. Thus, the gap in pain between the more and less educated has widened in each successive birth cohort. The increase seen across birth cohorts cannot be explained by changes in occupation or levels of obesity for the less educated, but fits a more general pattern seen in the ongoing erosion of working-class life for those born after 1950. If these patterns continue, pain prevalence will continue to increase for all adults; importantly, tomorrow's elderly will be sicker than today's elderly, with potentially serious implications for healthcare.

What do self-reports of wellbeing say about life-cycle theory and policy?

I respond to Atkinson's plea to revive welfare economics, and to considering alternative ethical frameworks when making policy recommendations. I examine a measure of self-reported evaluative wellbeing, the Cantril Ladder, and use data from Gallup to examine wellbeing over the life-cycle. I assess the validity of the measure, and show that it is hard to reconcile with familiar theories of intertemporal choice. I find a worldwide optimism about the future; in spite of repeated evidence to the contrary, people consistently but irrationally predict they will be better off five years from now. The gap between future and current wellbeing diminishes with age, and in rich countries, is negative among the elderly. I also use the measure to think about income transfers by age and sex. Policies that give priority those with low incomes favor the young and the old, while utilitarian policies favor the middle aged, and men over women.

Experiential wellbeing data from the American Time Use Survey: Comparisons with other methods and analytic illustrations with age and income.

There has been a recent upsurge of interest in self-reported measures of wellbeing by official statisticians and by researchers in the social sciences. This paper considers data from a wellbeing supplement to the American Time Use Survey (ATUS), which parsed the previous day into episodes. Respondents provided ratings of five experiential wellbeing adjectives (happiness, stress, tiredness, sadness, and pain) for each of three randomly selected episodes. Because the ATUS Well-being module has not received very much attention, in this paper we provide the reader with details about the features of these data and our approach to analyzing the data (e.g., weighting considerations), and then illustrate the applicability of these data to current issues. Specifically, we examine the association of age and income with all of the experiential wellbeing adjective in the ATUS. Results from the ATUS wellbeing module were broadly consistent with earlier findings on age, but did not confirm all earlier findings between income and wellbeing. We conclude that the ATUS, with its measurement of time use, specific activities, and hedonic experience in a nationally representative survey, offers a unique opportunity to incorporate time use into the burgeoning field of wellbeing research.

Understanding and misunderstanding randomized controlled trials.

Randomized Controlled Trials (RCTs) are increasingly popular in the social sciences, not only in medicine. We argue that the lay public, and sometimes researchers, put too much trust in RCTs over other methods of investigation. Contrary to frequent claims in the applied literature, randomization does not equalize everything other than the treatment in the treatment and control groups, it does not automatically deliver a precise estimate of the average treatment effect (ATE), and it does not relieve us of the need to think about (observed or unobserved) covariates. Finding out whether an estimate was generated by chance is more difficult than commonly believed. At best, an RCT yields an unbiased estimate, but this property is of limited practical value. Even then, estimates apply only to the sample selected for the trial, often no more than a convenience sample, and justification is required to extend the results to other groups, including any population to which the trial sample belongs, or to any individual, including an individual in the trial. Demanding 'external validity' is unhelpful because it expects too much of an RCT while undervaluing its potential contribution. RCTs do indeed require minimal assumptions and can operate with little prior knowledge. This is an advantage when persuading distrustful audiences, but it is a disadvantage for cumulative scientific progress, where prior knowledge should be built upon, not discarded. RCTs can play a role in building scientific knowledge and useful predictions but they can only do so as part of a cumulative program, combining with other methods, including conceptual and theoretical development, to discover not 'what works', but 'why things work'.

Mortality and morbidity in the 21st century.

We build on and extend the findings in Case and Deaton (2015) on increases in mortality and morbidity among white non-Hispanic Americans in midlife since the turn of the century. Increases in all-cause mortality continued unabated to 2015, with additional increases in drug overdoses, suicides, and alcohol-related liver mortality, particularly among those with a high-school degree or less. The decline in mortality from heart disease has slowed and, most recently, stopped, and this combined with the three other causes is responsible for the increase in all-cause mortality. Not only are educational differences in mortality among whites increasing, but from 1998 to 2015 mortality rose for those without, and fell for those with, a college degree. This is true for non-Hispanic white men and women in all five year age groups from 35-39 through 55-59. Mortality rates among blacks and Hispanics continued to fall; in 1999, the mortality rate of white non-Hispanics aged 50-54 with only a high-school degree was 30 percent lower than the mortality rate of blacks in the same age group but irrespective of education; by 2015, it was 30 percent higher. There are similar crossovers in all age groups from 25-29 to 60-64. Mortality rates in comparable rich countries have continued their pre-millennial fall at the rates that used to characterize the US. In contrast to the US, mortality rates in Europe are falling for those with low levels of educational attainment, and have fallen further over this period than mortality rates for those with higher levels of education. Many commentators have suggested that poor mortality outcomes can be attributed to contemporaneous levels of resources, particularly to slowly growing, stagnant, and even declining incomes; we evaluate this possibility, but find that it cannot provide a comprehensive explanation. In particular, the income profiles for blacks and Hispanics, whose mortality rates have fallen, are no better than those for whites. Nor is there any evidence in the European data that mortality trends match income trends, in spite of sharply different patterns of median income across countries after the Great Recession. We propose a preliminary but plausible story in which cumulative disadvantage from one birth cohort to the next, in the labor market, in marriage and child outcomes, and in health, is triggered by progressively worsening labor market opportunities at the time of entry for whites with low levels of education. This account, which fits much of the data, has the profoundly negative implication that policies, even ones that successfully improve earnings and jobs, or redistribute income, will take many years to reverse the mortality and morbidity increase, and that those in midlife now are likely to do much worse in old age than those currently older than 65. This is in contrast to an account in which resources affect health contemporaneously, so that those in midlife now can expect to do better in old age as they receive Social Security and Medicare. None of this implies that there are no policy levers to be pulled; preventing the over-prescription of opioids is an obvious target that would clearly be helpful.

Creative Destruction and Subjective Well-Being.

In this paper we analyze the relationship between turnover-driven growth and subjective wellbeing. Our model of innovation-led growth and unemployment predicts that: (i) the effect of creative destruction on expected individual welfare should be unambiguously positive if we control for unemployment, less so if we do not; (ii) job creation has a positive and job destruction has a negative impact on wellbeing; (iii) job destruction has a less negative impact in US Metropolitan Statistical Areas (MSA) within states with more generous unemployment insurance policies; (iv) job creation has a more positive effect on individuals that are more forward-looking. The empirical analysis using cross-sectional MSA-level and individual-level data provide empirical support to these predictions.

Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century.

This paper documents a marked increase in the all-cause mortality of middle-aged white non-Hispanic men and women in the United States between 1999 and 2013. This change reversed decades of progress in mortality and was unique to the United States; no other rich country saw a similar turnaround. The midlife mortality reversal was confined to white non-Hispanics; black non-Hispanics and Hispanics at midlife, and those aged 65 and above in every racial and ethnic group, continued to see mortality rates fall. This increase for whites was largely accounted for by increasing death rates from drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis. Although all education groups saw increases in mortality from suicide and poisonings, and an overall increase in external cause mortality, those with less education saw the most marked increases. Rising midlife mortality rates of white non-Hispanics were paralleled by increases in midlife morbidity. Self-reported declines in health, mental health, and ability to conduct activities of daily living, and increases in chronic pain and inability to work, as well as clinically measured deteriorations in liver function, all point to growing distress in this population. We comment on potential economic causes and consequences of this deterioration.

People in sub-Saharan Africa rate their health and health care among the lowest in the world.

The health of people in sub-Saharan Africa is a major global concern. However, data are weak, and little is known about how people in the region perceive their health or their health care. We used data from the Gallup World Poll in 2012 to document sub-Saharan Africans' perceived health status, their satisfaction with health care, their contact with medical professionals, and the priority they attach to health care. In comparison to other regions of the world, sub-Saharan Africa has the lowest ratings for well-being and the lowest satisfaction with health care. It also has the second-lowest perception of personal health, after only the former Soviet Union and its Eastern European satellites. HIV prevalence is positively correlated with perceived improvements in health care in countries with high prevalence. This is consistent with an improvement in at least some health care services as a result of the largely aid-funded rollout of antiretroviral treatment. Even so, sub-Saharan Africans do not prioritize health care as a matter of policy, although donors are increasingly shifting their aid efforts in the region toward health.

Subjective wellbeing, health, and ageing.

Subjective wellbeing and health are closely linked to age. Three aspects of subjective wellbeing can be distinguished-evaluative wellbeing (or life satisfaction), hedonic wellbeing (feelings of happiness, sadness, anger, stress, and pain), and eudemonic wellbeing (sense of purpose and meaning in life). We review recent advances in the specialty of psychological wellbeing, and present new analyses about the pattern of wellbeing across ages and the association between wellbeing and survival at older ages. The Gallup World Poll, a continuing survey in more than 160 countries, shows a U-shaped relation between evaluative wellbeing and age in high-income, English speaking countries, with the lowest levels of wellbeing in ages 45-54 years. But this pattern is not universal. For example, respondents from the former Soviet Union and eastern Europe show a large progressive reduction in wellbeing with age, respondents from Latin America also shows decreased wellbeing with age, whereas wellbeing in sub-Saharan Africa shows little change with age. The relation between physical health and subjective wellbeing is bidirectional. Older people with illnesses such as coronary heart disease, arthritis, and chronic lung disease show both increased levels of depressed mood and impaired hedonic and eudemonic wellbeing. Wellbeing might also have a protective role in health maintenance. In an analysis of the English Longitudinal Study of Ageing, we identify that eudemonic wellbeing is associated with increased survival; 29·3% of people in the lowest wellbeing quartile died during the average follow-up period of 8·5 years compared with 9·3% of those in the highest quartile. Associations were independent of age, sex, demographic factors, and baseline mental and physical health. We conclude that the wellbeing of elderly people is an important objective for both economic and health policy. Present psychological and economic theories do not adequately account for the variations in patterns of wellbeing with age across different parts of the world. The apparent association between wellbeing and survival is consistent with a protective role of high wellbeing, but alternative explanations cannot be ruled out at this stage.