We are pleased to host this symposium featuring commentary from speakers and participants of Northeastern University School of Law’s annual health law conference, Diseases of Despair: The Role of Policy and Law, organized by the Center for Health Policy and Law.
All the posts in the series will be available here.
As a note, additional detailed analyses of issues discussed during the conference will be published in the 2019 Winter Issue of the Northeastern University Law Review.
After decades of improvement, overall life expectancy in the United States has decreased over the past two years. In a widely-read paper published in 2015, economists Anne Case and Angus Deaton found that pronounced increases in death rates among middle-aged non-Hispanic men and women were driving these declines.
Case and Deaton linked this alarming trend to so-called “diseases of despair,” which include substance use disorders, suicides, and alcohol-related diseases. Their report went on to highlight two other important points: First, the U.S. stands alone as the only industrialized nation facing this anomaly. Second, the increase in mortality rates was far higher for middle-aged non-Hispanic whites with less education than for their college-educated counterparts.
In an updated report issued in 2017, Case and Deaton noted that this reduction in life expectancy, especially due to deaths related to diseases of despair, was not confined to particular geographic regions within the U.S. Rather, the trends have become widespread, though there is variability in mortality rate increases across regions. Further, although the declines are specific to whites, overall mortality rates for other populations, such as non-Hispanic blacks, remain higher than mortality rates for non-Hispanic whites.
The overall decline in life expectancy in the U.S. and the concomitant rise in diseases of despair, especially the dramatic increase in deaths related to opioid overdoses and suicides, raise a plethora of questions.
To explore the causes of the phenomenon, and discuss potential solutions, Northeastern University’s Center for Health Policy & Law held a conference in April 2018, titled “Diseases of Despair: The Role of Policy and Law,” which brought together researchers, policymakers, practitioners, and advocates from across disciplines. The conference focused on suicide, opioid and substance use, and violence, and emphasized the role of law in both causing and addressing these problems.
Without trying to summarize all of the presentations and conversations, several of which are represented in the Symposium that will follow here on Bill of Health, it became clear over the course of the two-day conference that there is a considerable body of evidence about the causes and possible remedies of these preventable causes of death.
Academics, experts, and advocates have engaged in research and knowledge dissemination on these topics for years. They have also issued numerous policy analyses and recommendations for effective, evidence-based interventions. Although it is always important to attain more evidence, especially regarding interventions to address the underlying determinants of these diseases, we came away from the conference, as we come away from reading the contributions to the Symposium, realizing that what is most lacking is an understanding of how we can get effective, evidence-based solutions enacted and implemented. To solve that deficit, we may need to extend our research and analysis beyond problems of public health to those of the body politic.
Public health research has long demonstrated the important role that social determinants play in establishing population health. The World Health Organization (WHO) defines social determinants as “the conditions in which people are born, grow, live, work, and age.”
In their 2017 report, Case and Deaton hypothesized that several social trends, including long-term declines in employment, income, marriage, education, and health led to what they call “cumulative disadvantage” or “cumulative deterioration.” With fewer opportunities, lower income, and increased social isolation, individuals feel helpless and experience less control over decisions that affect their lives, let alone decisions that might help them rise above their limited circumstances.
When individuals feel helpless, they are more likely to engage in risky behaviors, such as excessive alcohol and substance use, violence toward oneself or others, and forgoing necessary health care.
Although Case and Deaton focused their research on how cumulative disadvantage particularly affects people with less education and income, other researchers have focused on how regional differences also add to this disadvantage. Still other researchers have shown how similar cumulative disadvantages, including the stresses created by discrimination, can help explain the significant racial disparities in health that continue today.
Several speakers at the conference, including Symposium contributors JoHanna Flacks and Nicholas Terry, expanded upon this story, discussing the critical role that social determinants have played in diseases of despair.
In his keynote remarks, Dr. Michael Fraser, the Executive Director of the Association of State and Territorial Health Officials discussed the startling connections between substance use disorders and the loss of jobs and social capital in struggling communities.
In her presentation detailing the geographic variations in diseases of despair, Professor Shannon Monnat from Syracuse University emphasized how economic, familial, and community factors greatly affect diseases of despair. Aligned with the work by Case and Deaton, Monnat’s research found that drug mortality rates are higher in places with more economic and family distress.
Speakers also pointed to the detrimental role that law, which is itself an important social determinant, has played in fueling the crisis. Scott Burris, for example, recounted how our drug laws have acted as unintended negative social determinants, helping to create the substance use disorder crisis. In their talks, Lindsey Vuolo, Renee Landers and Brietta Clark described the many ways in which the legal system has helped to exacerbate gender and racial health disparities.
Other speakers pointed to legal barriers to safe injection sites, regulations that hamper access to evidence-based medication-assisted treatments for opioid addiction, lack of enforcement of mental health parity laws, the expanded constitutional right to firearms, and changes to Medicaid as legal impediments to readdressing the different diseases of despair. In her talk and Symposium piece, Aila Hoss discussed how laws have undermined harm reduction strategies.
Our understanding of the many causes of diseases of despair and the numerous barriers to prevention helps to suggest solutions. While no speaker offered a magic bullet, many presented compelling evidence relating to the efficacy of particular interventions. Some of these interventions require law reform, for if law has helped to drive the problem, as many of our speakers suggested, law reform has to be part of the solution. Other proposals involve community-based programs, such as those described by Dr. William Martin, to address the social isolation and community fragmentation that have helped to drive diseases of despair. Tamar Ezer discussed the potential of medical-legal partnerships.
The deeper problem is how to get these many solutions implemented and scaled-up, and more broadly, how do we reverse the declines in wage growth, family structure, and social fabric, not to mention entrenched poverty and structural racism, that undermine population health? Asking such questions forces us to confront a problem that may be even more vexing than preventing diseases of despair.
The story that Case and Deaton and our speakers and authors relate of the withering of the social fabric, especially in rural communities and among non-Hispanic whites without a college degree, closely resembles the picture painted in J.D. Vance’s “Hillbilly Elegy” as well as Arlie Hochschild’s “Strangers in their Own Land.” Although not about diseases of despair per se, these books offer striking portraits of the challenges faced by rural, working-class white communities, the very ones most affected by diseases of despair, in the face of globalization, wage stagnation, and technological transformation.
Researchers and pundits have pointed to such challenges and the divisions and resentments (toward immigrants, racial minorities and the “coastal elites”) that result from these challenges and can by exploited by politicians to help to explain increasing political polarization, the rise of resentment politics, and ultimately the election of President Trump. Indeed, as Monnat’s research shows, there is a striking association between the counties that have high levels of diseases of despair and those that supported President Trump.
Whether or not the identical distal forces are responsible for both diseases of despair and the rise of the politics of resentment, and regardless of the directions in which the causal arrows point, it’s clear that the American polity is currently under considerable stress. Political polarization is at record levels, trust in institutions including Congress, the Presidency, political parties and the media is remarkably low, and essential norms that undergird democracy, including mutual toleration and forbearance, are showing signs of fissure.
Relatedly, and importantly for public health, our capacity to address both the upstream economic, social and political problems that underlie diseases of despair, as well as the more proximal manifestations of such problems, such as fentanyl deaths or mass shootings, is faltering, especially at the federal level.
Although Congressional leaders have promised to take up opioid-related legislation in the summer of 2018, Congress’ track record on the subject leaves reason to be skeptical that any significant steps towards implementing evidence-based solutions will be enacted. In addition, scientists have been leaving the government, key health policy positions, including the director of the White House Drug Control Office have remained vacant for considerable periods of time (the President nominated James W. Carroll Jr. for the position in April, 2018) and tax cuts are depleting the funds available for public health.21
Perhaps most importantly, truth itself, and the value of evidence, are increasingly contested. When credible news stories are derided as “fake news” and policy is made on Twitter, it is hard to feel sanguine about the prospects of enacting and implementing evidence-based approaches to diseases of despair. The science might suggest that firearm regulations can reduce deaths by suicides, or that safe injection sites reduce opioid overdoses, but in this political moment, we need to ask whether and how science can influence law and policy.
For public health researchers and advocates this presents a critical set of challenges: how do we address the deep social and legal forces that forestall the implementation of evidence-based solutions? How do we prevent the same forces that cause diseases of despair from simultaneously undermining our ability to implement evidence-based interventions? And what role should public health researchers and advocates play in efforts to ameliorate diseases of democracy?
To these questions, neither the conference nor Symposium offer easy answers. We know far more about how to prevent a disease of the body than a disease of the polity. Still, some of the speakers pointed to potential sources for hope.
Dr. Martin, for example, stressed the value of community-based interventions led by land-grant universities and community extension services. Such institutions are deeply connected to their communities; they know and are trusted by those who are the most affected by diseases by despair.
Community-based interventions also offer the potential for repairing the social fabric and sense of isolation and hopelessness that have jeopardized not only our health but our democracy. In “Dreamland, The True Tale of America’s Opioid Epidemic,” to which many of our speakers referred, Sam Quinones described the fledgling efforts by former addicts and family members of addicts to raise awareness about and tackle the opioid epidemic. Such efforts represent small but perhaps significant steps in the community-building that may be critical to reversing the social isolation and hopelessness that has helped to fuel both our political and public health crises.
Likewise the student activism that followed the mass shooting at Marjorie Stoneman High School in Parkland, Florida in February 2018, demonstrated a level of political engagement that may be crucial if our democracy is going to respond in a positive manner to our social and health problems.
Still, the conference and Symposium leave us feeling sober. Community interventions and community engagement are necessary, but it is not at all clear that they are sufficient in size or power to combat the myriad social and political ills that are fueling our diseases of democracy and of despair. Understanding how we can tackle both problems so that our laws and policies support rather than undermine health remains the public health challenge of our time.
Wendy E. Parmet is the Matthews Distinguished University Professor of Law and Faculty Director, Center for Health Policy and Law; Professor of Public Policy and Urban Affairs, Northeastern University School of Public Policy and Urban Affairs.
Jennifer Lea Huer is the Managing Director, Center for Health Policy and Law; Lecturer, Bouvé College of Health Sciences, Northeastern University.