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From New Yorker

From Vox

So what’s going on here? Is there an American underclass that’s falling behind and dying earlier than the rest of the country? Is the divide between college graduates and non-graduates increasingly central in determining life outcomes for Americans, down to the very number of years we get on this planet?

These are two different questions, and the answers seem to be, respectively, “yes” and “no.” Case and Deaton are highlighting a real problem, confirmed by other researchers: Americans with different levels of education die at different rates, and the least-educated Americans have seen their death rates surge in a way that more-educated Americans have not.

But the relevant divide does not seem to be between people who earned a bachelor’s degree — who remain a minority among American adults — and people who didn’t. Other research suggests that the problem is concentrated in specific areas of the US, and between the very least-educated Americans (particularly high school dropouts) and the rest of the country, rather than between college grads and non-grads.

Moreover, the cause of the divergence between high school dropouts and the rest of the country does not seem to be caused by “deaths of despair.” There is no doubt that the opioid epidemic in particular has wrought spectacular damage in the US. But some researchers are finding that stagnating progress against cardiovascular disease is an even bigger contributor to US life expectancy stalling out, and to mortality divides between the most- and least-educated Americans.

That implies we might want to think more specifically about heart disease, and about the American underclass, and less about the bachelor’s/non-bachelor’s divide that Case and Deaton highlight. That might enable us to produce a more useful policy agenda for tackling the problem.

Non-college grads in 1992 and non-college grads in 2021 are very different groups of people

The biggest problem to be aware of when evaluating the Case-Deaton results is that the divide they’re describing, between college grads and non-grads, has changed a lot over time. In 1992, the year they begin their analysis, 22 percent of people between the ages of 25 and 84 had a four-year college degree. In 2021, the final year they analyze, the share was 35 percent.

This rising education level suggests that there’s a large population of people — some 13 percent of adults — who wouldn’t have finished college 30 years ago, but who do now. One might reasonably expect this group to be healthier than people who wouldn’t have finished college in either period — and less healthy than people who would have finished in either period. The people still left out of college in 2021 are probably more socially and economically disadvantaged, and thus less healthy, than people who were able to attend, and people who could afford college in 1992 were relatively more advantaged, and probably healthier, than those who could.

So a group of people moving from not finishing college to finishing it should have the effect of making both college grads and non-grads, as groups, less healthy. The non-grads are losing their healthiest compatriots, and the grads are adding a somewhat less healthy group to their mix.

This means we cannot look at graphs showing a widening mortality gap between college grads and non-grads and conclude, “Something is really going wrong with less-educated Americans.” That may be true, but it may just be a statistical artifact. As Stanford economist Caroline Hoxby noted in her comments on the latest Case-Deaton paper, it’s “entirely plausible that selection accounts for most or even all of the widening mortality gap.”

Case and Deaton try to adjust for this problem. They look at how the gaps between grads and non-grads change within specific birth cohorts: among people born in 1940, say, have college grads and non-grads seen their death rates diverge more and more over time? This analysis muddies the picture considerably. For men born in 1940, for instance, the gap between grads and non-grads has shrunk over time. There’s no noticeable increase in the gap for men or women born in 1950 and 1960. Gaps do emerge over time for the cohorts born in 1970, 1980, and 1990.

What’s more, this approach doesn’t really fix the problem. To separate the world into college grads and non-grads, they check to see if people have completed a degree by age 25. But they concede that a growing share of people are getting bachelor’s degrees after 25. That means that these aren’t fixed categories, and the very same selection issues might come into play when looking at cohorts like this.

The problem is with high school dropouts, not all non-college grads

The good news is that other researchers have attempted more rigorous approaches to get around the selection problem. Economists Paul Novosad, Charlie Rafkin, and Sam Asher analyze mortality from 1992 to 2018 among the least-educated 10 percent of Americans. By definition, this group becomes no larger or smaller as a share of the population over time: it’s always 10 percent. Identifying just who this group is requires some clever statistical work, but yields some very interesting results:

This is how the trends look once you hold ranks constant. From 1992–2018, most White Americans have been doing fine mortality-wise — but the least educated 10% have faced catastrophic mortality increases. 9/N pic.twitter.com/3ZpybrYyYj

— Paul Novosad (@paulnovosad) December 16, 2022

Among both Black and white middle-aged Americans, death rates were falling among the most-educated groups pre-Covid. For those in the middle of the education spectrum, death rates have been falling for Black Americans and stagnant for whites; Black death rates still exceed those for whites but the gap is narrowing. For the least-educated, which roughly means high school dropouts, death rates have been rising starkly for white men and women, and rising slightly for Black women, while staying roughly constant for Black men. (Novosad, Rafkin, and Asher also look at death rates in other age ranges, but note that death is rare enough before you get to your 50s that it doesn’t affect life expectancies in the US as much.)

Case and Deaton in their latest piece describe this as confirmation that the “qualitative” takeaway from their research is correct. I’m not sure I’d be that generous. “White high school dropouts are dying at higher and higher rates” implies that a small but significant share of the population is experiencing a mortality crisis. “Americans without a college degree are dying at higher and higher rates” implies that the majority of Americans are experiencing a crisis, since a majority of Americans don’t possess a college degree even today. That might be a better narrative for convincing people to care about the most vulnerable, but it doesn’t give us as much information about where the problem is.

The problem is highly geographically concentrated

At this point you may be wondering: If we’re concerned about how lower-socioeconomic-status Americans are doing in terms of mortality, why are we dividing them by education? Why not compare rich versus poor Americans, normally identified based on income?

In 2016, economists Raj Chetty and others used US income tax data and death certificates to track how mortality varied based on income and how the relationship changed between 2001 and 2014. That isn’t a terribly long period across which to compare, but Chetty and colleagues confirmed that more income is associated with lower death rates and that the gap got worse over the period studied.

Four charts showing that richer Americans have seen life expectancy grow faster Chetty et al 2016
Life expectancy has grown faster for richer Americans since 1992.

But they also found that the gap varies substantially based on geography. While it’s true that rich people in America live significantly longer than poor people, that’s much less true in New York City. It’s not true in California as a whole. Heavily urban areas with high education levels see a modest relationship between income and death rates. More-rural, less-educated areas, by contrast, see a very strong relationship between the two.

Two charts showing that in New York and San Francisco, being low-income hurts your life expectancy less than it does in Detroit or Dallas Chetty et al 2016
Different US cities have very different relationships between income and life expectancy.

Areas with smaller mortality gaps tend to be places, the researchers find, with lower rates of smoking and higher rates of exercise, which makes sense when you consider that the variation in death rates between cities is driven not by factors like car crashes or suicide but conditions like heart disease and cancer, which are themselves driven in part by lifestyle conditions. Local unemployment rates and other indicators of the health of the local labor market did not seem to be associated with longevity, nor did income inequality. These aren’t firmly causal findings, to be clear, but they might be suggestive of potential causes to investigate.

This work doesn’t debunk the Case-Deaton research, but it does highlight ways in which that research is somewhat incomplete. Case and Deaton do not break down their findings by state or city to see if the relationship they find is only showing up in certain places. Together with the Novosad research, this data suggests that if we want to tackle rising mortality among some Americans, we need to be thinking specifically about problems with the very poorest high-school dropouts in certain areas of the country, rather than about some kind of broader — and therefore harder to address — national malaise.

What’s causing these early deaths?

One of the more useful contributions of the latest Case-Deaton paper is its decision to zoom out from focusing on “deaths of despair” to include other contributions to rising mortality in the US, in particular cardiovascular disease.

There’s little doubt that the ongoing opioid crisis has contributed to surging deaths, particularly among more vulnerable Americans, with smaller roles attributable to non-drug suicides and alcohol. One recent paper found that increasing drug use from 1999 to 2016 reduced the life expectancy of American men by 1.4 years, and that of women by 0.7. In West Virginia, the most affected state, the reductions were 3.6 and 1.9 years respectively. In 2020 and 2021, Covid was the dominant force reducing life expectancy, with the effects very different based on class: People with disproportionately high-paying laptop jobs who were able to work from home were less exposed and so died less.

But the overall life expectancy problem in the US also has far more to do than we often recognize with stagnating progress against cardiovascular disease, which is still the leading cause of death in the US. Researchers Neil Mehta, Leah Abrams, and Mikko Myrskylä argued in a 2020 paper that the dominant reason life expectancy has stalled in the US is not that drug deaths have grown but that a previously large, robust decline in deaths from cardiovascular disease has stalled out. The death rate fell by half between 1970 and 2002, but given that it’s still common enough to cause 695,000 deaths in 2021, a stalled decline could be a very big deal.

Though explanations for this stagnation are still unclear, the authors present a couple of options: rising levels of obesity (especially at younger ages, compounding negative health effects over more time), or, counterintuitively, the US’s early success at discouraging smoking (which could explain why its cardiovascular death rates aren’t falling as fast as those in Europe, which gave up smoking later on). They find that the stagnation from cardiovascular disease is broad-based geographically in the US, unlike the rising death rates among low-income Americans studied by Chetty et al. 

Economists Novosad, Rafkin, and Asher make similar points in their paper on the fate of the least-educated Americans over time. As of their data endpoint in 2018, “deaths of despair” — that is, from drug overdoses, suicides, and alcoholism — “account for a large share of mortality increases for young whites, but a very small share of rising mortality among older whites and very little of the divergent mortality rates of black,” they note. “Further, deaths of despair have increased more uniformly across the education distribution than deaths from other causes.” In other words, while the overall rise in mortality is concentrated among the least-educated, the opioid, suicide, and alcohol-related rise is not.

The middle-aged whites without high school diplomas Novosad and colleagues study have, however, seen their death rates from cancer, heart disease, and respiratory disease increase, while more-educated Americans have seen death rates from these diseases fall. A new investigation from the Washington Post similarly concludes that chronic conditions like heart disease and cancer are driving more of the life expectancy divide between rich and poor counties than factors like opioid overdoses or homicides.

All this points to a very specific challenge that policymakers must confront: How to reduce deaths from cardiovascular disease (and also cancer) among the poorest, least-educated Americans. Case and Deaton like to prescribe various economic measures as ways to combat rising death rates, like eliminating the link between employers and health insurance, expanding affordable housing, strengthening unions, and removing needless requirements that certain workers have bachelor’s degrees.

I happen to think all those policies are good ideas. But I’m somewhat skeptical they would move the needle on heart disease among high school dropouts, especially compared to more targeted approaches like expanding cholesterol screening or ensuring Medicaid covers medicines like semaglutide that reduce the risk of heart disease.

People dying now cannot wait for the whole US economy to transform to be more worker-friendly, as nice as that might be. They need solutions that are tailored for their specific problems, that can be implemented soon.

“Kenya has recognized and increasingly sees value in regional security partnerships and regional security engagements more generally,” Joseph Siegle, research director at the Africa Center for Strategic Studies, told Vox in an interview. Kenya has been part of an African Union peacekeeping force in Somalia since 2011 to help combat the al-Shabaab insurgent group in the country. That effort has yielded mixed results, though, and many news reports have pointed to the Kenyan National Police force’s track record of human rights abuses within Kenya as cause for concern, particularly in a hostile environment like Haiti.

Over the past few weeks, Kenya has ramped up its diplomatic efforts with both the US and Haiti; the East African nation signed a defense agreement with the US that will provide resources for Kenya’s fight against al-Shabaab, as the AP reported last week. Kenya and Haiti also established diplomatic relations in September.

Will this be different from previous international interventions? That’s a good question.

Since Haiti’s independence, wealthy nations have meddled in the island country to its detriment. But, as Jake Johnston, a senior research associate at the Center for Economic and Policy Research, told Vox, “It’s not always the same, and the interventions we’re talking about now — it’s not the same as the early 20th century US occupation, or France sending gunboats off the shore in the early 19th century.”

Still, more recent peacekeeping efforts have a checkered past as well. Though they may have succeeded in stabilizing Haiti in the short term, they have failed to bring lasting stability and peace to the country and in some cases contributed to destabilization.

In 1994, a US-led UN peacekeeping mission deployed to Haiti following a 1991 coup, which overthrew the democratically elected Jean-Bertrand Aristide. Mines, who was part of that mission, argued that “the interventions have been, often, the only thing that resets a government in Haiti so that it could function and people [could] eat again.”

“It created the foundation for a very, very, very long process of democratic consolidation,” he added. “That is a long process, particularly for a country like Haiti, whose total civil society had been destroyed.”

But whatever democratic consolidation successfully occurred over that mission and the peacekeeping period that followed through 2000 later collapsed, partly due to the economic strain of international sanctions and alleged corruption after Aristide’s return to power. He fled an armed uprising in 2004, and once again UN peacekeeping forces came to calm the violence that broke out between Aristide’s opponents and his supporters.

Peacekeepers on that mission — which lasted for over a decade — were likely responsible for a cholera epidemic that began in 2010 after the disastrous earthquake, killing 10,000 Haitians and sickening hundreds of thousands more. That incident, according to a 2016 report from then-Special Rapporteur Philip Alston, provided “highly combustible fuel for those who claim that UN peacekeeping operations trample on the rights of those being protected, and it undermines both the UN’s overall credibility and the integrity of the Office of the Secretary-General,” the New York Times reported.

Sexual abuse and exploitation were also an issue during that UN peacekeeping mission, though it’s not unique to Haiti, according to a 2020 Human Rights Watch report. Sri Lankan peacekeepers have been accused of heinous sexual abuses in Haiti, including hundreds of allegations of sexual abuse and exploitation of children , going back as far as 2007, the Associated Press reported in 2017.

It’s too early to know what oversight for the present security mission will look like. A State Department spokesperson told Vox via email that “we continue to prioritize the protection of human rights, and the promotion of accountability for MSS personnel, in conversations with international partners on the Multinational Security Support mission.”

But the big question is: Will this actually work?

Even if this intervention can somehow mitigate gang violence and stabilize Port-au-Prince, it will do nothing to address a parallel crisis: the government’s lack of political legitimacy.

Henry took over as acting prime minister and acting president of Haiti on July 20, 2021, 13 days after Moïse’s assassination. At the time of his death, Moïse had chosen Henry as his next prime minister but Claude Joseph was still technically in the position, creating confusion about who would lead the country. Joseph initially took over leadership of the government, but quickly stepped down in favor of Henry. Over the next half year, doubts developed about Henry’s commitment to seeking justice for Moïse’s assassination.

In the two-plus years of Henry’s leadership, not only has the immediate crisis of the gang violence grown worse, but he has also enabled the hollowing out of Haiti’s institutions. The judiciary — though it was dysfunctional before Henry’s leadership — is largely unable to prosecute gang-related and corruption crimes, and the terms of Haiti’s last remaining senators expired in January, leaving the government with no elected officials, as Henry indefinitely postponed parliamentary and presidential elections in 2021.

And right now, that doesn’t look like it’s going to change. There’s no political agreement for Henry to step down or for Haitians to install a transitional government to go along with it.

That’s not to say that a framework doesn’t exist; in fact, there are multiple frameworks. Two hold particular promise: the Montana Accord and the December 21 Accord, two proposals designed by cross-sections of Haitian society over the last two years.

The Montana Accord provides a roadmap “to create the conditions for national stability with a view to a return to constitutional normality and the restoration of democratic order” over a period of two years. It proposes a National Transitional Council, composed of members of civil society organizations and political parties, which would choose and oversee transitional leadership. Within a month, the leadership would establish an independent body to hold elections. The framework also addresses the matters of constitutional changes and justice and accountability for the perpetrators of the current crisis. It also provides for needs like education, health care, and public safety. The Montana group even chose its proposed leadership in 2022, but negotiations between Henry and the group stalled in August 2022.

The December 21 Accord, negotiated after the Montana Accord stalled by a group of political leaders, civil society actors, business sector leaders, and Henry, is also a potential transitional framework, as Mines discussed in a March blog post. Henry, as part of the agreement, was supposed to hold elections this year, for a new government in February 2024, but there’s no indication that he’ll actually do that.

Thus far, however, the US and the UN have effectively treated Henry as Haiti’s legitimate government representative, which isn’t a view most Haitians, either in the country or in exile, share. That contributes to the perception among some constituencies that a security mission will only entrench Henry’s power.

“Henry has been the sole leader, the executive, for over two years,” da Rin said. “He has ruled without any oversight or control from the judiciary or the parliament that ceased completely to exist in January of this year, when the last elected officials’ mandate expired. So it is really necessary to have a more legitimate government, to have a legitimate interlocutor with the international community and for Haitians to not believe that the … security mission won’t be helping only to consolidate his power.”

But the lack of a political solution shouldn’t preclude an intervention, Rep. Sheila Cherfilus-McCormick (D-FL), the first Haitian American Democrat elected to Congress, told Vox in an interview. “When you see people who are suffering, living in atrocities and violence like we’ve never seen before in Haiti asking for help, who are we to say, ‘No, we don’t want to help, we’re not going to send peacekeepers to fight the gangs,’” she said. “The more we wait, the more lives we risk.”

Cherfilus-McCormick insisted that Henry must step down, though, and that the US has a role to play in that process. “The [Biden] administration does need to go a step further and no longer support [Henry] and support the transition government. There are civil society members who have come together and who have private sector support, who can compose this transition government,” she said. “So why aren’t we supporting them?”

A State Department spokesperson told Vox in an email that the security mission “will not support any political leader or party. It will strictly focus on improving security in Haiti, answering the call from across the Haitian government, private sector, and civil society” and that the Department of Defense will assist with “logistics, equipment, billeting, basing, airlift, communications, and medical support.”

Details about additional humanitarian support — food and fuel for people in Port-au-Prince, medical care, and other critical aspects of everyday life — remain scarce for now, and it will be months before the multinational force has the necessary training, equipment, and cohesion to start its specific mission in the first place. But even though that aspect of stabilizing the country is just getting underway, it’s unclear how far into the future various stakeholders have thought about their decision.

“You can’t send troops in there and combat gangs and think that that’s actually addressing the drivers of instability and insecurity,” Johnston said. “And so what’s your plan? Are you going to occupy Haiti forever with foreign troops to prevent any instability? I don’t think so.”

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