Unemployability and the National Minimum Wage

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I recently a met someone who to all intents and purposes is unemployable.  That is to say they are unable to sell their Labour to any employer in the current Labour Market and I can’t see that changing any time soon.

I met him because we recently recruited a new Production Manager. Our current Production Manager is moving with his wife to Canada as she couldn’t get work as an Academic in the UK.   

We had a lot of really good applicants and could have recruited 2 or 3 times over.  None of the applicants were unemployed, however about a third of them weren’t working. They tended to be older applicants coming back to the workforce after a period on the sick, or who otherwise weren’t economically active.  The unemployable chap was in this category.

We have a rule that we pay at least the National Living Wage, and quite a bit more for jobs like Production Manager.  Confusingly George Osborne rebranded the National Minimum Wage as the National Living Wage, which isn’t very helpful, but it did give Ian Duncan Smith the chance to fist pump in the House of Commons.  I am legally prevented from telling you my opinions of IDS, which I am sure is a great comfort to him.

Paying above the NMW is a good thing on principle but it is good business sense too.  In the North East setting a wage rate even slightly above NMW makes us an attractive employer.  That and the free Gin.   

But it is also because of our experiences of low wages.  We were offered, and briefly tried recruiting a Business Management and Marketing Apprentice through a government sponsored scheme.  For employees like this the NMW doesn’t apply, and most employers pay the legal minimum for Apprentices -£2.60ph.   There was little attempt to hide the fact for the most employers this was just very cheap labour ready for exploitation. 

If you were wondering why there are so few Saturday jobs these days this is the reason. Why would shops employ middle class kids part time for £5 an hour when they can get full time workers cheaper?

We were shocked at the low level of wage, and decided that we would set a wage rate higher than that.  The problem was how much?

I had a contact at the Labour Market Research Dept at the Trades Unions Congress.  For the sake of discretion let’s called him Brother Gavin.  The TUC has one of the few research departments left that looks at wage rates and differentials.  In the past research like this was a big bit of Industrial Relations (for younger readers this is what Human Resources used to be called).

Brother Gavin patiently explained to me that the going wage for someone with no particular skills and no particular experience was £0ph.   The same was true for people with only the lowest levels of manual skills.  There is no wage rate set by the TUC for jobs like that because in a world of the NMW there is no demand for that Labour at £7.50ph. 

The individual who applied to work for us was in this category.  He was a nice chap, enthusiastic and trying hard to get back into the workforce after a period out of the Labour Market, but his skills and experience were very narrow and very out of date.  At £7.50 an hour I don’t know of any employers who would recruit him where he would want to work.  The Care sector always needs new recruits, but he wants a more traditional male job, not a job that he perceives as woman’s work.   

We ended up agreeing a wage structure for our apprentice with the TUC, which paid quite a bit more than £2.60ph, but in the end the Apprentice we had tried to recruit went somewhere else, and we gave up.  We decided not to hire lower than the NLW ever again.

The introduction of the National Minimum Wage is the biggest change in the UK Labour Market in the last few decades and one of the most transformative Left Wing policies of all time.  The increase in wages for people at the lower end of the Labour Market has transformed people’s lives, and as the NLW becomes more prevalent it will transform a lot more.

This massive impact has been almost completely unseen by a huge chunk of the population, who don’t work at that end of the Labour Market, and don’t recruit from there either. This includes a huge chunk of Labour voters. Even cleaners come via agencies who handle the wage negotiations.   

One of the biggest criticisms of the NMW is that it has distorted the labour market – which rather misses the point. It was meant to distort the Labour Market fundamentally.  Lots of people have benefited from as a result.

There are however an increasing number of people in the Labour Market who can’t sell their Labour at £7.50 an hour.   If I can pay even a small amount more and get a wide choice of potential employees who bring a much wider skill set why would I pay the minimum?  The NMW hasn’t just increased wages, it has increased employers expectations of what employees will do.  There are still people out there recruiting people with very narrow skills, however in the North East the supply of basic manual Labour outstrips supply hugely.

While all of this is going on unemployment apparently continues to fall:

http://economia.icaew.com/en/news/july-2017/uk-unemployment-falls-to-lowest-level-in-over-40-years

https://www.theguardian.com/money/2017/may/09/uk-firms-struggle-to-find-employees-even-before-brexit-bites?CMP=twt_gu

I month or two back I wrote about why I don’t buy the idea that unemployment is as low as the statistics claim.

https://jon-chadwick.com/2017/03/18/unemployments-rising-in-the-chigley-end-of-town/

We have huge numbers of economically inactive, and plenty of others who are classed as full time self employed who aren’t working enough hours to come off benefits.   Just under a quarter of the UK workforce 16-64 are currently economically inactive but not counted as unemployed when the Government releases it’s statistics.

Historically there are plenty of examples of labour markets clearing at a level with a high level of unemployment

There was traditionally a view on the Left that it was in the interests of Capitalists to keep reserve of labour that could be used to depress wages. I was never entirely sure how this was actually happening, who co-ordinated these activities?  Was there a club too which, if you were invited, decided how bad unemployment would be.   I think that maybe there have been times when Governments made decisions that led to high unemployment but I am baffled how the Capitalist conspiracy works

What is true however that labour markets might not clear at a rate which leads to full employment, for lots of reasons, and if wages can’t fall then it is likely that markets won’t find a level that creates full employment no matter what steps the Government takes to stimulate demand.  For lots of manual roles it is increasingly easy for companies to replace workers with technology.  Most newspaper articles about technology substitution have photos of humanoid robots to illustrate them, but in reality it is mundane things like Self Service Checkouts in supermarkets replacing manual roles rather than anything more sophisticated.    Clever Digital technology is transforming big chunks of our leisure time, but it isn’t replacing workers to the same extent.  It is old fashioned technology which is doing that.   

It won’t take too long for people to find clever take downs of the technology substitution argument on the internet.  Mostly these rely on the work of Neo-Classical economist David Ricardo to explain why Capital spending and Wages are different things.   The problem is that real actual businesses don’t think or operate like Neo-Classical economists.  If they did no-one would have invested in Spinning Jennies.  As technology removes low value added, low skilled jobs the jobs that are left are more service oriented and require a more diverse range of skills.

All of this doesn’t mean that the NMW is a bad idea – on the contrary it is a huge success.  But this success has had a cost, and that cost is a group of people displaced from the workforce.   As the NMW/NLW goes up so does the risk of further displacement. 

Historically the answer that people have promoted to tackle problems like the has been to encourage increased Labour market flexibility. 

When right wingers talk about flexible labour markets they tend to mean taking away rights and protections to make it easier to hire them or treat them badly.  The acquisition of rights by workers is felt to be a big disincentive to hiring workers.   I am not sure I have ever experienced a real life situation in which this was true, and i can think of more examples where granting extra rights to employees has benefited organisations I have run.

There is however another approach to Labour Market flexibility – making markets more flexible by increasing labour market participation. The wider the pool of potential candidates the easier it is for employers to find someone who matches their requirements.

In particular the big change in women participation in the workforce, has imho, been more significant in increasing labour market flexibility than cutting workers rights, and I am strongly of the view that positive flexibility – increasing the pool of workers by encouraging people from a widest range of backgrounds into the workforce – is a much better way to make markets flexible than cutting benefits and reducing workers rights.  Immigration has much the same effect.

Higher Minimum Wages and increased Labour Market flexibility is all good news even if the Government’s statistics are dodgy.   

But none of this helps people who are unable to sell their Labour at £7.50 per hour.  All main political parties have embraced the NMW, and often compete as to who can make the most attractive promises on raising the hourly rate.

But much less thinking has been done about dealing with the economic and political consequences of Labour Market displacement.  It has become an invisible topic, with older, often male workers in unfashionable parts of the country becoming marginalised, and suffering all of the consequences of that, including short life expectancy.  The only Labour Market options open to them are Self Employment and the On Demand economy.

But just as the impact of the NMW has passed by the majority of the population so has the marginalisation that goes with it.   Left wing pop stars don’t right songs about it, and Left Wing politicians often can’t see beyond the White Vans and the Cross of St George.

When TV addresses this group at all it is in wholly negative terms.  Frank Gallagher has replaced Yosser Hughes.

Does Austerity really kill? If so how many? How can it if we are all living longer?

We are all living longer.  Life expectancy is increasing year on year.

This has become such a ubiquitous news story over the last few years that no-one ever seems to question the concept of an ever ageing population.  While I am not disputing that there has been an increase in life expectancy I am sceptical about some of the claims made, and I am even more sceptical about the way they are used to justify Health policy decisions.

In an ideal world we would like to believe that politicians sit down with Senior Clinical Advisors and Civil Servants, work carefully to identify how to improve how NHS outcomes and efficiency, and then devise strategies using clear evidence and expert reference groups.

In fact this is a pretty rare occurrence, and this style of technocratic policy making is well out of fashion across the political spectrum.  We are sick of experts.

Mostly policy formulation is a massive noisy clamour of ideas. An almost inseparable mass of journalists, lobbyists, SPADs, hobby horse riders and politicians generate a huge number of policy options.  Whoever gets the Ministers ear and can generate sufficient excitement in the papers gets their idea adopted.

Problems are used to justify pre-determined solutions, rather than solutions created to solve problems.  Data is retro-fitted to solutions.  Andrew Lansley in the British Journal of Nursing defended his plans to outsource care to the private sector as reforms to address an ageing population.

Caring for the ageing population and covering the annual £600m of new drug treatments mean NHS costs are rising at an unaffordable rate and underline why we need to rethink how the system works”

In fact these were solutions heavily promoted by lobbyists looking for a problem to pin themselves too. Having been generous in my praise of Norman Fowler last week I think I am allowed to call Lansley a total muppet.

When we look at the ONS data it doesn’t really support my cynicism. Life expectancy is still rising,  and mortality rates are falling.   Comparing 2003 to 2015 Mortality Rates are 20% lower. 

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Lots of people have explanations why the figures are improving. Personally I think that there are 3 broad reasons:

  1. A cohort effect – my Grans generation grew up before the NHS, by Dad’s generation lived all their lives with comprehensive state funded Healthcare. 
  2. A treatment effect – new drugs and treatments have extended peoples life span, Statins, for example
  3. A life style effect – smoking rates have plummeted, for example

Generally the popular press like to emphasise the treatment effect because they are lazy and they can fill masses of column inches by reprinting press releases from big Pharmaceutical companies.   The Daily Mail is the worst offender for this, but most newspapers are guilty to an extent.

The life style effect is harder to quantify because we have to balance out the positive effects on health (huge reduction in smoking, smaller reduction in alcohol consumption), with the negative – obesity levels are still too high and are wiping out too many of the gains made by other public health improvements.

All of this looks like to directly contradicts one of the other most prevalent claims being made in the media – Austerity Kills.  Austerity stories fall into 2 categories; those which deal with individual cases, and those which deal with the impact of austerity on the whole population.

Having worked for the NHS, Department of Health and DWP I can assure you that stories of individual hardship caused by Government Welfare Reforms are true.  Maybe not all of them, but there are clearly individual cases where lives have been shortened, or made unnecessarily harsh due to poor Government policy decisions.   Decisions about Welfare Reform were taken without any consideration of the impact on individuals or on the NHS as a whole.

It seems shocking that any Government should make a decision that shortens anyone life, however lots of decisions are made every year, often with popular support from the public that increase Mortality and Morbidity

For example – we could increase our Cancer survival rates if we disinvested in expensive end of life last chance drugs and spent the money instead on improved access to Diagnostic Tests.  We have known this for a very long time, however it is politically very difficult to achieve.  Pharmaceutical Companies who sell expensive last chance drugs find it easy to get journalists to put their case across, local MPs don’t want to be seen to be withdrawing care, and boring stuff like faster diagnostic access or awareness campaigns to get people to present earlier are easier to cut. The movement of Public Health services to Local Authorities, where they can be more easily cut, has made things worse.   We can measure the impacts of these poor policy choices by comparing deaths over time, or to other countries. 

It is harder however to start and quantify the impact of Austerity at a whole population level, even though instinctively I believe that there has been a significant negative effect.  If you take a population on a low income and you make them poorer, less securely housed and colder in winter time then you will increase their Healthcare Resource Utilisation rate and their mortality rate.

If our overall health statistics are getting better how do we quantify the excess deaths from Austerity?  Is the overall population effect of Austerity a myth?

Going back to the ONS graph we can see a slight uptick on the right hand side.  Deaths increased between 2014 and 2015 for both sexes.  This is pretty unusual.  Since 1995 this is the first increase for men, and the 4th for women – and each of these previous increases were much smaller.  The overall mortality rate increased from 953 deaths per 100,000 population in 2014, to 993 deaths per 100,000 population in 2015.  Total deaths increased by 5.6%, from 501,424 deaths in 2014 to 529,613 deaths in 2015.  

Partly this could be explained away as a bigger population, with more older people having more deaths in winter time.  The increase was concentrated in the first 3 months of the year, which would suggest that this is a short term effect like a virulent Flu or a harsh winter rather than a longer term Austerity effect.

A recent paper in the BMJ compares the ONS data to an alternative view of mortality from the Faculty of Actuaries.  This is a much less well covered source, but has a massive impact on our lives.  It is the actuarial models which determine how much you have to put into your pension, and it is their data which is used by big Companies to justify closing their final salary pension schemes.

Their model of morality showed that mortality improved by 2.2% pa for women and 2.6% pa for men between 200 and 2011. From 2011 onwards the improvement in mortality stopped for men, and got worse for women. 

Had the continued on their trend they would be 11% lower for men now than they are.

The actuarial data shows that the recent decline is not a short term event, driven by a one off event like a virulent flu strain, or a harsh winter.   This is a medium to long term decline. The co-incidence that these dates map exactly to changes in NHS expenditure and the introduction of Austerity measures is hard to ignore.

This starts to give an indication of the likely scale of the impact of Austerity on life expectancy.   Lives are being shortened, or at least improvements in mortality are stopping, and it is hitting women harder than men.

This isn’t the same scale of Public Health catastrophe that has hit Non-Hispanic White Americans without a College Degree that Deaton and Case identified, and which I wrote about last time.

https://jon-chadwick.com/2017/07/01/guns-and-drugs-with-david-wojnarowicz-norman-fowler-klaus-nomi-and-donald-trump/

It does however give us a clear early warning that the improvements in Public Health that we have experienced in our lifetimes are being undone by economic policy decisions in the same way they were in America.

Just like the USA the people who are being affected are being excluded from the debate about policy.   There is plenty of chatter about Social Murder on Social Media, but largely this blots out the voices of the people who living shorter lives rather than making them louder.   If we don’t find a way to represent people in these debates, or give them a voice to challenge preconceptions then maybe an angry orange faced politician will come along who will.

There is of course a silver lining to this rather doomy data.   

The private sector companies who closed their pensions schemes or cut benefits due to an ageing population have received a £28bn improvement in their pension liabilities as a result of declining mortality.   

I am sure that the big companies who are benefiting will use these funds to improve pension schemes, won’t they?

Sources

https://www.nao.org.uk/wp-content/uploads/2004/03/0304364.pdf

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/provisionalanalysisofdeathregistrations/2015

http://adc.bmj.com/content/early/2015/01/07/archdischild-2014-307151

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/excesswintermortalityinenglandandwales/201415provisionaland201314final

http://www.bmj.com/content/357/bmj.j1946

https://www.actuaries.org.uk/documents/summary-cmi-working-paper-97-cmi-mortality-projections-model-cmi2016

https://www.actuaries.org.uk/learn-and-develop/continuous-mortality-investigation

http://www.theactuary.com/news/2017/03/slowdown-in-life-expectancy-could-cut-pension-deficit-by-28bn/

 

Guns and drugs with David Wojnarowicz, Norman Fowler, Klaus Nomi, and Donald Trump. Part 2.

As a partial follow up to my last blog I wanted to share some data on HIV/AIDs reporting in the USA, just to give a perspective on how hard it is to actually get a grip on the data.

This is from the CDC HIV Infection Report 1989:

“All 50 states and the District of Columbia require health-care providers to report new cases of acquired immunodeficiency syndrome (AIDS) to their state health departments. As of July 1989, 28 (56%) states also required reporting of persons infected with human immunodeficiency virus (HIV) (Figure 1). In addition, 10 states (as of May 1989) have proposals on reporting currently before their legislatures, governors, or voting constituencies.

The 28 states that require HIV infection reporting account for 45% of the U.S. population and 24% of U.S. AIDS cases reported as of June 30, 1989. States with HIV infection reporting had a lower median cumulative incidence of AIDS (388 AIDS cases per state or 14 cases per 100,000 population) than states without reporting (1244 AIDS cases per state or 31 cases per 100,000 population). Thirteen (46%) states with HIV infection reporting had greater than 500 cumulative AIDS cases, compared with 14 (64%) states without reporting.

Reporting systems among the 28 states have been developed independently and therefore vary widely in methodology and information collected. In 21 (75%) states, reporting is the responsibility of both the physician caring for the patient and the laboratory that tested the patient’s blood for HIV antibody. In five (18%) states, reporting is the physician’s responsibility alone, and in two (7%) states, it is the laboratory’s responsibility alone. Twenty (71%) states require a positive result on a supplemental test (Western blot or immunofluorescence assay) in addition to a repeatedly reactive enzyme immunoassay (EIA) before a patient is reported; three (11%) states will accept reports on patients repeatedly reactive on EIA; five (18%) states will accept reports on patients reactive on an initial EIA. All states, however, recommend supplemental testing before patient follow-up or initiation of partner notification procedures.

Eighteen (64%) of the 28 states require HIV reporting by patient’s name (Figure 1); however, under certain circumstances, 10 of the 18 states permit anonymous testing and therefore do not receive names on some reports. Most states request basic demographic data, and more than half request HIV risk information. Twelve (43%) collect clinical information, e.g., eight (29%) ask whether the patient was symptomatic, and four (14%) collect sufficient information to allow use of the CDC HIV infection classification system (1). Reported by: State and territorial health departments. AIDS Program, Center for Infectious Diseases, CDC”

In fact it wasn’t until 1999 that large Southern States like Texas and Florida started to produce standard reports on AIDs infections.   The difficulties with this data collection were entirely political – some states were notoriously unsympathetic towards patients with HIV and AIDs and were reluctant to devote resources.    There were still 20 states who weren’t reporting HIV at all, just AIDS.

I knew that there had been lots of delays and inconsistencies in reporting, however I had assumed that from the turn of the century things had got a lot better.

This is from a discussion I had via email about HIV/AIDs data last week:

we don’t have data that goes back that far and I’m not sure you could find it all in one place.  Reporting rules, laws, funding, etc… has changed so much since then and has not been standardized across states for very long in the scheme of things.  Each state and their big cities will have data going back that far but it may not be standardized from year to year or state to state or collected in the same way from year to year or across states.  You could contact each city health department (NYC and SF are separately funded cities so will have their own surveillance programs) and ask how to file a data request for the information.  You could also reach out to the CDC (HIV Surveillance Branch) and see if this is available through them.”

Looks like progress in developing Public Health data is still incredibly slow.

One of the things that we take for granted in the UK is the existence of accurate centralised Public Health data.   This helps inform policy, and allocate resources effectively.  In fact without accurate data it is hard to create meaningful policy interventions and ensure that resources are being spent to best effect.

Worth reflecting on this the next time someone tries to start a debate about whether Government or the free market is the best way to allocate healthcare resources.

 

 

 

 

Guns and drugs with David Wojnarowicz, Norman Fowler, Klaus Nomi, and Donald Trump.

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I don’t often write about healthcare, despite spending a long time working for the NHS, and even longer drinking cocktails with Doctors. I even had the office next to the Chief Medical Officer for a while. His office was warmer and had sofas, but his cocktail skills were mediocre. 

One of the most exciting stories in the press this year has been the reduction in new diagnoses of HIV in the UK, which many are attributing to the availability of PrEP – Pre-Exposure Prophalaxysis drugs.   

The number of new HIV diagnoses has actually been declining for a decade, from 7892 new cases in 2005 to 6095 in 2015. The US has seen a similar decline, albeit from a higher peak, falling to 39,513 cases in 2015.   Heterosexual sex is slightly more common as a means of transmission than homosexual sex between men in the UK.

The cautious celebrations about the improvements in the epidemiology of AIDS are in stark contrast to 2 recent papers from Angus Deaton and Anne Case, which compared the excess mortality rates among non-Hispanic White Americans to the AIDs epidemic. This is from their 2015 paper:

“If the white mortality rate for ages 45−54 had held at their 1998 value, 96,000 deaths would have been avoided from 1999–2013, 7,000 in 2013 alone. If it had continued to decline at its previous (1979‒1998) rate, half a million deaths would have been avoided in the period 1999‒2013, comparable to lives lost in the US AIDS epidemic through mid-2015.”

For those who haven’t been reading the works of Angus Deaton it’s important to point out that he isn’t the disgraced host of Have I Got News for You.  He is the Scottish-American Professor of Economics at Princeton who won the 2015 Nobel Prize for Economics. Anne Case is an expert in Public Health.

Their basic thesis is that non-Hispanic White Americans aren’t experiencing the same improvements in mortality and morbidity as other parts of the US population, due to high levels of drug overdoses, suicides, and liver disease.  While the life expectancy of non-Hispanic White Americans with College Degrees is increasing, for non-Hispanic White Americans without College degrees life expectancy is actually falling.

I am a massive fan of Deaton and Case’s work, which combines economics and public health in a very clever way to shed light on complex Public Policy problems.   It is the comparison with AIDS which was the most striking. 

In fact my initial reaction was to mistrust the comparison completely   

The best way to explore the impact of AIDs in the USA is by looking New York City.   UK numbers for comparison – the 1985 number is the total of pre-1985 deaths.

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The UK population grew from 57m to 65m over the period in question.  New York city grew from 7m to 8m.  If the numbers for NYC look shocking then you are reading them right.

The best known history of HIV in the USA is “And the Band Played On”, by Randy Shilts.   Shilts, and many similar works of the period, detail the awful response of the NYC authorities and the US Government. Mayor Koch, and Ronald Reagan’s Republican administration, dragged their feet in dealing with the crisis due to homophobia, preferring to moralise and blame the victims rather than act.  Money to deal with the crisis was slow to be committed, and access to treatment was delayed.  This was a significant factor in the spread of the disease.

The awfulness of the response from the authorities meant that the gay community viewed early reports and Public Health measures with corresponding distrust, which in turn helped the spread of the disease.  All of this took place in a media environment filled with grossly distorted and bigoted descriptions of “The Gay Plague”.   

Mayor Koch and Ronald Reagan provide a perfect model of how not to respond to a major Public Health issue.

The response of the NHS and UK public health to AIDs may not have been perfect, but is was notably better than the US.  At the time I remember mocking the “Don’t Die of Ignorance” publicity campaign, without grasping how significant it was.  When I worked at DH I realised how hard Norman Fowler had to fight to get any kind of recognition of the problem.   Norman is an unlikely Public Health hero, but his work deserves wider recognition, and he continues to speak out against the prejudice that still hampers the fight against AIDs elsewhere in the world.   

Belatedly the US authorities responded under pressure from well organised public campaigns.  These campaigns were not just political, but artistic, trying to change public perceptions as much as challenge politicians in the face of a media environment which was overwhelmingly hostile.   

One of these artist activists was David Wojnarowicz, one of the first people to address the AIDs epidemic across art and politics.

This is from his early work Rimbaud in New York.

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And this is probably his most famous piece. Silence = Death

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Wojnarowicz died of AIDS in 1992 and his ashes were scattered on the White House lawn as part of a protest against the US Government.

Over time the artistic engagement developed through books and plays like The Normal Heart, Angels in America, and Philadelphia.  Changes in attitudes towards the Gay Community led to changes of attitudes within the Gay community particularly towards safe sex.   

The movement by AIDS activists to gain funding for AIDS research, became a model for future lobbying for health research funding.   From actions of avant garde artists to corporate lobbyists.

By 2016 about 675,000 people had died of HIV/AIDS in the USA, over 100,000 in NYC alone.   This compares to over 20,000 in the UK.  Looking back from the distance of 3 decades we would all like to assume that we wouldn’t make the same mistakes again.

The Deaton and Case paper estimates that there are 500,000 fewer non-Hispanic White Americans than there would be if life expectancy for that group had improved at the same rate as the rest of the American population.  The drivers behind this decline are “deaths of despair” suicide, drugs overdoses (particularly prescription opiates) and alcoholic liver disease.  The epidemiology of these deaths follows a pattern of relatively falling incomes, even though non-Hispanic White Americans still earn more than other groups.   

In essence non-Hispanic White Americans without College degrees have been making bad lifestyle choices for a very long time.  Because they were economically advantaged they had better mortality and morbidity – wealth is a very significant factor in determining health status.  As these economic advantages have been reduced (but not eliminated) the lifestyle choices have got worse, and the extent to which they are impacting on this population have been revealed.  Sorry if that sounds like I am stereotyping, however we are dealing with large populations and lots of data, and it is hard to make that relate to people’s lives without making some rather sweeping statements.   

Despite the large numbers I am still not convinced that the analogy with the AIDs epidemic is right, and not just because of the difference in the numbers of deaths.   The impact of AIDs was particularly profound among specific groups where it had a devastating effect.   The excess mortality and morbidity Deaton and Case found impacts on more people, but it is spread out across a larger population.  We are able to put names and stories to the 675,000 while the 500,000 are largely numbers in actuarial tables.

There was however one aspect of the comparison which struck me when I was looking at the D&C paper compared to the AIDs epidemic.   

The political response has been just as rubbish.

Where you have communities with lots of synthetic opium, mass prescriptions for mood altering drugs, and loads of guns you will have a high mortality rate.   To expect otherwise is bonkers. On the right of American politics measures aimed at reducing access to synthetic opium, mood altering drugs and guns is politically impossible, regardless of the impact on mortality.  On the left of American politics their focus is on the constituencies who vote for them – which means that non-Hispanic White Americans without College degrees aren’t a priority.

But there is something more than just the usual crap US politics at work here. There is a real prejudice towards non-Hispanic White Americans without College degrees.  Red necks.  Mesh backs.  Hillbillies.  We are still blaming the victims for their own morbidity and mortality.  Too fat.  Too stupid.

One of the key lessons of the response to the AIDs epidemic is that if you deal with a population with prejudice and then demand that they change their behaviour don’t be surprised if that behavioural change is resisted.   We are making this exact same mistake again.   

In writing this I noticed one huge difference between the 2 epidemics – the artistic response.  While artists were central to shifting attitudes by articulating the experience of living, and dying, with HIV and AIDs there hasn’t been a similar articulation of the problems of non-Hispanic White Americans without College degrees.  They remain largely voiceless, unable to tell their side of the story, unable to challenge their portrayal in the media.

Once upon a time Bruce Springsteen would have articulated their experiences, but he is on the other side of the political rift in US society, and besides he hasn’t made a decent album in a very long time.   

The person who is articulating the anger and frustration of this population is former reality TV show star and one man performance art show Donald Trump. He is the response. He is just doing it incredibly badly.

 

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This is Klaus Noms, new wave musician, Counter Tenor and one time David Bowie backing singer.  He is sometimes described as the first famous people to die of AIDs.  His death was followed by Rock Hudson, Arthur Ashe and Freddie Mercury.   

There is no reason for Klaus to be in this story at all, other than I was thinking of him when I was writing this, and I wanted an excuse to share this piece of early 80s NY gothic funk.   

https://www.youtube.com/watch?v=gma5IUNMTn0

 

 

Sources

I would like to give a massive thanks to Rebecca T. Filipowicz, from the Department of Epidemiology at Emory University for helping me track down some of the data. 

https://www.newscientist.com/article/2117426-massive-drop-in-london-hiv-rates-may-be-due-to-internet-drugs/

http://www.bmj.com/content/349/bmj.g6096

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/602942/HIV_in_the_UK_report.pdf

https://www1.nyc.gov/assets/doh/downloads/pdf/ah/surveillance2014-trend-tables.pdf

https://www.gov.uk/government/statistics/hiv-annual-data-tables

https://www.brookings.edu/wp-content/uploads/2017/03/6_casedeaton.pdf

http://www.pnas.org/content/112/49/15078.full

https://frieze.com/article/stitch-time-0