Welcome to this session entitled The Deaths of Despair, The Great Educational Divide and Psychiatry, Where is the Hope? I think you all are extremely wise choosers of sessions. It's not easy to pick the best session that's going on, but I guarantee you, you guys have hit the lottery. This is really smart of you to be here. My name is Ken Thompson. I'm a psychiatrist in Pittsburgh, Pennsylvania, and I want to just start this off by saying that I have, in my practice over the last 30 years, witnessed the deaths of despair in abundance. And this particular session, as I've already sort of indicated, is extremely close to my heart because I feel like it's the beginning of a conversation in psychiatry that I am hopeful will help us get beyond some of the limitations that we've had historically in terms of some of the challenges we face, and that will emerge further as we go forward. As I said, I practice in Pittsburgh. I particularly work in an area called the Mon Valley, which is the area of Pittsburgh where the steel industry used to be. There's still a few, there's still actually a coke-making plant and a steel-making plant, but they're both outside the city. The number of people who work in the steel industry in Pittsburgh 40 years ago was about 150,000, and now it's about 4,000 total. So it's been a precarious and very dramatic decline, and uprooted and really changed the fabric of the city and the lives of the people who were in the neighborhoods and communities that have now been solidly left behind. So you can imagine what it was like. One morning, now almost a decade ago, I'm on my way to work and I'm listening to the radio and I hear a report on NPR about a study that's come out that's documenting the extent of the deaths of despair in the United States. And I listened to it and I said, oh my God, somebody is actually understanding what my experience is. Somebody's writing and talking about it. We were not writing and talking about it in psychiatry. This was not an area that we were thinking about. So I, in my old age, I've gotten a little bit audacious, and I decided I was just gonna call the authors of the study who I'm gonna introduce in a second. And I call and I get one of them on the line, and this will give you a hint of who it is. She said, she said, you're in McKeesport, Pennsylvania, and you're seeing the stuff that we're talking about. I said, absolutely, and I absolutely wanna do something if I can to get you to talk to psychiatrists about what you've been learning in this work that you're doing. Okay, that's nine years ago. It's taken nine years to get here, but I'm really pleased. The theme of this meeting, substance use, is clearly a key piece of this story. And I think for psychiatry, which for years and years and years, didn't really worry about the impact of mortality, of how many people died from psychiatric challenges, it was an issue. I mean, obviously, suicide has been an issue and a concern and violence, and deaths are a concern always. But the biggest challenge that we face, as you guys know, historically, has been the incredible number of people who live with disability, lifelong disability, psychiatric challenges, and premature mortality, but not to their psychiatric illnesses per se, but to the medical circumstances that they have. So suddenly, when you find that there's a report that, oh my God, it is psychiatric conditions, suicide, opiate use, alcohol, and I might even throw in violence and some of the other elements there, that is in fact causing, because of premature mortality, the life expectancy of Americans to decrease. And the life expectancy of Americans decreased not at the very end of life, it was people dying prematurely in their 40s and 50s and 60s. The cadre of people who are in this room, for the most part. So that has been a signal event, and I think psychiatry really needs to begin to understand what has been driving that. Earlier today, I went to a session with Nora Volkow, and she talked about the social determinants of substance use, and she talked about it from the concept of there's an outside and there's an inside us, the brain, and our genes, and the outside somehow impacts on our brains and our genes, and causes psychiatric disorders and challenges. Not just substance abuse, by the way, all psychiatric issues, conditions. But she did not talk about what it is that's going on outside. What are these forces that are driving the outside into the American population that's causing them to die young, to kill themselves, to use opiates and overdose, to drink themselves to death? We didn't talk about what those driving forces were, and this conversation we're about to have is gonna be about that. What's been going on in America that causes this terrible plague upon us? I want to introduce our speakers. I'm going to be interviewing them. It's gonna be kind of a loose interview, so I'm gonna ask them to answer some basic questions about their work and where it's taken them. And then hopefully we can turn this into a bit of a dialogue with the rest of you in the audience. They're both professors at Princeton. Are you both emeritus now? It's hard to believe that, you're still active. So Professor Anne Case is the Alexander Stewart, 1886 Professor of Economics and Public Affairs. She's emeritus of Princeton University. She's written extensively on health over the life course. She was awarded the Kenneth J. Arrow Prize in Health Economics from the International Health Economics Association for her work on the links between economic status and health status in childhood, and the Cozzarelli Prize from the Proceedings of the National Academy of Sciences for her research on midlife morbidity and mortality. She currently serves on the Committee on National Statistics. She's a research associate of the NBER, NBER, sorry, a fellow of the Econometric Society, and is an affiliate of the Southern African Labor and Development Research Unit at the University of Cape Town. She is a member of the National Academy of Sciences, the National Academy of Medicine, the American Academy of Arts and Sciences, and the American Philosophical Society. Sir Angus Deaton was born in Edinburgh, educated in Haywick High School at Fettis College, I know where that is, at Fitzwilliam College, Cambridge, where he was an exhibitioner in mathematics. After a brief, and this is hard to believe, I edited this, undistinguished career in the Bank of England, he returned to academics where he remained, where he has remained. He was a research officer at the Department of Applied Economics in Cambridge, worked with Sir Richard Stone on planning for growth. In 1975, he became professor of econometrics at the University of Bristol, and moved to Princeton as professor of economics, public and international affairs in 1983. He became a senior scholar and emeritus professor in 2016. He's the author of almost 200 papers in professional journals and six books, including The Great Escape, Health, Wealth, and the Origins of Inequality. And there's a range of other books that he's written, which I tell you you can look up on Google. He's also been very interested in health and economics, poverty, issues of economics and happiness, and how best to collect and interpret evidence for policy. He's a member of the National Academy of Sciences, of the USA, of the American Philosophical Society, and in Britain, a fellow of the British Academy and an honorary fellow of the Royal Society of Edinburgh. He's a past president of the American Economic Association. He holds multiple honorary doctorates from a wide range of universities. And he received the Svergi's Rigsbank Prize in Economic Sciences in memory of Alfred Nobel for his analysis of consumption, poverty, and welfare. He's a Nobel Prize winner. He was made a knight of the British Empire. Is it British Empire? What do they call it now? Just Knight Bachelor. Knight Bachelor, OK. No Emperor. We disclaimed that right away in 2016. So, very distinguished economists speaking to us. Two other things I want to note. They are married, and they've done this work together. That in itself would, for me, require a prize. And they are economists who haven't spent all their time trying to figure out what economics of health care are. They will talk about that, and they do think about that. But what they've really been thinking about is how the world that we live in and the economic relations and conditions that people live in determines or drives or supports or denigrates their health and well-being. And that's the work that they're talking about here. We are not talking about, we will talk a little bit about the economics of health care. From my understanding and my experience in the American Psychiatric Association and in psychiatry in general, we hardly ever talk about the economy and its impact on the world. We talk about the economy and its impact on how people live. We talk about the economy and how it impacts on our work and our incomes. This is different. This is something different. So I'm going to turn this over by starting with a very simple question. How did you come to this work? What fueled your interest in this? And we can maybe get to the second part. Where has it taken you? Well, first of all, thank you so much, Ken. It's a pleasure to be with you all today. We have not spent very much time with psychiatrists and I think that we would benefit a lot from hearing from you. How did this come about? Back in the summer of 2014, we spend a working holiday out in Montana. And on one side of the room, I was working on pain because it turns out I actually suffer from chronic pain and I thought, no, rare events don't happen to me. That's one of the first things you learn in statistics. So I was looking at the National Health Interview Surveys, which are large, nationally representative surveys run every year. And I was saying, oh my gosh, look at this. People's reports of pain are going up And at the other side of the room, Angus was working. I was working on suicide. Actually, no, I wasn't. Or at least I could tell the parallel story would be I was thinking about suicide and writing about it, but I was not. I was working on happiness at that time. And what a meaning we can attach to these surveys where people are asked how their lives are going in one form or another. And I'd become curious as to whether happiness and suicide were related to one another. And I hadn't worked on happiness for very long, but there were two people in Britain I knew who'd spent their lives working on happiness and they wrote together. And I wrote to them separately and said, what's the correlation between happiness and suicide? And one of them wrote back and said, yes, it's positive. And the other one on the same day wrote back, said, yes, it's negative. And so I was sort of curious. Are places that are happy places, places where there's a lot of suicide? And what I was thinking, I'm a skeptical sort of person, so I was thinking of actually undermining these happiness numbers, which I thought had lots of problems. And they're certainly not useless, but I was suspicious of them. So I was working on the other side of the room and I was looking across states and counties in the US, looking at suicide rates and using a large Gallup survey to look at happiness numbers. And the result of that in the end is they're completely uncorrelated across counties in the US. So this is not helpful for predicting suicide and it may suggest these happiness numbers don't really seem what they seem. One of the big outliers is exactly where we were sitting. The Rocky Mountains in the United States are a suicide belt. They're also a happiness belt. People are very happy as they live there and a lot of them kill themselves, but it's made up for other things elsewhere. So I was writing this up for a conference and what I wanted to do was I'd noticed, coming back to what Ann was doing, that there was an increase in suicide in midlife in the United States between people age 45 to 55. And that wasn't so startling, but what I thought was okay, at this conference it would be a good idea to put that in context. So how big is this increase in suicide? And of course we know that mortality as a whole is going down, so what's offsetting it? And that was when we discovered, when we got together across the room in the middle of the room, that the all-cause mortality rate for white non-Hispanics in America between 45 and 54 was actually rising. And so this just blew us away because this could not possibly be true. There's no large group, remember this is 2013 or 2014, there's no large group in the United States whose mortality rate is rising and here we'd find it. So we thought, we don't do this for a living, we're not demographers, we're not public health researchers or whatever, so we've almost certainly got this wrong. Because if it was true, everybody would know about it, including even us perhaps. And if it was wrong, then we were just idiots, like people who are trespassing in someone else's area. So we couldn't find anything wrong with it, we searched the literature, we looked at all the stuff on mortality rates. There was a huge literature on the convergence between black mortality rates and white mortality rates. But no one seemed to have pointed out the good, they pointed out the good part of that, which was polling mortality rates among blacks, but none of them had actually pointed out that some of that was being accounted for by rising mortality rates among whites and that was what was driving the gap. So we went on tour, we went around medical schools, we went to economics departments, we end up anyone we knew in the medical community and took this work around and people said, we've never seen this, seems right, you really discovered something. And that was what started this off. And the next stage was to find out what was happening. So you could take that. Just that, the mortality rate falling for this demographic over an entire century, the 20th century had been this amazing period where mortality rates year after year after year with a couple of blips like the 1918 flu, but the idea that it would turn around and start rising in the wrong direction was really, it was surprising to us that no one had seen that. But when we started to dig about, well, what is causing this mortality rate to go up, the three causes of death that were rising and rising pretty rapidly were drug overdose and a lot was already being written about the fact that the mortality rate from drugs was rising. But also deaths from suicide and deaths from alcohol, liver disease and cirrhosis. So if you go to the CDC, which we think is underfunded, they do write papers, but they are in little silos. So the people writing on alcohol would say, mortality from alcohol is going up among whites. But then it goes in the drawer and nobody sees it again. Same thing with suicide. Then there were the drugs. So when we put that all together and we published it, fortunately for us, the CDC came right in behind us and said, yes, these three causes of death were large enough to have caused all-cause mortality to go up. But primarily because we stopped making progress against one of the big killers in America, which is cardiovascular disease. We made really great progress after 1970 based on the fact that there were suddenly on the market these inexpensive, effective antihypertensives. And so there was medical advance. There was also behavioral change. People stopped smoking in very large numbers. And rates from cardiovascular disease kept going down. But when progress against cardiovascular disease started to waver, then this increase caused by drugs and alcohol and suicide were large enough that they pulled the all-cause mortality rate up. And that's what we'd find. And then the second thing in that very first paper, we missed the cardiovascular disease story in that first paper. That was the one bit that we didn't get right. But the other thing that's in that paper is we were very keen as economists and so on to have some social or economic background of who was dying. And that's very hard to get, especially for these relatively rare causes of disease. But since 1989, and basically for 47 of the 50 states, since 1992, the highest educational attainment is recorded on the death certificate. So we went, and this whole exercise was based on analysis of whatever, the 12 million death certificates. And that was the beginning of something that's become very important since then, which is all of this bad stuff is happening to people who do not have a four-year college degree. So if you look at people like us, like everybody in this room, you got a four-year college degree or more, you're basically exempt from this stuff with less than a four-year college degree. And it turns out junior college doesn't help you very much either. Less than a four-year college degree, that's where the suicides, where the drug overdoses and the services is increasing. And also the slowdown in cardiovascular disease mortality, which is a big, big, big deal, is actually turned up among people without a four-year degree. Meaning mortality rates are rising. The mortality rates are rising among those people too. So that is the big driver of mortality decline in the last third of the 20th century was the decline in cardiovascular disease mortality. And that has slowed for the population as a whole and it's actually turned up. The other thing that's worth remembering, and I always forget to say this, people without a four-year BA may be very rare in this room, but they're not very rare in America. About two-thirds of the population does not have a four-year BA or more. And it's currently what, about 68%, 62% do not, and 38% have a four-year college degree or more. So this is the majority. And they're voting for Donald Trump. We'll come back to that. We'll come back. We'll come to that. Yes. We'll come to that. You're not allowed to jump ahead of the question. No. No. Stay in your lane, mister. All right. So before we turn it back to you, I just wanted to say that very early on when we saw that it was drugs and alcohol and suicide, we see them all as having something in common. Not everybody does, but it's all, in a sense, death by one's own hand. It's all death that people die of in midlife that they should not die of. And we, as a shorthand, just started to use the term deaths of despair so that we didn't have to keep saying death from drug overdose and alcohol, liver disease, and cirrhosis and suicide. But when we used the term, the press picked up on it almost immediately, and it now has sort of entered the lexicon, and we've totally lost control over what it means to anyone because people use it as they'd like. I should say that it was Anne who invented the term. I was in hospital having a hip replaced at the time, and so I was not there to encourage it. But for us, it's very important that deaths of despair is a label for those three things. We have not invented a new clinical diagnosis called despair, and we're not trying to defend it on those grounds. And that actually is something I hope we will come back to in the conversation to begin to think about what despair actually might be as a concept within psychiatry. And how does what we understand the role of affect and emotions and the way people interpret the world they're in, how does that play out in the experiences that you guys have noted? So let's go to where we are now. We've sort of talked about the big fact, which is alluded to even in the title of the slide. I neglected by the way to mention that we have no disclosures. Nobody's got any affiliation with any pharmaceutical company or anything like that, just so we're clear about that. We've talked about the great education divide and its overall impact. What about some other areas that have shown up and where I know issues of concern, particularly around race, ethnicity, and how's that played out as time has moved along here? Because initially it was reported, I remember it as being reported, you know, it's white men and white working class men who are all dying, and that that was sort of the way the story went. That was the way the story was reported in the newspapers, but sometimes the news report would be correct, but the headline would say white men dying or worse, white rural men dying because apparently there's real prejudice against white rural men. It was always men and women. It was always urban and rural. One of the things that's changed from when we first started working on this though, is it's now not just confined to white non-Hispanics. When we started this work, it was the case that mortality rates from drugs and alcohol were falling very nicely in the African American community, and they were rising in the white community. And actually after about 2008, the mortality rates from alcohol and from drugs were higher among whites than they were among blacks. They were going in the right direction for blacks and the wrong direction for whites. And this was stunning to us, to think that like this, what is known as like the most privileged group in America, we're seeing this kind of dysfunction really got a lot of attention, especially in what was soon to be Donald Trump's America. But also something that I should have said before was that these stories are evolving, right? There's like the battlefield is a dynamic place. And so the things that we tell you about today will be true through 2022, which is the most recent data that we have. It takes the CDC a very long time to get all the death records from the states and anonymize them and make them available to the likes of us. So it is something that has changed over time with the arrival of fentanyl, that starting in 2013, mortality rates from drug overdose among African Americans stopped falling and started also to move in the wrong direction. And although African Americans are a lot less likely to die of suicide, suicide rates among African Americans have also started to turn around, although the rates are still much lower than they are among whites, they are also moving in the wrong direction. Yeah. I mean, one thing that's worth pointing out here was that, you know, black mortality rates have always been higher than white mortality rates. And, you know, we were focusing on whites because this was a group that no one had seen these bad things happening to. And we were just two or three years too early to see this going into the African American community. One story of why this happened was the initial throws of the opioid epidemic were iatrogenic. I mean, it came from pharma companies, you know, pushing doctors to prescribe oxycontin. And so there were painkillers that were being prescribed on a large scale. Very few of those were prescribed to African Americans. And there's a literature, not our literature, on, you know, African American pain is not taken as seriously as white pain and doctors don't prescribe as much. And in this case, that was good for them. But when the doctors pulled back and people started replacing oxycontin with heroin, which the dealers were selling outside the pain clinics, you know, here you are, your doctor's taking you off your oxycontin, we're going to substitute. And so there was this big switch to heroin and then later to fentanyl. And then when it became legal, sorry, when it became illegal, when it switched from legal to illegal drugs, it also moved into the African American and Hispanic communities. And you see this convergence, this decline in black mortality rates begins to reverse around 2012, 2013, as this horror moves into the full community. What has not changed is, and there's now a huge division between African Americans with and without a college degree. So what we said before about if you have a college degree, a four-year college degree or more, you're exempt applies to African Americans as well as to whites. And in fact, the gaps in mortality that are still big gaps, and they're big gaps for whether people have a BA or not, but it used to be that there was very little difference between African Americans, whether or not they had a BA and very little difference for whites. But the blacks with the BA crossed over the whites without a BA and the mortality rates for blacks with a BA are now very close to the whites with a BA and the whites without a BA are very close in mortality rates to the blacks without a BA. So the educational effect has grown enormously while the racial ethnic gap has become smaller over time. Some of that for good reasons, some for awful reasons. So one way that I think in psychiatry that we live through this is we obviously have been aware of the growing numbers of people dying from substance use and opiate ODs. We are aware of the inexorable climb of suicide, and in fact, we went to lunch, and I don't know if you guys have been down to the Hudson Yard to see the vessel, which is closed because people started to jump off of it. So you can't actually go up it. It's a giant monument to suicide right now and the despair that's out in our communities. Suicide as we've been aware of that, we probably haven't talked so much about the steady increase in the deaths from alcohol. But is it the fact that it's in a particular population that makes you decide that these are all somehow related to each other and rather than just sort of, boy, isn't it weird that these things all happened at the same time? I just see them all as showing a certain amount of despair. I mean, people don't wake up in the morning and say, I want to be a drug addict or I want to be an alcoholic. I think there are things that have happened. I can see that. Yeah. Why don't you say that then? Okay. You go on. I think that there was a study done, for example, in Flint, Michigan, in an ED where they used naloxone to bring people back from drug overdoses. And they allowed survey work to be done in this ED and people that they brought back from drug overdoses, they asked them a battery of questions. And one of the questions was, were you trying to kill yourself? And not a majority, but something like 40% of the respondents said they didn't know. So if the respondent themselves say they didn't know whether or not they were actually trying to kill themselves with this drug overdose, it's very hard for us to think that a medical examiner or a coroner is going to be able to make a precise determination of that. And so for us, binning these things together as well helps us not have to pretend we can make a determination whether or not this was accidental or whether this was intentional. Yeah. Someone once pointed out that, you know, you may not have meant to die, but that needle in your arm didn't get there accidentally. So these are classified as accidental deaths. But there was something else I thought you were going to say, which is, I don't think you said this, so let me say it again, that we think suicide in some ways is our guiding light here, because suicide kills you really fast, drugs kill you a bit slower, and alcohol kills you more slowly. But we've been very guided by Durkheim, which is not something economists usually read or think about, but these as being—so there is a sort of suicide element to all three of these deaths. So the second point I want to make is an empirical one. So one of the critiques of our work, which we would resist—we don't resist them all, but this one we would resist—is they say that, you know, in some places in America it's alcohol, in other places it's drugs. West Virginia, it's drugs. There's very little alcohol in West Virginia and very little alcohol deaths in Utah, for instance. In Utah, there are a lot of drugs. So they say the fact—if it's truly deaths of despair, you'd expect these patterns to be the same for all three cases, and that's not the case. And it's not the case simply because people, as Anne often likes to say, pick their poison. You know, if you're in a place where you were brought up not to drink alcohol, like Utah being a very good example, drugs and, you know, being a Mormon did not save people from the opioid epidemic, for instance. It did save them from alcohol. And so on around—I mean, these patterns are different in different places because of the different religious beliefs, different customs and morals. And so that's another good reason for sort of adding them together somehow, because each is not the same everywhere, and each is a sort of exit strategy. But interestingly, there's been really good work by—I believe he's a psychiatrist, Olson. Mark. Yeah, Mark Olson. Who looked at—who was able to take what is now the long form of the census, which is known as the American Community Survey, and match it with the National Death Index, and look and follow people through time and see what happens to people. And he knows a lot about them because of the census, of the long form of the census. And he can see who dies of drugs and alcohol and suicide. And a lot of the characteristics that are present in one are present in all three. For example, for all three types of death, people with a bachelor's degree or more are protected, but other educational categorizations are equally not protected. College is protective. Income is protective. I'm trying to think what else. But so all three of these seem to respond to economic circumstances and social circumstances in much the same way, which is also a reason why we put them together. The exception that proves the rule is veteran status, because veterans are less likely to die of drug and alcohol deaths, but they are more likely to kill themselves. But that is like the exception that proves the rule on people's social and economic circumstances. They also have- Things like unemployment. I mean, at some point we're going to get to what you said about the beginning, about deindustrializing. Right. Well, that, in fact, is where we're going to go. I was just going to comment that I don't know what the protective factor of the VA, but the only national health service that we have is for the veterans. So maybe that's a sign that there's some things that good care can do for people. Let's turn to the economy and the way we arrange our economic world. You know, I can imagine that there are folks who would say that this divide that you've noticed is somehow being driven by immigration, that it's being driven by automation, by globalization, that these are sort of the wages of those particular challenges that our society has been facing. How do you guys see this, and what is the economic restructuring that has caused this event to happen? Of course, because these are very long, slow-moving events, it's not like being able to run an event study and say, you know, at this point in time, this thing changed, and we can look right before and right after and see what kind of difference we find in terms of— There is some of that. There's some of that. For example, when China entered the World Trade Organization, we know the date of that, and there are researchers who have looked at places at a small level, at a commuting zone level, and seen that suicides are higher in those commuting zones where there was suddenly real competition from China. So there are a few of those, but most of the things that we're talking about are long, slow-moving events. So what we tell you is our best understanding of what's going on right now. Part of it is that for the likes of us, the North American Free Trade Agreement was a wonderful success, and globalization has been fabulous. It's meant that the U.S. has grown faster, and we can all buy beautiful glassware that's incredibly inexpensive, and anything else that your heart desires. But for people who were working in industries that were hit by these changes in globalization or have been hit by automation, their worlds came apart. They lost good jobs—jobs with a ladder up, jobs with on-the-job training, jobs that allowed them to get married. Working-class people tell our friends as sociologists who run surveys, and they tell us, our people tell us they can't get married until one of them has a good job. So marriage rates among people without a bachelor's degree plummeted. People cohabit, but unlike in Europe where those cohabitations tend to be quite stable, in the U.S. those cohabitations are really fragile. So people cohabit, they may have a child, they break up, they may repartner, they may have another child, but there's no stability in their home life. They've lost good jobs. Many of them have left the labor market altogether because they can't get a job at a decent wage. So instability in their work life, in their home life. They've stopped going to church, which in the U.S. was an incredibly important institution for 250 years. It was a place people could go for solace. They could go and get help. People would understand them. Well people have rejected that now, and it's not that they don't consider themselves spiritual, that takes place outside of a framework that might actually give them help. So that would be what Durkheim, who we've already talked about here, who wrote a tome on suicide in 1897, would call a recipe for suicide. That kind of instability, that kind of social disintegration. Yeah, I mean this deinstitutionalization, another important part of it is the sort of social capital that Bob Putnam wrote about, for example. You know, that book was called Bowling Alone, and the guy who was bowling alone was bowling in a union hall. That union almost certainly doesn't exist anymore, that union hall is gone. There used to be nearly 40% of the American working class was unionized in the private sector. Today it's 6%. And unions, I mean, I belong to a group that, especially when we grew up in Britain, unions were not our favorite people, you know, they caused disruption and all the rest of it. So when I talk about unions, especially to, you know, educated economists, I can see the room beginning to chill around me. But let me say a few things. There's a long, distinguished, pretty conclusive literature that unions raised wages for their members over what they would otherwise have been. They also raised the wages of non-members in the same industry, because you had to bring up the general thing, and they got some benefits too. The federal government is not capable of enforcing all the work standards and safety standards in every factory in the United States. The unions did that. So there's a lot of safety at work that was guaranteed by the unions. The unions were very important socially, as in Bob Putnam's Bowling Alone. There was a place to go, they were part of the life in the community. Perhaps most importantly, they provided political power, and they provided political power in local communities, they provided political power in the states, and they provided political power in Washington. So the unions were important in selecting politicians, they were important in lobbying. There was one year, this is, I checked this the other day, but it's changed a little bit. There was one year in which Alphabet, which is what used to be called Google, spent more money in Washington than all the trade unions put together. They backed off a little bit, and now it's Alphabet, Apple, and Amazon together that spend more than all of the unions spend. And that's not an accident. You know, the Chinese didn't do this. The deindustrialization didn't do this. Politicians did this. And the politicians backed by capitalism, by rich capitalists, in fact, have fought against unions from the start, and they've been very successful. They made it very hard to unionize, they've changed the laws, the right to work laws, which didn't used to exist. You're not allowed to, everybody had to pay in something to the union, that's no longer true, the Supreme Court struck that down. So you've had a legal and political environment that's gone after unions, and they've gone after unions for a very good reason, it means more profits and lower wages. And those lower wages, as Anne said, have all these social consequences, so that, you know, it's undermining marriages and so on. I mean, I think when we started this work, I was thinking, how would I feel if I had three kids, none of whom I knew, all of whom were living with other men and whose mothers were people I'd been involved with at some point in my life in these very fragile cohabitations. I mean, that is a recipe for social disaster. There's no church. There's no union anymore. This is what's happening in these communities like Ken started with. I mean, you know, and when he talked about— I wrote it down there. There were, what, 350,000 steelworkers, and now there are 4,000 steelworkers. That didn't happen overnight. That wasn't because China came in. It was because of a slow war against industries and deindustrialization, and Europe has handled that much better than we've handled it here. And something else Europe has done better, and this also comes to, what? Is it globalization? Is it automation? A story that we tell in our book and that we think is incredibly important is that to understand what's happened to working-class Americans, you also have to understand our healthcare system. First of all, the way we fund it, which is through employers. And second of all, that it is the most expensive healthcare system in the world. It's twice as expensive as most European countries, and it's half again as expensive as the next most expensive one, which is now a tie between Switzerland and France. The Swiss live five years longer than we do, and they spend much less than we do per head on healthcare. Now, why does that affect wages? Well, if I'm an employer, and I've got a working-class employee, and I have to pay $24,000 a year, which is now what a family policy costs, or my share of it, which is on average 70% of that, so call it $20,000. Suppose that worker's really only worth about $45,000 to me. I don't care whether I give that worker the money, or I give the worker some of that money, and I use the rest to pay the health insurance, which I am obligated to pay. Well, I'm going to, eventually, I'm going to decide I can do without that employee. I'm going to outsource those jobs. So, you know, if I'm a fancy hotel chain, and people used to be part of the family, the people who worked in the motor pool or cleaned the rooms, those people no longer work for the fancy hotel chain. They have no chance of moving up within the system, and so they're working at jobs where their benefits are lousy, they could be fired if they lose a few days of work from being ill, and so the cost of us providing health care, as poorly a job as we do in the U.S., at stunningly high prices, has a lot to answer for when it comes to the sorts of questions we're talking about today. Ken wants us to say that this is not your fault. Yeah. We, it's not. Not a psychiatrist's fault. It's not the psychiatrist's fault. You guys are not the problem. Not the main problem. The problems are hospitals. The problems are device manufacturers, and the drug manufacturers. They're the big, big, big items here. And the insurance companies. And the insurance companies. Which, in a sensible system, would not exist at all, because if you have a single-payer system, you don't need any insurance companies. They don't really exist in Britain, except as a subsidiary sort of thing. But maybe I can tell you a story that, we got onto this fairly early on. One of our relatives in our family was in the C-suite of a large oil company in the United States. And he told the story that one year, their health and, what are they called? The HR people. The HR people came along to their annual meeting for planning for the next year, and the HR people said, we have bad news for you. Our healthcare premiums will be 40% higher next year than they were last year. Now, that didn't happen every year. But, you know, sometimes it went up by 5%, sometimes by 20%. But there's an inexorable increase in these rates. And so, all the executives are just sitting around saying, we can't pay that. It's just not possible. And the HR people say, well, that's the bill that's coming in. And they said, what do we do? And they, well, they hired McKinsey, whose reputation is not so great these days either. So what McKinsey does is they do what they call reduction, they reduce the headcount. And of course, who are they going to fire? They're not going to fire the C. The thing about health insurance is, you're basically insuring a body, not insuring a salary. So if you earn $300,000 a year, your annual premium is still $24,000 a year for a family or 12 for a person. If you're the janitor, it's 24,000 for a person, 12 for a house. So the CEO and the janitor, it costs the company the same amount in the healthcare cost. And so what do you do? You fire the CEO, you don't fire the CEO, you fire the chauffeur. And so large corporations in America now basically have none of the service jobs that they used to have. So that's security, drivers, cleaners, all the maintenance staff, and all the rest of it. And that all being outsourced. And when you think of outsourced, you think of outsourced to India, but this is local outsourcing. And these outsourced companies are terrible places to work. You don't have, I remember as a kid in Scotland, you know, if someone we knew got a job with a big industrial outfit, like ICI was a big company in those days, it doesn't exist anymore, Imperial Chemical Industries. Or if you got a job like that, even if you were in the mailroom, which of course doesn't exist anymore, there's no email room. But if you got a job in the mailroom, you thought you were made for life. Because you had, you know, it was a good company, you belonged to this enterprise, which mattered to you, and you had the chance of working your way up. And it's not common that janitors finished up as CEOs, but it's not unknown either. And I think much more important is just the sense of community. One economist wrote that the guys, I think it was at Google, you know, who used to work for Google, and are now working for an outsourcing company, and they're doing exactly the same jobs they were doing before, but they're being paid a lot less. And the only difference is they don't get invited to the Christmas party anymore. You know, and that is a bad thing for people. So, you know, I think we've kind of gone through some of the potential villains here, the healthcare system, and the extravagant costs. I should mention, just so you guys don't feel so bad, of the, you know, if you had $100 of healthcare spending, about 6% of that goes to mental health. About 5% goes to primary medical services, and 2% goes to public health, which leaves, what is that, about 87% that is, in fact, going to the big corporation, healthcare, hospital kind of industry. So, one of the reasons that we all struggle so much to get the resources that we need is because it's being used by that mega entity within the corporate world that healthcare has become. We could use the words like neoliberalism as a way to describe some of what you guys have been, you know, describing here as sort of a failure of our economic system to make the resources and opportunities available for people to be healthy, to have the jobs that they need, to have the family lives that they need. You know, there's, something's obviously been failing, right? Instead of going in the right direction, been going in the wrong direction. Not for people like us. Except for us, which is where I wanted to take this. Thank you. What has this meritocracy, if I can use that term, what, how do we think about this meritocracy that we've created? We are clearly, even though we're only getting 6% of the healthcare dollar, that's a tremendous amount of money, folks, you know. We are the beneficiaries in this room, in this profession, of this meritocracy. How can we begin to think of what are we going to do to change what could be done to start to change how resources are distributed in our society? How do we recognize and support and reward the folks who are, you know, the essential workers, right? The folks who are out there whose wages have been frozen, whose family lives have been deteriorated in the way that you described. What kind of future do you guys see? What's a possible hopeful future? What could be done to combat despair? We could stop persecuting unions, which would be a good start. But, you know, we want to be very careful here. This is something that we can't do. I mean, you and your practices can do good things and you can help people. But, ultimately, political power has to come from people who grab it and take it. And right now, they don't see much alternative to Donald Trump. And a lot of that is our fault because we blame it on them themselves. We don't like unions. We persecuted unions. The legal system is tipped towards that. So that political power has to change. And, you know, we were talking at lunchtime today about how in Britain in 1945 when the Labour Party came to power and Clem Attlee had a cabinet, that cabinet had seven men in it who'd started their lives at the coal face. You know, that was a viewpoint that was well represented there. Now, that viewpoint is not represented at all. It's not represented through unions. It's not represented through Congress. There's only one member of the Senate who doesn't have a BA and they have some advanced other degree. I think there are three members of Congress who don't have a BA. The people we're talking about here just, they need to be represented and they need to be telling us what to do, you know, and we have to give them that power. There are a couple of other parts to this, though. One is that before the internet took over our lives, if you wanted to advertise a job, you would put an ad in the newspaper and you might get a couple hundred applications. But with the arrival of the internet, you might get several thousand applications for a job. Well, one very cheap way to, thing to use as a screen is a bachelor's degree. You know, that people without a bachelor's degree need not apply. Whether or not the job needed a bachelor's degree. So there's now been some pushback against that. Several states have changed their hiring practices so that if you say a bachelor's degree is needed for this state job, you have to explain in detail why that's the case. And companies like IBM and Accenture and Merck Cleveland Clinic have also taken this to heart and are no longer requiring a BA when it isn't needed. So there's, that is a, as a potentially hopeful sign as well. But one thing I think we want to be careful of is that the people we've talked to who are working class people, they don't want a handout or what they consider a handout. They don't want a handout, they want a job. They want a job that gives them self-esteem, that gives them status in their communities. And so rather than redistribution, there may be some scope for what is known as pre-distribution. Just change the rules of the game. You know, tighten up on tariffs. Make it competitive to actually start making glass again in the U.S., just as an example. But just try to think that perhaps we owe more to people who live inside our borders than we owe to the rest of the world. That's a controversial statement. Some people would say that if you're a cosmopolitan, a prioritarian, meaning you give priority to the poorest, and cosmopolitan meaning you do that around the rest of the world, then you would say, well, people in the U.S. just aren't as poor as people in Bangladesh, so I just think that's crazy to think about the poor in the U.S. But I think what that means is that that is actually, first of all, very ignorant about just how much poverty there is in the U.S. And second of all, there's got to be a real dialogue about what we owe people who are citizens of this country relative to citizens of the world. Angus might have something he wants to add to that. I'm not sure. I had something, but I've lost it. Okay. Okay. You'll come back. I'll come back. In psychiatry, we say that whatever's really important will come around again. Because I don't know about any of you out there in the audience, but I've frequently had something I wanted to say, and it went away while I was with a patient. And then it does turn out that it does come back up again. And in fact, in that whole process, I lost what I was going to say. So it may come up as well. But I think maybe the way for me to go forward at this moment, since it's not coming right yet, is to say we are at about 2.30, and that means that it's time for the audience to have a go at these folks and ask a question. So Larry, why don't you step on up and take a shot? Hi. I'm Larry Merkel from the University of Virginia. I'm a psychiatrist and an anthropologist, and I've been doing clinical and field work in central Appalachia, southwest Virginia for close to 30 years now. And with this question of death due to overdose versus suicide, I can tell you some from my experience down there. It's based on Raymond Firth, who was an anthropologist, one of Margaret Mead's husbands. He did a study in Ticopea where he looked at there was a group of people who very clearly wanted to die, and they committed suicide and died. And then there was another group that wanted help, and they would get the help. But there was this group in the middle that maybe they might die, maybe they wouldn't, and he called this gambling with death. And that's what I see in Appalachia. These are primarily evangelical Pentecostal people, so that's a very important part. I was down there talking with the deputy sheriff in one of these little small counties, and at that point there had been five gunshot suicides and about 20 deaths from overdoses. And he told me that he was sure that some of those people that died from overdose were trying to kill themselves. And when I've talked with people that have survived those kinds of things, what they tell me, like your group that says, I don't know, what they tell me is that if God wanted me to survive, I would have survived. If God wanted to take me, he would have taken me. So that's the gamble with death. They're upset, they're despairing, they're overwhelmed by poverty and discrimination and stuff, and they've sort of had enough. So they throw the answer to God, put your problems in God's hands, and they shoot up. And if they live, okay, well, maybe God wants me here for some reason. And if they don't, okay, they didn't. So that's what I see a lot of with that. One real quick thing, with the education difference in southwest Virginia and central Appalachia, as in most places, schools are paid for by property tax. In those areas, though, so much of the property is owned by timber companies and coal companies who don't have to pay any taxes because they made this deal with the state government a long time ago. So the only property taxes that are paid are by the poor people that own their homes. So there's very little money for education. So the education, as a consequence, is very poor. And then going along with what you said, they very much value getting a job. So why finish school if it's not going to do me any good? Let me get a job. And in their evangelical view, having a job and succeeding with that, having some value in their life from working is one of the key things. That means you're select by God. So just a little bit of tidbits to throw out to you. Thank you. Thank you. That is really— It sounds a lot like Barbara Kingsolver's book. Yeah, yeah, yeah, yeah, I—the people she was talking about in that book— These are your patients, yeah. Same place, absolutely, yeah. Thank you. Thank you. Hi, I'm Paul Nestedt. I'm the director of the Center for Suicide Prevention at Johns Hopkins. And I also work on a dual diagnosis unit, and that's my inpatient. So I sort of am fairly— You work— We work— A dual diagnosis unit. It means people who have substance use disorders, but also another psychiatric disorder. And I work in Baltimore. I was born and raised in Baltimore, so basically a collapsed steel town. We see despair. I certainly appreciate the value of unions, for sure, and the lack of them. However, as a suicide researcher and epidemiologist, I don't see people dying by suicide because they're despairing, or because they're sad, or because of lack of church, or family dissolution. I see psychiatric illness, of course, but I also see people that make very impulsive decisions sometimes. And so most of my research is focused on the role of guns. And I think that when I hear the epidemiology that you report, especially the racial differences— You mentioned the increase in black suicide, which I think has been most dramatic over the past couple years. In 2018 to 2021, we see a 16 percent increase in black suicide, even while white suicide actually kind of drops a little bit. A little bit, and now it's back up, yeah. But that black suicide increase, that 16 percent increase in that period, was driven by gun suicide. Every other method actually decreased. The other population went up as youth, of course. Youth suicide went up a little bit. Again, only gun suicide. Poisoning, hanging, everything else down. And we saw that after 2020, when there was an unprecedented run on guns. And there was sort of a disproportionate increase in gun ownership in black families, and in urban communities, regardless of race. And that's where the suicides went up. So I was wondering if you could comment on the role of lethal means access, guns in America, in terms of the suicide deaths. I know that's less relevant for a overdose. No, thank you. That's really interesting. And certainly having the means close at hand does make a difference, right? So having—you're unlikely to survive if you've got a gun and you use it, right? But the one thing that's interesting is that the dramatic increase that we saw in suicides from the 90s through to almost COVID is entirely among the people without a college degree, right? So if it's an impulsive move, it's an impulsive move just for that group. It's a group that directly tracked with gun ownership. College degree is another divide. And I feel like because the vast majority of suicide attempts are survived, 92% are survived, and the vast majority of suicide attempts are by policing, which have a 2% decalibration, that access between these is more than just this is one more community away, it's the difference between each one of the suicide attempts and the 150,000 suicide deaths. Right, but that still leaves the association between gun ownership and the need to have a gun, perceived need to have a gun, and the social category of folks without, you know, with a high school or less education. They don't seem to have a need to have a gun so that they can kill themselves. They have this lots of complicated psychology behind why they don't want to have a gun. Precise, no, precisely, but there's something going on in the minds of the population that deciding to arm themselves to the degree that they've decided to arm themselves. I think something like 80% of all gun deaths are suicides. 60%. 60%, but it's the majority of gun deaths are suicides, which is something that's strongly resisted on the right. We've been sympathetic to this, but part of it is when we started our work, it's very hard, the interview surveys do not collect data on gun ownership anymore because of the NRA, so it's actually been very hard to do that work, but it could be that this increase in suicide in the U.S. is all gun-driven. I don't think we'd object to that. No, it's not all gun-driven. Strangulation, hanging, that's also gone up quite a lot as well for both men and women. We should look into that. Yeah, we'll look. We've done some early work in which, within regions in the U.S., there was no correlation between suicides and gun ownership, even though there is the Rocky Mountain thing versus, you know, the coast. But we don't think of that as very strong. That is, you know, it's our, but it's probably, one thing that maybe we could come back to a little bit. These, this is not suicides, but it's, the metaphor's still there between suicides and drugs and things. And also, the sense that every time, historically, there's been a major opioid epidemic, it's marked social disintegration that existed before, like the American Civil War, the opioid wars in China, the gin craze in India, in England in the 18th century. So, I don't know, but these are really good questions and we should work on them. Just apocryphally, I have been told that when the Union Hall started to fall apart in Pittsburgh, the entity that moved in were the gun clubs, and that the gun clubs are the places that families go to organize their Saturday and Sunday picnics. So that's a, there's a correlation here that we obviously, what the causal links are and what the attitudinal links are is clearly something we need to sketch out more. Come on forward, sir. Thank you so much. Extreme honor to be here. My name is Matthew Basilico. I'm a resident psychiatrist at Yale. I actually did a PhD in economics at Harvard. David Cutler, Nathan Nunn. So, and I go up there on Mondays to lecture in the development sequence, and then in the spring I'll teach a class in economics and mental health. I think it's the first time. So, first of all, thank you so much for putting this together, and it's amazing to speak in many rooms where everyone would know who you are, and I have also experience in psychiatry of bringing both the kind of title of your book and then teaching Auditor in Hanson Pearson showed this, you know, deindustrialization shocks and kind of trying to explain your death and despair. And I'd say without a doubt, every resident I've talked with about this gets very interested in your work. And I guess what I want to suggest is with my psychiatry training, I think that there is something that's very important psychiatrically that you've identified that I'm not sure in our training or in the DSM that we have updated to, and it's of the following degree of specificity around types of distress. So I think we either think very blanketly about distress that might lead to anything from depression, anxiety, trauma, even schizophrenia risk, to very specific diagnoses from opioid use disorder to alcohol use disorder. What I understand from my read of your work is that kind of deaths of despair, we see increases in this specific set of life-ending desires, or at least kind of giving up on oneself as one's going through life. But then also this, as you say, proclivity to perhaps the authoritarian mindset, kind of far from Hannah Arendt. And again, I was interested, you kind of said that there's some piece of the deindustrialization story, but maybe that's not exactly it. I'm also kind of drawn to the post-Soviet work of Culler and Brainer. But I guess for kind of the psychiatric audience, I'm wondering if you could for a moment imagine yourself in kind of a clinical situation to say what is it that you're seeing kind of phenomenologically that folks in these categories would be at risk for these prefective diseases or even a set of political beliefs based on a set of demographic risk factors, deindustrialization, et cetera. But perhaps even further down, obviously there's hundreds of thousands of people that have these risk factors in the U.S., but only a subset of them are actually taking their own lives, and that's exactly the people we see in the clinic. That's a, do you want to take a stab at that? No. It's very useful, but I'm not quite sure what to say about it. I mean, it points to this idea of an authoritarian mindset. We think of the authoritarianism as just some sort of relief against what seems to be happening. It may be a lot more than that. I mean, my read of Arendt was exactly sort of this kind of similar type of distress, right, that come in these periods of identity instability. And again, I know the economists aren't kind of stretching a bit, but she saw that in the Weimar Republic that there was in that same kind of identity search this lurching for security, right, and that maybe for some people the same set of risk factors is security. For some of them it's, I'm gonna, and for some people it's opioid overdose or alcohol becomes a palliate. I guess the second thing I'll throw in there, again, with Paul's perspective at the time, I would just say I'm also really curious, just to give one maybe psychiatric kind of suggestion, is in the role of neurodevelopment in what we're seeing, because borderline personalities were something very comfortable in this room but not as comfortable in the, or like a utility function or things in economics, but the notion, like the attachment would be affected by family structure, transgenerational effect, and then perhaps that increase in kind of affective reactivity could lead to all these different things at once, but a specific set of, but again, thank you so much for coming in. I appreciate it. Thank you. Let me make maybe two quick responses to what you've just said just to try to tie a little bit, because I wanted to say this when you mentioned bringing glass back to the United States. One of the things that I had the experience of was there was a city outside of Pittsburgh, a small city called Washington, Pennsylvania. They call themselves Little Washington, and it used to be a major glassmaking center for the United States. I had a phone call from a young woman there who was part of an initiative to redevelop the downtown area of Little Washington, and she called me and she said, I know you're a psychiatrist, and she was on a rowing team that I was on. She says, I know you're a psychiatrist, and I know that you talk about issues of depression. What do you do when the whole town is depressed, when the whole place is depressed? And when you talk to them about what might be their future, the only future they have is what was in the past, i.e. to become a great glass manufacturing center. So if that ever becomes possible, sign up Little Washington. They're ready to go. But the reason I mention that is because I think one of the tools that we lack in psychiatry is that we work all the time from the level of the individual. This collective emotional experience is a collective emotional experience that is in a cadre of people who live in a world that is not the same world that many of us are inhabiting. And their experiences and their emotional lives that they're having are not reducible to an individual state. It is a experience of what is happening around them in all sorts of ways. So I think we have to begin to think a little bit more beyond our way of understanding diagnosis. There was another comment, but I'm gonna let it go because I wanna make sure everybody gets a chance to ask a question. Hi, I'm Alexander Moreira Almeida. I'm professor of psychiatry in Brazil. First of all, I'd like to thank you for the wonderful presentation. I have two questions. One, sometimes people think that this increase in death, of despair, of suicide are related to modern life. However, around the globe, the suicide deaths are declining. Only in the Americas, in Brazil, in Mexico, and in the United States, they are increasing. So I'd like to hear your thoughts about do you think why here in the Americas is so different from the rest of the world? The second point is you both raised that several factors that provided the people with meaning, with mission, community-like, religious life, family, stable families, unions, these are decreasing and people are much more atomized, much more isolated, and how do you think we could also overcome this? Thank you. So, I mean, I could start. I mean, this could be guns, of course, because the US has got this huge increase in gun ownership, which is not really happening elsewhere. The other, our story, of course, is this one about communities in distress, and that when there's an unmodified disintegration from deindustrialization or automation and so on, that there's no offset to it, which in Europe has been better because they have a very better developed welfare state. They also have, they don't allow pharma companies to addict and kill people for money, and, you know, and also they don't have a healthcare system that costs two and a half times as much as it should, and they don't finance it through what is effectively a flat tax on workers. So, I mean, that's some of the reasons why the deindustrialization, which you get in Europe, too, has not generated the same degree of deaths except in Scotland, where I come from. Do you want to ask the second one? I forgot what it was. And the second one was, oh, community. Yeah. Incredibly important, and I know this is something that Ken has been working on, so I'm going to turn the floor to him, but I think we believe entirely, people lose their jobs all over America. Millions of people lose their jobs every year. What's the big deal? What's the big deal? Well, if everyone in your community loses their job on exactly the same day, and the industry pulls out, and the tax base implodes, and the schools rot, then the community is gone, and without community, you don't have one of the really important pillars that helps you hold body and soul together. Yeah, I mean, it's just that this community is something economists are not very good at thinking about either, because we're an individualistic science, and it is this community destruction that we see as a very important part, because the community provides stuff that people need, and in which they can flourish, and without that. Yeah, just the other day, Mindy Fullilove is a psychiatrist here in New York, gave a presentation, and she talked about what happens when communities start to fall apart, and it's a process of going from confusion to disorder to nonsense, and in that process, there is a strong claim to pull for authoritarian, somebody to get us out of this mix. This, by the way, is your lucky day, because tomorrow at 1.30, you're able to, if you can, come to a presentation that's gonna talk about a method to connect people who are in adversity with each other to solve their problems together that originated in the favelas of Brazil. So your country actually has some answers to some stuff that we're struggling with in the United States. Leslie. Can you hear me? Yes. Leslie Geise, a retired psychiatrist on Maui, originally from New York, but I've been in a spot of sand in the middle of the Pacific for 30 years, anyway, thank you for your book. I mean, it's amazing to economists, and of the social determinants of health, and mental health that we talk about, what really stood out was the education, and I just heard Bryan Stevenson talk about until Brown versus Board of Education, there wasn't any secondary school for him, and he talked a lot about hope. I also understand about unions. Hawaii's the most union state. I had to belong to a union, that's a long story, and I also, since my husband worked at IBM, I understand about outsourcing, and not having a job for life, and all of that. My question is, you talked about the internet. Do you have any comment about social media affecting us as a society? Not just youth, but maybe everybody, with misinformation, and conspiracy theories, and politics, and so it's really a different environment. I'm 82, so it's a different environment, and a different world that many of us grew up in, and maybe it's too soon to have data about it, but you've commented on so many things, so my question is, do you have any comments on how you view social media in terms of things you've been talking about, and thank you for all that you've done. Thank you. Thank you so much. It's a really good question about the role of social media, and what it's done. We don't have answers to that, but that would certainly be something that is well worth exploring further, and ways in which it might be able to be used for good. So we've seen what it can do to our teenagers, and to people who are really lonely, but they see their friends online, but that's not the same as seeing them in the flesh, so, but, I think it's possible that it could be put to better use as well. I mean, I find very plausible the stuff that Jonathan Haidt has been selling, for instance, on this. Neither of us use social media, which tells you something about what we think about it, and largely because we, or at least me, I shouldn't speak for him, values my mental sanity, and I know that it would destroy it very quickly. But it reminds me of what happened with smoking. We've forgotten this now, but back in the 60s, when people were trying to find out whether smoking was bad for your health, one of the big things that was hard about that was almost everybody smoked. So it was actually very hard to find reasonable control groups and to sell to the medical community that this actually hurt people. It took a very long time and a very great deal of work, and I think we're sort of in that situation with social media now. It's very hard to find people who don't use it except crazy people like us, and you, yeah. But I suspect it is very destructive. And we've been at conferences where Mark Zuckerberg just sat there and said, you know, this is just to bring people closer together. No negative effect. A lot of negative. Yeah, Curtis. Thanks for this. I'm hearing you talk about unions and its benefits, but could you say something, certainly about the Davis-Bacon Act and how unions were very clearly discriminating against black people in the 1930s and very actively. And so, you know, these are jobs that you didn't lose because you never got them on the one hand. And then the other thing sort of related is in terms of the fifth vital sign, a farmer gets big sanction for that. But one thing I haven't heard much of, and I'm curious if you know anything about this, is perhaps my opinion, but I'm wondering why the Joint Commission is not an unindicted co-conspirator in this because they were very much pushing this fifth vital sign. And they've gotten now, Scott, free about this. I mean, the journal pain does no longer exist. I mean, and partly because of that. And that was a very, very negative thing. About the unions, one thing I should be careful about is there's a big difference between private sector unions and public sector unions. Private sector unions actually have to fight with people who have real resources on the other side. And so there's a countervailing power there. Public sector unions deal with politicians. And that's a very different thing because politicians can give in to them if they vote for them and punt it down the road. So most of the abuses that you read about today in unions are among public sector unions. Can I just say about pain, one of the things that the neuropsychologists have found, is that if you put someone in a scanner and you play a pass the ball game with them, so I think I'm passing the ball to two other people and they're watching my brain. And then I realize that they stopped passing the ball to me at all. The same part of my brain lights up as lights up when I'm in physical pain. So the absence of social connection, we think might actually, but you all would know a lot more about this than we would. So I'm just floating it out there and you can tell me like you're crazy, is that part of the lack of social connection is not unrelated to the increases in reports of pain that we find in these national surveys. We have time for maybe two questions if you're quick. Thanks for this work. And I'm Paul Grecken, I'm an addiction psychiatrist and medical director of a nonprofit opiate treatment program and I wanna emphasize the nonprofit because 30% of those programs are owned by private equity that see vulnerable patients as a source for profit in the Seattle area. And my question is about one thing you didn't comment on when talking about how we got here is the immense rise in inequality of wealth. As I understand it, it's as bad as it's been in 100 years. We're back to the robber baron era and there's been this steady slide in taxation since World War II. And I just wondered how you saw that fitting into this picture. I think a lot of the destruction of unions is strongly connected with that. And some of our colleagues have an important paper, Eliana Kuzemko and others showing the very strong correlation between unions, the prevalence of unions and inequality. In the United States. So if that got better, I think the other part of that would get better too. Just one quick thing on that. I'm not sure people mind there being say, if someone, Steve Jobs invents the iPhone and people are happy that he might make a lot of money off of it. But what they want for themselves is real economic stability and that's what the stunning inequality right now is that there's so much instability at the bottom. And also Steve Jobs helped people. Well now a lot of people are being screwed by rich people, which is different. Could you please clarify, I'm from Wyoming, where there are a few guns. And I thought we had made progress in terms of being able to do research on guns and gun behavior. What is the actual status right now? So can we defy it if it's restricted? At the federal level, statistics are not allowed to be collected in things like the Behavioral Risk Factor Surveillance System, the last time they were actually able to collect information on gun ownership and how it's stored was 2003. So it's been two decades since at the national level with a nationally representative survey that we had any sense of how many. Who is it that's unable to collect the information? The statistical agencies of the federal government. They're prohibited by the federal law. And are there ways around it so that we can get good information? I mean, it's starting to remind me of the abortion issue. It is, it is. I think there's more, you may know more than we know. We've actually repealed that. Yeah. We've actually repealed that, but there's no longer that restriction. I don't think it's still not in the BRFSS, I think, right? It's all about whether someone asks for the grant to get it, but they can now view those grants. So the CDC, Margo's group did a lot of work before, they didn't abolish that, and it's funny. But now you can get funding, I get funding, so. So we could do that. We should talk to you a little offline, if you don't mind, that would be great. I'm struck by the circular pathway of guns to Mexico to immigrants that come here for safety, the guns to Mexico and Central America, the immigrants coming here for safety, relative safety, and that there's so much that's not known. Well, it's especially troubling that the immigrants who are coming from Mexico for safety are being accused of bringing the guns to the United States when we're actually shipping all the guns to Mexico. We are gonna have to call this right now. I am hopeful that Sir Angus and Anne will hang around for just a minute, but we need to thank them for their work and their efforts here today. Thank you.

deaths of despair

educational divide

mortality rates

drug overdoses

alcohol-related diseases

suicides

socio-economic factors

deindustrialization

healthcare system

social disintegration

mental health

firearms

community connections