Mortality Among High-School Educated Whites in the U.S.: An Anthropological View

Fig. 1. All-cause mortality, ages 45–54 for US White non-Hispanics (USW), US Hispanics (USH), and six comparison countries: France (FRA), Germany (GER), the United Kingdom (UK), Canada (CAN), Australia (AUS), and Sweden (SWE).

Every so often a piece of research comes along that is a real game-changer—it literally shakes the earth under your feet.  I had that experience about a year ago when Anne Case and Angus Deaton, two economists, published an analysis of recent mortality trends in the United States.  If you electronically search “mortality trends” for the U.S., you will see that, overall, mortality rates are declining, as they are for Canada and Western Europe.  What Case and Deaton did was to separate out mortality rates for non-Hispanic Whites.  Starting about the year 2000, rather than continuing to decline like everyone else’s, mortality for this group bucked the trend and started to climb.  When causes of mortality were examined, deaths from lung cancer were declining, from diabetes were stable, and for three causes were climbing, dramatically.  These were chronic liver disease, suicide, and what Case and Deaton refer to, by default since that’s what the feds say, “poisonings” (read: unintentional drug overdose).

I’ve taught epidemiology off-and-on for a long time, and mortality rates just don’t jump around like this, unless, that is, something catastrophic is happening.  An example of a catastrophic event leading to high mortality rates was the fall of the former Soviet Union.  In the decade following that political upheaval mortality—especially male mortality—climbed, fueled by a potent combination of vodka and cigarette smoke.

A further component to their findings was that the changes in mortality rates were highest among non-Hispanic Whites who had a high-school education or less.  In 1999, rates of death from “poisonings” were 4 times higher for people with a high-school education or less than they were for people with a college degree.  In 2013 those death rates were 7.2 times higher for the less-well educated versus the well-educated.

I felt so compelled by this evidence that I dropped what I was doing in my classes—one on cognitive anthropology and one on the history of anthropological theory—and taught the Case and Deaton paper.  Even though it caught a lot of attention in the national press, at least for awhile, I was afraid that it would escape the notice of many of my students and, furthermore, that they might not really appreciate the magnitude of the results.

The pattern of results suggests that non-college educated Whites are experiencing some kind of profound stress and that in response they are self-medicating with alcohol (hence chronic liver disease) or with prescription opioid pain medication (with its attendant risks of overdosing), and that they are responding with major depression and the associated risk of suicide.  In their interpretation, Case and Deaton emphasized the stress of economic insecurity for working class Whites, noting that widening inequality might account for the trend.  This would seem to me to affect other population groups—like African Americans—even more than non-college educated Whites, yet the trend toward higher mortality from these causes is not observed in other population groups.  Case and Deaton also suggest that it might be specifically the transition in retirement programs from guaranteed benefit plans to defined-contribution plans, with their associated stock market risk.  In this interpretation, looking forward to an uncertain and possibly impoverished future is the source of stress.

For obvious reasons—and I’m talking about the election season in which we find ourselves—I have continued to think about this research, given the prominent place that Whites with a high school or lower education seem to be playing in support of one of the major candidates.  Is it, to quote a political strategist from a past campaign associated with the other major candidate, “the economy, stupid!”  Or, is it that, and something more?

As I considered the findings, I was reminded of an old paper by James P. Henry and John C. Cassel from the American Journal of Epidemiology in 1969.  They examined cross-cultural data on age and blood pressure, noting that, while many physicians believed the rise of blood pressure with age to be “natural,” it was in fact “cultural.”  In many communities around the world, especially those that had yet to be drawn very closely into capitalist, market economies, there was little evidence of an increase of blood pressure with age.  In what were called (back in the day) “modern” communities, blood pressure rose with age.

To explain these results, they drew on a process that Cassel had been thinking about for some time, namely, the inconsistencies and incongruities that can accompany profound culture change.  Cassel’s preferred research strategy had been to follow migrants into a new setting, where he predicted that the incongruity between the culture they arrived with, and the culture of their majority host community, created a period of stressful and taxing adaptation, as the migrants tried to adjust to their new setting.  The end result of this stressful adjustment, especially if it was not especially successful, was an increased risk of disease.  Henry and Cassel suggested that the same process could be occurring across the life-span of an individual, arguing that in the modern world, with the ever increasing pace of social change, an individual is born into and socialized in one culture, yet ends up living in another, as the world changes around him or her.

This strikes me as an eminently plausible interpretation for the Case and Deaton findings.  Non-college educated Whites are indeed facing economic stresses, but the broader cultural changes they are experiencing are even more profound.  And what can more effectively and graphically communicate to them that the world around them has changed than the fact that they will shortly trade their first African American president for their first female president?  (I trust Sam Wang and his Princeton Election Consortium.)

Cassel drew heavily on culture theory for his insightful interpretation of epidemiologic data.  Case and Deaton’s findings suggest that those insights are still relevant.


Biocultural Systematics is written by members of the University of Alabama Biocultural Medical Anthropology program.

Bill Dressler, a professor in the department, has conducted research in social epidemiology in Brazil and the U.S.

Fieldwork then and now: from graduate student to professor

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Dr. Weaver interviews a woman whose garden is the only consistent source of fresh vegetables for purchase in the Brazilian study community.

I just returned from two fieldwork trips: one to India for 6 weeks, and the other to Brazil for 4. The purpose of the first one was to scout new sites for my ongoing work on women’s mental health in India, the country where I did my doctoral research. The second was to continue my NSF-funded research project on food insecurity and mental health in rural Brazil.

More so than almost ever before, these two trips brought to the forefront the challenges of maintaining an active international research program as a young faculty member, and I want to talk about that in this post.

First of all, here’s an obvious truth that nobody ever told me: fieldwork changes once you’re out of graduate school. In the department where I studied, a year of fieldwork was the unstated minimum for anyone doing research with ethnographic components, and almost all of this work was international; those who stayed longer got extra hard-core points. Because this was simply the way things were done, it never occurred to me that this was the exception–rather than the rule–to most fieldwork experiences for anthropologists in academic positions. Faculty simply don’t get that time very often: most sabbaticals are only a semester, and a full year only comes about if you receive an external fellowship, are willing to go with half-pay, or something similar. Also, sabbaticals are increasingly few and far between; in my current department, I will get my first sabbatical after receiving tenure. That’s six years, typically. During my doctoral fieldwork, I was fortunate to have few other major life responsibilities, and no other professional ones. By contrast, faculty anthropologists doing fieldwork are often expected to supervise online courses, prep syllabi, write the book or paper about the last major fieldwork project…the list goes on. I didn’t know any of this as a graduate student, however.

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A woman carries a pot of freshly-caught swordfish to market in Southwestern India.

In so many ways that I only now realize, fieldwork in graduate school is a golden period. Not “golden” in the sense that it is always happy and wonderful, but golden in the sense that it was a one-time deal.

So, changes have come about, and many of these I believe are relevant for anthropologists at any stage. The obvious first change I’ve made in my approach to fieldwork is to stop judging an anthropologist’s mettle based solely on the length of time they have spent in the field. Ethnographers fetishize extended time periods. Just think of Malinowski, out there stuck in the Trobriands, a political exile for years on end–his experience is the model on which we’ve judged the acceptability of our fieldwork for a century. Now, this is not without reason; immersion is indispensible for good ethnographic fieldwork and must be done at some point, but generally academic employment isn’t set up for that. Increasingly, neither are the funding structures on which we rely to pay for this research.

I’ve come to realize, rather, how incredibly much can get done in six weeks, or even three weeks, if you know the right questions to ask. So much of fieldwork is figuring out what to ask, to whom, and when. If you are returning for a short time to a place you already know, it goes much faster. Thank goodness for that.

This depends, of course, on having already spent extended time in a place so that one has the necessary familiarity. “Parachute ethnography,” as it is sometimes rather pejoratively called, can be highly problematic, and this is not what I am advocating. Yet at the same time, I find myself pulled to make more happen in shorter periods of time, and figuring how to do that without losing authenticity is an ongoing challenge. So perhaps my point is that returning to a former field site as a junior faculty member can be highly rewarding and extremely productive, even if time allows for only a few weeks of work. If one were to go to a brand new field site for only a few weeks of work, things might look very different, but many anthropologists make this work. I’m not sure how yet, to be honest. Stay tuned.

A second change I’ve made is to prioritize regular contact with friends and acquaintances in my research sites during the 9 months when I am teaching in the US. This is true both for older field sites and for the brand-new ones I just began developing in India. Social media has been great for this. Now, I can get on Facebook and tell Arlete that I will be coming back to Brazil for 3 weeks in June, and can she work with me again as a research assistant? This smoothes the entry, too. I remember spending weeks–perhaps months–setting up this stuff as a graduate student. Now, it is much easier for me to hit the ground running when I arrive in India or Brazil. And again, this is true even for newer field sites, and exploiting that to its full potential is, I think, key to getting the most out of short fieldwork periods.

A third change I’ve made is to develop research projects that proceed in discrete phases and span multiple years. A good example is my current project in Brazil, Food Insecurity and Mental Health in Global Perspective, a 3-year, 3-site study I am conducting with colleagues Craig Hadley and Bonnie Kaiser (Craig works in Ethiopia, and Bonnie in Haiti). Phase 1 was dedicated to freelisting and ethnography only. Phase 2 is for ranking and rating exercises on freelist items plus participant-observation surrounding food buying and preparation, and Phase 3 will consist of questionnaires using instruments developed in the first two phases, biomarkers, and anthropometrics. Each of these can be done in a summer, especially with the help of graduate students. (Speaking of, I am currently seeking a new Master’s or Doctoral student to assist with this project in summer 2017. Read more about this here.)

And this brings me to the fourth change: increased collaboration. I wanted to do a cross-cultural comparative study with multiple phases of instrument development and mixed methods. Don’t have time to spend a full year in each of 3 countries? No problem! Team up with colleagues who can each work in one country, then split the work into short phases. This way, each person ends up with a manageable chunk of work in a single country to do each summer. Fortunately for me, biocultural work is especially well suited to this phase-based work because it often involves methods that build on one another.

Fifth and finally, I have learned tricks that help me capture more data from shorter periods of time. Good, deep ethnography takes time and investment, no question, and you have to give that time at some point. But there is so much that goes on in the everyday interactions of fieldwork that rarely made it into my fieldnotes when I was a graduate student because I was so singularly focused on what I imagined to be Ethnographic Experiences. At some point in my early research, however, I started voice-recording interviews where I was doing anthropometrics, blood tests, and questionnaires. So much valuable material has come out of those recordings. I didn’t expect this; these seemed to me like the most cut-and-dried structured interviews one could have, not those real Ethnographic Experiences. Yet, when I began transcribing them, people’s side comments about the questions I was asking added up to rich qualitative material. Now I always voice record interviews, no matter whether they are “ethnographic” (i.e. unstructured or semi-structured), or whether they are structured interviews organized around pilesorts, freelists, questionnaires, or other exercises. It creates a lot of work after the return from the field, but these recordings allow me to pick up on extra data that I would otherwise miss. They help me get the most out of those short fieldwork periods.

Despite the constraints of short fieldwork periods, I think I am a happier fieldworker now than I was in graduate school. It is not an easy thing to pick up and leave one’s life for a year (or more). Increasingly, work by anthropologists about anthropologists is documenting that fieldwork can be particularly hard on mental health (see, for instance, Rebecca Lester’s and Eileen Anderson-Fye’s presentations at 2015’s AAA meeting). For me, the hardest part about long-term fieldwork was missing the people and the rhythms of my everyday life. Short periods of fieldwork like those I now have to do are in some ways positive because they allow me to maintain that balance more effectively. It’s more feasible to bring my children on shorter trips. I won’t have to be out of contact for as long with my aging parents when I am away on shorter trips. I can–and indeed am expected to–keep working on other projects during fieldwork. All of this adds up to fieldwork becoming a part of everyday life, part of the yearly rhythm of my and my family’s existence. This to me is what being a career anthropologist is all about.

Lesley Jo Weaver (PhD/MPH, Emory) is an Assistant Professor in the Biocultural Medical program and an affiliated faculty member in UA’s Asian Studies program. She studies health and illness in India and rural northern Brazil.

Biocultural Systematics is written by members of the University of Alabama Biocultural Medical Anthropology program.