 Good evening and welcome to everyone here. I'm Mark Tessie Levine. I have the privilege of serving as Stanford's president, and I also have the privilege of welcoming you to the Tanner Lectures on Human Values. Now these lectures examine the scholarship and the scientific learning around human behavior and more fundamentally around human values. They're held annually at universities around the United States and also in the United Kingdom, and in this year's Stanford Lectures, we will focus on what our speakers call deaths of despair, as well as the social and economic forces that surround these deaths. Now the remarks and conversations that follow, both today, tomorrow and Friday, will advance the aspirations of Obert Clark Tanner, who established this lecture series more than 40 years ago. Obert Tanner was a scholar, industrialist, and philanthropist, and he wanted to contribute to a better understanding of human behavior and human values. Today, nine institutions host the Tanner Lectures. But for us at Stanford, this is a special honor because we have a special bond with Obert Tanner. He actually studied philosophy and earned his master's degree here in the 1930s, and then he was appointed to our faculty. He first taught religious studies from 1939 to 1944. He also served as acting chaplain, but then he returned to his home state and the University of Utah where he taught for another 30 years. Obert and his wife, Grace, saw these lectures, which they endowed, as an opportunity for scholars and broader communities to, quote, contribute to the intellectual and moral life of mankind. Appointment as Tanner Lecturers recognizes uncommon achievement and outstanding abilities in the field of human values. So we're humbled and honored once again to have such an inspiring group of speakers and also respondents with us in the next few days. Professor Ann Case will deliver the first lecture this week. Professor Case is the Alexander Stewart 1886 professor of economics and public affairs emeritus and the director of the research program in development studies at Princeton University. She also earned two degrees from Princeton, a master's in public affairs from the Woodrow Wilson School and a PhD in economics. Her research interests include labor economics, health economics, and the microeconomic foundations of development. She's written extensively about health over the course of human life. Her research conducted with her husband, Sir Angus Deaton, has revealed a surprising increase in midlife mortality rates among white non-Hispanic Americans who have a high school diploma or less. At the same time as midlife mortality rates in other developed countries have fallen. So very really shocking, surprising, and transformative finding. They attribute this rise in part to, quote, deaths of despair, that's mortality related to drug overdoses, to alcoholic liver disease, and suicide, which is her topic this evening. Professor Case's achievements have been recognized by some of the most prominent awards in her field. She received the Kenneth J. Arrow Prize in health economics from the International Health Economist Association for her work on the links between economic status and health status in childhood. The Proceedings of the National Academy of Sciences, an esteemed journal, awarded her the Cozarelli Prize for her research on midlife morbidity and mortality. Because of her work, Professor Case has been described as, quote, one of the leading health economists of her generation. Her leadership also extends across a variety of roles. She's a member of the President's Committee on the National Medal of Science and the Committee on National Statistics. She's a research associate of the National Bureau of Economic Research, a fellow of the econometric society and an affiliate of the Southern Africa Labor and Development Research Unit at the University of Cape Town. She's also a member of a number of learned societies, including the National Academy of Medicine, the American Academy of Arts and Sciences, and the American Philosophical Society. So we're very grateful that Professor Case has joined us to deliver this week's first lecture. And we're equally grateful that we will also hear from her husband, collaborator, and Princeton colleague Sir Angus Deaton tomorrow evening. Professor Deaton will deliver a companion lecture titled, Deaths of Despair and the Future of Capitalism. Now it's the first time for Stanford Tanner Lectures, and only the second time I'm told in the entire Tanner program that a wife husband team has served as lecturers in the same forum. Hearing from both of them will enable us to capture the expanse and depth of their research and their writings. Now following Professor Case's lecture this evening, we'll hear a response from Lisa Berkman. This is the structure of the Tanner Lectures. We want to really stimulate discussion, so there will be respondents both tonight and tomorrow, and then again on Friday, another event. Professor Berkman is a social epidemiologist, director of the Harvard Center for Population and Development Studies, and the Thomas D. Kabbitt Professor of Public Policy, Epidemiology and Global Health and Population. Professor Berkman has focused her research on social and policy influences on health outcomes. In particular, she's examined inequalities in health that are related to socioeconomic status, different racial and ethnic groups, and social networks support and isolation. After her response this evening, she will join Professor Case in a conversation and a short period of question and answers from you, the audience. Now tomorrow, Stanford Professor Victor Fuchs will give the response to Professor Deaton's lecture. Then on Friday morning, we will conclude with a discussion seminar elaborating on the themes discussed this week with two commentators joining Professor Case and Deaton. These commentators are Anna Limke, Associate Professor in the Department of Psychiatry and Behavioral Sciences here at the Stanford School of Medicine, and Daniel Wickler, Professor of Ethics and Population Health at the Harvard School of Public Health. Now at this point, I would like for us to pause and note the passing of Alan Kruger, who was a colleague of Professor's Case and Deaton, and a highly respected researcher, teacher, and public servant. He died last month. We were privileged to host him at Stanford very recently when he delivered the Wesson lecture. A number of you may have attended his presentation and many others at Stanford knew him and his work very well. I'm sure you will all want to join me in extending condolences to Professor Case and Deaton, to his other Princeton colleagues, and also, of course, to his family members. Now before I close, I want to acknowledge the McCoy family for ethics and society, and the Tanner Lecture Steering Committee. Thank you so much for your efforts to make this exchange of ideas possible. Thank you also to Professor's Case and Deaton, and the accomplished scholars who will be in conversation with them over the next three days. So now please join me in extending a warm welcome to Professor Anne Case. Thank you. Thank you, President Tessie Levine. Thank you to the Steering Committee for the Tanner Lectures, and to the discussants who have given their time to be here, and to all of you to join us here tonight. We are delighted to be here, and we feel really honored to have been invited to speak. I'm going to talk about work that comes from a new book that Angus and I are writing for Princeton University Press with this title, Deaths of Despair in the Future of Capitalism. It should be out in early January 2020, and just keep that in your minds if you're looking for a holiday gift for that hard to buy for someone, this may come in handy. As the title suggests, we think that American capitalism is not working for a large segment of the population. We don't think it's working for people without a four-year college degree, and that's two-thirds of Americans between the ages of 25 and 64. And what we'll do over the next couple of nights is first we'll talk about that tonight. We'll talk about what that means in terms of despair and lives coming apart. We're going to focus on the white working class primarily, because in the last 30 years that's a group that has seen real erosion and deterioration. But we're going to tie this back to what happened to the black working class 30 years prior. So we'll touch on that before the hour is out tonight. And then tomorrow night, Angus is going to come back and talk about the failures that we think are responsible for this erosion that we're seeing, and also some of the policies that we think might be possible to repair it. So the themes that we think run through these lectures. Collectively, we've all been reading about inequality and the arrival of this second-guilded age. But we don't think it's inequality per se that's the root cause here. We think it's that our system has become grossly unfair, and that unfair process just generates despair for some, and at the same time great rents for others so that despair and inequality are joint outcomes of whatever forces driving this underneath this. Now, we don't think that there's anything here that can't be fixed. I mean, our title is the future of capitalism. It's not the death of capitalism or even death to capitalism. We believe in a capitalist system, but we think that it needs to be repaired. And we think that thinking about a way forward is going to require us to be quite serious to outcomes beyond just material well-being. Okay, so in a nutshell, that's what we're going to do over the next couple of nights. But now let's take a step back, because I think to get a little context here, you have to think about the 20th century. The 20th century was a time of tremendous advance, technological advance, material well-being. Throughout the world, health improved, life expectancy went up. And to just give you a picture of what that looked like for a particular group, this has all caused mortality for men and women, white men and women aged 45 to 54 over the sweep of the 20th century. So a mortality rate is the number of deaths per 100,000 people at risk. So you could think of this as just the risk of dying in each one of these years over the course of the century. And you can see that we started in 1900 with a mortality rate of 1,500 per 100,000, which fell to less than 400 per 100,000 by the end of the century. You can see the 1918 flu epidemic, right, you see that spike up there. And you can see a plateau around 1960 caused by the fact that people who were about 50 then would have been smoking heavily in their 20s and 30s and 40s. And we're dying of lung cancer and heart disease. But then in the late 1960s two things happened. Behavioral change, people stopped smoking in large numbers. And also medical advance that onto the market came inexpensive, highly effective antihypertensives that reduced heart disease. And our mortality decline continued at 2% per year. And we got used to that. We began to think that that was something that was always going to continue. And if you look at countries that sort of kind of look like the United States, Canada, the UK, Ireland, Australia, so other English-speaking countries, France, Germany, other rich countries in Europe, mortality rates did continue to decline over this quarter century at about 2% a year. Unfortunately, in the United States something else happened. So mortality rates for white non-Hispanics, which used to look like Germany in the mid-1990s, actually started to turn up and go the wrong way. And it best have flatlined now. So they kind of lost the page. Hispanics, which is a thick blue line, it looks just like the UK, are doing also some mortality fall at 2% a year. And black non-Hispanics who start with a much higher mortality rate, and it's still higher than whites, but made more progress. Their mortality actually fell at a faster clip than any of these countries at 2.6% a year. Now, is this a big thing or a little thing that the US whites kind of lost the page? Well, it's a big thing. Life expectancy has fallen now in the US for three years running. That hasn't happened in a century. That hasn't happened since World War I and the 1918 flu epidemic. And it's being driven by what's happening to people in mid-life. Mortality rates for children are falling. Mortality rates for the elderly are falling. But mortality rates for people aged 25 to 64 have become either anemic or have actually gone the wrong way. Now in mid-life, the two big killers are cancer and heart disease. Those were our two engines of progress, that we were making really good progress on both those fronts, and progress on cancer continued. But progress against heart disease stalled. So if you compare what happened, these are now for whites aged 50 to 54. If you look at what happened to US whites, which we didn't have much to brag about relative to other countries, the UK, Germany, Sweden, France, back in 1990, but we've actually first progress slowed and then it flatlined altogether. So one of the big drivers for bringing down mortality rates has actually stopped playing that role. And we'll come back, it's not fully understood why that happened, but we can talk about that later. But what we are going to talk about is while that happened, at the same time, mortality rates started to rise for drugs, suicide, and alcoholic liver disease. We think of all three of these as being of a peace. We think of all of them as being a form of suicide. The people are either killing themselves quickly with a gun or a rope, or people are killing themselves more slowly with drugs or with alcohol. You'll see that I've divided the slides here now into people with less than a bachelor's degree, that's the red line, and people with a bachelor's degree are greater, the blue lines. And all of the disappointment is coming from the people with less than a bachelor's degree. Unfortunately, we can only divide by education starting in 1989 when the standard death certificate started to add education to it. By the early 1990s, most states were in compliance with that. But you can see that this actually started as far back as we can document it then. Even before the most heavy-duty opioids were being just like distributed in jelly jam jars to the population, there was already trouble afoot. This was on the rise. And while the biggest problem has been drugs, if you take suicide and alcohol-colliver disease together, combine their larger form of death than just drugs alone. Now, you might think, well, if I'm 50 in 2015 and I have this really high risk of suicide, but I might be a different kind of person who was 50 in 1995. So another way we can look at this, instead of looking by age group, is to look by birth cohort. And I should mention all of these data that we're going to show about deaths and mortality rates, those come from the national vital statistics which are available online, right? So underneath this are 30 million records of people who died in the United States between 1989 and 2017. If we look at them by birth cohort, and we look at people with less than a bachelor's degree, we get this really fairly unusual picture, which is, let's start with the cohort of 1945. That's the purple line. Their risk of dying of a death of despair, suicide, drugs, alcohol, say in their early 40s, their risk is lower than someone that age who was born in 1950, which is lower than someone in their early 40s who was born in 1955. And what you see is then with every birth cohort, the risk of dying of one of these deaths of despair is larger. So it's not just the baby boomers. It's not just the baby boomers who summer of love, everybody was taking drugs, maybe they got in the habit of it, and so then this is just coming back to roost. It's going through Gen X and Gen Y and into, I guess it's the millennials. Would that be the last one here? You can divide these by cause of death. So that upper left there is a picture I just showed you, but then you've got drugs alone, suicide and alcohol. And you see that same kind of progression, birth cohort to birth cohort in all three of these domains. Alcoholic liver disease is a little bit unusual because the liver is a really robust organ, right? So it can take a pretty good beating before it gives up on you. And so I had thought that you had to get to your mid-40s before you would actually see this kind of rotation, or you would see the later born birth coats having a harder time of it. But if you look, you can see the cohorts born in 75 and 80 and 85. They're still youngsters, by my standards. They're still youngsters, but you can see that they're doing worse than the cohorts that came before. And that's because of binge drinking, or that's one of the reasons why. That what's really toxic to the liver is four or five drinks in a sitting, right? And your liver doesn't know how to manage that kind of stress coming toward it. People with a BA are more likely to drink, and they drink more frequently, but people with less than a four-year college degree are a lot more likely to binge drink. And that's one of the things that puts them at risk here. So that's the kind of... It looks like the situation is not one that... It's one bad cohort that's going to move through, and everything else is going to be fine once they leave this stage. Thank you very much. Get out of here. This looks like it could be getting worse. If you compare those without a BA to those with a BA, so those are those same birth cohorts, it looks like these people come from different planets. So you see a little bit of evidence among the people with a BA and the latest born birth cohorts of drug problems, but it's just dwarfed by what's happening to people without a BA. It's more than just drugs. We really do think of all of these as being a form of suicide. If you take the drugs out of the picture, there's a really high correlation between suicide and alcoholic liver disease. Whether you're looking across U.S. states, or for example, if you put the U.S. in perspective and you look across countries and you look at what is the alcoholic liver disease and cirrhosis death rate against the suicide rate for all the countries in Europe and English-speaking countries. And I've circled the U.S. whites up there, which are higher than all the rich countries, way higher than Canada that you can see there in the middle. Suicide rates higher now than Japan or Sweden. And it's floating up toward the countries of the former Soviet Union. In those countries, suicide rates are falling. In fact, suicide rates are falling mostly around the world, except in the U.S. among whites where they're increasing. So we may meet them with them on their way down and us on our way up. Durkheim, I want to say, when you're thinking about suicide, then if we think about all of these as being a suicide, it took us back to Emil Durkheim and his writings on suicide in 1897. And what he wrote is really helpful to us. It's very hard to know how to predict a suicide, except if someone has tried it before, they're more likely to try it again. But that's not necessarily very helpful. Durkheim talked about social integration and social regulation. And he said that times of great upheaval, positive or negative, but just upheaval are times when people are going to be at risk. And that's what I think we're finding here. Durkheim, though, thought that better educated people would be more likely to commit suicide because they'd be less tied to taboos or religious regulation. They might be more likely to break out of their small community and move elsewhere. That actually goes back to Maserik, who preceded Durkheim in writing about suicide. And that's traditionally the view in this literature is that better educated people have higher risk. If that was true before, it is not true in the U.S. If you go back and you look at these birth cohorts again, the birth cohort of 1935, 1940, 45, all the way up to the birth cohort of 1980, and you compare what is the risk rate of people with less than a bachelor's degree with people more than a bachelor's degree. In those early-born birth cohorts, there's no daylight between the risk for people within without a bachelor's degree. But that risk gets bigger and bigger and bigger as we get to younger and younger and younger cohorts. These deaths of despair are hitting men and women about equally. Women were less likely to kill themselves in any of these ways. But the increase in deaths from these three causes parallels the increase in deaths for men from these causes among people without a bachelor's degree. So in our early work on this, when the newspapers would write it up, oftentimes the text would be right, but the headline would read white men dying. And I think that's largely because they couldn't imagine that women would kill themselves in these ways. And if you go back in the day far enough, women didn't kill themselves in these ways. But that's changed. Here's a question for you. Can you find the Great Recession in this? Right, this goes from mid-1990s up through 2017. There's this slow, steady, rising drumbeat. And it's really hard to say that the increase in unemployment or the loss of income over that period changed this trajectory much at all. We think the roots are much deeper and that it's not about the short-term circumstances. It's more about something longer-term. It's also happening at every level of urbanization in the U.S. So we're still looking at drugs, alcohol, and suicide. This is ages 50 to 54, but I could draw all these pictures for different age groups. And the same sort of pattern is going to show. Large central MSA is those of the big cities in America. The large fringe MSAs, which started a lower risk of dying one of these deaths of despair, but it's increased in parallel. Those large fringe MSAs are like where I live in Princeton, New Jersey. I imagine Palo Alto is also in a large fringe MSA. The places that have gotten a lot of attention from the newspapers are the rural areas. And they're there. They're there in red. But they're not really on a different path from these other areas as well. But it makes a good story, I think, to focus on what's going on in Appalachia. And certainly this is happening there, but it's happening virtually everywhere. I'm just going to skip ahead if I can. Oops. Sorry I went a little too far there. I wanted me to tell you that slide, but I wanted to move ahead. We divided the country into a thousand small regions, each with at least 100,000 people in them. And then if you look for people age 45 to 54 and you say what were their death rates from these deaths of despair in 2000? What does it look like in 2016? There's almost no part of the country you can look at that hasn't seen an amazing increase here. There's a little bit of hope up there in the central Midwest. And certainly you can see Appalachia struggling, but so is rural Maine and Florida and all throughout the south and up the Rocky Mountains and the West Coast. It's not as if this is an isolated thing. Now the means by which people kill themselves is going to be placed specific, but the outcome is going to be the same. And underneath this, I mean those are body counts, right? So that's actually something that you can physically count, although you may wonder about whether the coroner or the medical examiner got the cause of death correct, which is partly one of the reasons why we put drugs and alcohol and suicide together, since it's sometimes hard to tell when overdosed on purpose, trying to end it all, or whether it was a true accident. But underneath those counts there's a sea of pain and poor mental health among those people who didn't get a four-year degree. Pain is mysterious. And if you put people into an FMRI and you scan their brain while you play a game with them where you socially isolate them, then you stop all passing game and then you stop passing the ball to them, the same part of their brain lights up as lights up when you cause them some physical pain. So the connection, the mind-body connection is much more powerful, I think, than we sometimes give it credit for. And pain was increasing ironically during this period when there was a point, it's a little bit lower now, where a lot of prescriptions for pain were written to medicate every adult in America around the clock for a month, right? And ironically, pain is going up at the same time. I'm going to try to skip this one and this one and go to there. If you look at back or neck or joint pain, reported in the National Health Interview Survey and you look at people at various ages, let's start with the people who have a four-year college degree. Reported pain increases with age. That's not a surprise to some of us who are getting older, and I like to tell my students, you kind of see where you are and you kind of see where this is going, right? It's not going to be pretty. It's not going to be pretty. But that's, you would think, relative to that, when you look at people with less than a BA, what you see is that set of birth code hearts here, which we have to do because the data sets large as using the vital statistics. People born in the 1930s at any given age report less pain than people born in the 1940s who report less pain than people born in the 1950s and so on. And so what you see here is actually then cohort to cohort and increase in reported pain. Now, some people think, well, some people will ask, yeah, but America's getting fat. And we know that if you put too much weight on the joints, of course, those joints are going to show wear and tear. And certainly that is true. So again, from the National Health Interview Survey, you can look at someone's body mass index, which is a measure of kilograms per meter squared. So that's going to be weight over height squared. Many of you probably know BMI, a body mass index of 30. That's the official cutoff for being obese. And I've also marked the cutoff for being normal weight. And indeed, reporting sciatic pain, which is lower back pain that radiates down the leg and up over the toes, which is incredibly painful. Sciatic pain reports actually do increase with BMI. So that's not so surprising. But what is sort of surprising is this is how people were reported in 1997, 8, 9, 2000 in the National Health Interview Survey. And then this is what people reported 2014, 15, 16, 17. So at any level of body mass index, at any level of thinness or fatness, more sciatic pain. And that's not what you see among people who have a BA or more. So there's something else going on here. In general, the increase in body mass index, so the increase in weight can explain about a 25% of the increase in pain that's reported. But that leaves 3 quarters of it that we don't fully understand. Let's go here. And then go right to here. There's also a pain I should have mentioned though, pain correlates very strongly with suicide. So across the country, those regions where people report more pain are also those regions where people have higher suicide rates. Something else that correlates with suicide is mental health. And with the National Health Interview Survey starting in 1997, a battery of questions is asked where you can come up with an indicator for whether someone's at risk for serious mental illness or mental distress. And if you look at this bottom line for people with less than a BA, those were the responses by age indicating this fraction of people who are at risk for serious mental illness. And maxed out around age 50 which isn't sort of a surprise because people age 50 probably still have kids at home. They're worrying about their parents and their jobs are probably very stressful. And so the fact that it increases and falls is what we might expect. But what we wouldn't necessarily expect is that in later years of the survey that went up and up and up again. Putting them at risk for serious if mental health is correlated with suicide. People with a BA or more than any pattern at all and you can see that their risk is everywhere lower than the risk for people without a BA. Difficulty socializing with friends which is also social isolation being a correlate of suicide. If you people answering that question in the 1997 to 2000 range so being difficulty socializing with friends and with children but there was a whole shift up in that schedule between 1997 and say the last years that we have those data for 2016 nothing like that happening for people with a BA. So we're left with this what we call cumulative distress without a BA a steady cohort by cohort increase in suicide mortality, chronic pain, sciatic pain difficulty socializing difficulty relaxing mental distress heavy drinking increases in body mass index and then these things Angus will talk about tomorrow not marrying and not being married not being attached to the labor force experiencing lower and lower real wages and not being affiliated with any religion. So the things that we think help be pillars in people's lives eroding, eroding, eroding and I just want to run through one more set of slides though as promised which is these are whites, whites on average this is the most privileged group these are people who on average have more education they face less discrimination how can it be that this is happening to whites what's going on with blacks and I just want to show you this Dunesbury cartoon that came out when a paper that we had finished writing was released and so this is Ray saying to BD who you can't quite see nice day, oh easy for you to say oh but not for you, no my kind is dying off man my peer groups you're getting hammered lately what peer group is that middle aged whites are mortality rates are soaring they call them deaths of despair oddly it doesn't seem to affect blacks and latinos not the knot about that man we've always lived distressed lives we're used to it so black privilege absolutely we're lucky that way and black privilege looks like this if you look this these are the mortality rates I showed you at the beginning for blacks the mortality schedule is always and everywhere above that it has fallen quite dramatically and the black white gap has closed quite dramatically until the arrival of fentanyl one of the big killers that's hit the streets since 2013 but we think what's happening to whites now in terms of economics in terms of neighborhood of stability is what happened to the black community starting in the 1970s among people with a high school degree or less so this is a more special group than just less than BA there was almost convergence in the black white mortality gaps until the very end with the arrival of a very strong drug blacks were continuing to make progress whites were losing ground so part of this convergence the the gap in life expectancy is closing that's a good thing but if it's closing because blacks are doing well that's great if it's closing because whites are doing badly that's not so great in terms of deaths of despair black deaths of despair were flat or falling until the arrival of fentanyl at the very end of the period here so I've already said in many ways we think this is mirrors not all of but some of what happened to African-Americans beginning in the 1970s and we see it as another chapter in the saga of American labor William Julius Wilson describing what happened to the black community talked about inadequate access to job networks and employment lack of access to quality schools decreasing availability of suitable marriage partners exposure to conventional role models and he quotes Herbert Ganz talking about the problem existing mainly because of the large scale and harmful changes in the labor market resulting spatial concentration as well as isolation of such areas from the more affluent parts of the black community and we think that this is just another shoe dropping here with the white working class over time so it's also interesting that some of the same arguments that were made about black culture back in the 60s and 70s for example in the Moynihan report saying at the center of the tangle of pathology is the weakness of the family structure that's largely what's being said today in some quarters about the white working class so Charles Murray for example in his book Coming Apart who Charles Murray industriousness is the first among equal of all the values and he says white males of the 2000s were less industrious than they had been 20 or 30 or 50 years ago the decay in industriousness occurred overwhelmingly in white working class neighborhoods to him being Jewish town so what we think is the black culture quote unquote and the white working class culture are both signs that if you treat people shabbily enough or long enough bad things happen to them and we think that's actually probably going to be closer to an explanation when we can take a step back and look but we have to talk a bit about race status Martin Luther King talked about the fact that the southern aristocracy took the world and gave the poor white man Jim Crow so that when he had no money for food he ate Jim Crow a psychological bird that told him that no matter how bad off he was at least he was a white man better than a black man and I think that there is some of that under the surface and it's pretty hard to talk about so Andrew Chirlin does a very nice job in his book Labor's Love Lost saying that whites didn't consider their status until their whiteness premium was lessened by legislation in the last few decades of the 20th century at that late date the old whiteness based system had been in place for so long it was invisible to them and the new equal opportunity laws seemed to white workers less like the removal of racial privilege and more like reverse discrimination or as Carol Anderson said if you've always been privileged equality begins to look like oppression so that we think is also at play here but we think that with many of the things that we look at in the book if you divide things up by education blacks and whites look alike it's just that blacks are a lot less likely to have a college degree than whites so the dysfunction that's happening in communities with for people with less than a bachelor's degree is going to hit them more harder than it's going to hit whites so I'm going to leave you on this happy note about the cumulative distress this is where Angus is going to pick it up tomorrow and he's going to talk about some of the whys of how that's happened so thank you thank you very much I want to start by saying thank you to Ann Case and Angus Deaton for actually writing a totally superb piece of work one that I admire for many reasons and also to thank President Tessie Levine for inviting us and hosting the Tanner Lectures I thought at first when I was asked to be discussant this was an easy job I actually had lots of things to poke at in much of the earlier work that Case and Deaton have done in terms of focusing on a specific age group in terms of this story of rather rural or urban looking at and focusing on whites and now instead what I read which many of you I look forward to having you all read probably do as well is a 250 page really opus that takes a much much broader view and it takes the view that we're looking at the long run we're not looking at one single age group you've invoked one of my favorite people on earth which is Durkheim which actually incites and instills in me the comments that I'm going to make today so by enlarging the story and particularly talking about racial differences and incorporating that I think there are very very important lessons that we can learn so what I'm going to do today after saying all those things that I really like is try to talk about what does an epidemiologist think about this what does a social epidemiologist who was very heavily steeped in Durkheim early on say about what's going on and what can we think about overall so I want to say that from an epidemiologic's perspective I'm going to talk a little bit about what health is, what health of despair, deaths of despair look like I also want to talk more about cardiovascular disease which you actually brought in some and homicide which I think is a neglected part and quite important for us I'm also going to try to do this and kind of put it into a larger context and also important from an epidemiologic perspective to really think about life course trajectories so the things that kill us at 50 are not the things that happen to us at 50 there are perhaps the things that happen to us when we were 10, when we were 20, when we were 30, when we were 50 they are quite cumulative so for us to think about a manifestation of something at 50 doesn't necessarily do service to what's going on and in fact I really like the birth cohort plots because you can see the birth cohorts changing over time but you also understand a life course model and I'll talk a little bit more about that then as a social epidemiologist our role is really to think about what are the social determinants of health what are the things that actually are fundamental causes or serve to shape the patterns of illness what is so important in the United States I'm actually going to talk a fair amount about what Durkheim would have called like disintegration or lack of integration the social isolation social exclusion this idea that with growing inequality we have this kind of disintegration where now even white working class people how feel like they're socially excluded now that excludes almost everybody except maybe the people in this room at this point but when we start to think about the processes that happen it's important to think about that from a policy perspective because I wasn't exactly sure how the two of you were going to divide this I wanted to say a word about underlying issues beyond the opioid epidemic and beyond health care that I think the political issues that we have which I think you'll talk about more winner take all politics the issues and policies that really don't help workers and their families get good jobs and do good jobs in both world are very challenging and are very fundamental to the story and finally I have a very close colleague and happens to be a neighbor who says populism is democracy's way of saying pay attention to me and I'm going to end with that and come back to how we think about populism and why actually I think it's very important to tell a story that's broader than the white person's dilemma here so just to put this in perspective this is actually the famous graph that you showed and it honestly says that US whites you know have this incredible experience it is for a very narrow age growing and when it first came out we thought is this a fluke is this just one little age group is this more generalized I think what this work shows is that in fact this isn't a fluke this is a much more generalized pattern it's happening to even younger and younger generations and it is something really to worry about this is the other thing that I think we should be worrying about and contextualizing and makes the issue harder and harder for us to come to grips with is that this is the US ranking among OECD countries these are data from National Academy of Medicine panel that I was on these are for women which looks slightly worse than they do for men but basically we were never terrific we were at our best in the middle of the pack 1980's, 1970's 1960's we were not at the top and mostly what we did was look at life expectancy and it kept on getting better so we kept feeling better but look what everybody else did everybody else moved way ahead of us and what looks like progress to us is in fact stagnation so that we are now at the bottom of OECD countries so any explanation that we have has to think about what's going on in America that places us in that way this is also a slide that looks at mortality rates by levels of education looking at a very broad age group and here are people with the lowest level of education so this is looking at inequalities you can say the United States does by far worse than any other country in health among those with the highest level of inequalities but actually we don't do so great among those with middle level levels of education either and finally even among people who are the best off we still suffer we are still not at the bottom one would say this is a story of inequality that surely the best off in the United States would be doing better but they aren't we do as about as well as Denmark which is not one of the models in these cases but look at all the best off other countries where people do much worse so when I talk about social disintegration I think it affects all of us in some way the other thing is that there are I think the data that and did very good job today of the falling mortality rates for blacks in America is totally accurate if you look at this larger picture however there's been some recent data this is by both at all who who published a piece of work in BMJ that suggests that all is not well among many of our racial and ethnic groups and so if you look from 1999 to 2016 you see this steady drop but if you take the nadir when we were doing best whenever that group was being best which is somewhere around 2012 2010 2011 for women and 2004 2010 you actually see that there have been upticks in mortality among all groups so if you look at blacks for instance third from the bottom there you see if you look at 487 to 375 to 386 it looks like things go down but if you look at the rate at 375 and you look at what's happened in the last couple of years you see an uptick and you see it for men and women you see it for many of the external causes and even for things like drug use so I would say that we should be careful about talking about this as a white problem that in fact while it may be that African-Americans lagged they may also now be catching up the other thing is that as cases said mortality rates have been increasing absolutely over the last couple of years and while it's important to recognize that accidental poisoning and mental illnesses account for a large part of that these are for women I'm going to show them for men which is a little bit different heart diseases also account for this increase in diabetes, transport accidents and other causes of death so this is not just three causes of death it's actually a larger story it looks more like a continuous story when you look at what men's decline looks like which is accidental poisonings take a big part of the picture mental illnesses which by the way are not all mental illnesses they also like depression they also include some neurological kinds of diseases potentially increases in dementia those sorts of diseases diseases that we often think of as diseases of aging and one of the things that we've been thinking about is that it's almost like some people have accelerated aging like whatever processes, whatever ways in which stress is influencing thing it pushes on the system so there are these deaths of despair that are we think of younger causes but there are also other causes going on so let's look at drug related deaths this is a a slide that shows these are all the individual drugs the blue line there shows the opioid prescription opioid epidemic but what some people have started to look at is that in fact this is an exponential curve over a 38 year period of annual accidental drug poisoning deaths and actually if we look at each one we tell an individual story but if you look at them all together like that you have looks like a very classical infectious disease epidemic modeling curve in which there's an exponential increase from all the all drugs so it isn't so important to look at each one or the other not that we shouldn't be concerned about opioids but it isn't the whole story what we're looking at is a 40 year exponential rise and these sorts of things finally this is a very complicated map which I can only read when I look at my notes which I haven't got with me right now but it's a heat map from the same paper looking at how drug epidemics go by on the top are total deaths men women whites blacks others and then rural and going down this side are the kinds of drugs and so what you see is the yellow circle up there is the opioid prescription opioid epidemic it certainly strikes whites very heavily but what you see down there is actually a cocaine epidemic happening in a younger stronger age set of age groups very much at the same time so looking at them together is really important homicide I wanted to come back to homicide violent crimes in the U.S. have risen for also consecutive years and as we've really been shown suicides outnumber murders 6 to 1 for whites but murders outnumber suicides 3 to 5 3.5 for blacks these are suicide rates which are 2.5 times higher than the rate among blacks here's white non Hispanics there's black non Hispanics 2015 and 2016 you actually see a little blip increase for 2016 for blacks but here are the homicide rates for blacks so we should not be ignoring homicide rates as I would say deaths of despair or integration I think they are part of the story and if we look at gunshot wounds the same thing sort of happens so in the pale bars are non suicide rates and the black bars are suicide these are fatal gunshot wounds these are hospitalization admissions notice the numbers more black patients than white patients what happens is that black Americans are shot during assault not suicide whites are shot in terms of related to suicide the black bars over there so we see gunshot wounds but we see an opposite story so integrating this story seems to me very important and finally just to bring home the a difference in life expectancy for blacks and whites I want to talk about a five year gap overall in life expectancy if you look at it between less educated and more educated whites it's a 6.4 year gap if you look at it for blacks it's a 5.3 year gap but you'll notice that even blacks with a college education don't come up to the median for whites during this time cardiovascular deaths the data from the ad health study it's a little hard to see because of how great it is but it looks at educational gradients and you'll see that in the it's whites blacks and Hispanics and that there's a very clear educational gradient for very young people now these are young adults thinking about this and always blacks have lower good cardiovascular health and to come for a few minutes to Dirkheim so I think Dirkheim's major contribution in suicide was actually not so much about education although that sits there but it had to do with social integration so he said suicide varies inversely with the degree of integration of the social groups of which the individual forms apart this is the fundamental contribution of Dirkheim in suicide and he challenges us to think about suicide which we often think of as the most individual, most painful sort of individual decision a person can make and say what's important about understanding this is that this act which on the surface seems so intimate and personal actually is guided by social facts that it is socially patterned and that I think is a major contribution of this piece and one that is fundamentally important and actually as Kaye showed Dirkheim argues that individuals are bonded to society by two forms of integration one is attachment that is just the intimacy and love and connection that we feel but also by regulation he argues that the reason the Catholic Church actually has fewer suicides is in part because it's forbidden you have regulation to tell you what kind of behaviors that you have what's normative and both of these things are important this work in fact guided the very first paper I ever wrote which was my dissertation looking at social integration and mortality these are data from Alameda County I went to the other school across the bay and it looks at people who are not married report very few friends who very few relatives who don't volunteer and who don't belong to religious groups so those are the people who are most disconnected and they are in the green bar and you can see they have about two and a half times mortality rate of people who are most connected and the important thing here is actually that it doesn't matter whether you're married or not whether you're friends or relatives there's no one thing that actually does this it's just that you have to find connection some place it's not very prescriptive so immediately we thought this is the American dilemma it couldn't happen in France so here's France actually it looks exactly the same the difference the difference is that almost nobody's isolated it's not in the toxicity it's not in the risk that we see the difference it's actually in the distribution of the risk overall and here we see data from male professional health study at Harvard where we actually have better data on mortality from different causes and you see these risks are not confined to accidents and suicide although they're definitely there you see them for heart disease argues that heart disease is a disease of both economic conditions and disadvantage as well as disconnection and isolation and in fact we've repeated this using the Gallup data across all the countries that you can look at in Gallup I'm only showing you the OECD ones and you see here are this is self-reported health except for Switzerland every country has a relative risk that's related to social isolation so what does this mean that we should do at this point it's very hard and I know that Angus Deaton will talk about it much much more tomorrow but I wanted to take one stab at saying that white working class Americans are experiencing disadvantage this part of the story is true for many years they experienced while they were experiencing disadvantage they still felt very privileged so these quotes I think of Andy Chirlin and others really really are important and take it home however they're not alone lots of other people are also disadvantaged and they're traveling with them secondly I want to focus on the quote that Jenny Mansbridge had given that populism is democracy's way of telling us to listen harder and in another slide that she shows she shows and this I think goes to part of the heart of the matter of winner take all kind of politics that the percent of income shared and polarization in the US House of Representatives looks like that that as we think about polarization and why I think populism is important for us to consider is that I don't think we want to feed the beast in some way of white working class privilege like now we should be in arms right because before we weren't in arms that Case and Deaton have really provided us with a formidable challenge it's really to identify the determinants and ultimately think about what are the solutions to the kinds of trends that we're seeing and while white Americans are currently experiencing this it's only because we haven't looked maybe at the flip side of other causes or what is happening or what did happen and how the end of Jim Crow laws actually really pushed us ahead and finally that when we think about who's feeling this it's people who are isolated who are disintegrated who are no longer integrated into an American society and it's not fundamentally a white problem I really would like to suggest that this is an American problem and encourage you as you move forward to think about the ways in which working class men and women have really pulled apart from society and really aren't reaping the benefits of human rights that we really thought all Americans were entitled to and somehow playing into the white American story it's true from a health advantage sort of but I think it's easy to integrate a larger frame but it's dangerous from a political perspective or from the perspective of solutions because we really have to think about what's at stake when who governs when we have one percent of sort of a population guiding our government today and how polarized it is what we think the solutions will be so I think this is the enormous challenge that Case and Deaton have they've presented us with a very challenging really exciting volume and I look forward to the rest of the talks thank you thank you very much that was terrific and really really helpful I had a just a couple of things I wanted to add a couple of things I didn't say we've we've divided the country up into people who went to college and the people who didn't in part because we wanted not to have what we would call in my tribe negative selection over time for example people who don't finish high school that group is very different in 2016 or 2017 that it would have been in 1940 say that they're much more negatively selected but if you just make that divide by four-year BA not it's about 67% who fall into the not category and that hasn't changed and unfortunately it's stubbornly not changing more people are going to college but they're not finishing four-year BA's and I think that that's something that Angus might talk more about tomorrow as well that we don't think the solution is that everyone should go to college we think everyone should be able to go to college who would like to but it seems like especially in the state systems there's now a capacity constraint on how many kids can go to college because state governments don't just shave that out of the budget I you know I want to go on a couple of things one is I don't think we think of this as just a white problem I think what we'd like to do in the book is to say this is one piece of a bigger problem that's really about class rather than being about race and that it would be so helpful I think we could think about it in those terms but I think that the original sin of America makes it really hard to think about it in those terms hopefully maybe we will be able to if you think back to 1970 and then in the 80s with the crack epidemic when the face of the epidemic was black it was a criminal act in 2017 when the face of the epidemic is white it's a medical problem well that was wrong then but it's not clear we shouldn't make it wrong now but we should make it clear that everyone does better with the black increase in the black deaths especially among the cocaine that's fentanyl we were showing as well the tick up at the end within the black community there were heroin users who were maintaining a life for themselves as addicts but were functional but once you start to mix fentanyl into that suddenly the mortality rates went way up and that happened with cocaine as well I imagine I'm looking at Anna Lemke here and I hope she's going to provide her expertise on these questions as well I have a hard time with the homicide because these things that we were talking about are things you do to yourself so these are self inflicted in a sense whereas homicide is coming from the outside and certainly a problem worth worrying about but I think of it as being somewhat different than that the social disintegration across all of these communities is huge I think we think that maybe what protected the black community a bit in this last round was the church the black churches the black kin networks sense of community you find that in a lot of the European countries and as you say with the beautiful side of France that looks like that group that's not connected is a really small group but among that group there are very high risk I think those were my thoughts on it I don't know if Angus wants to add anything at this point or if you want to respond on the homicide and say no if you were really a sociologist do you understand that homicide fits with these things as well so let me comment on that one because I do think of this somewhat differently so to think about suicide as an individual act that you're doing to yourself ignores the social patterning it ignores the fact that it's actually what we would call a social determinant so yes you take your life but where does cardiovascular disease fit in that well it's sort of on the spectrum I think you'd say well you don't take your medication or you have a really lousy job and oh sorry you have a really lousy job so I don't think of these things as importantly as individual acts versus other acts I think about well what is the social patterning what do you think is really the fundamental cause and the fact that it causes you to commit suicide or to take drugs or to smoke is smoking any less an act you know an individual act then so I think homicide fits into the story in the sense of there being a lot of violence a lot of despair and acting out that way and that we can think of many other chronic diseases so that's I think the way in which I would love to enlarge the story even though it's not to dispute those facts I mean I think those are you know I almost said in there there's a very famous Wade Hampton Frost story that says mortality is a fact everything else is inference so you know the facts are the facts but the inference is huge so I just see that as a more integrated thing and maybe just to respond to the class and race issue because that is something that probably all of us you know struggle with in some way in America that I actually love that frame this as a class problem because I think it ultimately identifies thing it's you know leads to a solution that's very important but at the same time class in America is so integrally involved with race that it becomes very important and my worry which is more even a political worry is that it leads to well it isn't immigrants it feeds it sort of feeds into our worst individualizing kind of feelings that we should now we should worry about whites because most of us are white and not and I think you don't mean to do that and that's what that the ending was great but I just would be very thoughtful about whether there's a way to integrate race and class I think we'll open this up to Chris one more mic I saw a hand over here so I want to thank you you're on I want to thank you for excellent presentations you use one measure of social economic status is obtaining or not obtaining a BA have you corrected for income because of my thinking income may be a more important factor in deaths of despair that's a really good question to which there's lots of different answers one is that we have education on the death records we don't have income on the death records and we don't know I wish there were a lot of other things we'd love to know about how much your mother loved you what happened to you when you were five right well I mean but we can't get that information but we think that actually short run income or changes in that have very little effect on this progression that we've been seeing we think that status your status is very important your social connection is very important whether or not you're able to make friends to have a home life that's stable Angus will talk about more of this tomorrow but we think those things are actually more important than just playing material well-being in causing this to happen hope, expectation and status I think are really central I'm Cynthia and I work with the pain and stress neuro biology lab and we are looking at a cohort of children located in Shelby County Tennessee and we've measured a number of factors which are contributing to a bimodal distribution the 90-10 split between those which are at the very impoverished level and those which are at the very wealthy level so we have found and developed a social adversity index and we have found that combining given factors such as education age marital status household income have had a huge impact on our ability to interpret our data and looking at biomarkers as well as subjective reports so this would have to be done on a population-based study just like what is specific to the United States we're seeing is very different and other national areas but income and the amount of income that is present in a home has nothing to do with how many individuals are in the household or what the structure and support system the social aspects of partnership have so I think that just picking one factor or another is somewhat limiting would you comment on that please? we used to joke that you could tell the difference between a sociologist and an economist because a sociologist would take a lot of factors and want to make it into an index and an economist would take an index and want to break it up into random parts and look at each of those parts separately we don't actually think there is such a thing as socioeconomic status because like the impact of education is going to be different and again in context specific than income than someone self worth and their sense of status right so some people may not have a job that brings them status but they may be an organist in their church and that's what gives them status and so we think that the kinds of the granular data that are needed to try to tell the story well are not the kind of data that economists tend to have on hand which is why we think that the ethnography reports are incredibly important because they give both context and although they can't give you the context as a country they give you context into which you can then look at each of these component parts Hello my name is Apollo Egan and I was just curious about since you mentioned BA degrees of bachelor's do people have any records of people whom I tap perhaps a community college degree or credentials and skilled trades be it culinary arts, carpentry or cosmetology or dental hygienists things like that something that maybe have a skill and they're working but it seems as though the death certificates don't mention any other degree I mean they don't mention any you know AA or AS they actually do have those people with say a two year college degree fall somewhere between people with a four year college degree and a high school degree but they're much closer to people with a high school degree than they are to people with a college degree and with this work especially with the death rates but also with what we would call morbidity the you know the absence of being well a good question but we we worry a we always have to worry a little bit if you select out a group that has a very particular degree they may be very special people in certain ways so it's not as if you could say to someone go get that degree it's going to keep you alive or keep you happy and maybe something about the person who then selected that that route which is why we try to do this in a crude way but in a way where we don't have to worry as much about people who selected into those groups hi yeah sorry I'm like behind the podium hi yeah so I just wanted to ask a question kind of about trends you maybe saw with like social media I was a fifth grade teacher for five years and over the course of those five years I saw younger and younger students getting more and more on social media and it was affecting their personal relationships so I was just wondering if you saw any of that in your research we we haven't that's a really weird question we haven't looked at that I have a personal opinion about that don't worry and then I'm going to ask Lisa her personal opinion about this I'm one of those people who would say what is the YouTube right so I come from under I'm behind the veil of ignorance here I I think that it takes young people especially away from making real social connection so that they can't actually look someone in the eye and have a conversation I think that it gives a false sense of belonging I also think that especially for young people the kind of damage that can be done by the viciousness that can be done where adults are not present when I was young we could leave school at school we would go home there were adults I was lucky there were adults there and your perspective you get some perspective on what was happening at school if school comes home with you in your pocket and people are at it all night you never get a rest from it so it worries me a lot especially with young people I don't know what Lisa so my personal experience or feeling is exactly the same as yours oh microphone my personal experience is exactly the same as yours and I get asked this a lot because of all the work on social networks and is this a friend, is this a real friend and I keep saying there's not much research on this it's not a real friend and as soon as I do three people from the audience raise their hand and they say I met my husband you know on this or they have a support group that's really important to do it so my personal bias is exactly the same the data aren't very strong and I think certainly this kind of surfing the web, social media that has no personal kind of connection is likely to be we're likely to be right but we're likely to be wrong about some part of this and that's the part that would be really interesting to know if I'm correct my impression is that the phenomena you're talking about begins around 1970s in thinking about the reasons that you gave to explain what we are looking at I can't think of why should it be the 1970s why didn't it start 1960s why didn't it start 1990 what is so unique about 1970s can come tomorrow when Angus is going to talk at length about the changes to the economy that took place over that period which put some people on a downward trajectory whose real wages are falling median wages in this country have been flat for 50 years going back to 1970 essentially and below the median that's the halfway mark below that median real wages have been falling so there were things that made the economy work for people up until that point and then beyond that people's ability to get jobs where there was a ladder up where there was on-the-job training when there was hope for the future where she wanted to marry you because she saw that you were a good prospect a lot of things started to deteriorate and this particular population in a way that I think brought this on I don't know if Angus wants to add given he's going to be okay sorry I wasn't sure if you said yes or no sorry I will say something about that tomorrow but it's a very important thing and I'm not sure I'll say it quite in that form but Bob Putnam has a new book that he's working on is basically a whole series of about 50 graphs all of which either peak or have a trough in 1970 so 1970 is really the hinge point at which the American economy stopped prospering and came apart and again I don't want to steal the thunder from tomorrow's talk but did that not happen in all these other countries because it's really striking thing you've made the point it's not just men it's women too it's a rural it's urban too but it is just US which makes you think a lot about what kind of social policies may have been in place to buffer workers who were displaced for example when some of the jobs left the country went to China went to Vietnam went to wherever that and when robots came started to come in when AI started to really advance some countries did a much better job than the US has done first in terms of universal healthcare so and we think that that sort of insurance makes a really big difference I don't want to steal Angus's thunder either for tomorrow so I I'm not sure how much of the how far we should take this but just this idea that we have a healthcare system in the US which is a larger by half than the next most expensive system which is Switzerland even though the Swiss live longer than the Americans do we have this big funnel that's funneling money up that's helping to keep wages low that's making a difference you're asking me to stop yeah without stealing your thunder I would just add that this political process of having a house of representatives be very very polarized also during the 60s 70s and sort of into the 80s looked very not polarized even though there were strong sort of politics but they just sort of swung like this and with this rising inequality came this increasingly polarized political process so I somehow think that that's part of it I don't know whether that I actually don't like that graph or believe it because a lot of what's happening there is to do with the south because it's all to do with race and you know there was not polarization because the democrats turn into republicans and you know once you cry for that most of that goes away so I mean I do think that's an issue I will talk a little bit by tomorrow but I mean what answers is right I mean I think these deep forces like the slowing of economic growth since 1950 decade by decade which is common across most rich countries and the big question and I won't talk about this tomorrow but you can take this home tonight is you know whether what's happening in the US today is going to happen in those other countries 20 30 years from now and there's long history of health events in the United States finishing up in Europe 20 or 30 years later or whether Europe really has successfully inoculated itself against this and this is a peculiar American pathology and I don't think we know the answer to that question but that's the big underlying question underlying all this work also whether these middle age people when they get into old age and are supported by Medicare and Social Security will start doing as well as the other leader doing today or they'll carry this pathology of their cohort with them into old age and if that happens we have a real problem because all the problems of financing Medicare and Social Security are going to be exacerbated by having a huge chunk of people who are very sick and who are much sicker than the current people going back to the and the very unfortunately the data on mortality from other countries comes with a lag so with the US every year in December with a year's lag you get all the death records the Canadians haven't released theirs in several years now but for the data that we do have it begins to look like drugs are a bigger problem the English speaking countries all think they have a drug problem and they do if you take the US out they're all going up but it's just dwarfed by what's happening in the US largely because they've kept their opioids in check and we haven't but if you go for example to the UK drugs not a problem suicide not a problem but their rates of death from alcoholism are rising birth cohort to birth cohort to birth cohort which makes us think that it is possible that we may be at a point where these countries which have been showing themselves to be doing so well suddenly are going to be seeing problems as well especially for example places like the UK where austerity has been in place for so long and now with Brexit God knows but just what's going to happen there next Thank you I love the Jenny Mansbridge quote that populism is a way of saying look at me or listen to me and I'm just wondering with respect to solutions the problem is if you listen to what populists are saying in terms of their solutions that doesn't seem to be quite the answer that we're looking for so I'm wondering you know just a little time for speculation from both of you about what we can do about the future of capitalism here some of this will be untapped tomorrow but it's true one of the last times I was here at Stanford I heard Condoleezza Rice say that the last election was that can you hear me now election and that I think Brexit was sort of the same people were angry they felt like they were invisible they saw one lever they could pull and they pulled it but I think that if people thought that their legislators both at the state level and at the federal level were actually interested in the fact that they did not see a ladder up they didn't see hope for the future I think a lot of what looks ugly would kind of disappear and people would would grab hold of something that would be helpful I would just add that the longer article not just the quote talks about earlier forms of populism which were much more of the people entirely of the people and that the risk and why I brought it up was that the risk of isolating one group feeds into this idea well it's an immigrant problem it's a race problem it's not when in fact it's not really and it's not I don't think what you mean to say so I think it's important to be conscious of that and to frame it that there's a way for some more solidarity across groups when they're maybe experiencing the epidemic at somewhat different waves but not entirely different so it isn't an other making I'd like to refer to a book that I'm sure you're familiar with in the mid 1990s which is Rifkin's The End of Work and in that book he refers to this middle age group that will never work again typically the poster child would be the minor who will not move can't be trained in other fields but will never work do you have any solutions for that one? Yeah I think a lot of those people do find work they just don't find work that's as well paid and that has a promising future so like right currently we have an unemployment rate at 3.8% which is so stunningly low but a job is the jobs are not the same right so you give up the $40 an hour job now you've got a job flipping hamburgers it's just you're counted as being employed but it doesn't give you any hope for the future it doesn't have prospects so I think if we need to find a way in which we can bring labor back to the table when profits are being divided up here and that labor should get a share how we do that again I don't want to take away from tomorrow's lecture but I think that that's going to be essential so we take one here and then one last one on that side hi I have a question about using capitalism as a framework for understanding the different dots of despair that you had talked about today for me I think I really believe capitalism to have a certain level of dehumanization and by putting profits over people at the core if we use this as understanding of why we have different issues in our society I feel like there are a lot of limitations by considering capitalism as something that can still be work through but are simply broken I was wondering about your limitations and possibilities in using that framework see capitalism is what brought a lot of the world tremendous progress in the last 250 years I don't think by itself is evil but in its roots capitalism gives people incentives to try harder to do better to make profits right but it's a machine you have to keep on the rails because what you want to do is give people reward for their efforts for their innovation for their ability to make things better but you don't want them to start blocking off the path for other people to do the same so it's a very delicate machine that you really need to keep your eyes on at all times to make sure it doesn't start to run out of control that's the way I see it but I see it actually as having been an engine that has worked for all parts of the world to make the world a much better place over the past 250 years hi thank you thank you all for a great lecture and for the work that you've done inspiring those of us just starting out to try to tackle some of these problems in an effort to maybe end the night on a high ish note I'm curious if you've identified any insulating factors when you think about inoculating so in your stratification plot did you identify outliers geographic regions or other dimensions that did not fit the correlation well and did you dig at all deeper into those to try to understand what potential social or otherwise inoculating factors there may be against the contagion that you've identified great question I don't have a good answer Angus do you want to a great question I don't have an answer but we would love to hear from John Taylor as well can we do one more okay great question so I can help thinking about you're not on there you go I can help thinking about mobility through the income distribution and if you're stuck you're going to despair if your kids are stuck you're going to have a lot of despair so there's evidence that upward mobility has declined and that may be part of the story and probably is worse if you don't have a college degree is also differences across the United States as you know in the degree of upward mobility so could that be underlying this issue that you're seeing despair because it doesn't look like the prospects are good and it's even worse if you don't have a college degree I think we actually don't find differences across the country like some regions are just thriving which comes back to this like there's a lot more mobility but for sure it's the hope for the future for you and your children so going back to Robert Putnam again this idea that I might be able to shoulder this myself but if my kids don't have a chance so if you're in a town where there was an industry and the industry closes down you know you're suddenly flipping hamburgers but the school system is collapsed because the tax base is imploded and so what's going to happen to your kids and we know that the physical mobility that used to help keep America running well people are less likely to move than they were a generation ago and we could do a whole lecture on that and why that might be the case and what you might say about that but I think that is central to what we're seeing here is that people need hope and without it we're in for a bad spell on that sharing note I'm going to turn it back to the president who will have something nice to say that will make us feel well I wanted to thank Anne and Lisa for getting us off to a great start and I think we very much look forward to part two tomorrow night so please all come back and speaking of hope I think we can hope that it will be even more inspiring tomorrow as we learn about some of the levers that we can pull and hopefully some of the solutions that we might be able to tackle so thank you very much all for being here