In 2015, Princeton economists Anne Case and Angus Deaton released a bombshell study that revealed a dramatic rise in mortality among non-Hispanic, middle-aged white people in the United States. Published in the Proceedings of the National Academy of Sciences, their paper found that the increase in deaths among middle-aged white Americans between 1999 and 2013 is “comparable to lives lost in the U.S. AIDS epidemic through mid-2015.”

Their latest report, published in Brookings Papers on Economic Activity, explores the forces behind this spike in deaths, which they say most severely impacts middle-aged white people with a high-school education or less. By contrast, mortality rates are falling for white Americans with college degrees. The authors note that this trend contrasts with developments in Europe, where mortality rates are “falling for those with low levels of educational attainment, and are doing so more rapidly than mortality rates for those with higher levels of education.”

Instead of identifying a single culprit, the scholars point to a number of reinforcing factors, including a rise in “deaths of despair,” such as drug overdoses, suicide and alcoholism, as well as an overall decline in the working class.

These lethal conditions are decades in the making and cannot easily or immediately be undone, they conclude.

The husband-and-wife team of economists observes that the epidemic of “deaths of despair,” “spread from the Southwest, where it was centered in 2000, first to Appalachia, Florida and the west coast by the mid-2000s, and is now country-wide.”

Today, such deaths are spread across the country and cannot be dismissed as a condition of rural America. The professors write, “Although we do not see the supply of opioids as the fundamental factor, the prescription of opioids for chronic pain added fuel to the flames, making the epidemic much worse than it otherwise would have been.”

The paper also notes a prevalence of deaths from chronic diseases, as well as declining progress in combating heart disease and cancer. Ultimately, the scholars point to underlying socio-economic factors, emphasizing that these trends cannot be reduced solely to income.

“These deaths of despair have been accompanied by reduced labor force participation, reduced marriage rates, increases in reports of poor health and poor mental health,” Anne Case explained in an interview with NPR. “So we are beginning to thread a story that it's possible [the trend is] consistent with the labor market collapsing for people with less than a college degree. Those people are less [likely] to form stable marriages, and that in turn has effects on the kind of economic and social supports that people need in order to thrive.”

“The rates of suicide are much higher among men [than women],” Case continued. “And drug overdoses and alcohol-related liver death are higher among men, too. But the [mortality] trends are identical for men and women with a high school degree or less. So we think of this as people, either quickly with a gun or slowly with drugs and alcohol, killing themselves. Under that body count, there's a lot of social dysfunction that we think ultimately we may be able to pin to poor job prospects over the life course.”

The paper also notes that “Mortality rates of black non-Hispanics have been and remain higher than those of white non-Hispanics as a whole, but have fallen rapidly, by around 25 percent from 1999 to 2015.” So the issue is not that the white working-class is dying at a greater rate, but that the mortality gap is narrowing for a subset of the population.

As the following figure illustrates, the mortality rates for middle-aged, white Americans converged with their middle-aged black counterparts roughly a decade ago.

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Sophie Bjork-James, a researcher at Vanderbilt University with expertise in conservative social movements and critical race theory, told AlterNet that standards have been plummeting across the working class, and communities of color remain hardest hit.

“If we look at economic trends over the past 30 or 40 years, it’s clear that for the majority of Americans, quality of life and income have gone down, regardless of racial group," she said. “For most Americans, their economic position is less positive than it was for their parents.”

While Deaton told NPR he sees their findings as “part of the decline of the white working-class,” black and Latino people remain most adversely impacted by plummeting socio-economic standards. The Pew Research Center determined in 2014 that the current wealth gap between white and black people in the United States is at its highest point since 1989, with white homes possessing 13 times the median wealth of their black counterparts in 2013. White households possess more than 10 times the wealth of their Hispanic counterparts, Pew notes.

According to a report released in August 2016 by the Institute for Policy Studies, “If average black family wealth continues to grow at the same pace it has over the past three decades, it would take black families 228 years to amass the same amount of wealth white families have today.”

Poor black and Latino immigrants are also more likely to attend lower-performing schools than their poor white counterparts.

“If you look at developments since the housing crisis in 2008, most of the wealth that disappeared was from people of color—African Americans and Latinos—as opposed to whites,” said Bjork James. “If you look at other measures of overall quality of life, it's still very much stratified by race.”