Research shows some places are better for people’s health than others. But why? As economists try to make sense of sentiments, some are exploring regional levels of sentiments like hope, purpose, and happiness.

They say these subjective feelings can be measured with hard data. Economists also say that, given the rise in “deaths of despair” – things like suicide, alcohol poisoning, and opioid overdoses – they also have undeniable impacts on how long and how well people live.

In this episode of Six Hundred Atlantic, we’ll talk to Brookings Institution economist Carol Graham about “geographies of despair,” where many have given up hope. We’ll discuss growing regional mortality gaps with Dartmouth health economist Jonathan Skinner. We’ll look at health and wealth, living and dying, purpose and despair and ask how they’re impacting our country and our economy.

JAY LINDSAY:
Gary, Indiana, and New York City aren’t often compared.

Gary is a small city on the southern edge of Lake Michigan with a population of about 75,000.

New York is … New York. It’s a superstar city with about 112 times more people than Gary and exponentially more influence.

But in 2016, Gary, Indiana, and New York City were linked together by a disturbing finding.

According to a landmark Stanford University study, the poorest men in New York City could expect to live an astonishing five years longer than the poorest men in Gary.

This finding got a lot of attention, and it shows geographic place can be extremely important when it comes to health. But the question is, “Why?”

Why are some places so much better for people’s health than others?

This season of 600 Atlantic is looking at geographic disparities, which were the topic of the Federal Reserve Bank of Boston’s most recent annual economic conference.

Geographic disparities are regional differences in variables such as income, opportunity, and health. It’s when living in one place seems to come with big advantages over another.

Few health statistics illustrate the impact of these gaps as starkly as life expectancy. And at last year’s Boston Fed conference, Dartmouth economist and health policy expert Jonathan Skinner introduced research that indicated regional gaps in longevity are growing.

Skinner looked at mortality across the country over a 15-year period ending in 2014.

What he found was troubling – a 41 percent increase in the already existing gap between places with high death rates and lower death rates.

Here’s Skinner:

JONATHAN SKINNER
One hopes that it will moderate, because if not, we really will have separate parts of the country where in some areas people are enjoying ever longer life expectancy, and other areas, they are consigned to a declining life expectancy. That, to me, is very disturbing for the United States as a democracy.

JAY LINDSAY:
As economists try to make sense of this growing disparity, some are exploring territory that’s traditionally been left to other social scientists.

They’re looking at regional levels of things like hope, purpose, and happiness. These feelings are subjective, so they can be tricky to measure.

But it’s also undeniable these indicators of well-being do have significant impact on health – because they affect people’s behavior.

The rise in “death of despair” across the nation is the critical factor in the growing mortality gap, and these can be linked to measures of well-being. Economists say they must be better understood.

Here’s Boston Fed economist Christopher Foote, who organized the Boston Fed conference:

CHRISTOPHER FOOTE:
… I think the economists have traditionally tried to measure the quality of life, not on what people say, but on what they do. Are they leaving an area? Are they willing to pay a high price for rents or housing prices to live in an area? Now, I think the profession is much more open to asking people how happy are you in this area? And sort of correlating their answers with more data that can be measured more objectively.

JAY LINDSAY:
I’m Jay Lindsay, a member of the Communication team at the Federal Reserve Bank of Boston. On this episode of 600 Atlantic, we’re looking at health and wealth, living and dying, purpose and despair, and how they impact our country and our economy.

Skinner’s research into regional death rate disparities looked at mortality rates within defined geographic units called “Hospital Referral Regions.”

The U.S. is divided from coast-to-coast into 306 of these regions.

Skinner calculated mortality rates in the regions in the year 2000 and 2014. Gaps in longevity between races have been shrinking, and he wondered if that was also happening in the longevity gaps between regions.

Instead, he was struck by the remarkable 41 percent expansion in the regional gaps.

His data showed longevity improving along the east and west coasts. But the middle of the country was falling further behind.

JONATHAN SKINNER
There are a variety of reasons why all of this is happening, but it still means that the disparities based on geography are growing.

That to me is quite disturbing. In other words, this idea of like that in the past, and then in the 20th century, you could count on the sickest regions catching up to the healthier regions. Now, that day has passed. Now, we are looking at the sickest regions getting sicker and the healthier regions staying healthy and a widening disparity between the two.

JAY LINDSAY:
Economists have several theories why this is happening.

A prominent hypothesis focuses on differences in local health behaviors, like smoking.

In fact, Skinner found that higher smoking rates in a region were the top predictor of higher mortality. But he cautions against assuming a clear cause-and-effect relationship.

He noted research shows the changes over time in smoking – such as a general decrease – don’t necessarily predict changes over time in longevity.

The correlation between smoking rates and mortality may be more about how smokers tend to behave, and less about the smoking itself.

JONATHAN SKINNER:
It could be that people who engage in other kinds of risky behavior are also more likely to smoke. If someone likes to drink and drive their car fast, they might also be predisposed to smoking. I don't think social scientists have disentangled all the causal factors out at this point.

JAY LINDSAY:
Research also indicates that smoking is a symptom of other chronic and complex health-related problems in a community – such as low education, limited job opportunity, or mental health issues.

These are factors that have been tied to the rise in “deaths of despair,” including suicide, drug overdoses, or alcohol-related deaths.

The term “deaths of despair” was coined in 2015 by Princeton economists Anne Case and Angus Deaton, a husband-and-wife team who studied mortality rates among middle-aged men.

Case and Deaton found that mortality rates for white middle-aged men were rising in the United States, even as mortality rates for middle-aged men in other countries were falling.

The difference was largely explained by the deaths of despair arising from suicide or substance abuse.

And deaths of despair are also an important factor in the widening mortality gaps across the United States documented by Skinner.

It’s important to note these deaths don’t look the same everywhere.

In Kentucky, for instance, opioid overdose is a common cause. In West Texas, it’s more likely alcohol abuse. Regardless, they’re rooted in the same hopelessness.

Brookings Institution economist Carol Graham notes the victims of these deaths of despair have a clear demographic profile: They are strongly concentrated among whites with less than a college education.

CAROL GRAHAM:
It's a big enough phenomenon to drive up our overall mortality rate, so there's something going on.

JAY LINDSAY:
Graham studies how variables like happiness and personal well-being influence economics. She said these victims of deaths of despair inhabit what she called a “geography of desperation.”

These are often rural areas hard hit by the exodus of manufacturing. They’re also filled with people who don’t have work, but they are unwilling or unable to move, even though their prospects have dried up.

CAROL GRAHAM:
They're not unemployed and unhappy, they're beyond that, they tend to be very isolated, they tend to not have strong communities, and they have a very large gap in terms of their well-being, which is everything from life satisfaction to reported stress, to optimism for the future, and everybody else.

JAY LINDSAY:
Graham says her research shows that no other group – including the poorest members of traditionally disadvantaged minority group – have less hope for the future than this group of lower educated white men.

She blames the collapse of what she calls the “blue-collar white narrative.”

CAROL GRAHAM:
The blue-collar white narrative was they had privileged access to the American Dream.

JAY LINDSAY:
In that narrative, all a young man needed to do was finish high school. After that, he had a job that provided for himself and his family for life.

But when the industries those young men were looking to step into went away, the stable jobs went away, and the stable family disappeared, too. Then came the despair.

Graham said her research indicates blue-collar whites have struggled to think differently about their future, even though their circumstances have changed.

They seem, for instance, relatively uninterested in higher education – even though it’s one of the key ways to a better life.

CAROL GRAHAM:
I can't fully explain that, but I think, and I have some good data that would back this up, more aggregate data, that the trajectory for blue collar whites was, you finish high school and you got one of these jobs, whether it's steel worker, coal miner, car factory worker, and you never thought about going to college because you finished high school and that was your ticket to this stable, middle class life.

JAY LINDSAY:
Graham notes it’s a major contrast with the poor from minority groups, who are far more committed to college.

CAROL GRAHAM:
For minorities, and this holds true of both Hispanics and Blacks, their only ticket to get ahead of where their parents started is to get an education. They don't have, or didn't have and still don't have, privileged access to particular kinds of jobs, and in today's world you need a college education to be on those skilled jobs. For some reason, or, I think, for that reason, the belief in education being important and the sort of persistence to get a college education is higher among poor minorities than it is among poor whites.

JAY LINDSAY:
It all speaks to their lack of hope and general pessimism. And that can feed this sometime fatal cycle of despair.

Graham added it’s just a fact that optimists live longer, and she cited some of her own research.

That research found that respondents born between 1935 and 1945 who reported being optimistic when they were in their 20s were more likely to be alive in 2015.

CAROL GRAHAM:
Basically, hope and well-being matters to people's longer-term outcomes, and we've shown this in other papers, as well.

JAY LINDSAY:
So how does the need to improve things like hope and “well-being” translate in an economic context?

What can policymakers do?

Does it all really just come down to improving people’s income – or opportunities for income?

But Federal Reserve Bank of Boston president Eric Rosengren says the focus on well-being in economics is about more than making money.

ERIC ROSENGREN:
I think it's really thinking about a broader sense of what makes people happy. And it's certainly easier if you have more money because you can buy more things that will make you happy. But it's not the only thing that makes you happy, and part of it's having a rewarding life and thinking that you're doing important things. And those are things that sometimes are hard to capture in an economic model. But these well-being models are trying to capture some of that.

JAY LINDSAY:
Graham says her data shows that while income is important for happiness, health matters more. And things like a sense of purpose in life and in work, or meaningful friendships, are also tremendously important.

CAROL GRAHAM:
Take life satisfaction, the most common measure of well-being, and you see that income matters, but it doesn't matter as much as you would think. So the whole debate on does income matter to happiness is ridiculous because, yes, it matters some, it just doesn't keep on mattering.

JAY LINDSAY:
The Stanford study this episode started with – which compares life expectancy in Gary, Indiana, and New York City – had as its key finding that higher income correlates with higher life expectancy across the board.

But Skinner points out that its Gary-New York City comparison also indicated income isn’t everything, because it showed vastly different life expectancies for people at the same income level.

He notes that income changes also don’t seem to predict changes in deaths of despair.

Income clearly isn’t all there is when it comes to how long – and how well – people live.

JONATHAN SKINNER:
There is a very important role for income, but there's something else that's going on that I think researchers don't entirely understand. That seems to be a first-order goal to figure it out.

JAY LINDSAY:
The geographic disparities economists grapple with – in longevity and health, in job opportunity and quality of education – are highly impactful.

And after decades of research and policymaking, it’s still unclear how to address them.

That has some economists asking if it’s time to do things differently.

Traditionally, policymakers have focused on improving prospects for people – rather than enhancing conditions in specific places.

They’ve reasoned that individuals can always move, so it’s best to equip them to take advantage of opportunity wherever they are.

But on this season of 600 Atlantic, we’ve seen that people don’t always move to areas of more opportunity. We’ve seen that geographic disparities appear to be hardening in places. That’s made economists increasingly willing to consider shifting their policy focus from “people” to “places.”

Here’s Christopher Foote:

CHRISTOPHER FOOTE:
I think this is one of the more exciting areas of economic theory and economic study. To what extent do we really need to shift our paradigm and start thinking about what can be a reasonable justification for saying: “I want to help city X versus the people in city X?” And we'll see a lot more of that research in the future.

JAY LINDSAY:
In our next episode we’ll delve into the pros and cons of changing the ways economists and policymakers tackle some of the country’s most fundamental and persistent problems.

Because even though there’s excitement about a new way of looking at things, some experts just don’t think policies that focus on places, not people, can work.

That’s next time on 600 Atlantic.

JAY LINDSAY:
Thanks for listening to Six Hundred Atlantic, and please check out the rest of our debut season, which includes five episodes and a bonus episode. Learn more and subscribe to our mailing list at bostonfed.org/six-hundred-atlantic. Listen and subscribe to Six Hundred Atlantic on Apple Podcasts, Spotify, Stitcher, and TuneIn.

Most of the interviews and reporting for this season of Six Hundred Atlantic were done prior to the onset of the COVID-19 pandemic. But the trends discussed are decades in the making and are particularly relevant during a time of economic upheaval. The pandemic’s impact on these trends are the focus of a special bonus episode of Six Hundred Atlantic, which features a discussion with urbanist Richard Florida and Harvard economist Ed Glaeser. We invite you to listen.

The producers would like to thank our expert contributors for lending their time and insights. They are Christopher Foote, Carol Graham, László Kulcsár, Christopher Mayer, David Neumark, Jonathan Skinner, Eric Rosengren, Katheryn Russ, and Abby Wozniak.

Six Hundred Atlantic is a Federal Reserve Bank of Boston podcast hosted by Jay Lindsay. Produced by Jay Lindsay, Allison Chase, and Peter Davis. Executive producers are Lucy Warsh and Heidi Furse. Recording by Steve Osemwenkhae. Engineering by Steve Osemwenkhae and Alex Cronin. Project manager is Allison Chase. The chief consultant is Christopher Foote. The podcast is written by Jay Lindsay and edited by Christopher Foote, Allison Chase, and Nicolas Brancaleone. Graphics and website design by Meghan Smith and Stephen Greenstein. Production consultants are David West and Thomas Stranberg.