Declining Destinies

Increasing Mortality and Decreasing Fertility in America

In late 2016, news sources across the U.S. reported a sobering statistic: The average life expectancy of Americans had fallen for the first time since 1993.

The numbers are not, in some ways, startling. For an American man born in 2015, the average life expectancy dropped from 76.5 to 76.3 years, and for the woman, from 81.3 to 81.2 years.[1] But for a developed nation, one for which such dips have happened only a few times in the last century, this is big news.

This statistic comes on the heels of some other sobering numbers that came to national attention recently. Anne Case and Angus Deaton of Princeton University published a paper in 2015 pointing to a rising morbidity and mortality among a certain segment of the non-Hispanic white population, those aged 45-54—i.e., in this group, people are getting sicker, and also dying younger.[2] The paper was an immediate sensation, and although it has its limitations (some have argued the specific parameters of the study)[3], it does demonstrate that at the very least, when it comes to longevity, America is losing when compared to other wealthy countries. As Case and Deaton point out, “This change reversed decades of progress in mortality and was unique to the United States: no other rich country saw a similar turnaround.”

Why the increases? Case and Deaton point to what they term “deaths of despair”—rising rates of drug overdose, alcohol poisoning, chronic liver disease and cirrhosis, and suicide. In a later analysis, the authors acknowledge a commentary on their original 2015 work, noting that

increases in mortality from deaths of despair would not have been large enough to change the direction of all-cause mortality for US whites had this group maintained its progress against other causes of death. For the two major causes of death in midlife, heart disease and cancer, the rate of mortality decline for age groups 45-49 and 50-54 fell from 2 percent per year on average between 1990 and 1999 to 1 percent per year between 2000-2014.[4]

In other words, Americans are both losing ground in the fight against some of the biggest killers, and also killing themselves—intentionally, by their own hands, or through alcohol and drugs—at alarmingly high levels. On the other end of the life spectrum, American fertility has been declining for years. Total completed fertility is now at its lowest point ever. Again, this is not news. But taken with a rising mortality rate, it signals a cultural sickness at the core of the American psyche that it will take much, much work to overcome.

Deaths of Despair

One of the most significant factors in this research is what many are beginning to call an “epidemic” of opioids—i.e., drugs that derive from the opium poppy, such as OxyContin and Hydrocodone, and on the illegal side, heroin and illicitly cooked fentanyl.

In 2016, the Centers for Disease Control and Prevention (CDC) issued a report summarizing “an epidemic of drug overdose (poisoning) deaths”[5]: “More persons died from drug overdoses in the United States in 2014 than during any previous year on record.” In that year, “there were approximately one and a half times more drug overdose deaths in the Untied States than deaths from motor vehicle crashes.”[6]

These staggering numbers are at least partly the consequence of widespread physician misunderstanding and consequent overprescribing of opioid painkillers in the 1990s. In Dreamland, Sam Quinones details how aggressive pharmaceutical advertising and infiltration into the medical field worked with the emerging belief that all pain must be treated seriously to usher in a huge surge in the prescribing of narcotics.[7] The type of pharma-led medical conferences that Quinones describes—in which pharmaceutical companies quite literally created the need for furthering medical education, and then decided what that education should be as well as sponsoring it at luxurious locations—is no longer permitted. Nonetheless, Big Pharma’s aggressive advertising campaigns had a huge impact at the end of the last century, when millions of Americans were first becoming addicted to opioid painkillers. Today, Americans consume about 80 percent of the world’s prescription painkillers; according to a recent National Safety Council survey, about 99% of doctors still prescribe such medications for longer than the recommended three-day period.[8]

Combine these phenomena of doctors overprescribing, patients in real physical or emotional pain, and drugs that are highly susceptible to abuse, and you have a recipe for turmoil. Fortunately, more and more governing bodies are recognizing this epidemic, and it is becoming much harder for patients to “shop around”—visit different doctors to get different prescriptions written, then different pharmacies to get the medications they need. “Lock-in” is a new tool being used by Medicaid and a number of private insurers, in which a patient is quite literally “locked in” to one particular doctor and one particular pharmacy, easily tracked online.[9]

But for many, the damage has already been done, and those unable to access the pills their bodies require actually step down to heroin. According to the CDC, opioid painkiller addicts are 40 times more likely than those who don’t use these painkillers to then become heroin addicts.[10] Heroin overdoses have more than tripled in the U.S. in the last four years.[11] As the laws of economics might dictate, supply is rising to meet demand. Heroin is cheaper, more readily available than ever before,  and also of a higher purity, leading to more severe addiction.[12]

Case and Deaton—and most of the commentators on their research—have pointed to the non-Hispanic white population specifically in discussing these trends. And while the CDC does say that the overdose death rate from 2013-2014 increased for both sexes, for people between 25-44 years of age and 55 or less, and for non-Hispanic whites and blacks alike, the data show that there is still a stark racial divide when it comes to opioid use and dependence. In 2015, about ten times as many whites died by opioid poisoning than either Hispanics or blacks.[13] Some have suggested that physicians are more wary of doling out prescription painkillers to minorities, deeming them to be either more susceptible to becoming addicted or more likely to then turn around and sell the drugs on the street.[14]

A separate phenomenon but most certainly linked in cause is an uptick in alcohol-related deaths.[15] Alcoholism has been relatively underreported, likely because it’s old territory. Alcohol has been readily available for most of history, unlike, for example, opioids, which are always taking different forms depending on demand and ability to transport, and have been more difficult to access. But according to a recent Washington Post story, alcohol-related deaths are also at a 35-year high.[16] The increases in opioid-related deaths have been more dramatic, but alcohol still kills more people annually. One likely reason for this increase in deaths is that per capita alcohol consumption is up—more Americans are drinking more alcohol. As the Post reports, “The number of American adults who drink at least monthly rose by a small but significant amount between 2002 and 2014—from 54.9 percent to 56.9 percent.”[17]

The most violent in the “deaths of despair” category is suicide, which has also been on the rise. The suicide rate in the U.S. in 2014 was at its highest point in almost 30 years, affecting every age group except the very oldest.[18] Analyzing data from the National Vital Statistics System, the CDC found that from 1999-2014, the U.S. suicide rate increased a staggering 24%.[19]

These increases in dying are also coupled with a decrease in new life. For 2016, the Total Fertility Rate in the U.S. was 1.87, beneath that of both Sweden and the United Kingdom, and well below the 2.1 necessary to maintain population.[20]

Declining fertility in the U.S. is not a new phenomenon. After reaching a peak in the late 1950s, fertility began to plummet in the 1960s, reaching a low sometime in the mid-1970s. There was a small increase in the 1980s and 1990s, but another sharp turn downward about the time that the most recent Recession began.[21] So certainly, the economy plays a large role in the fertility rate. But far more serious are long-term trends in later childbearing, coupled with a reduction in the amount of children desired—both enabled by the modern contraceptive.

The Reasons Why

What all of this data fail to tell us—although myriad researchers and media pundits have offered explanations—is why, precisely, Americans seem to be drugging, drinking, and taking their own lives at such incredible rates, while simultaneously rejecting children. The reasons are complicated and many, but a few stand out.

First, the role of economics cannot be ignored. In his important work on this subject, Love’s Labor Lost: The Rise and Fall of the Working-Class Family in America, Andrew Cherlin describes the emergence of what he calls the “hourglass economy”: “the idea of a declining demand for labor in the middle of the labor market relative to demand for workers at the top and, to a lesser extent, at the bottom.”[22] The “hourglass economy” does not affect men and women equally. While men were pushed further and further down the rungs of employment, women “were able to move into professional and managerial occupations—in part, by graduating from college in increasing numbers.”[23] But women, it turns out, don’t want to marry men whom they view as unemployable and unstable. In Cherlin’s account, women in the “working classes” began to turn away from marriage in droves. But while resisting marriage, they didn’t want to lose the opportunity to have children. Ever-increasing numbers of women began having children outside of marriage, and the rate of unwed childbearing was somewhere around 40% in 2015.[24] More children are now born to unwed but not necessarily unpartnered women, as cohabitation has also been on the upswing for decades. Cherlin highlights that such unions are wildly unstable; the result is often that children grow up with only one of their parents.

America has seen periods like this before, Cherlin says, times of nontraditional attitudes toward marriage and childbearing and periods of low economic prospects. The past several decades, however, have marked the first time in American history when these two forces coalesced. In the Great Depression, the economy was miserable, but attitudes toward marriage, family, and childbearing remained the same, so there was no significant change in overall patterns. And over the past several decades, economic prospects remained largely the same for a certain group of Americans—the educated—yet their attitudes towards family institutions have greatly liberalized. Still, there was no consequent change in behavior. The educated, in spite of professing shifting attitudes towards the importance of marriage and childbearing within marriage, still adhered to very traditional patterns. Cherlin concludes: “Only among young adults who have experienced both a deteriorating labor market and a nontraditional culture do we see the kinds of changes in family and personal lives that characterize the less-educated today.”[25]

Economics are indeed crucial, but the labor market does not account for everything. In the 2017 follow-up to their original 2015 report, Case and Deaton analyze the causes for the increases in mortality that they had observed in 2015. They find that although the economy plays a role, “it cannot provide a comprehensive explanation.” Why? In part, comparison groups which have experienced the same worsening economic conditions—American blacks and Hispanics, other wealthy European nations—have not experienced the same mortality outcomes. Instead, Case and Deaton propose what they term “cumulative disadvantage over life,” which takes into consideration worsening outcomes in the labor market, but also recognizes deteriorating families and ill health.[26] As traditional family life and employment began to decay, life became more difficult for the less educated. The authors argue:

Traditional structures of social and economic support slowly weakened; no longer was it possible for a man to follow his father and grandfather into a manufacturing job, or to join the union. Marriage was no longer the only way to form intimate partnerships, or to rear children. People moved away from the security of legacy religions or the churches of their parents and grandparents, towards churches that emphasized seeking an identity, or replaced membership with the search for connections. . . . These changes left people with less structure when they came to choose their careers, their religion, and the nature of their family lives. When such choices succeed, they are liberating; when they fail, the individual can only hold him or herself responsible. In the worst cases of failure, this is a Durkheim-like recipe for suicide.[27]

The loss of social support and the decline of job opportunity work together to diminish life prospects for the less educated. Not surprisingly, those states that make up the U.S. “Rust Belt”—the geographic region hit the hardest by the loss of manufacturing jobs—have also seen a spike in suicides.[28]

Working together with family instability and poor economic prospects is an increase in social isolation or loneliness. In an interview with Fortune, John Cacioppo, author of a book on the topic, describes the loneliness “epidemic” in the U.S. today and its effects.[29] Cacioppo reports that in the 1970s and 1980s, the “percentage of Americans who responded that they regularly or frequently felt lonely was between 11% and 20%,” depending on the study. Comparatively, in 2010, the AARP conducted a survey and found that the percentage was closer to 40-45%. Cacioppo credits this rise to a combination of increased mobility and a deterioration of generational connections; people form “networking” relationships online but are losing out on face-to-face interactions. Not mentioned, but certainly related, is the failure of the marriage culture noted by Cherlin and others. Ever more people leave work, and go home to an empty residence. In response to a question about the Case and Deaton study, Cacioppo says that while people aren’t dying of loneliness, per se, “they are dying of cardiovascular diseases, cancer, accidents, suicide, and diabetes. Based on your genetics and your environmental history, loneliness can make these conditions strike earlier than they otherwise would have.”[30]

What Is To Be Done?

Unfortunately, most of these trends have been bad and getting worse for some decades, so any hopes for relief seem slight.

Nonetheless, there have been at least a few promising trends. First, policymaking bodies have recognized the opioid epidemic and taken dramatic steps toward curbing access to such substances. It’s harder to get hooked on prescription painkillers now, which is good news.

Second, the tuition bubble is, some predict, about to burst or even already bursting.[31] College is becoming increasingly unaffordable, while the worth of a bachelor’s degree is declining due to a saturated market. What will happen when the price of education is no longer worth it? We are already witnessing increases in technical certifications, on-the-job training programs, etc. Perhaps programs like these can lead to bettering prospects for the working classes, even to something like a revival.

Third, and this may be a stretch, but I suspect that something of a feminist rejection of the traditional work environment is beginning to take place.[32] Women are recognizing that the corporate, workplace environment is inimical to life with small children. More companies are offering work-from-home options, increased flex time, more part-time positions, etc., in an effort to keep female employees. It remains to be seen what, if any, effects such measures have on desired number of children, but one may hope.

Still, it must be admitted, our prospects are bleak. Many have pointed to the Gilded Age, a period that witnessed one of the starkest divides between the classes, as a point in U.S. history similar to today. In his book Family Cycles: Strength, Decline, and Renewal in American Domestic Life, 1630-2000, Allan Carlson argues for four periods throughout U.S. history that saw a robust family life, followed by decline. One of these periods of decline—1880-1930—was also closely correlated to “evergrowing economic inequality over the course of the century, a clear consequence of the rise of industrial capitalism.”[33] Conversely, the next period of “revival” saw a leveling of incomes, and income inequality greatly reduced. Carlson writes, “A viable, culturally dominant middle class—complete with its family-centered orientation—emerges as the extremes of great wealth and great poverty diminish.”

The point being—we have been here before, although certainly not to this extent. If Carlson’s analyses are correct, we could see a period of revival in the next decade.  “The odds are against it,” he cautions, because we have now in place a court system extremely hostile to the natural family.[34] Nonetheless, Carlson concludes his book with the work of Eric Kaufmann, author of the 2012 Shall the Religious Inherit the Earth? In Kaufmann’s analyses, by procreative power alone, religious communities which take the biblical admonition to “be fruitful and multiply” seriously—the Hutterites, Old Order Amish, Ultra-Orthodox Haredi Jews, and American Mormons, among others—are set to outpace the liberal establishment in the baby-making arena and hence dramatically change world demography in the next century. If we can but keep the other side from stealing our children through the ideology of public education and the media, we may ultimately win the war.

Nicole M. King is Managing Editor of The Natural Family.

[1]     Rob Stein, “Life Expectancy in U.S. Drops for First Time in Decades, Report Finds,” NPR, December 8, 2016. 

[2]     Anne Case and Angus Deaton, “Rising Morbidity and Mortality in Midlife Among White Non-Hispanic Americans in the 21st Century,” PNAS 112.49 (December 8, 2015).

[3]     For a summary of these reasons, see “Jonathan Auerbach and Andrew Gelman, “Stop Saying White Mortality is Rising,” Slate, March 28, 2017.

[4]     Anne Case and Angus Deaton, “Mortality and Morbidity in the 21st Century,” Conference Version, Brookings Papers on Economic Activity Conference Drafts, March 27, 2017, at 13.

[5]     Rose A. Rudd et al., “Increases in Drug and Opioid Overdose Deaths—United States, 2000-2014,” Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report 64.50 (January 1, 2016): 1,378-82.

[6]     Ibid. 

[7]     Sam Quinones, Dreamland: The True Tale of America’s Opiate Epidemic (New York: Bloomsbury Press, 2015).

[8]     Dina Gusovsky, “Americans Consume Vast Majority of the World’s Opioids,” CNBC, April 27, 2016.

[9]     Ibid.

[10]   John Cassidy, “Why Did the Death Rate Rise Among Middle-Aged White Americans?” The New Yorker, November 9, 2015. 

[11]   Rudd et al., “Increases in Drug and Opioid Overdose Deaths.”

[12]   Ibid. 

[13]   Kaiser Family Foundation, “Opioid Overdose Deaths by Race/Ethnicity,” available at,%20Non-Hispanic%22,%22sort%22:%22desc%22%7D, accessed May 11, 2017.

[14]   Steven Ross Johnson, “The Racial Divide in the Opioid Epidemic,”, February 27, 2016. 

[15]   Christopher Ingraham, “Americans Are Drinking Themselves to Death at Record Rates,” The Washington Post, December 22, 2015.

[16]   Ibid.

[17]   Ibid.

[18]   Sabrina Tavernise, “U.S. Suicide Rate Surges to a 30-Year High,” New York Times, April 22, 2016.

[19]   Sally C. Curtin, Margaret Warner, and Holly Hedegaard, “Increase in Suicide in the United States, 1999–2014,” Centers for Disease Control and Prevention, NCHS Data Brief 241, April 2016.

[20]   The Central Intelligence Agency World Factbook, “Country Comparison: Total Fertility Rate,” available at, accessed May 11, 2017.

[21]   Mark Mather, “Fact Sheet: Decline in U.S. Fertility,” Population Reference Bureau, July 2012, available at, accessed May 11, 2017.

[22]   Andrew Cherlin, Love’s Labor Lost: The Rise and Fall of the Working-Class Family in America (New York: Russell Sage Foundation, 2014), 124. 

[23]   Ibid.

[24]   Centers for Disease Control and Prevention, National Center for Health Statistics, “Unmarried Childbearing,” available at, accessed May 11, 2017. 

[25]   Cherlin, 147.

[26]   Case and Deaton, “Mortality and Morbidity in the 21st Century,” 2017. Emphasis added.

[27]   Ibid., 30.

[28]   Cf. “Drug Overdose Death Data,” the Centers for Disease Control and Prevention, map depicting “Statistically significant drug overdose death rate increase from 2014 to 2015, US States,” last updated December 16, 2016, available at

[29]   Laura Entis, “Chronic Loneliness Is a Modern-Day Epidemic,” Fortune, June 22, 2016.

[30]   Ibid.

[31]   Cf. Derek Thompson, “This is the Way the College ‘Bubble’ Ends,” The Atlantic, July 26, 2017, available at

[32]   Cf. Margaret Wente, “Has the Gender Revolution Stalled?” The Globe and Mail, May 25, 2017, available at

[33]   Allan C. Carlson, Family Cycles: Strength, Decline, and Renewal in American Domestic Life, 1630-2000 (New Brunswick, NJ: Transaction, 2016), 107.

[34]   Ibid., 161.