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By Why Is This Happening?

Life expectancy in America has gone down three years in a row. You might expect to see shorter life expectancies in the aftermath of war or famine — to witness it in an industrialized nation in the middle of an otherwise prosperous era, however, is unprecedented. It is a distress signal that something has gone horribly wrong.

Jonathan Metzl traced that distress signal to its origin and found something remarkable. He writes that the policies promising to Make American Great Again, policies rooted in centering and maintaining the power of whiteness, are shortening the lives of the white Americans who vote for them. From supporting conceal carry to cutting social services, Metzl explores just what policies white voters are willing to risk their lives for.

**This conversation explores death by suicide and gun violence**

JONATHAN METZL: Because Tennessee didn't do the expansion, that cost every white citizen in the state two to three weeks of life, just because of this ideology. And it's ironic that the people I interviewed for the book, who were the staunchest supporters of blocking Obamacare and telling me about the “witch doctor Obamacare,” all these kind of things, those were the same people who were giving away three weeks of their life in support of these politics, and voting for people who did so.

CHRIS HAYES: Hello, and welcome to "Why Is This Happening," with me your host, Chris Hayes. So, when do you think the last time that life expectancy in the United States fell for three years in a row? Think about that for a second. Life expectancy is one of those just sort of gold standard indicators of the progress of a society, along with things like material wealth or per capita GDP. One of the things that happens, societies, they get wealthier, they grow and people live longer. And the reason people live longer is because the healthcare system gets better, diseases that kill people at young ages start to get knocked out, things like malaria for instance, which is still a huge battle in huge parts of the global south.

Things like maternal and infant mortality get better. Right? Like these are all the signs of progress. A progressing society is one in which people are living longer. And the reason they're living longer is because the society is getting richer and the healthcare is getting better and everything's going good, right? Pointed in the right direction. And that's generally true. The U.S. has a lower life expectancy than a lot of the other OECD countries, but much, much higher than what we call developing countries. Say, a place like Mozambique or Indonesia, right?

Now, when you see a society that starts having life expectancy go down, something is happening. Something's up. That's a distress signal from that society. An example of a place where life expectancy started to go down was Russia right after the fall of the Soviet Union. This sort of collapse period in which all sorts of societal institutions were coming apart. And you saw a big spike in all kinds of deaths, things like suicide and alcoholism, things like that.

In the U.S., the last time that life expectancy went down three years in a row was 1915 to 1918. And what was happening then were two things, World War I and the global flu pandemic that killed 50 million people, including 650,000 Americans.

Right? So, maybe you know this history, maybe you don't. You've got the World War, and what happens is in the war all these people around each other who transmit a flu then they all come back home at the end of the war, where they then take that flu, transmit it into the host countries, and across the globe 50 million people die from the global flu pandemic. 650,000 die in the U.S., and the global flu pandemic and the deaths from the war itself mean that US life expectancy goes down from 1915 to 1980.

That's the only time that U.S. life expectancy went down until 2015, 2016, 2017. Think about that for a second. Economic recovery is in full swing. Maybe if you saw those numbers in 2008, 2009, you would think, okay, huge Great Recession, people are out of work. Maybe they don't have access to health care. Maybe there's a surge in things like suicides. No. Life expectancy kept bumping along, progressing. Three years in a row, 2015, 2016, 2017. That is a wild, wild statistical artifact. It doesn't make any sense.

It should not be happening. A rich developing society that is not in the midst of some obvious crisis like a global flu pandemic or the end of a World War should not be seeing life expectancy decline for three years in a row. It should not be happening. There isn't a very good precedent for it. And yet, that is what's happening in the United States of America.

So, back in 2015, two Princeton professors, Anne Case and Angus Deaton, wrote a study of midlife mortality for white people, particularly white people without a college degree, and they found it was going way up. In fact, it had been better than African-Americans, and was now 30 percent worse in some cases. Again, what was driving this, what they call deaths of despair, alcohol-induced death, suicide, and particularly opioid overdoses. Something is happening in America, and particularly among white America, that is driving the effect we are seeing of lower life expectancy. And it is a genuine social mystery.

Because when you zoom out, all the macro indicators say this should not be happening and it is happening, and it is particularly notable that is happening so intensely among white Americans. We know forever that there have been massive health disparities in America by class, socioeconomic status, and particularly race, and it is still the case. Life expectancy in America is lower for African-Americans than white people. All those health disparities are there, but they've been converging a little bit and they've been converging because white health is getting worse.

So, what is the answer? What does it mean? What is driving us? My guest today has a theory. Just a heads up, in this conversation we do talk a lot about suicide and gun violence. If those are issues that have a particularly intense effect on you, you just should know that before you go in.

Jonathan Metzl is a psychiatrist and sociologist. He runs a center at Vanderbilt University. And he just wrote a book called "Dying of Whiteness: How Politics and Racial Resentment is Killing America's Heartland." And his theory is that a certain kind of politics of whiteness, a politics of whiteness that leads people to elect political leaders that pass certain policies, is actually driving the negative health effects on white people themselves. People are basically taking years off their lives by the people they vote for, who promise to protect their position in the social hierarchy. That's the theory behind the case.

And if you listened last week to the conversation with Dorian Warren, where he talked about that W.E.B. Dubois idea of the mental wage of whiteness, right? The way the intangible benefit that whiteness confers on a person. And then, the wage stagnation that's happened. Right? Not just the actual real material wage stagnation, but the sort of psychological wage stagnation as a society grows ever more equal, as white people are no longer quite as centered as they once were in the national story.

This conversation is like a Google map zoom in on that core idea. What is happening among a certain strata of white Americans, particularly rural white Americans, conservative white Americans, who feel under threat. And this feeling of threat is intimately bound to their whiteness, and who pursue a politics to preserve that whiteness and the status of it, that produces social artifacts that lead to their deaths. That is the thesis of Jonathan Metzl's book and it's the grim tragic loop that much of the country right now is caught in. To unlock the mystery of those statistics about life expectancy I told you about, but also understand a lot about what's driving politics in certain parts of the country. You're gonna want to listen to Jonathan Metzl.

CHRIS HAYES: You've practiced as a doctor?

JONATHAN METZL: I trained as a psychiatrist. I went all the way through and then I got interested in issues of politics and race and social context. And so, I ended up going back to school to get a PhD in critical race theory and American history. And I've been trying to combine those two over the course of my career.

CHRIS HAYES: That's really interesting. What made you want to do that?

JONATHAN METZL: You know, it's great to do medical training. I learned a lot about illness and treatment and medical systems. But there were so many issues that were coming up in my medical training that we couldn't address. Initially, it was that people were coming in with disorders that were linked to poverty or because they couldn't get food, because they couldn't get medication. They couldn't get transit to the hospital. And even though the doctors tried to be sympathetic or empathetic, it turned out that those answers to those questions had to do with much bigger forces, like economy, food distribution systems, structural racism, oppression, history. And so, I wanted to be able to tell the other side of that story. So, I ended up going back to school to try to do that.

CHRIS HAYES: It's so funny, because we had a guy named Abdul El-Sayed on the podcast. Really fascinating guy. He ran for governor of Michigan, but he's a Rhodes Scholar and then was a clinician, and then left that to get his doctorate in public health, taught at Columbia, who basically told a very similar story, right? That he was like seeing patients and what he was encountering was the things that were making the ill were essentially result of social structures that were making them sick.

JONATHAN METZL: We started a new movement through my program and some other places called structural competency, and the basic idea is exactly that. Namely, that doctors are taught to be sympathetic, to be racially sensitive. All those things are important. But if somebody's coming in with a disorder that's caused by racism or poverty, you actually need to understand the upstream factors in addition to the clinical factors. And it's good to see medicine broadening its focus.

CHRIS HAYES: Really, there are people trying to teach that to medical students?

JONATHAN METZL: We started a movement and there's now a movement called the structural competency movement. And basically the argument is medicine by itself is not enough. It's great to be a great doctor. But if you really want to help people in this context, you actually have to ally with urban planners, with community organizations, people who understand how to get food out in the middle of food deserts. So, we've got I think 20 medical schools now teaching our materials.

CHRIS HAYES: Where do you come from? How do you get your politics?

JONATHAN METZL: My politics in part are what I write about in the book. I'm somebody who my father is a Holocaust survivor. He escaped Austria. My grandparents were displaced persons in Switzerland. It took them about 10 years to get into this country. When they got to the United States, we were located, my father and my grandparents, in Kansas City. We started off cleaning homes, then opening a bodega, opening a meat shop, a kosher meat shop.

CHRIS HAYES: I just want to be clear. They don't call it a bodega in Kansas City.

JONATHAN METZL: Yeah. I have to say-

CHRIS HAYES: This is the New Yorker in you retconning "bodega" back in Kansas-

JONATHAN METZL: My mom is from Queens. My mom's from Kew Gardens, and so we had to call it a bodega.

CHRIS HAYES: You got it. Tiffany at one point to me ... We had one conversation on the podcast where I said the bodega, she's like, "I don't know if people know what a bodega is."

JONATHAN METZL: No, Philly, Baltimore, they don't have bodegas. Chicago doesn't have a bodega, but I'm telling you, if you're not going to call our thing a bodega, you'll have to take that up with my mom.

CHRIS HAYES: Okay.

JONATHAN METZL: So basically, and everybody who bought kosher meat at the store had to put a dollar into the jar to send my father to medical school. My dad went to med school. He came to New York. He met my mom. My dad's very patriotic. He joined the Air Force, stationed in Turkey. I was born there on an Air Force base, and then we all moved back to Kansas City.

JONATHAN METZL: And so, we were from Kansas City, Missouri, and very proud, but we were also people who escaped a war zone and people who had known government oppression and anti-Semitism. And so, it was this kind of combination of feeling strongly about the region we were living in but also knowing that there was a bigger world out there that could impinge on that at any time.

CHRIS HAYES: Missouri is a really interesting state. It's where the book starts. It's where your first sort of study is. The book is called "Dying of Whiteness." What was the seed for this book? How did you start on this?

JONATHAN METZL: The seed was twofold. First, it was based on my growing up experiences in a way. I grew up in a Kansas City where people had very different ideologies, very different backgrounds.

I had a lot of friends who are Republican, Democrat, pro-gun, anti-gun, everything imaginable. And in the Kansas City that I grew up in, we found a way to make it work. And I can give you many examples of that. All of the camps we went to, the schools. There was a push for integration, diversity.

Of course, there was also a strong history of racism and oppression in Missouri, but I would say when I was in high school, the state senate was really evenly divided between Democrats and Republicans. And so, they devised a power-sharing agreement where every year the chairmanship would flip back and forth between Democrat and Republican.

So, people were different and we knew it and we found a way to get along. And then, over the course of ... as I moved away from Missouri and every six months I go back to visit my parents, and it felt like every six months or so some pillar of that kind of neighborliness ended up getting chipped away.

So, first it was you need guns to protect yourself and people started getting on edge about that. We need tax cuts that were going to eviscerate the roads, bridges, and schools, and parks that we all use. And all of a sudden, this neighborliness was replaced with a kind of tension. I feel very sensitive to that. So, I think that-

CHRIS HAYES: You felt that palpably in sort of going back.

JONATHAN METZL: A 100 percent, a 100 percent. I mean, let me give you one example. When I was doing my research for the book, I went and talked to people across Kansas City and in the suburbs about what it meant to see people carrying firearms around in public spaces, and I talked to a number of African-Americans. I'll never forget there was one guy named John who I spoke to. I'm changing all the names, but he said he used to love shopping at Sam's Club because that was where he got the best discounts for his home goods and things. And then, he started seeing white guys walking through the aisles carrying open and concealed carry weapons, and he found it to be a form of racial intimidation.

JONATHAN METZL: And he said he and members of his family, he forbid people he knew and his family members from going to Sam's Club because he felt like the people who were open carrying were doing it to intimidate people like him.

CHRIS HAYES: Wow.

JONATHAN METZL: In the book, I have a number of cases like that, where basically the minute you change things that are the social fabric of society, all of a sudden people start to mistrust each other more. And so, I would say yes, it was based on a general sense. But when I started to do the research for the book, all of a sudden this idea of neighborliness was replaced with this concern, which maybe was subterranean the entire time, but this concern that someone else is going to rip me off.

And so, when I talk to struggling working class white people, who were brave and courageous in many ways, but this concern that minorities and immigrants are going to take privileges or resources that are mine. It was almost like because of the policies, people were set to mistrust each other. And I guess I just spent a lot of time thinking about yeah, we can track, like I do in the book, death or illness or politics, Twitter, all these big things, but on the every day level, what does it mean for people's social interaction to put a lot of guns in society and to reject health care reform so that everybody's scrambling for healthcare resources? To cut away the tax base so that working-class people, all of a sudden, their schools suck?

And really what I found was the minute that becomes the economy, this sense of mistrust and anxiety really ratchets up and people end up becoming much more balkanized and much less neighborly.

CHRIS HAYES: There's a public health phenomenon that is at the core of this book, right? So, you're sort of writing about ... you’re kind of theorizing around the data. Right? And the data has gotten some headlines and it's about what's happening to Americans' health, particularly white Americans' health. And we should note, there are massive health disparities in America, racially and along class and educational and income lines. But if you just zoom in on white people, something really weird has been happening.

JONATHAN METZL: That's exactly right.

CHRIS HAYES: To them in terms of mortality and morbidity. What is happening? What's the data saying?

JONATHAN METZL: Part of this book, that's exactly right, is a data book. I did a bunch of deep dives into databases, that track injury and death and longevity and other factors. It turns out, if you're a white American and you live in a state that, for example, allows the free flow of firearms, that rejected Obamacare and rejected a Medicaid expansion basically, or did these massive tax cuts, that the actual policies, the policies that were supposed to make white America great again are as dangerous to your health as are asbestos or not wearing a seatbelt or secondhand smoke. They literally became disease risk factors that shortened life.

And I have some of the numbers here. For example, Missouri. Missouri was a state that it was quite hard to get a permit. People did it, but it wasn't like anybody could go get a gun. As it became easier and easier and easier for people to get guns, the rates of death and injury went up in many populations. But the one I track most dramatically was white male suicide. And just over the five years that they did away with the permit laws in Missouri, white male suicide ended up costing the state $300 million. It cost 11,000 white male life years.

So, I'm using databases to track this, but the numbers are exponential. And I track it all back to these particular policies. Similarly in Tennessee, I compare Tennessee and Kentucky. One state did the expansion, the other state didn't do the expansion.

CHRIS HAYES: For Medicaid under the Obamacare?

JONATHAN METZL: Exactly. That's exactly right. And because Tennessee didn't do the expansion, that cost every white citizen in the state two to three weeks of life, just because of this ideology, and the reason-

CHRIS HAYES: Just non-expansion.

JONATHAN METZL: Just non-expansion. And the reason that is, is because ... and it wasn't just poor people, working class people. It was an aggregate number. And the reason that is, it makes sense if you think about it. It's that if there is no health base, if there's no safety net, what happens is people start going to the emergency rooms and they're sicker when they go to the emergency rooms. It drains resources from the system.

And so, all of these resources that should be spread throughout the system end up getting drained down to the bottom and the entire health care system suffers. And so again, it's worse if you're working class or poor person. It's definitely worse if you're a minority or immigrant, but it's ironic that the people I interviewed for the book who were the staunchest supporters of blocking Obamacare and telling me about the “witch doctor Obamacare,” all these kind of things, those were the same people who were giving away three weeks of their life in support of these politics, and voting for people who did so.

CHRIS HAYES: The stuff about guns was really striking to me, because when we talk about guns in America, there's two things that we talk about. We tend to talk about mass shootings, which get a lot of attention understandably, but are relatively statistically rare, people shooting 10 or 12 people in a school for instance, like happened in Parkland. And then, we talk about urban violence, right? And urban violence is always very racially coded. And it is true that there are higher rates of violence in places like Cleveland, Baltimore, Chicago.

The thing we don't talk about is the thing that kills most people, by far. I mean, three to one, right? Something like that, a year? Which is suicide. And one of the things you write in the book is that when you're looking at the data that is showing life expectancy in America declining among white populations, one big part of the driver is suicide.

JONATHAN METZL: One of the most powerful parts of the book and really of the research and really of my entire career was the research I did in Missouri for this book. I went through southern parts of Missouri, very red state Missouri, very pro-gun Missouri, and I was honored that people let me into their homes. They let me into their families. And they let me into their support groups. And the support groups that I sat in on were support groups for people who had lost often children or husbands or wives or parents to gun suicide, and the pain in the room was immeasurable. Immeasurable. Just so much concern and so much fear and loss.

And part of that was of course to lose someone by suicide doesn't make sense in any context, but the other part of the story was that these were very pro-gun people who had believed so deeply that guns were their protectors. That gun was the thing that was going to stop a bad guy and all these kind of things. And so, they were kind of coming to terms with how is it that this thing that was supposed to protect me that I carry with me all the time ended up costing me the person that I cared most about in my life. And it was immensely, immensely powerful and sad, but also meaningful to talk to people and really ask them that question.

And when I would ask them, "Did this change the way you felt about guns?" I learned actually that was the wrong question, because they would always say it's not the gun's fault. But what I would ask them, "What can we do to protect and keep people say within pro-gun communities?" They would always say, "Something really needs to be done. We need to do something about this." But there was no logic for them. In other words, the polarization was so intense that they couldn't take a stance that was against the NRA. They were striving for some kind of story, and so just an answer to your question, this gun suicide story was so hard because there was no ready-made cultural language for people to process what was happening exactly.

CHRIS HAYES: One of the things we know about suicide, and I think I understand people's inclination to say, "It wasn't the gun. That was just the tool that they used." But one of the things that data show us about suicide is actually opportunity matters a tremendous amount, right? I mean, if you stop someone or people that fail when they attempt to commit suicide, there's actually very low rates of repeat attempts, and people go on to have fulfilling lives.

JONATHAN METZL: The numbers on gun suicide bare that out 100 percent. In other words, I'm a psychiatrist, right? People always say, "Oh, was it a cry for help? What were the warning signs?" But gun suicide has its own temporality, it's own linearity. Very often gun suicide, numerically, is what's called an impulsive act. People will decide within 59 minutes or less. It's not like they've seen a psychiatrist or have a long history of mental illness. The typical story that I heard, and I think people see, are he was really drunk. He got fired. He found out his wife was having an affair. Something like that. Like this moment of total despair, and then there's a gun available. And the sad truth is that the same guns that people want not locked up in safes because they're there to protect you, in those 59 minutes or less, that is the biggest risk factor in mortality because it's not like they're any more or less suicide attempts across the country, across the world. But gun suicide is lethal 96 percent of the time. Whereas overdose, which is the most common global way to attempt suicide, it's lethal about three to four percent of the time. And so here's this toxic mix of available guns, a moment of despair, and at that one moment, you have access to an incredibly efficient way to end your own life, and at that moment, it's not a mental health issue.

So when I talk to psychiatrists-

CHRIS HAYES: It's an availability.

JONATHAN METZL: It's an availability issue. And that's why when people ask me, "What can psychiatrists do about gun suicide?" And I said, "It's not about prediction. You can't predict who's going to do this. It's about prevention. You don't want a gun there at that moment."

CHRIS HAYES: You write about this in the book, gun suicide is a distinct thing in the category of suicide in terms of how people undertake it, the impulsivity of it, and ultimately the lethality. And is there a connection? Gun deaths have now surpassed I think for the first time auto deaths, and the bulk of that is suicides. What is driving those numbers?

JONATHAN METZL: Right. So in terms of gun suicide, again, I'm a mental health practitioner and people say, "was there a disorder of somebody's brain? Was it something about the despair?" I'm sure it was all of those things. I'm sure it was all of the above very often. But gun suicide tracks onto laws about how people buy, store, and carry firearms. So in the book, I compare Missouri and Connecticut, and I just show here's one state that did one thing with its laws, and here's another state that did another thing with its laws. And Connecticut making it hard for people to get guns and also enacting the kind of laws that would take guns away from people who are at high risk, lead to dramatic decreases in gun suicide. Whereas Missouri, where it was just almost a free for all in a way, people in critical race studies say whiteness is invisible, and what that means is we don't talk about whiteness because it's the authority. But here, in this case, I was seeing that this plague of white suffering was invisible. Because we couldn't talk about whiteness, we couldn't talk about the fact that white people were dying because of these tools that were supposed to be markers of their own power.

CHRIS HAYES: There's just something so tragic and intense about the notion of this sort of fear mongering about the other, about the home invader, about the evening news while you live in the distant St. Louis suburbs and the notion of a black assailant coming to the door, and the need to buy a gun to protect against that, and that gun being there at your moment of utmost despair leading to a lethal suicide.

JONATHAN METZL: It made me so upset. I mean, I'm an objective researcher, and I try to be neutral. I replayed a lot of the interviews verbatim in the book, and a couple of them were from people who lived right outside of St. Louis who were elderly white men who ended up, because Ferguson was happening, they all ran out and got weapons because, as you say, 200 miles away, there was some racial unrest happening or some factors like that. So this idea of the racial other, it's so irresponsible, but it's something that wasn't just based in the news. I mean, the NRA was saying, "get a gun because there's a carjacker or a gang banger, and they might attack you. That's why you need a gun." I look at a lot of gun advertisements and this idea of basically they market them to white males saying, "these are symbols of your power, your privilege, restoring the balance of power." And I didn't see anything that was like, "be careful in your moments of despair. This is a lethal tool. This can kill you or anything like that."

So we've seen in this country that that ties into a larger story, which is just the reasons people own guns in this country, have undergone a dramatic shift over the past 20 years in large part because of these exact stories. 15 years ago, people, the majority felt like they needed guns for hunting. Now that's about 20 percent of gun owners. Everybody else feels like they need a gun now for protection, and the minute that happens, we're fearing each other.

CHRIS HAYES: And the crazy thing about that is that has switched at the time that crime in an objective sense has fallen in an unprecedented fashion.

JONATHAN METZL: Exactly right. Basically people have never been more safe from a statistical angle. And so this whipping up of fear of other people is part of the story, and the other part, going back to your question before, is about automobiles, right? I mean, people who I talk to, I talk to a lot of pro-gun and anti-gun and everybody in between audiences, and people will tell me, "Well, guns are in the Constitution and cars are not, and that's why they're different stories." But I don't buy that for a second. In the mid-1990s, we had about 40,000 car deaths a year in the United States, and we felt as a society that that number was too high. So we didn't go take away everybody's car. What we did is we invented anti-lock brakes, we invented airbags, we made safer cars, smarter cars.

CHRIS HAYES: We also had a tremendously important and socially transformative movement against drunk driving.

JONATHAN METZL: Exactly right.

CHRIS HAYES: Which completely altered behavioral norms. I mean, this is a matter of the data.

JONATHAN METZL: 100 percent right. So in other words, I think all these things, what they say together, is that we as a society decided, not Republican or Democrat, we decided that these were too many deaths. And so what happened was we did what we do best as Americans, we got together, and we figured out a hard problem, and now car deaths are probably half of what they were in the 1990s.

CHRIS HAYES: Amazing.

JONATHAN METZL: The numbers are exactly opposite for guns. The gun deaths now are nearing 40,000, probably more than that, and so it's exactly the opposite story. And that story is one, as you say, a lack of political will; a messaging that polarizes people, that makes it hard for them to ... I mean, I really feel like these polarizing messages make people feel like it's impossible to find common ground when these are problems we can be solving.

CHRIS HAYES: Okay. So that's all based on data around gun suicides, but there's another driver in the dying of whiteness that really stands out or stood out to me, and let's get to that in just a minute.

So guns are one area that's driving this increased mortality, particularly gun suicides. I want to be specific on that because what's happening in the context of non-white communities, communities of color, particularly poor communities of color is just a very different story. Although, obviously, gun suicides happen there as well, but that's not the driver in the way that it is in the rural Missouri you're talking about. There's also the other thing that we're seeing is opioid addiction and alcohol addiction actually. I think one of the interesting things you talk about and one of the things that got a little buried when the sort of Angus Eaton paper came out talking about what's going on with this mortality rate for white people is that alcohol had a lot to play with it, which is an interesting part of the story because I think we think about the opioid crisis as a crisis of the drug and the chemicals, and the fact that alcohol deaths are going up too says that there's something maybe else going on.

JONATHAN METZL: I struggle with this data. I mean, I know it's there. I know it's important. I know that it's remarkable that we're seeing up to a four year decrease lifespan for people who are in the majority group in this country. White men are having a falling lifespan in part of the country, which is unheard of.

CHRIS HAYES: It's just that doesn't happen.

JONATHAN METZL: It happens after famines, it happens after atomic bombs. It doesn't happen in the middle of a prosperous country that's an industrialized country. So it's completely unheard of.

CHRIS HAYES: Am I correct that overall, across all races and everything, American lifespan has declined for three years in a row?

JONATHAN METZL: That is true, but it's particularly ... I mean, yes, that's definitely true. But I feel like white men are major drivers of this, in part because they have a higher perch to fall from in a particular way, but again, we have the money and the means and the resources. And part of what I show ... I mean, the reason I say I struggle with calling these deaths of despair, they are deaths of despair, and obviously what I'm trying to do in my book is put a racial lens around a lot of that economic literature to say it's not just about drugs, it's about the ways that whiteness itself can be very self-destructive. And so it's a performance of whiteness that is leading to people supporting these politics, these policies. So it's this interplay. I know, believe me, I know there is despair. I've seen it. In a way Trump has seen it and he speaks to that, and there is a lot of despair. People feel like they were in a position of privilege, whatever. I might think of it. Of course, I'm a white person as well.

But there is a sense of frustration and helplessness, and I think the opioid crisis is part about despair. But the point I try to make in the book is it's also about social policy. It's also about policies. It's also about infrastructure. It's about investing not just in treatment and rehab centers but also in jobs and roads and bridges and schools.

CHRIS HAYES: So the statistical thing that is happening in this country right now doesn't have a good precedent and doesn't make a lot of sense.

JONATHAN METZL: I mean, there really is no precedent for what we're seeing, and the irony is the people who are being the most affected it by it are the ones who are voting for it.

CHRIS HAYES: And so this is where the theorization of dying of whiteness comes in I think in a really fascinating way, right? Because I think the theorization that we had seen before had a lot to do with the sort of forgotten places, the hollowing out of rural America, big macro-economic and globalized trends that were ripping communities apart in ways that were creating behaviors that were dangerous from a health perspective and also psychological conditions that were dangerous, right? Increased levels of depression, anxiety, despair.

You're saying something that is related to that but distinct, right? Because you're theorizing in it in a particular way around race.

JONATHAN METZL: Right.

CHRIS HAYES: How?

JONATHAN METZL: There are a couple of ways to address that. Let me just first start with what I think the main point about race is, it's that the politics that claim to restore or bolster whiteness end up turning whiteness itself into a high risk category. That the categories that are supposed to make whiteness great again end up, as we've been talking about, shortening the lifespans of working class white Americans, and whiteness itself becomes a negative health indicator in the data that I look at. And that ties into several things. One is profoundly effective messaging that working class white Americans should not form common cause with other people across socioeconomic lines. In other words, the messaging is you should mistrust African-Americans or immigrants because if you allied with those workers, that might form a very powerful force to demand concessions. So there's this idea of whiteness itself is distinct, and it's played to through the history of guns, for example. History of guns, there's been a 200-year history in this country that gun ownership was a white prerogative, and that rejection of the Affordable Care Act ties into these long histories that if you give healthcare to everybody, then your population is going to suffer. Tax cuts, this idea that lazy minorities are going to be getting what's yours.

And so there's been this profound messaging that basically has people caught. If you think about like the white working and middle class, they're caught between immigrants and minorities who are supposed to be nipping at their heels for what they want, and people above, who really are taking away the tax base that's helping them, and all of the energy in all of this is telling people, "You should look down at the people who are nipping at your heels, not up at actually the people who might really be causing what's screwing up you screwing up your life."

JONATHAN METZL: After writing the book, I've been asked a lot by people who probably in New York more than anyplace. They're saying, "What'll it take for people to recognize that their politics are bad for them? What's it going to take for them to wake up?" Or something like that. And I keep thinking, "Well, from their perspective, they're making a sacrifice in order to win an election, right?” So from their perspective, why are you going to be the person who asks that question when, for them, we get to choose all the judges. We won the elections, factors like that. So there is this mortal trade off. But the flip side of this that I try to get at in the book is that that trade off is also necessary for the GOP platform. In other words, if working class white Americans are not willing to lay down on the tracks.

Imagine, for example, if people in Tennessee had said, "Well, I'm a Republican, but dang, I want good healthcare," or, “I'm in Kansas,” another place I go in the book, “and I'm a Republican, but I demand that we have good schools and we have good roads.” The minute that people who are Conservative Republicans start asking for those things, there's no way the GOP can do the tax cut bill. There's no way that they repeal Obamacare initiatives or any of that. None of that works. And so part of what I argue is that the success of GOP politics at this one moment depends on assumptions about the disposability of working class white bodies and that this is also been a story that's been a very regional story, right? That's one of the things that's important now that in a way it was easy for people in New York to overlook it because that was what was happening in Mississippi, and now this is a national platform.

CHRIS HAYES: But here's the thing that I think is really important. I mean, the ways in which you get sort of white middle class people to sort of ignore their class interests and have solidarity with the titans in Capitol, right? Again, this is an old story. But what ends up happening in the analysis is that people take the material concerns as real, and the non-material concerns is like weird or like a swindle or a con. And so they think, "Well, these people are misassessing their own interests." And one of the things I think that you say in the book, you started with this guy Trevor I think, right?

JONATHAN METZL: Right.

CHRIS HAYES: Who is someone who is a sort of working class white guy with health problems who doesn't care if expanding Obamacare would help him personally. He doesn't want Obamacare to be expanded because other people, people of color particularly, will then get benefits. He's actually making an affirmative choice about what's more important to him. I mean, this is the important thing. It's not that people are tricked.

JONATHAN METZL: Right.

CHRIS HAYES: Like they actually have an ... Like whiteness, the value of whiteness is actually more important. They're making an affirmative choice about what the thing is, the thing they like, they value that gives them a sense of well being more than like having healthcare.

JONATHAN METZL: The flip side of the question of when are Trump supporters going to wake up is when are people who are liberal going to wake up themselves to the depth of these ideologies that people are willing to put their lives on the line. That case of Trevor is a perfect example. This was a focus group I was doing in a low income community in Tennessee and this guy was on death's doorstep, had an oxygen mask under his nose, had liver failure, and even at that time, I asked him, "Gosh, if you live 20 minutes away in Kentucky, you would get much cheaper medications and better healthcare because they adopted the marketplace and expanded Medicaid." And he said, "I don't want any part of that because I don't want my tax dollars going to Mexicans and welfare queens." The guy wasn't crazy. He was basically saying, "Here's a choice I'm making, that I'm a kamikaze in a way. I'm laying down on a line for something that's important to me, and that thing is an ideology, a construction of whiteness where I might not be at the top of the pyramid, but I'm certainly not at the bottom." And in a way, whatever benefit ... I mean, obviously there is a benefit to being white in this country, and he was willing to die for that.

CHRIS HAYES: And you see that in many places.

JONATHAN METZL: I see that kind of politics. I don't think it was ... It's not quite as apparent across the board. Some people were overtly racist and said it to me. I do see that strain of our bodily concerns are secondary to this bigger ideology. We're defending whiteness like a fortress.

CHRIS HAYES: Although they never call it whiteness.

JONATHAN METZL: Right.

CHRIS HAYES: I mean, very rarely I think. In the book and I think generally in our politics, it's not constructed by the folks defending it as such, right?

JONATHAN METZL: It's funny in that regard-

CHRIS HAYES: It's like real America or whatever the-

JONATHAN METZL: It's hard, I'm telling you personally, it's hard to talk about whiteness. I mean, my last book was about black power protesters, and I would go on television all the time and talk about the black power movement and Black Panthers and things like that. It was cool. But now when I go on TV and I talk about whiteness, the minute I say whiteness, all of a sudden it's like, "You're a white traitor. You're a white sell out." So even talking about whiteness itself is risky, right? Because what you're doing is it's like exposing what's behind the curtain or you're looking too hard. So I agree with that, but I do think that tension lies beneath many of the issues and guns is another great example. There's this whole racial history of guns, and if you understand that racial history about who got to own a gun, then you understand, for example, why the castle doctrine, as one example, this idea that a man's home and his car and his everything else is a fortress is such a powerful motif in gun culture because of this idea that basically this libertarian white idea that you're defending your ... It's not just a castle of a castle, it's a castle of whiteness is what I talk about.

And another example would be why is it that when white open carry advocates in the south, they can walk into Walmart or they can go buy coffee or go to Starbucks, but when black open carry advocates walk into Walmart, they get tackled or arrested or shot. There's the whole racial politics around these issues that isn't called racial politics, but it underlies many of these issues. So I'm just trying to expose that because I think it's better if we talk about it.

CHRIS HAYES: When you talk about the ideology being whiteness, I guess my question is like why has it gotten worse? Is it the dawning demographic eclipse that looms in the future?

JONATHAN METZL: I think that there's something very important happening right now, and let me be clear, you asked about whiteness, and I'm not making ... I have no idea what anybody's thinking. I don't know what's in anybody's heart. I don't know who's racist and who's not. We're very good at covering that up in any case. And I'm not making any claim about whiteness as biology.

CHRIS HAYES: No, no, no. Very clearly, it's about a sort of constructed social category with very real and tangible affects.

JONATHAN METZL: And part of those tangible effects are not because people are racist, they're because concerns about the loss of white authority that were fringe narratives in this country for a while or they were regional narratives in this country for a while, worked their way into community, county, city, state politics. So the risk I'm talking about of whiteness is not whether you're racist. It's whether you live in a state where the state health authority is setting policies about healthcare or guns or schools that set state policy. The risk is actually the policy and so what I'm talking about is how these backlash politics that were not setting state agendas, there was a much more centrist agenda in the states I talked about, but the minute they start setting policies that impact people's health, that's when people start dying of whiteness and instead of saying "Oh my God, look what happened in Tennessee when they didn't expand, let's not do that.” Or “look what happened in Missouri when we spread a lot of guns, lets not do that.” Instead what we're seeing is that these horrible state policies are becoming the platform for the Trump administration.

CHRIS HAYES: And in some ways the variable here, right, is that the intensity of the backlash, particularly in 2010 in terms of the real transfer of power is that you get, nine years ago you get this transfer of power and many of these, what you talk about is a regional problem, places like Kansas, places like Missouri, places like Tennessee. Power in the hands of this one party that then begins to implement this agenda.

JONATHAN METZL: And this liberal fantasy, it was my own fantasy also, but the idea was basically I remember when Trump got elected and there were all these articles in the paper that were like “when voters see what's going to happen when farmers see what tariffs do, they're going to wake up.” Or “when people see that they're not going to get covered by health care.” And I was like look, I just wrote a book about this, and I guarantee you when they see that they're going to become more supportive of Trump. In a way the more extreme people's situations get the more ideological they get and so in a way, unless you can present an argument that's going to convince them that you're going to better these particular issues, I feel like just them turning on Trump because a curtain is pulled up was, I mean again, we were all shocked by that election in one way or another, but I would say that when people started saying “people in the south just need empathy or that when they see what's really happening…” and I kept saying like my book's not out yet, but if my book was here I would tell you that actually when that starts happening they're going to become more ideologically driven, not less.

CHRIS HAYES: I mean we've seen, I've seen interviews with farmers who are literally having their bottom line affected by these tariffs, right, it's very clear. The president launched this sort of trade war with China, he's imposed tariffs, they've responded by not buying American soybeans. Soybeans are one of the biggest export crop we have, you can go and stick a microphone in the face of a bunch of farmers across the Midwest who grow and sell soybeans who are like "Yes, I can read off my spreadsheet the dollar value that this has hurt me. I'm still behind Trump."

JONATHAN METZL: Displacement, first of all, is a very powerful tool so as long as that's somebody else's fault, I will say to be fair, a lot of people who were suffering also felt like Trump was standing up for their interests and he was their champion and so in a particular way I did come to appreciate that these politics were giving people something that was not quantifiable by the analytic tool that I was using. It was this sense of “I'm part of an ideologically-driven mission in a particular way” or something like that.

CHRIS HAYES: Right. And I mean I say this to people on the left all the time, there's ton of people on the left for whom this is true. Speaking for myself, I and I know people in New York who have voted for many candidates who literally would materially make their taxes go up, would reduce their bottom line and no one's like you're crazy. What's wrong with you? Don't you realize that? And it's like no, actually, there are other things important to me. It's more important to me to have a society that is just and equitable and pluralistic and diverse and doesn't separate children at the border, than what happens to my tax rate. I have concerns that are not material. Somehow it just seems weird to people in the other direction but it's just like, everyone's walking around with these concerns.

JONATHAN METZL: Right, think about it.

CHRIS HAYES: What's our place in the world? What's our place in the country? Who are we? Those are the essential ones. There's this idea that the material concerns are the real ones. Or why don't people like, and actually it's the other way around. Who you are, the concerns about identity, who you are, what community are you a part of, where do you stand in the story of the nation, how central are you, what are you inherit, what can you lay claim to? That's the stuff.

JONATHAN METZL: I just wrote a book about health and I can tell you that it made me humble that health is just one part of identity. I rode to this interview today on a Citi Bike and I didn't wear a bike helmet. There are candidates that I voted for that have done bad things to my own interests, or that have spread policies that are bad for people in dense urban areas, or HIV policy, or you name it. And so in a way, it's important to recognize as you suggest that health is just one of the indicators, but identity is this big, big complicated thing. And when people say like what's going to change people's minds I'll say "Well let me ask you a question. What kind of argument would somebody need to make to you so that you would carry around an AR-15?" In other words, there's nothing I can think of that would make me do that for myself, and so-

CHRIS HAYES: Literally nothing.

JONATHAN METZL: Yeah.

CHRIS HAYES: You literally, there's literally nothing you can convince me. I mean I'm trying to think. I guess my answer to that would be an actual apocalyptic breakdown in society, which like-

JONATHAN METZL: "Walking Dead" or-

CHRIS HAYES: Right, exactly. "Walking Dead." I guess if it were like the "Walking Dead" I would get an AR-15 and try and shoot the zombies so they didn't get my kids.

JONATHAN METZL: Right, right. But again so that's what we're getting at. Now again, this is part and parcel of why I'm trying to argue that our disputes should not be about identity because people's identities are really complicated. But when it's about policy then I feel like it's actually a bit more mutable, maybe I'm, you're smiling, maybe I'm being more idealistic at this point in the conversation.

CHRIS HAYES: Well, it's funny because we just had this whole conversation about how deeply bound these identities are. And you're talking about, you write about this in the book about these sort of suicides support groups, the most intense type of visceral grief and loss, I don't know. I don't want to have sort of despair. I do think that persuasion's possible and people do change their minds, but I don't know how do you redirect away from this very visceral sense that they are bound up in a project that's preserving some part of their place in the world even if it's doing material harm?

JONATHAN METZL: Two ways. One, it's not my job to change anybody's minds. In other words, part of that narrative actually has to come from working class white communities. If there's a progressive conservative movement for example. Something that basically says we're conservative but we also want more out of our elected officials for our own lives. That will be a game changer. Again, that's not coming from me. I would tell people, what would it take to turn on Trump and they'd laugh at me. But I do think it's fair that there could be a movement within conservatism that actually, there's no historical precedent for that. So one would be a movement within conservatism that actually also wants healthcare and education and betterment. But the other is just, we're so polarized that the issues feel so impossible.

I'm sighing right now as I tell you this in a particular way, but it's not like people haven't changed course politically when a politician offered them something that seemed to better their own material circumstances. And the Democrats, there were problems with the Democratic formulation but the Democrats were the experts at that for 50 years, 100 years. And so in a way, the reason why I have a hard time answering this question is because sometimes when I talk to Democrats and they're like the Trump base is like this big iceberg in the middle of the Atlantic and it's never going to change or go away and I'm like actually that's not right. You're just not offering something that is resonating in a way-

CHRIS HAYES: But wait a second. I feel like you're arguing on the other side of this. Because if the whole point is, people have non material concerns, what can I offer you, I can offer you here, I'll give you $1,000 a month and I'll give you healthcare and I'll give you all these things, but you're going to have to give up your centeredness in the national story as a white man. Because I'm just not going to reify that because that's actually not what our coalition's about because we just can't be about that. And like you can take or leave that trade, but the whole point is that, I guess it's all relative. What is the material bid that you can move someone off of their, there's some market exchange rate, right, for like the value of whiteness where it's like what's it going to take? But the point is that's high.

JONATHAN METZL: Very high.

CHRIS HAYES: And what I can't, what I cannot give you as a Democratic candidate in the year 2019 in the era of pluralizing diverse 21st century post-Obama America, I cannot give you the thing. I can't counter offer the thing that Donald Trump is offering you. I can't. I cannot say "You're right, white man. That you have it the worst. And that these other people are coming to take your shit.”

JONATHAN METZL: No, I think 1,000 percent agree with you. And I think you're right to call me on that in a particular-

CHRIS HAYES: I'm not calling you. It's a fascinating question to me. It's just like an unresolved one.

JONATHAN METZL: I mean part of the issue statistically speaking is that policies, I mean it's the flip of my argument that policies that are supposedly bad for minority and immigrant communities end up being really bad for white populations. The flip side is true also that policies that help working class white people also help working class people across the board and so for me-

CHRIS HAYES: Often on disparate levels. In absolute sense, yes, but disparately.

JONATHAN METZL: Disparate, right, exactly right. But there are obviously bigger structural problems and so in a way I guess that's the piece I'm trying to hold on to. Is to say I don't want to give up on thinking about initiatives that are going to help working class people because they are actually going to help people across the board. For me that's the potential promise of a potential progressive movement if it's going to spread beyond what it is right now, which is actually that it's making promises or slogans or ideologies about particular stances or particular positions that end up being potentially beneficial even for the people I'm talking about in this book.

CHRIS HAYES: Part of the sort of deep question that I keep returning to, and we've had several conversations about this. I talked to Nikole Hannah-Jones about this and I've talked to Ta-Nehisi Coates about it, there's two ways of looking at the value of whiteness. So one way is that it's essentially whiteness is used as a wedge that makes people in general at the bottom of the social hierarchy worse off. So that's one argument. And I think there's a strong argument to say that America doesn't have the sort of welfare state that comparable OECD countries have because of the wedge of race, and we have lower, we have worse life expectancy, we have higher incarcerations rates among white people, we have higher maternal mortality among white people, again disparate but across OECD, still worse right here. So it's a net negative, right. It ends up screwing the very people that are sort of the part, at the crux of it. That's one argument and think is the argument you make in your book.

But the argument that Nikole Hannah-Jones make is actually it works out well. White people do get the better part of stuff. Like they do, they are better educated, they do have better health outcomes. That we want to tell ourselves oh they're actually screwing themselves in some way, but when you look at it, who's got most of the pie? They're doing alright.

JONATHAN METZL: There's a tremendous obviously defensiveness of this particular construction of whiteness that we're talking about and in a minute I just want to make clear that I'm not talking about all white people, I'm talking about a policy, but of course there is a particular sense of anxiety about demographic change that white populations actually have that particular material benefit and it's at risk because of demographic changes or globalization or changing workforce or other people rising up through the ranks and so it's not so much that white people are worse off, it's that there's a fear that basically this particular position that people are holding on to so deeply, is at risk of falling. And certainly I think that you see this in the gun debate for example, I mean ads for example that I talk about in the book quite clearly reference that particular history. That the world may be changing, but if you're protecting yourself with a Glock, it'll restore the balance of power in a way.

And so there is this sense of, it's a sense of holding on. It's not a sense of just we're victims in a particular way. And then I also think other people have written about this, just a sense of oh I have a psychiatrist but I hate to use the word guilt, but there is a kind of sense of kind of, you're stuck in this box in a way and I think, just again, I did feel talking to a lot of people that if there was some way to get people out of this particular construction, they might have taken it, but it was beyond the framework of knowing how to actually, how can we get out this situation where we were the enslavers at a particular point. Where we drive to work and there are people who are much worse off than us but I think that there was just so much anxiety and again, all the rhetoric was basically saying people are going to carjack you or they're going to steal your big screen TV or something like that and so there was just no way out of this box. I mean, part of what I'm writing about is not just about this dying thing, it's about the box of whiteness and how we can't get out of that.

But I do just want to make one other point about that, which is there were many white people who didn't spout this narrative that I talked to and the whole conclusion of the book is talking about examples of really brave remarkable people that I met across the course of my work, talking to school board people in Kansas and people who were working against gun violence in low income communities who were saying similar things to what we were, but they were red state Republicans.

CHRIS HAYES: Totally. Yeah I mean it's always really important to talk about the fact that you just can't, we're talking about millions of people and people have all sorts of idiosyncrasies and this is a point that we've made before on the podcast that if a county of 10,000 people in a red county, right, that goes 70-30 for Trump, you're talking about 3,000 people in that county who didn't vote for him.

JONATHAN METZL: And this leads back to policy, right. That there are many ways to be white, there are many expressions of whiteness and part of my frustration is that the dominant mode of who gets to define whiteness, the biggest megaphone right now is in a way the worst one. So it's exactly this politics is what's crowding out all the other rhetorics and part of the point I make in the conclusion is there's so many other ways to be white that are generous and compassionate and multi-cultural and thinking we're the demographic majority, it's our responsibility to take care of immigrants. There are all these other things in our country and so part of the issue, and that's why I focus on policy is to say that we've let our worst angels set the health policies. That that's really the moment that we have to push back on.

CHRIS HAYES: Jonathan Metzl is a psychiatrist and a sociologist. He's the director of the Center for Medicine, Heath, and Society at Vanderbilt University. His new book's called "Dying of Whiteness: How the Politics of Racial Resentment is Killing America's Heartland." That was great. Thanks Jonathan.

JONATHAN METZL: Thanks so much.

CHRIS HAYES: Once again my great thanks to Jonathan Metzl, the book's called Dying of Whiteness: How the Politics of Racial Resentment is Killing America's Heartland." You should definitely check it out. Also, if you liked that conversation, there's a lot of conversations that we've done that relate to it. It's kind of right in the center of a lot of the areas of concern that WITHpod has been pursing from the time we launched. There's a great conversation about life in Appalachia with Eliza Griswald you should check out. There's a conversation with Ta-Nehisi Coates and Nikole Hannah-Jones, both of which are about race and how race and racial supremacy and white supremacy structure American life. George Goehl talked about organizing folks in rural America, particularly white folks in rural America. And Michael Tesler talked about the ways in which people's racial attitudes were increasingly predicting their politics. So you should check out all those conversations. We will link to them on the website.

As always would love to hear your feedback. We've been getting some great suggestions for topics. They go right in the file when we get them. Well that's not true. If they're good, they go right in the file. Some of them are bad. And we just ignore those. But most of them are good. I just want to be clear. Most of them are good. You can tweet us at #WITHpod, you can email withpod@gmail.com. We always love to hear from you.

Related links:

"Dying of Whiteness," by Jonathan Metzl

"The New Jim Crow," by Michelle Alexander

"What's the Matter with Kansas?" by Thomas Frank

You might also like:

School Segregation in 2018 with Nikole Hannah-Jones

Fracking Trump Country with Eliza Griswold

Organizing in Trump Country with George Goehl

Medicare for All with Abdul El-Sayed

"Why Is This Happening" is presented by MSNBC and NBC News, produced by the "All In "team and features music by Eddie Cooper. You can see more of our work, including links to things we mentioned here by going to nbcnews.com/whyisthishappening.