An international study published this year in PLOS Medicine measured the health impacts of the COVID pandemic, based on a survey of over 15,000 people in 13 countries. It found that the pandemic resulted in worse health for more than a third of respondents. Anxiety and depression exacted the biggest cost, especially among young people aged under 35. The authors say that only focusing on COVID cases and deaths overlooks this larger burden of the pandemic and the impacts of policies to control it.
The researchers used a measure known as the quality-adjusted life year (QALY), a generic indicator of disease burden, with scores ranging from 1 (perfect health) to 0 (death), together with data on COVID deaths. Such surveys enable researchers to begin to disentangle the effects of lockdowns and other policies from the impacts of COVID. The researchers found the health impacts of the COVID pandemic and lockdowns were between five and eleven times larger than the COVID-related deaths alone. Moving beyond counting deaths to understanding the overall health of the population globally can help us to be better prepared for potential future health shocks, they say.
However, the lessons extend beyond better preparation for such shocks. They include a more general mistake of prioritizing physical health over mental health — in this case COVID cases and deaths over mental disorders and social isolation. This prejudice highlights a widespread neglect or underestimation of the situation of young people, who are bearing the brunt of the mental ill-health arising from sweeping societal changes- social, cultural, economic, environmental.
Young people's declining wellbeing
A 2021 advisory by the US Surgeon General on young people's mental health states that, "the challenges today's generation of young people face are unprecedented and uniquely hard to navigate. And the effect these challenges have had on their mental health is devastating."
The advisory says recent national surveys of young people have shown alarming increases in the prevalence of certain mental health challenges. "In 2019, one in three high school students and half of female students reported persistent feelings of sadness or hopelessness, an overall increase of 40% from 2009." Since the pandemic began, rates of psychological distress among young people have further increased, the advisory notes.
"The challenges today's generation of young people face are unprecedented and uniquely hard to navigate."
Gallup reported in May that the percentage of U.S. adults who report having been diagnosed with depression at some point in their lifetime has reached 29%, nearly 10 percentage points higher than in 2015. The percentage of Americans who currently have or are being treated for depression has also increased, to 18%, up about seven points over the same period. Both rates are the highest recorded by Gallup since it began measuring depression using the current form of data collection in 2015.
Again, younger people are the worst affected. Those aged 18 to 29 (34%) and 30 to 44 (35%) have significantly greater depression diagnosis rates in their lifetime than those older than 44. Those aged 18 to 29 (25%) also have the highest rates of current depression or treatment for depression.
Many academic studies of young people's wellbeing report similar findings. More American adolescents and young adults in the late 2010s, compared to the mid-2000s, experienced serious psychological distress, major depression and suicidal thoughts, and more attempted suicide and took their own lives, one 2019 study found.
The reasons for this unfolding tragedy remain unclear and contested. A new British study states: "The prevalence of emotional disorders and symptoms (i.e. depression and anxiety) rose among young people in the first two decades of the 21st century …. The reasons for this rise are unknown."
And a new international study notes: "Little is known about societal processes that contribute to changes in adolescent mental health problems."
The reasons for this unfolding tragedy remain unclear and contested.
The U.S. Surgeon General's advisory (which cites my research) states that mental health is "shaped by many factors, from our genes and brain chemistry to our relationships with family and friends, neighborhood conditions, and larger social forces and policies. We also know that, too often, young people are bombarded with messages through the media and popular culture that erode their sense of self-worth — telling them they are not good looking enough, popular enough, smart enough, or rich enough. That comes as progress on legitimate, and distressing, issues like climate change, income inequality, racial injustice, the opioid epidemic and gun violence feels too slow."
In May this year, the Surgeon General issued an advisory on social media and youth mental health, saying: "We are in the middle of a national youth mental health crisis, and I am concerned that social media is an important driver of that crisis – one that we must urgently address."
The complexity of causation
However, my purpose here is not to review the growing literature on young people's wellbeing, but to discuss its social and political implications, especially with respect to how we define and pursue human progress. So while most research in different disciplines continues to focus on rates and trends in health problems, and on health interventions and policy responses, I have focused on what the patterns and changes in ill-health mean, not just for young people, but for all of us, and our future.
In fact, I wonder if we can, scientifically, untangle the complex causation behind what is happening with young people - and, politically, if we need to. The reason is, as I have discussed in my previous Salon essays, the nature of complex, adaptive systems, which is what human societies are.
These systems are dynamic and self-organizing, governed by feedback and driven by often multiple and diffuse interactions between their components. Change in one part of the system can cause changes, often non-linear and unpredictable, in other parts. Characteristics "emerge" from the collective behavior of the whole system, not from the behavior of its individual components. Rather than deterministic one-to-one relationships between "causes" and "effects," there are many possible paths between them.
Young people best reflect the characteristics of our times because they are growing up in them.
Complexity explains why, as I have consistently argued, specific policy reforms are not enough. We need whole-system change, based on changes in culture — in our worldview, narratives, values and beliefs. The situation of young people — children, adolescents and young adults — underscores the necessity for deep, fundamental change.
Young people best reflect the characteristics of our times because they are growing up in them. Their health is an important predictor of future population health because many of the attitudes and behaviors — and even the illnesses — that determine adult health have their origins in early life. About 75% of mental-health problems begin before age 25. While some of these mental disorders are minor and transient, other problems can be severe and recur throughout life. New US research shows increases in poor mental health in younger age groups such as adolescents and college students are now extending up the age scale to adults in their prime (aged 26-49).
I began researching young people's changing world for the Australian Commission for the Future in the 1980s, suggesting in a report that rising rates of youth suicide, crime and drug use, were linked to increasing family conflict and breakdown, youth unemployment, child poverty, education pressure, and — a novel dimension — concerns about the world's future. At the time nuclear war was a prominent fear, as it is again now, with the heightened tensions between the West and Russia and China. There is also, now, more awareness of the spectre of catastrophic climate change, which is not only a future threat but our lived reality.
As evidence emerged, and grew, about young people's declining health and wellbeing I deepened my study to explore the existential aspects of their lives and how progress and modernity are undermining these. The impacts are not limited to mental health; physical health is also a concern. Lack of physical activity, poor diet, and increasing obesity (all also linked to mental health) are fueling a rise in chronic problems such as type 2 diabetes at ever-younger ages.
My own focus has been on the effects of cultural change. Rising materialism and individualism are defining characteristics of modern Western culture. Both have conferred benefits to people, including to their health and wellbeing. However, there is growing evidence of diminishing benefits and rising costs. The costs include a heightened sense of risk, uncertainty and insecurity; a lack of clear frames of reference; a rise in personal expectations, coupled with a perception that the onus of success lies with the individual, despite the continuing importance of social disadvantage and privilege; a surfeit or excess of freedom and choice, which is experienced as a threat or tyranny; the confusion of autonomy with independence; and a shift from intrinsic to extrinsic values and goals.
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An intrinsic orientation means doing things for their own sake. Intrinsic goals tend to meet basic human needs for competence, affiliation and autonomy. They are "self-transcending" and good for wellbeing. An extrinsic orientation means doing things in the hope or expectation of other rewards, such as status, money and recognition. It is "self-enhancing" in the sense of being concerned with self-image. It is not good for wellbeing. A focus on the external trappings of success and 'the good life' increases the pressures to meet high, even unrealistic, expectations — and so the risks of failure and goal conflict.
The change is not just a matter of greater vanity, selfishness and greed (although many people today express concerns about these traits). It is something deeply existential and relational, about how people think of life and how they see themselves in relation to others and the world, and this profoundly affects their wellbeing.
A 2009 report of an inquiry by the Children's Society in Britain says it deals with the experiences of children in general because the world in which most children grow up is more difficult than it should be. It points the finger at an "excessive individualism", which holds that people's main duty is to make the most of themselves and to be as successful as possible, "a struggle of each against all."
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Writing from the combined (and unusual) perspectives of political science and psychotherapy, Pam Stavropoulos says that depression reveals "the strain and effect of living with the disjuncture between the individualist 'ideals' of liberalism and the relational reality of our lives."
The depressed often berate themselves for failing to live up to these "ideals," she says. Focusing on the individual experience alone artificially detaches people from the wider sociopolitical context, which never ceases to influence emotional wellbeing. "Recognizing the politics of depression is a prerequisite of its healing."
It is not surprising, given the complexities of social changes and their effects, that the topic of young people's wellbeing is vexed and contentious, marked by contradictory and ambiguous evidence and disciplinary and conceptual differences. Each stream of evidence can be challenged or open to other interpretations: for example, not every time-trend study has found a rise in disorders; reported increases might result from a greater willingness to admit to problems or mistakes in recall; high prevalence and professional concerns have been attributed to increased diagnosis and the "medicalization" of normal human emotions; parental and public perceptions might reflect changing attitudes to, or greater awareness of, the problems associated with "being young." All these matters are being discussed in the scientific literature.
Young people's wellbeing is vexed and contentious, marked by contradictory and ambiguous evidence and disciplinary and conceptual differences
Notwithstanding these uncertainties, there is a strong case to review the usual narrative that describes young people's health and defines what is done about it. Taken together, the evidence presents a compelling picture of increased and widespread psychological problems in young people.
An epidemiological perspective supports this framing in showing that there is a relation between the mean or average of a health characteristic in a population and the prevalence of the related disorder. If social changes have increased the overall population risk of mental illness (the mean), then more people will fall within the high-risk end of the population distribution, and this high-risk group will grow and keep replacing — so making more demands on mental health services — until society acts to reduce the population risk.
An island of misery, or the tip of an iceberg?
About 10 to 15 years ago, I proposed we needed a new narrative of young people's health.
The long-established story is — or was at the time — that young people's health is continuing to improve in line with historic trends. Death rates are low and falling, and most young people say they are healthy, happy and enjoying life. For most, social conditions and opportunities have generally gotten better. Health efforts need to focus on the minorities whose wellbeing is lagging behind, especially the disadvantaged and marginalized.
But there was another, very different story. It suggests young people's health may be declining — in contrast to historic trends. Mortality rates understate the importance of non-fatal, chronic ill-health and self-reported health and happiness do not give an accurate picture of wellbeing. Mental illness and obesity-related health problems and risks have increased. The trends are not confined to the disadvantaged. The causes stem from fundamental social and cultural changes of the past several decades.
I have used a maritime metaphor to illustrate the difference between the two perspectives: Are troubled youth an island of misery in an ocean of happiness? Or are they the tip of an iceberg of suffering? It matters which story is more accurate. The old narrative says interventions should target the minorities at risk. The new narrative argues that broader efforts to improve social conditions are also needed.
I posed two questions to highlight the implications of the two stories: What would we do differently if young people's health, overall, was not improving, but declining? What would we do differently if the social factors behind young people's health problems were not primarily those of "marginalized minorities," but the characteristics of "mainstream majorities?"
The obvious answer to both questions is that we would do things very differently. Yet, by and large, we are not (although the Surgeon General's advisory on youth mental health implicitly acknowledges the new narrative).
Political and policy implications
Changing the representation, or story, of young people's health would have the immediate effect of underscoring the need to expand and improve healthcare services.
How societies address social problems and challenges depends on how these are represented or framed. Changing the representation, or story, of young people's health would have the immediate effect of underscoring the need to expand and improve healthcare services, which dominate current policy considerations. However, the new narrative has more profound implications, not just for young people (on which, obviously, youth research focuses), but also for society as a whole and national goals and priorities.
Staying with the old story of young people's health - health problems in youth are 'the price of progress', which is making life better for most people but at a cost to a few — means that health interventions will continue to focus on a minority of people at risk, especially the disadvantaged. Adopting a new story — recent "progress" has harmed a substantial and growing proportion of young people to varying degrees – suggests that, in addition to specific, targeted interventions, a much broader effort is needed to change social conditions.
To give effect to the new story of young people's health, more emphasis is needed on: the big picture of their changing world; total health and wellbeing, and "living well," not a narrow focus on ill-health; the mainstream of society, not just the marginalized and disadvantaged; and developing the social and cultural, as well as economic and material, resources available to young people.
Possible responses across different sectors and scales include:
• Research: More emphasis on population health, including social determinants of health and transdisciplinary synthesis, to improve conceptual coherence, understanding and application.
• Healthcare: More attention to health promotion and disease prevention, especially with mental health, to address the immediate need.
• Education: Making teaching and the curriculum more relevant to young people's world and their hopes and fears, including refocusing the goal of education on improving their understanding of the world and themselves, and so enhancing their health and wellbeing in the broadest sense.
• Business: Better regulation to uphold young people's right to protection from abuse, exploitation and harmful influence, especially the growing 'commodification' of childhood and adolescence: the commercial manipulation and indoctrination of young people into an unhealthy, unsustainable, hyper-consumer lifestyle.
• Politics: Making better health and wellbeing, broadly defined, the central purpose of government, its governing principle.
Health and progress
The contrast between the old and new stories of young people's health and wellbeing is part of a larger contest between the dominant narrative of material progress and a new narrative of sustainable development. Material progress represents an outdated, industrial model of progress: pump more wealth into one end of the pipeline of progress and greater wellbeing flows out the other.
Sustainable development reflects (appropriately) an ecological model, where the components of human society interact in more complex ways. Not only does sustainable development better fit the new story of youth health, it is likely to achieve better outcomes in relation to the old story's focus on socio-economic disadvantage and inequality because it less intent than material progress on economic growth and efficiency.
Sustainable development is likely to achieve better outcomes in relation to the old story's focus on socio-economic disadvantage and inequality.
Related to this contest, the new story of youth health also challenges the orthodox story of human development, which places Western nations at its leading edge. It shows that the dominant measures of development – not just income, life expectancy or happiness, but also education, governance, freedom and human rights – are not enough. However desirable these qualities may be, they do not capture the more intangible cultural, moral and spiritual qualities that are so important to wellbeing. And it is in these respects that Western societies do not do so well.
The rise in life expectancy, which more than doubled globally in the 20th century, is a cornerstone of human development. While there are competing theories about what produced the health gains, they can be, broadly speaking, attributed to factors such as material advances, especially better nutrition; public-health interventions such as sanitation; social modernization, including education and social welfare; and improved medical treatment and care. Life expectancy globally has continued to rise in this century, but has stalled in some developed countries and, in the US and some other countries, has fallen in recent years, even before the COVID pandemic.
Historically, then, medicine and other health professions have been part of a broad, progressive movement that has improved not only life expectancy and health, but quality of life more broadly. The connection was close; the early emphasis in public health was on how social conditions influenced health and how they might be improved. Today the relationship has changed. Health professions appear to be increasingly engaged in countering the growing harm to health of adverse social trends, at least in developed nations.
A wider, more comprehensive, view of health would contribute to a better understanding of human development.
At the same time, however, they have become part of the problem because of a scientific emphasis on, and political advocacy of, a biomedical model of health based on individual cases of disease, and their associated risk factors and treatments, at the expense of a social model of disease prevention and health promotion. This has contributed to a separation of population health from social conditions, to the detriment of both.
The current dominant perspective suits business and government. It is in biomedicine that profits are to be made, not in social health. The biomedical model also limits the political significance of health to the politics of healthcare services. This policy focus is challenging enough as governments struggle with rising demand and costs. However, the challenge is easy compared with trying to reconcile emerging health-based social realities with existing wealth-based political priorities. Embedded in the biomedical model is a disguised ideology that defends and promotes the status quo.
Thus, as discussed above, the most important application of my perspective on young people's health and wellbeing may be in the contribution it can make to a much broader political and public debate about the lives we want to lead, the societies we want to live in, and the futures we want to create. This debate is intensifying, but health research plays only a limited part in it.
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A wider, more comprehensive, view of health would contribute to a better understanding of human development, and of health as a social dynamic: a cause of social changes and developments, not only a consequence, through effects on population resilience, morale and vitality. This effect may well influence how well humanity responds to global threats such as climate change; it is probably impacting on our societies today, including on our politics.
The health of young people should be a focal point in the larger contest of social narratives. They should, by definition, be the main beneficiaries of progress; conversely, they will pay the greatest price of any long-term economic, social, cultural or environmental decline and degradation. If young people's health and wellbeing are not improving, it is hard to argue that overall life is getting better.
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