Tag Archives: aging

Philip Cohen at 50, having been 14 in 1981

This is a sociological reflection about life history. It’s about me because I’m the person I know best, and I have permission to reveal details of my life.

I was born in August 1967, making me 50 years old this month. But life experience is better thought of in cohort terms. Where was I and what was I doing, with whom, at different ages and stages of development? Today I’m thinking of these intersections of biography and history in terms of technology, music, and health.

Tech

We had a TV in my household growing up, it just didn’t have a remote control or cable service, or color. We had two phones, they just shared one line and were connected by wires. (After I moved out my parents got an answering machine.) When my mother, a neurobiologist, was working on her dissertation (completed when I was 10) in the study my parents shared, she used a programmable calculator and graph paper to plot the results of her experiments with pencil. My father, a topologist, drew his figures with colored pencils (I can’t describe the sound of his pencils drawing across the hollow wooden door he used for a desktop, but I can still hear it, along with the buzz of his fluorescent lamp). A couple of my friends had personal computers by the time I started high school, in 1981 (one TRS-80 and one Apple II), but I brought a portable electric typewriter to college in 1988. I first got a cell phone in graduate school, after I was married.

The first portable electronic device I had (besides a flashlight) was a Sony Walkman, in about 1983, when I was 16. At the time nothing mattered to me more than music. Music consumed a large part of my imagination and formed the scaffolding of most socializing. The logistics of finding out about, finding, buying, copying, and listening to music played an outsized role in my daily life. From about 1980 to 1984, most of the money I made at my bagel store job went to stereo equipment, concerts, records, blank tapes for making copies, and eventually drums (as well video games). I subscribed to magazines (Rolling Stone, Modern Drummer), hitchhiked across town to visit the record store, pooled money with friends to buy blank tapes, spent hours copying records and labeling tapes with my friends, and made road trips to concerts across upstate New York (clockwise from Ithaca: Geneva, Buffalo, Rochester, Syracuse, Saratoga, Binghamton, New York City, Elmira).

As I’m writing this, I thought, “I haven’t listened to Long Distance Voyager in ages,” tapped it into Apple Music on my phone, and started streaming it on my Sonos player in a matter of seconds, which doesn’t impress you at all – but the sensory memories it invokes are shockingly vivid (like an acid flashback, honestly) – and having the power to evoke that so easily is awesome, in the old sense of that word.

Some of us worked at the Cornell student radio station (I eventually spent a while in the news department), whose album-oriented rock playlist heavily influenced the categories and relative status of the music we listened to. The radio station also determined what music stayed in the rotation – what eventually became known by the then-nonexistent term classic rock – and what would be allowed to slip away; it was history written in real time.

It’s like 1967, in 1981

You could think of the birth cohort of 1967 as the people who entered the world at the time of “race riots,” the Vietnam and Six Day wars, the Summer of Love, the 25th Amendment (you’re welcome!), Monterey Pop, Sgt. Peppper’s, and Loving v. Virginia. Or you could flip through Wikipedia’s list of celebrities born in 1967 to see how impressive (and good looking) we became, people like Benicio del Toro, Kurt Cobain, Paul Giamatti, Nicole Kidman, Pamela Anderson, Will Ferrell, Vin Diesel, Phillip Seymour Hoffman, Matt LeBlanc, Michael Johnson, Liev Schreiber, Julia Roberts, Jimmy Kimmel, Mark Ruffalo, and Jamie Foxx.

But maybe it makes more sense to think of us as the people who were 14 when John Lennon made his great commercial comeback, with an album no one took seriously – only after being murdered. The experiences at age 14, in 1981, define me more than what was happening at the moment of my birth. Those 1981 hits from album-oriented rock mean more to me than the Doors’ debut in 1967. My sense of the world changing in that year was acute – because it was 1981, or because I was 14? In music, old artists like the Moody Blues and the Rolling Stones released albums that seemed like complete departures, and more solo albums – by people like Stevie Nicks and Phil Collins – felt like stakes through the heart of history itself (I liked them, actually, but they were also impostors).

One moment that felt at the time like a historical turning point was the weekend of September 19, 1981. My family went to Washington for the Solidarity Day rally, at which a quarter million people demonstrated against President Reagan and for organized labor, a protest fueled by the new president’s firing of the PATCO air traffic controllers the previous month (and inspired by the Solidarity union in Poland, too). Besides hating Reagan, we also feared a nuclear war that would end humanity – I mean really feared it, real nightmare fear.

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A piece of radio news copy I wrote and read at WVBR, probably 1983. The slashes are where I’m going to take a breath. “Local AQX” is the name of the tape cartridge with the sound bite (“actuality”) from Alfred Kahn, and “OQ:worse” means that’s the last word coming out of the clip.

On the same day as Solidarity, while we were in D.C., was Simon and Garfunkel’s Concert in Central Park. They were all of 40 (literally my mother’s age), tired old people with a glorious past (I’m sure I ignored the rave reviews). As I look back on these events – Reagan, the Cold War, sell-out music – in the context of what I thought of as my emerging adulthood, they seemed to herald a dark future, in which loss of freedom and individuality, the rise of the machines, and runaway capitalism was reflected in the decline of rock music. (I am now embarrassed to admit that I even hated disco for a while, maybe even while I listened 20 times, dumbstruck, to an Earth, Wind, and Fire album I checked out of the library.)

I don’t want to overdramatize the drama of 1981; I was basically fine. I came out with a penchant for Camus, a taste for art rock, and leftism, which were hardly catastrophic traits. Still, those events, and their timing, probably left a mark of cynicism, sometimes nihilism, which I carry today.

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About 1984, with Daniel Besman (who later died) in Ithaca. Photo by Linda Galgani.

Data aside

Maybe one reason 1981 felt like a musical watershed to me is because it really was, because pop music just got worse in the 1980s compared to the 1970s. To test (I mean prove, really) that hypothesis, I fielded a little survey (more like a game) that asked people to rate the same artists in both decades. I chose 58 artists by flipping through album charts from 1975-1984 and finding those that charted in both decades; then I added some suggestions from early respondents. To keep the task from being too onerous, as it required scoring bands twice from 1 (terrible) to 5 (great), once for each period, and some people found it difficult, I set the survey to serve each person just 10 artists at random (a couple of people did it more than once). The participants were 3/4 men, 3/4 over 40, and 3/4 White and US-born; found on Facebook, Twitter, and Reddit. The average artist was rated 11 times in each period (range 5 to 19). (Feel free to play along or share this link; I’ll update it if more come in.)

The results look very bad for the 1980s. The average change was a drop of .59, and only three acts showed noticeable improvement: Pat Benatar, Michael Jackson, and Prince (and maybe Talking Heads and the lowly Bryan Adams). Here is the full set (click to enlarge):

Technology and survival

I don’t think I would have, at age 14, given much weight to the idea that my life would repeatedly be saved by medical technology, but now that seems like business as usual, to me anyway. I guess as long as there’s been technology there have been people who owe their lives to it (and of course we’re more likely to hear from them than from those who didn’t make it). But the details are cohort-specific. These days we’re a diverse club of privileged people, our conditions, or their remnants, often hidden like pebbles wedged under the balls of our aging feet, gnawing reminders of our bodily precarity.

Family lore says I was born with a bad case of jaundice, probably something like Rh incompatibility, and needed a blood transfusion. I don’t know what would have happened without it, but I’m probably better off now for that intervention.

Sometime in my late teens I reported to a doctor that I had periodic episodes of racing heartbeat. After a brief exam I was sent home with no tests, but advised to keep an eye on it; maybe mitral valve prolapse, he said. I usually controlled it by holding my breath and exhaling slowly. We found out later, in 2001 – after several hours in the emergency room at about 200 very irregular beats per minute – that it was actually a potentially much more serious condition called Wolff-Parkinson-White syndrome. The condition is easily diagnosed nowadays, as software can identify the tell-tale “delta wave” on the ECG, and the condition is listed right there in the test report.

Rhythm_WPW

Two lucky things combined: (a) I wasn’t diagnosed properly in the 1980s (which might have led to open-heart surgery or a lifetime of unpleasant medication), and; (b) I didn’t drop dead before it was finally diagnosed in 2001. They fixed it with a low-risk radiofrequency ablation, just running a few wires up through my arteries to my heart, where they lit up to burn off the errant nerve ending, all done while I was almost awake, watching the action on an x-ray image and – I believed, anyway – feeling the warmth spread through my chest as the doctor typed commands into his keyboard.

Diverticulitis is also pretty easily diagnosed nowadays, once they fire up the CT scanner, and usually successfully treated by antibiotics, though sometimes you have to remove some of your colon. Just one of those things people don’t die from as much anymore (though it’s also more common than it used to be, maybe just because we don’t die from other things as much). I didn’t feel like much like surviving when it was happening, but I suppose I might have made it even without the antibiotics. Who knows?

More interesting was the case of follicular lymphoma I discovered at age 40 (I wrote about it here). There is a reasonable chance I’d still be alive today if we had never biopsied the swollen lymph node in my thigh, but that’s hard to say, too. Median survival from diagnosis is supposed to be 10 years, but I had a good case (a rare stage I), and with all the great new treatments coming online the confidence in that estimate is fuzzy. Anyway, since the cancer was never identified anywhere else in my body, the treatment was just removing the lymph node and a little radiation (18 visits to the radiation place, a couple of tattoos for aiming the beams, all in the summer with no work days off). We have no way (with current technology) to tell if I still “have” it or whether it will come “back,” so I can’t yet say technology saved my life from this one (though if I’m lucky enough to die from something else — and only then — feel free to call me a cancer “survivor”).

It turns out that all this life saving also bequeaths a profound uncertainty, which leaves one with an uneasy feeling and a craving for antianxiety medication. I guess you have to learn to love the uncertainty, or die trying. That’s why I cherish this piece of a note from my oncologist, written as he sent me out of the office with instructions never to return: “Your chance for cure is reasonable. ‘Pretest probability’ is low.”

pretest-probability-is-low

From my oncologist’s farewell note.

Time travel

It’s hard to imagine what I would have thought if someone told my 14-year-old self this story: One day you will, during a Skype call from a hotel room in Hangzhou, where you are vacationing with your wife and two daughters from China, decide to sue President Donald Trump for blocking you on Twitter. On the other hand, I don’t know if it’s possible to know today what it was really like to be me at age 14.

In the classic time travel knot, a visitor from the future changes the future by going back and changing the past. The cool thing about mucking around with your narrative like I’m doing in this essay (as Walidah Imarisha has said) is that it by altering our perception of the past, we do change the future. So time travel is real. Just like it’s funny to think of my 14-year-old self having thoughts about the past, I’m sure my 14-year-old self would have laughed at the idea that my 50-year-old self would think about the future. But I do!

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Get your dependency ratio off my lawn

Old people work more than they used to. This is important if you’re worried about what an aging population means for the economy.

When they taught me demography, I learned about the dependency ratio, which was the number of people presumed to be dependents (those ages 0-14 and 65+) relative to those presumed to be working (those ages 15-64). It’s a traditional measure, and a little archaic now that people spend much more time in school. But it’s nice because it sort of assumes that those “working age” adults are being productive whether they have jobs or not – it’s not just counting employed people – so it has an unstated recognition of (mostly women’s) unpaid labor.

In some economic work (see my paper here for an old review) people assume that non-employed women are being productive. But we don’t usually assume that about old people. That is, non-employed younger adults are assumed to be doing unpaid work, while non-employed old people are assumed to be really retired. I’m sure people are looking at the unpaid work of old people (I just haven’t yet). But their paid work profile has changed a lot, too – especially women’s.

This means the catastrophic view of productivity effects of again needs to be tempered by a better understanding of how much old people work. Here’s what I mean.

First, what the World Bank calls “Dependency Ratio, old,” which is the number of people age 65 and older as a percentage of the population ages 15-64. This is supposed to reflect the burden of age on the the young(er).* Here is it for the USA and the world (click to enlarge):

dependency ratio old

That’s the Baby Boom generation hitting older ages there at the end of the USA trend. As a result, the dependency ratio (old) has increased 30% in the USA since 1980, and the world is following.

But old people work more (or, we don’t label people “old” as early, you might say). Here’s the average annual hours of paid work for people in the USA ages 65 and older. Note this includes all those working no hours in the average, which is what you need to do if you’re interested in the total economic benefit/burden ratio (click to enlarge).

dependency ratio old

Since 1980, women ages 65-74 have increased their hourly employment hours by 138%, and men’s have gone up 44%. For the 75-plus community, the relative increases are even greater: 172% for women and 55% for men.

Now, if you add up those hours, you can calculate how much of a burden old people are relieving from the young by their employment hours. In this figure I calculate the total hours worked for each age-gender group and divide it by the total number of people ages 65 and older. Looking at the bottom blue area, for example, this shows that in 2015, the total population of men ages 65-74 did 166 hours of paid work for each person age 65 and older. Regardless of the size of the old population, then, there is that much less supporting of them to do (click to enlarge).

hours worked per person 65 and older

The per-person contribution of paid work hours from people 65 and older has increased 72% since 1980, from 206 to 354 hours per year. Most of the increase is from women’s employment, and it’s just starting. The oldest Baby Boom women, the women who led the increase in women’s employment over their careers, are still only 69 in 2015. Further, this measurement of paid hours may be an indicator of the unpaid productivity of these groups as well, as their health and activity levels improve.

It may be useful to track the population age composition over time (as in the World Bank data above), but it’s not reasonable to assume a constant level of dependency associated with people of different ages.

*Note: Of course, I use terms like “burden” in the classical demographic sense and tongue-in-cheek. I actually want more old people to live longer and work less, because that burden is what life is all about. But there is the issue of making sure everyone has their needs met.

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Old people are getting older and younger

The Pew Research Center recently put out a report on the share of U.S. older women living alone. The main finding they reported was a reversal in the long trend toward old women living alone after 1990. After rising to a peak of 38% in 1990, the share of women age 65+ living alone fell to 32% by 2014. It’s a big turnaround. The report attributes it in part to the rising life expectancy of men, so fewer old women are widowed.

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The tricky thing about this is the changing age distribution of the old population (the Pew report breaks the group down into 65-84 versus 85+, but doesn’t dwell on the changing relative size of those two groups). Here’s an additional breakdown, from the same Census data Pew used (from IPUMS.org), showing percent living alone by age for women:

pewage1

Two things in this figure: the percent living alone is much lower for the 65-69s, and the decline in living alone is much sharper in the older women.

The age distribution in the 65+ population has changed in two ways: in the long run it’s getting older as life expectancy at old age increases. However, the Baby Boom (born 1946-1964) started hitting age 65 in 2010, resulting in a big wave of 65-69s pouring into the 65+ population. You can see both trends in the following figure, which shows the age distribution of the 65+ women (the lines sum to 100%). The representation of 80+ women has doubled since 1960, showing longer life expectancy, but look at that spike in the 65-69s!

pewage2

Given this change in the trends, you can see that the decrease in living alone in the 65+ population partly reflects greater representation of young-old women in the population. These women are less likely to live alone because they’re more likely to still be married.

On the other hand, why is there such a steep drop in living alone among 80+ women? Some of this is the decline in widowhood as men live longer. But it’s an uphill climb, because among this group there is no Baby Boom spike of young-olds (yet) — the 80+ population is still just getting older and older. Here’s the age distribution among 80+ women (these sum to 100 again):

pewage3

You can see the falling share of 80-84s as the population ages. If this is the group that is less likely to live alone the most because their husbands are living longer, that’s pretty impressive, because the group is aging fast. One boost the not-alones get is that they are increasingly likely to live in extended households — since 1990 there’s been a 5% increase in them living in households of at least 3 people, from 13% to 18%. Finally, at this age you also have to look at the share living in nursing homes (some of whom seem to be counted as living alone and some not).

In addition to the interesting gerentological questions this all raises, it’s a good reminder that the Baby Boom can have sudden effects on within-group age distributions (as I discussed previously in this post on changing White mortality patterns). Everyone should check their within-group distributions when assessing trends over time.

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No, poverty is not a mysterious, unknowable, negative-spiral loop

I don’t have much to add on the “consensus plan” on poverty and mobility produced by the Brookings and American Enterprise institutes, referred to in their launch event as being on “different ends of the ideological spectrum” (can you imagine?). In addition to the report, you might consider the comments by Jeff Spross, Brad DeLong, or the three-part series by Matt Bruenig.

My comment is about the increasingly (to me) frustrating description of poverty as something beyond simple comprehension and unreachable by mortal policy. It’s just not. The whole child poverty problem, for example, amounts to $62 billion dollars per year. There are certainly important details to be worked out in how to eliminate it, but the basic idea is pretty clear — you give poor people money. We have plenty of it.

This was obvious yet amazingly not remarked upon in the first 40 minutes of the launch event (which is all I watched). In the opening presentation, by Ron Haskins — for whom I have a well-documented distaste — started with this simple chart of official poverty rates:

offpov-brookingsaei

He started with the blue line, poverty for elderly people, and said:

The blue line is probably the nation’s greatest success against poverty. It’s the elderly. And it basically has declined pretty much all the time. It has no relationship to the economy, and there is good research that shows that its cause at least 90% by Social Security. So, government did it, and so Social Security is the reason we’re able to be successful to reduce poverty among the elderly.

And then everyone proceeded to ignore the obvious implication of that: when you give people money, they aren’t poor anymore. The most unintentionally hilarious illustration of this was in the keynote (why?) address from David Brooks (who has definitely been working on relaxing lately, especially when it comes to preparing keynote puff-pieces). He said this, according to my unofficial transcript:

Poverty is a cloud problem and not a clock problem. This is a Karl Popper distinction. He said some problems are clock problems – you can take them apart into individual pieces and fix them. Some problems are cloud problems. You can’t take a cloud apart. It’s a dynamic system that is always interspersed. And Popper said we have a tendency to try to take cloud problems and turn them into clock problems, because it’s just easier for us to think about. But poverty is a cloud problem. … A problem like poverty is too complicated to be contained by any one political philosophy. … So we have to be humble, because it’s so gloomy and so complicated and so cloud-like.

The good news is that for all the complexity of poverty, and all the way it’s a cloud, it offers a political opportunity, especially in a polarized era, because it’s not an either/or issue. … Poverty is an and/and issue, because it takes a zillion things to address it, and some of those things are going to come from the left, and some are going to come from the right. … And if poverty is this mysterious, unknowable, negative spiral-loop that some people find themselves in, then surely the solution is to throw everything we think works at the problem simultaneously, and try in ways we will never understand, to have a positive virtuous cycle. And so there’s not a lot of tradeoffs, there’s just a lot of throwing stuff in. And social science, which is so prevalent in this report, is so valuable in proving what works, but ultimately it has to bow down to human realities – to psychology, to emotion, to reality, and to just the way an emergent system works.

Poverty is only a “mysterious, unknowable, negative spiral-loop” if you specifically ignore the lack of money that is its proximate cause. Sure, spend your whole life wondering about the mysteries of human variation — but could we agree to do that after taking care of people’s basic needs?

I wonder if poverty among the elderly once seemed like a weird, amorphous, confusing problem. I doubt it. But it probably would if we had assumed that the only way to solve elderly poverty was to get children to give their parents more money. Then we would have to worry about the market position of their children, the timing of their births, the complexity of their motivations and relationships, the vagaries of the market, and the folly of youth. Instead, we gave old people money. And now elderly poverty “has declined pretty much all the time” and “it has no relationship to the economy.”

Imagine that.

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Why does the news turn social science into garbage?

I'm reading garbage. But I look smart. I feel smart. And doggone it, I'm pretty wealthy.

I’m reading garbage. But I look smart. I feel smart. And doggone it, I’m pretty wealthy.

Okay, I could have added “sometimes” in the title.

Someone at the New York Times‘s One-Page Magazine took this interesting study (paywalled) of conversational styles among a sample of older couples over a period of 13 years and turned it into this:

Forget counseling: a new study in The Journal of Marriage and Family found that couples who have been married for more than 35 years and are over the age of 60 are more likely to change the subject rather than confront toxic topics in their relationship.

Forget counseling? Not only do the authors not say this is a good thing (the study did not include marital outcomes), they specifically suggest the research might help shape future approaches to marital therapy at older ages.

But why care? It’s just another gossipy piece of social science fluff that doesn’t reference the actual study, written to give NYT readers a harmless chuckle while they peruse the Sunday paper. Ha ha. Ick.

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The declining birthrate doesn’t spell disaster

I have an essay in Time online, to accompany their cover story on child free living (which I haven’t read yet).

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Poverty Poses a Bigger Risk to Pregnancy Than Age

Originally published in TheAtlantic.com.

The problem of income inequality often gets forgotten in conversations about biological clocks.

The dilemma that couples face as they consider having children at older ages is worth dwelling on, and I wouldn’t take that away from Judith Shulevitz’s essay in the New Republic, “How Older Parenthood Will Upend American Society,” which has sparked commentary from Katie Roiphe,Hanna RosinRoss Douthat, and Parade, among many others.
The story is an old one—about the health risks of older parenting and the implications of falling fertility rates for an aging population—even though some of the facts are new. But two points need more attention. First, the overall consequences of the trend toward older parenting are on balance positive, both for women’s equality and for children’s health. And second, social-class inequality is a pressing—and growing—problem in children’s health, and one that is too easily lost in the biological-clock debate.

Older mothers

First, we need to distinguish between the average age of birth parents on the one hand versus the number born at advanced parental ages on the other. As Shulevitz notes, the average age of a first-time mother in the U.S. is now 25. Health-wise, assuming she births the rest of her (small) brood before about age 35, that’s perfect.

Consider two measures of child well-being according to their mothers’ age at birth. First, infant mortality:

cohen_infantmortality.pngSource: Centers for Disease Control.

Health prospects for children improve as women (and their partners) increase their education and incomes, and improve their health behaviors, into their 30s. Beyond that, the health risks start accumulating, weighing against the socioeconomic factors, and the danger increases.

Second, here is the rate of cognitive disability among children according to the age of their mothers at birth, showing a very similar pattern:

cohen_infantmortality2.pngSource: Calculations made for my working paper, available here. To match up children with their birth parents in the Census, I had to limit the sample to children living with two married parents, where both are in their first marriage, so it’s a pretty select group.

Again, the lowest risks are to those born when their parents are in their early 30s, a pattern that holds when I control for education, income, race/ethnicity, gender, and child’s age.

When mothers older than age 40 give birth, which accounted for 3 percent of births in 2011, the risks clearly are increased, and Shulevitz’s story is highly relevant. But, at least in terms of mortality and cognitive disability, an average parental age in the late 20s and early 30s is not only not a problem, it’s ideal.

Unequal health

But the second figure above hints at another problem—inequality in the health of parents and children. On that purple chart, a college graduate in her early 40s has the same risk as a non-graduate in her late 20s. And the social-class gap increases with age. Why is the rate of cognitive disabilities so much higher for the children of older mothers who did not finish college? It’s not because of their biological clocks or genetic mutations, but because of the health of the women giving birth.

For healthy, wealthy older women, the issue of aging eggs and genetic mutations from fathers’ run-down sperm factories is more pressing than it is for the majority of parents, who have not graduated college.

If you look at the distribution of women having babies by age and education, it’s clear that the older-parent phenomenon is disproportionately about more-educated women. (I calculated these from the American Community Survey, because age-by-education is not available in the CDC numbers, so they are a little different.)

cohen_infantmortality3.pngMost of the less-educated mothers are giving birth in their 20s, and a bigger share of the high-age births are to women who’ve graduated college—most of them married and financially better off. But women without college degrees still make up more than half of those having babies after age 35, and the risks their children face have more to do with high blood pressure, obesity, diabetes, and other health conditions than with genetic or epigenetic mutations. Preterm births, low birth-weight and birth complications are major causes of developmental disabilities, and they occur most often among mothers with their own health problems.

Most distressing, the effects of educational (and income) inequality on children’s health have been increasing. Here are the relative odds of infant mortality by maternal education, from 1986 to 2001, from a study in Pediatrics. (This compares the odds to college graduates within each year, so anything over 1.0 means the group has a higher risk than college graduates.)

cohen_infantmortality4.pngThis inequality is absent from Shulevitz’s essay and most of the commentary about it. She writes, of the social pressure mothers like her feel as they age, “Once again, technology has given us the chance to lead our lives in the proper sequence: education, then work, then financial stability, then children”—with no consideration of the 66 percent of people who have reached their early 30s with less than a four-year college degree. For the vast majority of that group, the sequence Shulevitz describes is not relevant.

In fact, if Shulevitz had considered economic inequality, she might not have been quite as worried about advancing parental age. When she worries that a 35-year-old mother has a life expectancy of just 46 more years—years to be a mother to her child—the table she consulted applies to the whole population. She should breathe a little bit easier: Among 40-year-old white college graduateswomen are expected to live an average extra five years compared with those who have a high school education only.

When it comes to parents’ age versus social class, the challenges are not either/or. We should be concerned about both. But addressing the health problems of parents—especially mothers—with less than a college degree and below-average incomes is the more pressing issue—both for potential lives saved or improved and for social equality.

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