Life expectancy in America has declined for two years in a row

https://www.economist.com/news/united-states/21733980-thats-not-really-meant-happen-developed-countries-life-expectancy-america-has

by doener • 9 years ago

175 166 9 years ago

economist.com

lerie82• 9 years ago

What I took from this was more dug addicts are dying, not "the average American", or did I miss something?

thomasfoster96• 9 years ago

Well if you’re calculating “the average American”, you have to include drug-addicted Americans.

ars• 9 years ago

Average is not the same as typical.

IncRnd• 9 years ago

Unfortunately, average, typical, and modal are often confused.

MaxfordAndSons• 9 years ago

If the mortality amongst drug addicts is moving the needle such that it's reflected in the national average, that means that drug addicts are average Americans.

Also, it's not just addicts who die from an overdose that is contributing to this effect. A hidden/functional addict is still going to die sooner on average than a non addict.

refurb5• 9 years ago

Life expectancy is a very blunt tool when measuring citizen's well being.

A few ways life expectancy can go down:

- babies that other would have died and not counted live long enough with modern medicine that they drag the average down

- refugees or immigrants in poor health increase, dragging the average down

- a change in methodology in how life expectancy is calculated

llamataboot• 9 years ago

It may be blunt, but it's also pretty striking. Along most measures of wellbeing and health, the US lags behind most other industrialized countries.

ajmurmann• 9 years ago

It seems like it's not all states though. Funny enough the ones that are behind are also the ones that don't seem to want any welfare.

refurb5• 9 years ago

Have an unbiased source? Most surveys I've seen have the US in the top half of western countries.

taneq• 9 years ago

babies that other would have died and not counted live long enough with modern medicine that they drag the average down

Something similar happened when seat belts (or was it airbags?) became mandatory. There was a sudden spike in serious injuries from car crashes, as what would have been instant fatalities became injured survivors.

mikeash• 9 years ago

And decades earlier, when metal helmets were issued to soldiers, head injuries in war increased dramatically.

scarmig• 9 years ago

Although it's true that any of those could influence life expectancy, there's no evidence that they play into the decrease here. In fact, the article calls out something very specific as a contributor: the opioid epidemic.

dragonwriter7• 9 years ago

All of those things could theoretically occur, but there hasn't been a methodology change in the US, the age distribution of deaths doesn't support the first explanation, and other demographics of deaths don't support the second. So, they are irrelevant.

refurb5• 9 years ago

That's not what the CDC said.

https://news.ycombinator.com/item?id=16089110

notadoc• 9 years ago

Lingering effects of the great recession.

There is a very strong and well studied relationship between unemployment, economic stress, and drug abuse. These are people who are depressed (clinically, economically, or often both), and they are self medicating.

https://www.theatlantic.com/health/archive/2017/04/joblessne...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3935688/

Unfortunately the media-driven obsession with this topic is focused on everything other than the underlying problems driving the abuse, which is a guaranteed way to never solve anything.

forapurpose16• 9 years ago

Lingering effects of the great recession

Other countries went through the Great Recession, didn't recover as well as the U.S., and are not suffering from the problem. Also, the problem started in the last couple of years while the Great Recession began in 2008 (EDIT: and has since ended, with unemployment low for the last two years).

majormajor9• 9 years ago

I'd say less the recession and more just a particularly-hard-hitting-in-America trend away from the country's historical industrial base. The 20th century US benefited massively from being on the front lines of modern industrialization and mass production, creating a ton of jobs especially in certain regions. And in areas that haven't been able to replace those jobs as the US economy becomes based in different areas and other countries take over in mass production, that's been a particularly rough blow.

The sense of hopelessness in a truly fucked town is particularly brutal. Retraining and education sound nice, but aren't going to be all that appealing in practice for a lot of people, even if the money is there. So now the US suffers the hardest from the loss of this industry, the other side of the coin of getting to benefit the most from the growth of it. Add in a historical lack of awareness around the dangers of new painkiller drugs... and you've got the recipe for a disaster without needing any judgmental conclusions about a society as a whole.

Britain, another even-earlier industrial power, has similar things going on in some regions, but I'd argue never saw quite the same peaks as the US.

It will be interesting to see what a more controlled country like China does if/when all those jobs that first drew money to the country fully evaporate.

coldtea2• 9 years ago

Other countries went through the Great Recession, didn't recover as well as the U.S., and are not suffering from the problem.

Other countries (in the developed world at least) don't do as a shitty job dealing with welfare and healthcare, or have people feel like shit for not being "winners".

and has since ended, with unemployment low for the last two years)

Unemployment is the easiest thing for government to sweep under the carpet. Heck, if they could fully get their way, working 12hours/day for $1/month would still qualify as employment.

Even so: https://www.theatlantic.com/business/archive/2017/12/great-r...

Or:

Economist Logan said that when he looks back, he sees a permanently changed economy. The downturn "left a lingering impact on jobs and on some sectors that never recovered," he said. For example, just before the recession, about 14 million Americans worked in manufacturing; today, that sector has about 1.5 million fewer jobs. And millions of families saw their home equity wiped away in foreclosures, Logan said. "A lot of people lost their jobs and their net worth. And then they had to take a lower paying job. ... It was a blow that they never recovered from," he said.

https://www.npr.org/2017/12/14/570556990/unhappy-10th-annive...

https://www.salon.com/2017/11/21/the-great-recession-is-the-...

dragonwriter7• 9 years ago

Other countries went through the Great Recession, didn't recover as well as the U.S.

The US recovery looks decent in top-line aggregate terms, but the distributional aspects are quite bad. (And that was true of the recovery from the previous recession, as well.)

For broad social impacts, the distributional aspects are more significant than the top-line aggregates.

theparanoid• 9 years ago

An equivalent (but more so) case was the Russian decline in life expectancy during the 90s for the same reasons.

akhatri_aus• 9 years ago

During the Great Depression though, life expectancy rose - especially during the dust bowl.

hfourm2• 9 years ago

This could just be because the rate of improved quality of life (access to food, medicine, medical improvement) was exponentially increasing compared to the offset of the economic depression.

matte_black6• 9 years ago

Is there a way to measure “Life expectancy of people most similar to you”?

Seems like that would be a more meaningful metric for an individual, rather than lumping them in with every drug addict.

pasquinelli• 9 years ago

it's not about you, it's about us, america. if you want meaningful metrics for you, talk to your doctor.

matte_black6• 9 years ago

It’s a vanity metric. Life expectancy gives no actionable information for anyone except for “move to another country”.

hueving4• 9 years ago

When it comes to health 'us, America' is so incredibly diverse in behavior that it's nearly meaningless.

We can have a medical break through that lets us revive stroke victims as brain dead patients that live for years in beds. Simultaneously we can have a smaller opioid epidemic that kills fewer people than the stroke victims and makes way more addicts. Average life expectancy increased, but who really gives a crap in that case?

dragonwriter7• 9 years ago

Is there a way to measure “Life expectancy of people most similar to you”?

Sure, to some degree of similarity, if you want to spend effort analyzing the multidimensional demographic and other factors in mortality data; there's very little public policy value in that, so the public organizations that compile public health information to support policy aren't likely to package that up for you, though.

matte_black6• 9 years ago

Nor should they, because the process has to be done on an individual basis.

maxerickson• 9 years ago

They do some demographic breakdowns:

https://www.cdc.gov/nchs/products/databriefs/db293.htm

I wouldn't be that surprised if they also sliced out "substance abuse", because mortality of the using population is likely a useful metric in characterizing the problem.

hueving4• 9 years ago

there's very little public policy value in that

That's incredibly myopic and would point to a massively flawed system if that's true. It's incredibly valuable for public policy on both ends of the political spectrum to know if certain demographics are dying much sooner than others.

A single national average is about as useless as you can get unless your goal is to bemoan the decline of the US or highlight how much better one nation is than another.

volgo2• 9 years ago

Republicans and poor people are Americans too

decebalus13• 9 years ago

Is there a way to measure “Life expectancy of people most similar to you”?

Wow.. whenever someone asks me why the US doesn't have humane social services and still regards drug addiction as a crime in need of punishment, I'll point them to this comment.

matte_black6• 9 years ago

I don't get why this is a big deal.

We already serve up content based on people similar to you or making similar choices as you, why not health forecasts?

If I eat healthy, exercise, get the proper amount of sleep and am not addicted to drugs, why not show me how other people with similar habits as me are doing, instead of averaging in people who treat their body like a dumpster?

Showing me the life expectancy averaged across an entire country of 300 million doesn't motivate me to do anything. There is nothing I can do that will make any impact on that number. By this logic we should show life expectancy as the average of the entire planet, that would be the best wouldn't it? No.

Showing people an accurate life expectancy however, could motivate them to make changes to their lifestyle or stay the course if they are happy with it.

I don't know, maybe people just have negative knee-jerk reactions to anyone proposing individualist sentiments.

refurb5• 9 years ago

Calm down.

It's a reasonable question. Is there life expectancy data for different segments of the population?

volgo2• 9 years ago

Welcome to America. This is the typical rhetoric going around in the Bay Area

itronitron• 9 years ago

people most similar to you likely includes many drug addicts

dredmorbius• 9 years ago

Discussions of "risk factors" tend to take this into account.

Age, sex, and socioeconomic status dominate.

There are a number of conditions linked to genetics -- types of anemia, heart disease, Tay-Sachs syndrome, off the top of my head.

Environmental exposures map strongly to socioeconomic status, though there are of course regional variations.

Weight, "body mass index" (a horrible measure), body fat percentage (far more useful, but harder to obtain), and various specific exposures and behaviours will cover much else: drink, smokes, injectable drugs, unprotected sex, other high-risk activity.

This is pretty much the life work of epidemiologists, public health statisticians, and actuaries.

pcurve• 9 years ago

https://www.washingtonpost.com/national/health-science/fuele...

Looks like it's attributed to drug epidemic

edit: I've posted this WP article because I couldn't actually read the Economist article due to paywall, and I figured other readers may have same issues.

robbiep• 9 years ago

The article specifically mentions this

birken• 9 years ago

A recent episode of "The Weeds" podcast was all about this [1]. I highly recommend listening to it and the podcast in general.

The general thoughts are (especially for those poo-pooing the findings):

- The cause is likely a massive increase in drug overdose deaths, whose average age of death is lower than other common causes (>20% year over year increase, mainly opioid-related) [2]

- The drop in life expectancy is not happening in other countries, just the US (not measurement error)

- It's sort of a big deal, especially if you consider that opioid-related deaths could be going down, or they could be accelerating, we just don't have the data. And if they are accelerating this could be much worse than it already is.

1: https://www.stitcher.com/podcast/voxs-the-weeds/e/52748846

2: https://www.cdc.gov/nchs/data/health_policy/monthly-drug-ove...

nubbins• 9 years ago

Also the fact that we now are aware of the opioid problem and are starting to really crack down on over-prescription of pills causing addicts to turn to heroin or fentanyl has to be a big factor. What percent actually OD on pills?

DasIch• 9 years ago

This is something also covered in the podcast. Instead of an over-prescription problem you now have a heroin/fentanyl problem which was expected but assumed to be temporary without prescription pills as an introduction to these drugs. It doesn't look like solving the over-prescription problem is helping at all though.

sprafa• 9 years ago

Also of note - how closely related opioids are to poverty and desperation. From reading recent studies, economy in the US is halving - on one side are people desperately fighting for their lives agaisnt an unstoppable force of wild capitalism, the other half is enjoying the wild benefits of digital globalized capitalism, and the benefits of software expanding everywhere and finance controlling the world.

The entire power of the rest of the industries (film, media, pharmaceuticals) seems to rely on copyright, which is genius, since the US has guaranteed all other countries have to play by its rules as far as copying goes through GATT and all the other trade treaties signed since. Looking back, all of it has actually been brilliant, outside of disconsideration for what the destruction of industry would do for the middle class (See Vaclav Smil's comment - "without manufacturing there is no middle class"). But the idea of copyright, and replicating the US model of agressively pursuing violations of it everywhere, was genius in the digital age - it's a way of permanently entrenching and making sure no competitors can arise, because almost anything can be copyrighted, therefore any similar enough competition is opening itself up to a copyright violation lawsuit. Basically, the US has been rebuilt along the lines of the same people who decided all of this back in the 1990s as a way to construct a new american empire (which I'm fine it btw, I prefer it to its competitors), and the result has been the mass anihilation of livelihoods in the rural and industrial areas. The result of this "error in judgement" has been Donald Trump - anger at the establishment and a willingness to anihilate it all in exchange for a promise to return to the Valhalla of yesteryear, when making a living was easy and the government was making sure all boats were rising with the tide, instead of leaving some behind.

Anyway, back on the topic of opioids - in Portugal we had this problem. We solved it by decriminalizing drugs and treating hard drug users as people in need of help. Perhaps, in the end, we will inspire the rest of the world to follow suit. It has always been my hope.

pjc50• 9 years ago

Basically, the US has been rebuilt along the lines of the same people who decided all of this back in the 1990s as a way to construct a new american empire

This reminds me of the great collapse in Russian life expectancy for Russians after the end of communism: http://www.nybooks.com/daily/2014/09/02/dying-russians/

The country became extremely unequal and was effectively looted by its oligarchs.

a willingness to anihilate it all in exchange for a promise to return to the Valhalla of yesteryear, when making a living was easy and the government was making sure all boats were rising with the tide, instead of leaving some behind

Quite a lot of people said they would have preferred to remain under totalitarianism in the Soviet Union than to die of hopelessness in the post-Soviet crony "capitalist" wasteland. I hear there are even people in Portugal nostalgic for Salazar?

pkaye• 9 years ago

What would be the life expectancy if we excluded drug addiction causes?

forapurpose16• 9 years ago

Other measures of human welfare that are declining in the U.S.:

* "This year, the number of domestic undergraduate students dropped 224,000"

https://www.nytimes.com/2018/01/02/us/international-enrollme...

* If nothing is done, the number of Americans with health insurance is expected to decline by millions this year (due to the repeal of the health care tax (I forget the term they used) in the new tax law).

* With CHIP not being funded, the number of children with health insurance also should decline.

pknopf• 9 years ago

The system will stretch us thin, until we break.

I don't know what "break" means, but I don't think it will be pretty.

shams93• 9 years ago

I lived through the LA riots, breaks means every block in every city on fire with people angry out of their mind breaking everything they can get their hands on and people shooting everywhere. You reach a breaking point and you have sudden social collapse.

rayiner4• 9 years ago

The first number is a good thing. We’re overeducated in the US.

dqpb• 9 years ago

Define overeducated

AnthonyMouse7• 9 years ago

The first number is a good thing. We’re overeducated in the US.

Is that even possible? It's not as if we're swimming in demand for unskilled labor at a living wage.

The underlying problem seems to be that college (along with housing and healthcare) are too expensive and people can't afford them.

AnthonyMouse7• 9 years ago

If nothing is done, the number of Americans with health insurance is expected to decline by millions this year (due to the repeal of the health care tax (I forget the term they used) in the new tax law).

This is a bad metric. We should be worried about healthcare costs, not insurance coverage. You can have "universal coverage" and still be wrong, because people are paying $5000+/year in insurance premiums they can't afford.

If it didn't cost a hundred thousand dollars to get sick then it wouldn't be a problem for people to not be insured against it.

majormajor9• 9 years ago

If it didn't cost a hundred thousand dollars to get sick then it wouldn't be a problem for people to not be insured against it.

This is a dicey one. One of the things that drives treatment costs up is more advanced technology. Should we go back to 70s/80s-era cancer treatments, HIV treatments, surgical outcomes?

We need a lot more national discussion about where the real opportunities to save money are, and what should and shouldn't be covered, and if there's a one-size-fits-all solution or not, because some of the costs will continue to trend upwards as we become more able to keep more people alive for longer (otherwise a good thing!). Some [surgeries, drugs, treatments] cost tens of thousands of dollars and save lives. Some cost tens of thousands of dollars with dubious outcomes. That's where the meat is.

But we have no hope whatsoever of getting there if we can't even agree that mandated health insurance at at least some minimum level is necessary policy. Insurance needs that much to be able to work at all. Or give me the reverse: if you opt out of health insurance when you're healthy, saying the sick can fend for themselves, then you don't ever get to opt back in. (That's not gonna happen, obviously.)

forapurpose16• 9 years ago

This is a bad metric. We should be worried about healthcare costs, not insurance coverage.

I agree with your general point. However, I'll add that some people will be too poor to pay for health care, no matter what it costs, and they may be the people who need it most (the indigent).

Addressing the more specific issues of metric, I think the best metric is QALY (qualty-adjusted life years) lost due to lack of health care delivery.

But my strong impression is that insurance availability correlates strongly with lost QALY.

volkl48• 9 years ago

Your first point is misleading. As birthrates fluctuate (ex: "the baby boom" was a high point), so do the number of people who can potentially be starting college in a given year (at the traditional age).

The next few years of Americans to turn 18 are smaller than the year before them. If the likelihood of Americans to go to college remains similar, domestic student populations will decline for reasons of demography, not malaise.

forapurpose16• 9 years ago

If the likelihood of Americans to go to college remains similar

That's a problem. Prior generations became more educated than their predecessors, more able to understand the world, and did higher-skilled and better-paying work. Now, it's stagnated (or is going backward).

biohax20152• 9 years ago

It’s very frustrating to watch America decline and not being able to do anything about it. Has democracy failed? Is it time for a rekindling of the study of comparative politics? It seems the Chinese have a viable solution to the problem of a largely uneducated and passive populace.

theonemind• 9 years ago

Democracy can't fail until we actually try it. Public opinion has about the impact of statistical noise on public policy: https://www.globalresearch.ca/study-congress-literally-doesn...

Personally, I'd characterize the US as a plutocracy.

as787987• 9 years ago

And the Chinese solution is?

forapurpose16• 9 years ago

It seems the Chinese have a viable solution

Viable to whom? And who gets to decide? If the Chinese solution is so popular, why don't they hold an election?

There is no legitimate government without democracy, without the people deciding who should govern them and how.

thablackbull• 9 years ago

So serious question, do you consider Trump as a legitimate government? As I understand it (non-American here), Trump won through the electoral college and most Americans do not support him.

thatcat• 9 years ago

Chinese have a viable solution to the problem of a largely uneducated and passive populace.

How so?

biohax20152• 9 years ago

Professional politicians who know what the people need better than the people themselves.

make33• 9 years ago

blind plutocratic capitalism has failed, not democracy

sumedh3• 9 years ago

Has democracy failed?

An outsider was elected even though he was running against establishment candidates with huge money backing them.

I say democracy won.

tensor• 9 years ago

You say that as though Trump doesn't have huge money backing him, not to mention foreign governments with equally deep pockets.

abootstrapper• 9 years ago

First, I'm not sure that's a good metric to measure the success of democracy. Second, Trump lost the popular vote.

refurb5• 9 years ago

Did it occur to you that the reason why things seem so rosey in China is because the state controls the media?

It's easy to show your country is doing well when you don't have free press?

grecy• 9 years ago

Has democracy failed?

The US is only 5% of the World's population. There are plenty of Developed countries doing much, much better than the US.

You're doing it wrong, but the rest of the world is ticking along.

zo1• 9 years ago

Like Sweden, UK and Germany?

dragonwriter7• 9 years ago

It’s very frustrating to watch America decline and not being able to do anything about it. Has democracy failed?

No, Empire failed (or, rather, is failing), as empires do.

America has also pretty much failed to democracy, and part of that was trying to democracy and empire together, or maybe just neglecting issues with democracy because empire was more important. Democracy works a lot better where people are actually practicing something that produces democratic outcomes, and the US is very close to the worst of established “democracies” at doing that, and has steadfastly refused to even consider trying to do better.

Is it time for a rekindling of the study of comparative politics?

“Rekindling” implies that it died out; it didn't, and remains an active field.

It seems the Chinese have a viable solution to the problem of a largely uneducated and passive populace.

In what way?

nopinsight• 9 years ago

https://www.cdc.gov/nchs/products/databriefs/db293.htm

“Life expectancy at birth decreased 0.1 year from 78.7 years in 2015 to 78.6 in 2016, largely because of increases in mortality from unintentional injuries, suicide, and Alzheimer’s disease, with unintentional injuries making the largest contribution. This is the second year in a row life expectancy has declined (1). Changes in death rates at younger ages have a larger impact on life expectancy than changes at older ages. The increases in death rates at the younger ages from 2015 to 2016 resulted in the decrease in life expectancy observed during that period.“

PS I got this link from another commenter here.

coldtea2• 9 years ago

It's probably because life expectancy, like maternal deaths (of which the US has U.S. the worst rate in the developed world), can't be faked and spin-doctored by government sources as easily as can unemployment rates.

And by "it's", I refer to the fact that this is known, not to the reason why this happens. Unemployment rates, declining middle class, bleeding working class, and people working shitty subsistence jobs that count as "full employment" would be my guess for the latter (and all that comes from eat: low self esteem, depression, drinking, drugs, poor health coverage, homelessness, et al).

candiodari2• 9 years ago

Actually it's easy. Just take maternal deaths. The US is pretty straightforward in maternal deaths and baby deaths.

If an infant is born alive, and dies, it is an infant death in the US. Even if it is completely nonviable (e.g. no heart). In the Netherlands any baby that dies in < 2 weeks after birth is not an infant death. If a child dies < 5 years it is not counted in life expectancy calculations. I'm not sure what the situation in the US is. But frankly, any time a number sounds extreme (and this one does) your first thought should frankly be "how have governments faked this number". Just like for private companies, if a number sounds too good to be true, it almost always is.

So the numbers aren't as comparable as people claim. There is obviously a difference, but it's not as dramatic as advertised.

hacknat• 9 years ago

Can anyone point me to the ethnic breakdown of the opioid epidemic? Does it cut across ethnicity/race evenly or does one group suffer more (my guess would be white men).

anonytrary• 9 years ago

Fat people U depressed people => accounts for what, 80%?

jk2323• 9 years ago

This is really bad news and reminds me of: https://www.amazon.com/After-Empire-Breakdown-Perspectives-C...

This guy predicted the downfall of the Soviet Union in his mid 20ies based on statistical indicators like life expectancy.

beebmam• 9 years ago

Time to end the war on drugs and start treating drug addiction as a disease...

thedevil• 9 years ago

I didn't see any link in the Economist, but I think this is the original source:

https://www.cdc.gov/nchs/products/databriefs/db293.htm

doctorless• 9 years ago

I’m surprised to see nobody call out alcohol consumption.

While this is a few years old, the data should be relevant; alcohol takes years to manifest into full-blown health crises: https://pubs.niaaa.nih.gov/publications/Surveillance95/CONS1...

Additionally, there has been an upswing in youth consumption in the past decade directly. We need to have a public conversation about what we’re doing to ourselves, especially in places with the extreme “beer culture” like SV, Seattle and Portland.

ianai3• 9 years ago

It’s not just alcohol. Diets heavy on fat and cholesterol seem to only get more popular year after year.

maroonblazer2• 9 years ago

Unless there's been some very recent findings that I missed, everything I've been reading for the last several years has found that fat and cholesterol are not the problems we once thought they were.

elsewhen2• 9 years ago

http://www.thelancet.com/journals/lancet/article/PIIS0140-67...

woopwoop• 9 years ago

Additionally, there has been an upswing in youth consumption in the past decade directly.

Cite? According to this[1] paper, there was a decline in underage alcohol consumption between 1991 and 2013, but that doesn't quite contradict what you said.

[1] https://pubs.niaaa.nih.gov/publications/surveillance101/Unde...

JoeAltmaier• 9 years ago

Look no further than "What restaurants opened in the 1950's", since folks who lived thru that are in their 60's now.

Taco Bell, KFC, Dunkin Donuts, Burger King, Shakeys, Pizza Hut, Little Caesars, IHop, Carl's Jr, McDonald's and on and on.

http://www.whendidithappen.com/wdih/restaurants/1950.htm

zhengiszen• 9 years ago

Many call to see the relation with the Afghanistan War and its consequences (or payback). Action = reaction of was it premeditated by the 'elite' as a population regulator as we saw with the cocaine. A way to destroy the more fragile part of the population.

bjourne• 9 years ago

The last time life expectancy was lower than in the preceding year was in 1993. The last time it fell for two consecutive years was in 1962-63.

Nothing really bad happened in 1962 or 1963. So couldn't the current two-year "trend" be explained by randomness? Life expectancy can't continue to rise forever.

68c12c16• 9 years ago

the statistical data given in this article seem to show us only one part of the whole picture...

And according to an article published at [1] (and of course, by intuition for many of us), there seems to be an association between a person's wealth and that person's longevity.

If the income gap between different social strata has been widened in the past decade, then it is very likely that the life expectancy of poor people in the country decreases much faster than that overall data could tell us....

============

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4866586/

Life expectancy in America has declined for two years in a row

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