Princeton University economists Anne Case and Angus Deaton call these “deaths of despair” — the deaths from suicide, drug overdoses and alcoholic liver disease ravaging swaths of the country. The victims, overwhelmingly, are less-educated Americans whose loss of life was preceded by a loss of jobs, community and dignity, and whose deaths, the authors argue, are inextricable from the policies and politics transforming the U.S. economy into an engine of inequality and suffering. “The American economy has shifted away from serving ordinary people and toward serving businesses, their managers, and their owners,” Case and Deaton write in their new work, “Deaths of Despair and the Future of Capitalism.”
Although the authors completed this book before the onset of the coronavirus pandemic — it was published four days after President Trump declared a national emergency — their diagnosis is still painfully relevant. Mass unemployment and mass infection, occurring simultaneously in a nation where health insurance often depends on employment, threaten to both prove and aggravate the conditions Case and Deaton describe. The debate over how quickly to ease social distancing restrictions and get the economy moving again forces a reckoning: How do we balance the risk of increased coronavirus infections if we reopen the economy too soon against the risk of more deaths of despair if we do so too late? “Jobs are not just the source of money; they are the basis for the rituals, customs, and routines of working-class life,” Case and Deaton write. “Destroy work and, in the end, working-class life cannot survive.”
Reading this book during a pandemic, I found myself bracing for more death — from the virus or from despair, and, more likely, from both.
Many memoirs, histories and investigations have been written on America’s white working class in recent years, probably too many, but fewer purely economic studies. Case and Deaton are world-renowned practitioners of the dismal science (Case is a top expert on the links between economic and health status, while Deaton snagged a Nobel in 2015 for his work on household poverty and welfare), and their lens on the subject makes for stark reading. They estimate the magnitude of the deaths of despair in the United States by comparing the improving trend lines of recent decades — i.e., if mortality rates had continued falling as before — with what actually came to pass.
“When we add up those numbers from 1999, the critical point where the turnaround began, to 2017,” the authors report, “we get a very large total: 600,000 deaths of midlife Americans who would be alive if progress had gone on as expected.” Case and Deaton liken that number to “what we might see during the ravages of an infectious disease, like the Great Influenza Pandemic of 1918.” They also compare it to the roughly 675,000 deaths of HIV/AIDS in the United States since the early 1980s.
Case and Deaton are largely dismissive of arguments that stress the supposed individual or cultural failings of the white working class, and they focus instead on systemic shortcomings that lead to deaths of despair. Manufacturing towns and cities have seen their factories boarded up, they write, and “in the wreckage, the temptations of alcohol and drugs lured many to their deaths.” Education is another consideration, the authors argue, with “almost all” of the increase in deaths due to suicide, alcoholism and drug overdoses found among people who lack bachelor’s degrees. Deteriorating health matters as well. “Many people are experiencing pain, serious mental distress, and difficulty going about their day-to-day lives,” Case and Deaton write. These conditions make it harder for them to work, which reduces income and undercuts work as a source of “satisfaction and meaning” in their lives.
More than 30 million Americans have sought unemployment aid since mid-March, a level of dislocation not seen since the Great Depression. In this context, the impulse to return to work is understandable. Yet the loss of earnings, Case and Deaton contend, is just part of the challenge. “Much more important for despair is the decline of family, community, and religion,” they write, a decline they regard as related to falling wages and disappearing jobs, but distinct from them. Other authors have tackled this problem recently — see, for instance, Timothy P. Carney’s insightful 2019 book, “Alienated America” — and collectively, their conclusion is clear: Long before we began social distancing, Americans had already grown far too distant from one another.
Case and Deaton focus on the white working class because it is undergoing a particularly harrowing shift, not because they believe this demographic matters more than others (they don’t) or because it is worse off in absolute terms than others (it isn’t). Black mortality rates remain persistently higher than white ones, the authors point out, even considering the increased deaths of despair among white Americans. But black mortality rates are falling faster than white rates — and the deaths of despair among white citizens are the difference. “The main reason why death rates of blacks fell more rapidly than death rates of whites at the beginning of the twenty-first century is that blacks were not suffering the epidemic of overdoses, suicide, and alcoholism,” Case and Deaton explain.
The grim irony of this racial split is that the appearance of African American progress itself may be a contributing factor in the rising deaths of despair among white Americans. Case and Deaton note a survey published in 2017 finding that more than half of white working-class Americans believe that discrimination against whites is as big a problem as discrimination against minority groups. (More than two-thirds of college-educated white Americans disagree.) The authors conclude that the simultaneous erosion of work and community life, together with “at least the perception of a loss of racial privilege,” forms a potent combination, more powerful than simply income losses. It’s an arena I wish they had explored further.
The authors often write in the dispassionate tone of their profession, but they break free of such detachment when pointing to the underlying culprit behind all these trends: the corruption of the American economic system, which they argue looks “more like a racket for redistributing upward than an engine of general prosperity.” The skewing of wealth and income toward the richest Americans and educated elites over the past half-century — aided by government policies and legislation — has “slowly eaten away at the foundations of working-class life, high wages and good jobs,” Case and Deaton write. The aftermath of the Great Recession, “when so many people lost their jobs and their homes, and the bankers continued to be rewarded and were not held to account,” affirms their point. The answer, they point out, is not simply to tax the rich but to remake the system. “The right way to stop thieves is to stop them from stealing, not to raise their taxes,” they write.
Case and Deaton condemn America’s health-care system and health industry more than any other sector, decrying it as “a cancer at the heart of the economy” because of its “extraordinary and extraordinarily inappropriate costs.” The system, which makes up 18 percent of U.S. gross domestic product, not only eats away at workers’ pay but also holds wages down through the costs of employer-provided coverage. “The exorbitant price of health insurance has caused firms to shed workers; this is not a natural disaster but rather one based on rent-seeking, politically protected profiteering, and weak enforcement of antitrust in the healthcare sector,” they write.
A case for such a system could perhaps be made if it did not also yield such poor health outcomes compared with other rich countries. “How it is possible,” Case and Deaton ask, “that Americans pay so much and get so little?” They blame doctors, hospitals, pharmaceutical companies and medical device manufacturers. “The trillion dollars that, from a health perspective, is waste and abuse is, from the providers’ perspective, well-earned income.” The opioid epidemic is just one of the more flagrant examples of abuse and unfairness; in that industry, corporations have explicitly profited from death.
Thanks to Case and Deaton, the notion of “deaths of despair” has become an obligatory reference in analyses of America’s white working class. The authors wrote a much-publicized article on the subject in the Proceedings of the National Academy of Sciences in 2015 and have continued to refine their research, including in a 2017 think tank paper and now in this volume. But it is worth noting the latter half of their book title. For all their criticisms, Case and Deaton have come to write of capitalism’s future, not just its failure. “We believe that capitalism is an immensely powerful force for progress and for good, but it needs to serve people and not have people serve it,” they write.
Unfortunately, their policy proposals — such as universal health insurance, reforms in corporate governance and the use of non-opioid alternative treatments for chronic pain — are not terribly detailed, nor do they appear to match the scale of the problems the authors outline. In broad strokes, Case and Deaton want to better regulate capitalism, not supplant it with “some fantastical socialist utopia.” (There’s a lot of room between those options.) The authors denounce the health-care system as a perversion of capitalism, enabled by an alliance of lobbyists and legislators. “The law, which ought to have protected the weak against rent-seeking by the strong, has increasingly moved to support the shakedown,” they write.
I’d very much like to read Case and Deaton on the coronavirus crisis, to see how they would bring their expertise to bear on an emergency that disproportionately affects African Americans and those on the margins of our economy, a wicked problem pitting the need to stay in against the urge to clock in. By laying bare the failures of American health care and the disparities embedded in our economy, this crisis may force a reevaluation of those systems. If not, what will?