In 2017, overdoses became the leading cause of death among Americans 50 and under. The same year, it was reported that there were 129 suicides per day, which is nearly triple the number of homicides. Deaths related to alcohol killed nearly 1 million people between 1999 and 2017, often brought upon by liver disease like cirrhosis. For a long time, deaths of this sort were understudied or slipped below the media radar—perceived as tragedies that had to do with individual stories rather than with systemic issues.
In November 2015, Princeton economists Anne Case and Angus Deaton published a paper that was the first to group deaths from overdose, suicide, and liver cirrhosis under the umbrella of despair. This study, alongside their subsequent research, led to the popularization of the phrase “deaths of despair.” The coinage specifically applied to middle-aged working-class white people who were dying prematurely in such high numbers that it was raising the entire country’s midlife death rate. Mortality rates, from suicide in particular, had been steadily falling among other wealthy countries, except in the United States. Life expectancy, a basic indicator of a society’s health, was simultaneously improving around the world, except in the United States.
Case and Deaton sounded the alarm, and captured the attention of journalists and writers who were struggling to grasp the political appeal of Donald J. Trump’s then-nascent presidential campaign. His so-called “forgotten people” happen to fit the precise demographic criteria Case and Deaton studied: white, middle-aged, without a college degree. Days after their study was published, economist Paul Krugman summarized its findings in an op-ed column with the headline, “Despair, American Style.” Krugman dismissed the usual suspects put forth by conservatives, like welfare dependency or secular society’s annihilation of family values. The “materialist” explanation put forth by Case and Deaton seemed more plausible to Krugman: that rising mortality can be traced back to inequality and the “hollowing out” of the middle class. Ultimately, Krugman concluded that he wasn’t sure what was causing despair, or whether universal health care and higher wages could bring relief from “existential despair.”
Case and Deaton expand on their 2015 study in their new book, Deaths of Despair and the Future of Capitalism, in which they argue that suicides, overdoses, and income inequality are consequences of capitalism in America as it is constructed in the 21st century. The authors write that we are living in a “mirror-image” of a Robin Hood society, where resources are being redistributed upward from the poor to the rich. The primary culprits plundering America’s economy may sound familiar: price-fixing pharmaceutical companies whose drugs are massively overprescribed, corporate rent-seeking, wage stagnation, the deterioration of unions, and a health care system they call “a disgrace.” To cope with diminishing social and economic status, white people without a college education are, they find, increasingly turning to opioids, alcohol, and more drastic measures in the face of a more unequal society.
“It is not only the radical left that is concerned about the future of capitalism and democracy as they are practiced in America,” Case and Deaton write. “There is a recent flood of books not only by long-standing critics but also by erstwhile defenders, successful entrepreneurs, and powerful ex-policy makers.” Case and Deaton’s book is a grim addition to this flood of concern from capitalism’s usual boosters. They marshal more than a dozen studies to make the case that American capitalism is failing an aging white working class. Interwoven with their narrative of generational entropy are even more statistics measuring levels of physical pain, addiction, suicide, mental distress, and increasingly worse jobs with lower wages that illustrate how hard life has become for those without a college degree. Deaton’s previous work, The Great Escape, praised the power of markets and capitalism to lift people out of poverty and improve living standards for billions of people. This book, mapping capitalism’s dark side, does not do that.
That deprivation and austerity harm workers is (of course) central to the “radical left” critique of capitalism. Exercising freedom in a democracy means little without the ability to also exercise economic self-determination. Now that those who’ve crunched the numbers see how deadly American capitalism can be—are they also coming around to some of the left’s proposals to fix it?
Case and Deaton model their theory of despair on French sociologist Émile Durkheim’s 1897 monograph Le Suicide. Durkheim’s methodology, which was pioneering at the time, involved traveling around France in search of death certificates, looking not only for the manner of death but also demographic and biographical details of the deceased. Only in the aggregate, he believed, could the social patterns of suicide across France and other European countries be understood. Prior to Durkhim, suicide was thought of strictly in individual terms; but his study upended this view, positing that people are most at risk during times of external discord and societal upheaval. Unanchored from the structures of daily life that make the world comprehensible, meaningful, and joyful, people, Durkheim argued, become isolated and adrift.
Despair may sound like an abstract phenomenon for economists to study, but using education as a dividing line—which for them is a close proxy for class—Case and Deaton’s data illustrates just how despair has creeped into the lives of many. Over the last 20 years, representative national surveys show, white people without a bachelor’s degree have reported greater difficulty shopping, watching a movie, relaxing at home, and socializing with friends. They also have reported higher levels of pain, mental distress, and ill health. The percentage of white people ages 45–54 without a bachelor’s degree reporting they’re unable to work rose to 13 percent in 2017 from 4 percent in 1993. For Case and Deaton, the deterioration of conditions of daily life is one of the “background” causes of deaths of despair.
As feelings of physical pain and social isolation have made life harder to bear, manufacturing jobs have been replaced by service jobs, which have fewer benefits and lower wages, a central issue in the authors’ “upheaval” narrative. The primary upheaval experienced by the white working class today, according to the authors, is the power imbalance between capital and labor. This imbalance has been a “slowly unfolding calamity,” according to Case and Deaton. “Rising economic and political power of corporations, and the declining economic and political power of workers, allows corporations to gain at the expense of ordinary people, consumers and particularly workers,” they write. Meanwhile, those at the top of corporations have seen their wealth soar.
“Among America’s 350 largest firms, average CEO earnings in 2018 was $17.2 million, 278 times average earnings.” In the 1960s, the difference in compensation “was only 20 to 1,” and nearly a third of workers had a union job. Today, union density hovers at around just 10 percent. Union halls were once the “center of social life,” according to Case and Deaton, but work life today is more lonely and atomized, and low-wage work, with few benefits, feels impersonal and unfulfilling. Low-wage work has also led to the stagnation of real wages and purchasing power for the working class, all while the cost of health care has skyrocketed, largely because of effective lobbying and government capture. The very structure of the financial system in this country, Case and Deaton argue, is largely responsible for the “deaths of despair” crisis they warned about in 2015.
It wasn’t long ago that a union job in a manufacturing town meant the ability to be the breadwinner. You could afford to buy a home and a car, raise a family, and even take that family on a vacation once a year—all without a college degree. A recent study compared counties that retained auto plants with those that lost auto plants and, in Durkheimian fashion, found that opioid overdose deaths increased 85 percent in the counties where plants had closed.
Of course, these conditions aren’t experienced only by middle-aged white people. But long protected by a governmental and societal safety net, the white working class is now, in Case and Deaton’s telling, in free fall: “Our main argument in this book is that the deaths of despair reflect a long-term and slowly unfolding loss of a way of life for the white, less-educated, working class.”
In a chapter titled “Black and White Deaths,” Case and Deaton seek parallels between present-day white despair and what they term “African-American despair,” which descended upon cities after 1970. “What happened to blacks and whites differs perhaps more in when than in what,” they write. When manufacturing jobs disappeared in Rust Belt cities, low-skilled black workers, already at a disadvantage as a result of discriminatory housing and lending policies, were hit hardest. What followed were twin epidemics—HIV/AIDS and crack cocaine—that devastated black communities and which the government did little to alleviate.
There are indeed eerie similarities between the deprivation experienced by white people today and the black despair from decades ago. But the latter’s never really ended. Despite the alarming death rates among white people of a certain age and class, mortality rates among black Americans are higher and their life expectancy remains lower. To this day, young black men account for more new HIV infections than any other group in the United States. African Americans also have more than twice the infant mortality rate as white Americans.
The over-quantification of Case and Deaton’s narrative ultimately hinders their analysis of race and the politics of health. Despair in African American communities, especially during the crack era, cannot be fully comprehended without factoring in policing and incarceration, which Case and Deaton spend little time discussing. While billions of dollars were being allocated for more health-oriented solutions to opioid deaths, the state doled out brute force and militant policing toward crack cocaine. Simultaneously, President Ronald Reagan slashed funding for public housing.
Case and Deaton appear much more comfortable identifying the deadly rot in America’s economy than they do in calling for its excision. Rather than ending corporate “plunder” for good, they call for “reducing” it; rather than ending rent-seeking, the accumulation of wealth without creating any new wealth, they call for “limiting” it. “We do not argue for higher taxes on the rich,” they write, because, curiously, they do not see inequality itself as “the fundamental problem,” even though earlier in their book they observe that despair, death, and inequality are all linked. Rather, they conclude, “the fundamental problem is unfairness.”
Their data illustrates every way life has only gotten harder for those without a bachelor’s degree. “A four-year degree has become the key marker of social status,” they write, “as if there were a requirement for non-graduates to wear a circular scarlet badge bearing the letters ‘BA’ crossed through by a diagonal red line.” Later, they sound more like a Pete Buttigieg campaign ad, writing that providing free college “would be extremely expensive and would distribute most of the benefits to those who need them least.” Would free public college, as in Bernie Sanders’s proposal, really do much to benefit millionaires and billionaires?
If free public college sounded expensive, providing the barest moral minimum in response to the current coronavirus pandemic will cost the government trillions of dollars. The conditions for despair to set in took decades to materialize. Now, in just two weeks, some 20 million Americans have filed for unemployment. The government’s gutted administrative state, its frail and antiquated safety net, and a for-profit health care system are proving to be utterly incapable of protecting our collective health and well-being.
The path out of despair favored by Case and Deaton—tweaking capitalism to be more fair—is in contention with the alarm bell they’re ringing. If the estimated 150,000 deaths this year from suicide, alcohol, and overdoses combined didn’t already make this clear, the threat of Covid-19 means that now is no time for half-measures.