‘Deaths of Despair’

Over the last decade, deaths from drug overdose rose by a steady 3 percent per year until 2015, when the rate accelerated to an alarming 16 percent per year. In 2017, 22 of every 100,000 Americans died by overdose, and 14 by suicide.

Plenty of data is available, but we still don’t know very much about the deeper issues underlying these “deaths of despair”—as Princeton professors Anne Case and Angus Deaton have dubbed them. While the CDC and other federal agencies publish data on life expectancy and related trends, they tend to avoid broad explanations for what they report. Redfield’s brief statement called for action but offered no clear answers.

Of course, academics and commentators are always eager to propose explanations. Researchers outside the public sector tend to look at “deaths of despair” as economic and medical problems, requiring economic and medical solutions. At an event with Harvard’s Center for Population and Development Studies, Deaton and University College London’s Michael Marmot identified income inequality as “the key to global health” in general and to deaths of despair in particular. Meanwhile, in the New York Times, Moises Velasquez-Manoff proposed that we fight suicide with better drugs, arguing that because “no new classes of drugs have been developed to treat depression (and by extension suicidality) in about 30 years” the United States should liberalize the use of ketamine as an alternative to conventional antidepressants.

But the limits of these approaches become more obvious the more we learn about deaths of despair. On the one hand, it’s difficult to believe deaths of despair are simple markers of economic anxiety. The CDC’s new report on suicide shows that the rate grew at the same pace before the 2008 recession as during and after it, and while it’s rising fast among people old enough to have lost a job to automation, it’s rising just as fast among people too young ever to have held such jobs. Overdose deaths are hardly exclusive to the straitened circumstances of blue-collar, red-state America. They happen relatively frequently in the Rust Belt, but also in New England and the mid-Atlantic, and are rarest in Nebraska and the Dakotas. An inconsistent correlation between deaths of despair and economic hardship makes it difficult to formulate policy-based solutions. Case and Deaton admitted last year that economic “policies—even ones that successfully improve earnings and jobs, or redistribute income—will take many years to reverse the increase in mortality.”

Medical explanations run into similar problems. Plenty of drugs already exist to make people feel better, and Americans have been using them more frequently than ever. From 1999 to 2014, the proportion of Americans on antidepressants grew by 65 percent—and that’s not even counting the use of opioids and other painkillers. Similarly, more Americans than ever are in therapy: People diagnosed with a mental illness in America were over 25 percent more likely to receive treatment in 2016 than in 2003. But despite the increasing prevalence of mental health treatment, the rate of suicide is still growing. It’s impossible to know how high the rate would be without the widespread use of antidepressants, painkillers, and therapy, but their ubiquity suggests that despair runs deeper than the suicide rate can measure.

When a social crisis resists easy economic or medical answers, it’s tempting to declare the problem insoluble and demand that it be taken out of “back alleys” and into the sterile supervision of state-approved experts. San Francisco pursued this idea. Last fall, the California state assembly passed AB 186, a bill authorizing the city to set up “safe injection sites” where addicts could bring their own drugs to consume while state employees would provide any necessary paraphernalia and emergency first aid. AB 186 aimed to provide addicts with a sterile environment and education on “safe” drug use (the bill did not specify the content of this education, but one can assume the legislators did not intend an abstinence-based curriculum).

Similar proposals in Philadelphia, Seattle, and several states provoked a response from Deputy Attorney General Rod Rosenstein. In a New York Times op-ed, Rosenstein declared that the federal government would prosecute any “safe injection sites” that open. “Injection sites,” he argued, “normalize drug use and facilitate addiction by sending a powerful message to teenagers that the government thinks illegal drugs can be used safely.”

Following Rosenstein’s lead, California governor Jerry Brown vetoed AB 186 when it reached his desk on September 30. “Fundamentally,” Brown explained, “I do not believe that enabling illegal drug use in government sponsored injection centers . . . will reduce drug addiction.” Brown and Rosenstein hope to reduce deaths of despair, not simply manage them. The problem is, proponents of “safe injection sites” clearly do not share that intention. Like others who want to “decriminalize but regulate” morally questionable practices, they redefine health from abstaining from harmful practices to simply not dying of them. “Safe injection sites” shift the focus from confronting the problem head-on to providing a setting where the problem can persist, and even grow.

Research into deaths of despair won’t shed much light if the underlying assumptions are faulty. What if the life expectancy declines aren’t primarily economic, or even medical, and the roots of American despair lie elsewhere? Some suggest that it’s time to take a serious look at declining community and family life. Harvard’s Tyler J. VanderWeele, for example, has found a link between church attendance and lower rates of suicide, especially among women, while University of California, Riverside sociologist Augustine Kposowa has noted “accumulating evidence that divorced and separated people have much higher suicide rates than their married counterparts.” For men, divorce correlates strongly to suicide.

These results shouldn’t be all that surprising. Church and family represent an organic social safety net—without them, people can become isolated, lose a sense of purpose, and be poorly equipped to cope with despair when it comes. It’s easy to see how social isolation, especially if combined with losing a job or becoming reliant on an expensive medical treatment, can lead to a sense that one’s life isn’t going the way it should.

The downside of focusing on family, church, and community, from the perspective of an academic researcher or a federal agency, is that there aren’t easy solutions. There are no taxes, tariffs, therapies, or pills to keep people in pews and families intact. It’s reasonable to expect that the near future will therefore bring more campaigns for safe-injection sites, proposals to legalize the next miracle drug, and perhaps more latitude for euthanasia so as to make suicide itself more “safe.” It’s hard to believe any of these will increase Americans’ life expectancy or stem the decline. But it’s also possible that enough researchers will resist prevailing explanations, take seriously Redfield, Brown, and Rosenstein’s calls to investigate the real problems behind the decline of American life expectancy, and so begin the difficult task of reversing it.