The economists Anne Case and Angus Deaton published their article “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century” in 2015, the same year the journalist Sam Quinones published Dreamland, his book on the opiate crisis. Both raised the alarm that many middle-aged, non-college-educated white people had lost the will to live, either committing suicide directly with guns or by hanging or indirectly through alcohol and opiate addiction.
But it wasn’t until 2016 that one-third of the country saw a much more conspicuous sign that we’ve got a problem. It came in the form of a Super Bowl ad for Movantik, a drug for treating opiate-induced constipation. Anyone watching the Super Bowl could reasonably infer that opiates were now so ubiquitous that a company would spend millions of dollars advertising a drug to mitigate their side effects. And of course, nine months later, the anguished white working class elected President Trump, whose inaugural address heavily emphasized Rust Belt despair.
Case and Deaton’s new book, Deaths of Despair and the Future of Capitalism, addresses these themes. Through simple figures and clear prose, it presents a huge body of evidence from the Centers for Disease Control and Prevention’s WONDER database and other sources that the arc of the white working class’s fate over the last two decades is long, but it bends toward nihilism and an early grave.
The long-run trend in industrialized nations is toward increased life expectancy. Over the last two decades, that trend has held for almost everyone except non-college-educated white Americans, especially those in late middle age, whose mortality improvements in other areas have been offset by increased deaths from “accidental poisoning” (read: drug overdose), suicide, and alcohol-related diseases such as cirrhosis. There have been so many of these “deaths of despair” among non-college whites between the ages of 45 and 54 that the long-term decrease in mortality for all late-middle-aged whites leveled off around 2000 and has not improved since. College-educated white people continue to live longer, but the white working class increasingly has the demographic profile of a failed state.
Because mortality (death) is often presaged by morbidity (poor health), Case and Deaton devote two chapters to showing the white working class’s subjective experience of health and pain. Whites without college educations are far more likely than those with college educations to report ill health. Indeed, self-reported health for non-college whites in their 20s is similar to that of college-educated whites in their 70s. They are more likely to rate as “seriously distressed” on a measure of depression and anxiety. They report more pain. Working-class whites are not only dying more than college-educated whites: They are also ailing more.
Why? As suggested by the “future of capitalism” phrase of their book’s title, Case and Deaton put some of the blame on the shift over the last several decades toward market-oriented reform, freer trade, and leaner and meaner corporations that outsource ancillary functions. The problem is that this trend (often referred to, though not by Case and Deaton, as neoliberalism) was a global trend, and most social scientists date its onset to around 1980. This makes it a poor candidate to explain something that started in America around 2000 and has only really affected America.
Other explanations for rises in deaths of despair seem plausible looking only at the United States but appear less so when comparing us to our peers. For instance, Case and Deaton point to the effects of the “China shock,” or the collapse of American manufacturing employment after China joined the World Trade Organization in 2001, but China trades with the whole world, not just the U.S. The authors argue that the effects of the shock have been worse in America because healthcare is so expensive here, which has inhibited growth in take-home pay at the bottom of the class structure. But this fails to explain why black Americans, who also face an expensive healthcare system, have seen different mortality patterns than non-college whites.
A better explanation may start by disaggregating deaths of despair into suicide mortality, alcohol-related mortality, and drug overdose mortality. Curiously, of all the figures in the book, none of them plots drug, alcohol, and suicide deaths separately. However, as Charles Lehman of the Washington Free Beacon notes, drug overdoses account for the great bulk of the growth in deaths of despair. From 1999 to 2017, alcohol-related mortality and suicide rose by a troubling 58% and 38%, respectively. Fatal drug overdoses rose by a horrifying 260%. If all three causes rose in tandem, then the intersection of race and class would be a good explanation. That almost all the growth is in drug overdoses suggests a much more specific, and specifically American, story: The “pain revolution” in medicine, or the massive rise in prescriptions of opiate painkillers, created an opiate crisis.
It is interesting that this crisis mostly hit working-class whites, just as the 1980s crack epidemic disproportionately hit working-class blacks, but this mostly tells us that drug fads can be demographically specific. Occam’s razor suggests that the white working class is now dying of heroin and fentanyl overdoses because it first got hooked on OxyContin.
Case and Deaton end their book with the obligatory “What is to be done?” chapter, but between them completing their book and me finishing my read of it, it has become obvious that a better place to end is: “What’s next?”
I am writing this review from home rather than my office because, like most Americans, I am under a public health order to stay home to stem the coronavirus pandemic. Like many college-educated workers, I have it pretty good in that I can work from home and still receive my full paycheck. But many non-college-educated workers have been laid off, especially those working in bars or restaurants.
The resulting unemployment and disruption will hit the working class particularly hard. But even aside from these economic problems, the coronavirus is likely to drive an increase in deaths of despair. Man is a social animal, which makes social distancing an unpleasant experience. In theory, texting and online chatting mean that physical distance need not imply social isolation, but if you’re the nonverbal type whose preferred mode of socializing is watching a game at the bar, quarantine will be a very lonely experience. And we know that loneliness drives suicide, which is why rural widowers are at such high risk.
The epidemic also promises to increase deaths related to chemical dependence. If you stockpiled toilet paper, you are not going to use the toilet compulsively, but if you are an alcoholic who stockpiled booze, you might find yourself bingeing, especially if you are bored and anxious. And consider the opiate addict who was revived twice last year but now finds EMTs too busy treating respiratory failures to administer Narcan and emergency rooms too full to admit an overdose.
Case and Deaton published their article announcing deaths of despair in 2015, just as fentanyl-laced heroin replaced diverted pharmaceuticals as Americans’ opiate of choice. The result was an even worse spike in accidental poisonings than the one documented in their article. Their book’s March 2020 publication date is likely to prove a similarly ill omen — a portent of the social and economic dislocation caused by the coronavirus and the deaths of despair that will follow close behind.
Gabriel Rossman is an associate professor of sociology at UCLA.
