How might individual deaths of despair point to much broader institutional failings? How might today’s US healthcare system operate as “a cancer at the heart of the economy”? When I want to ask such questions, I pose them to Anne Case and Angus Deaton. This present conversation focuses on Case and Deaton’s book Deaths of Despair and the Future of Capitalism. Case is the Alexander Stewart 1886 Professor of Economics and Public Affairs Emeritus at Princeton University. Deaton, winner of the 2015 Nobel Prize in economics, is the Dwight D. Eisenhower Professor of Economics and International Affairs Emeritus at Princeton University, and Presidential Professor of Economics at the University of Southern California. His previous books include The Great Escape: Health, Wealth, and the Origins of Inequality.
ANDY FITCH: Your book describes “deaths of despair” as, to some extent, a label of convenience. So could you introduce this deaths of despair designation by pointing to some clarifying contrasts it offers: in terms of which US population groups these deaths do and do not afflict, or in terms of comparable European societies (struggling with their own economic transformations and social divisions) not suffering from similar rates of such deaths?
ANNE CASE AND ANGUS DEATON: We have always wanted to draw a parallel with suicide, the ultimate death of despair, though we recognize that many addicts do not want to die. Some commentators have argued that we should include in deaths of despair other deaths where behavior is important, especially deaths from smoking, or deaths attributable to obesity. The case can be made, but we didn’t want to overreach, nor to engage with the vast literatures on such causes of death. We also thought that the three deaths of despair (by alcohol, drugs, and suicide) shared important features. They had risen in parallel. They were still, to some extent, flying under the radar.
This “deaths of despair” phrase certainly touched a nerve, and has since become part of the popular discourse. But we would argue that these deaths from alcohol, drugs, and suicide still don’t attract as much attention as they might. In both 2017 and 2018 (the latest years for which we have full data), 158,000 Americans died deaths of despair, more than have so far died from COVID. Preliminary information suggests that deaths of despair will have increased in 2019 from the previous year.
Contrasting these US rates with other rich countries’ rates for the past quarter century has played an essential part since we started this research, as has demonstrating that the increase in these deaths has mostly affected people without a four-year college degree. Nor was there any increase among African Americans, at least until 2013, with the arrival of street fentanyl. And contrary to frequent media reports on our work, deaths of despair rose in parallel for women and men. Since our 2017 Brookings Papers on Economic Activity publication, and now more fully developed in this book, our task has been to come up with a story that accounts for all of these communalities and differences.
So for finding and telling that story, could you say more about basic methodological challenges this “deaths of despair” metric poses: in terms of synthesizing external accounts (shaped by people’s social context) and internal accounts (shaped by their personal choices), in terms of bringing social-science analytic rigor to more opaque medical data, in terms of tracing an “epidemic” ultimately driven by institutional failings rather than by infectious disease?
Well in recent years, social-science “rigor” has come to mean experimental rigor, as in randomized controlled trials or similar procedures. We consider this a mistake, broadly, but especially when it comes to the investigation of slow-moving cumulative processes like the disintegration of American working-class life. Medical data, especially data on mortality, have often been used as an indicator, even the indicator, of social health. In 1848, Rudolf Virchow wrote that “medical statistics will be our standard of measurement: we will weigh life for life and see where the dead lie thicker, among the workers, or among the privileged.” Amartya Sen has argued for mortality as an indicator of economic success and failure.
From the start, we realized that these accelerating deaths of despair indicated something going very wrong — and that, to find out what, we’d need not only to look at individual behavior (as economists would), but to draw on other social sciences, especially sociology and political science. We also found the methods of history most helpful, eschewing simple monocausal stories in favor of richer accounts with sometimes tangled pathways, always engaging differential diagnoses as to what could and could not account for certain distinctions over time between places, ethnicities, and education.
Data alone can’t really answer questions of the relative importance of internal (personal choice) versus external (social context) forces driving deaths of despair. We certainly wouldn’t argue that it is all one and none of the other. But logic can be brought to bear on some of these questions. That the employment-to-population ratio has been in long-term decline for men without a BA, even as their wages have fallen, suggests that these men have not simply become lazy. A downward shift in the supply of less-skilled workers (with many preferring to sit at home playing video games, drinking and taking drugs) would have caused wages to rise for those remaining in the labor market. The fact that employment and wages have both fallen suggests a decline in the demand for less-skilled workers, which has knock-on effects for marriage rates, and more generally for individual and collective well-being.
Here alongside deaths of despair, could you place an epidemic of lives of despair: shaped by increasing rates of pain, disability, mental distress, economic and social withdrawal? What can morbidity rates tell us about what life feels like today for population groups suffering deaths of despair?
A great deal. In our very first paper on this topic, for example, we didn’t start out with a focus on non-college-educated Americans. That demographic group just jumped out at us from the data. Other than education, death certificates give little information about social backgrounds, and we were surprised at how closely education marked the rise in deaths of despair.
But once we discovered deaths of despair rising among less-educated Americans, though not among those with a college degree, we followed that divide throughout our investigations into pain, disability, mental distress, labor-force participation, wages, and religion. We found it astonishing that this division was so consistent across all of those different measurements. For many Americans, deterioration in these outcomes is an intermediate step between being well and being dead. For groups suffering all (or even some) of these afflictions, life clearly has become worse. We wanted to understand why.
Could you likewise outline some of the diversity even within this single demographic group — with African Americans lacking college degrees, for instance, placed most vulnerably on globalization’s front lines in the 1970s and 80s, and therefore not facing the same accelerating rates of despair as whites in more recent decades?
For African Americans, and indeed for Hispanics, our data didn’t show the same increases we saw for whites. But our book argues that these increased deaths of despair had just come earlier to many African American workers. When manufacturing jobs left many US cities, wages and employment fell first for America’s most vulnerable workers. Marriage rates among African Americans fell. Out-of-wedlock child-bearing increased. The crack epidemic took root.
Only later do similar trends start appearing in white working-class communities. And these parallels are of course less than perfect. White Americans don’t face the overt and covert discrimination that black Americans face. But similar social patterns have now emerged among lower-skilled whites. Modern capitalism discards whole groups of workers, starting with the least educated and/or the least secure. So processes that destroyed certain African American communities have now moved on to less-educated whites. More casually, and with insufficient evidence, we would argue that for many Hispanics, America still remains a land of opportunity — that since Hispanics weren’t a part of the 1950s and 60s blue-collar aristocracy, they haven’t seen a decline in opportunity comparable to what blacks and whites have faced.
Notably, the post-2013 rise in fentanyl deaths among African Americans again has been confined to those without a college degree.
Racialized aspects of this epidemic of despair likewise point to another key interpretive stance taken by your book. While rates of despair have risen dramatically among America’s working-class population, these rates have spiked specifically among a white working class that does not face the worst socio-economic disadvantages in the country, and that did not face corresponding rises in its poverty rate over the past few decades. So what do readers need to grasp here about Deaths of Despair not offering an acute focus on economic hardship per se, but on a broader convergence of factors: from declines in material well-being, to declines in normative family and occupational and community structures, to declines in self-perceived social status — all dynamically interacting with each other over multiple generations?
We think you have answered your own question quite eloquently. Poverty clearly harms people, but these other social conditions also strike deeply. As you mentioned, the people dying deaths of despair don’t belong to the most impoverished groups. That said, we have no way of measuring the incomes of those dying deaths of despair, who could often be the poorer members from this group of less-educated whites. But the story we tell would suggest that a conjunction of various factors, especially the loss of meaning in one’s life, proves much deadlier than poverty alone.
Here we recommend going back to Émile Durkheim, who at the 19th century’s end attributed suicides not to poverty, but to social dislocation and loss of social structure — both of which can also come about through positive social change, such as sudden and rapid economic growth.
For a broader range then of historical, sociological and cross-cultural reference, could you parse mortality rates and life-expectancy rates, perhaps by describing some main 20th-century drivers for each? And could you outline some of the most striking contemporary trends in both — perhaps again by contrasting rates for college- and noncollege-educated Americans, or for Americans and Europeans facing comparable economic circumstances?
We want to be careful here, for example about distinctions between life expectancy and mortality, or about what we can and cannot say about different educational groups in the US and elsewhere. Our 2015 Proceedings of the National Academy of Sciences paper started from an increase since the late 1990s in all-cause mortality among non-Hispanic white middle-aged Americans. This increase had not appeared in other wealthy countries. We then searched for the cause-specific mortality rates rising most rapidly, which led us to suicides, overdoses, and alcoholic liver disease (deaths of despair).
In an immediate response to our paper, Ellen Meara and Jon Skinner noted that this rise in deaths of despair did not look large enough to account for the increase in overall mortality, and that without a simultaneous slowdown in the decline of deaths from heart disease (which had been a main driver of mortality decline and life-expectancy growth throughout the 20th century’s last few decades), mortality rates would not have risen.
Other wealthy countries continued to make progress against heart disease while the US did not. It is not yet well understood why. Increases in obesity no doubt play a role. And perhaps less-educated Americans with hypertension have had reduced access to (or have just stopped taking) the inexpensive, effective drugs that can control this condition. Further complicating the picture, women started smoking in the US later than men, and also stopped smoking later. So for women, cancer deaths attributable to smoking are still working their way through the population.
More broadly, when we began this research on US mortality rates, we didn’t know that US life expectancy was falling. Mortality rates at each age are the building blocks used to measure life expectancy, but life expectancy is usually defined as life expectancy at birth — when we can’t yet differentiate between the more and less educated, because schooling lies in the future. Beyond some age (generally taken to be 25 or 30), completion of a BA is unlikely to change, and we can measure the number of years one can expect to live beyond that age (life expectancy at age 25 or 30) separately for those with and without a four-year degree.
Another complication is that education does not appear on death certificates in most European countries, so we have not studied European mortality in the same way. But work by Johan Mackenbach in Rotterdam has shown that, if anything, European health inequalities, as measured by educational qualifications, have narrowed, not widened.
Could we likewise consider generational cohort effects in morbidity, mortality, and life expectancy: with older Americans today feeling better in some respects than their middle-aged counterparts, with deaths of despair only recently starting to increase among elderly populations, and with certain ominous indications of despair beginning to appear and then to accelerate among progressively younger cohorts?
Again, these findings come straight out of the data, and you’ve touched on the main points quite well. Of course these results should terrify us all, especially in terms of our healthcare system’s coming strains, as people in such distress move into old age.
Now for more granular trackings of despair, pain stands out as one critical factor. You tell us that pressures of social distress, of labor-market corrosion, of monopolistic rent-seeking, and even of political polarization “all collide around pain.” You again document stark differences in pain levels depending on education levels (even as fewer Americans, in any class, take on physically taxing jobs). You note arresting statistics showing today’s elderly populations reporting less pain than today’s middle-aged populations. And you point to Big Pharma’s ubiquitous pain-relieving products not seeming to have achieved their ostensible goal of reducing America’s pain. A death of despair, you say, “often passes through pain.” Which of our broader institutional failings pass through pain as well?
The link from pain to opioids seems the most straightforward. The existence of high levels of pain, particularly among certain populations, gave opioid manufacturers and distributors an opportunity to make huge profits off fellow Americans’ suffering, putting them on a path to addiction and eventual death. Many targeted communities (say in Ohio, West Virginia, and Tennessee) were places where mines and industries had closed in recent years, while leaving behind a legacy of pain from heavy manual work and from accidents. Evidence also suggests that prolonged use of opioids can cause increased pain, even if providing relief in the short run. And addiction rates also strongly correspond to suicide rates, further extending this clear line from pain to opioids to death.
But we also wonder if social dislocation, and the loss of good jobs, might often cause pain. Pain, after all, is processed by the brain, so is, in one sense, always “in the mind,” whether or not it is associated with physical injury. An ex-miner now working in an Amazon warehouse, facing much less danger of physical injury, simultaneously faces a lost way of life, which may also hurt. We don’t know for sure. Fraught public discussions of pain go back multiple generations now. Jockeying between the “tough it out” crowd, and the “duty to help” (and perhaps to sell our products) crowd, makes these questions even harder to resolve. But the data on who experiences pain (men or women, elites or workers, blacks or whites) has usually played out in all the ways one might expect in an unequal society. Society is always more sympathetic to the reality of the pain of high-status or favored groups.
Increased pain takes us, as you say, to increased opioid prescription, addiction, mortality, and lethality — as well as to stark medical and cultural differences between America’s and Europe’s opioid usage and its consequences. Could you flesh out some of the supply-side and the demand-side factors making this 21st-century epidemic again both distinct to our society, and acutely concentrated within specific communities?
It isn’t really possible to parse out demand-side factors and supply-side factors in this opioid epidemic. Pharma companies literally looked at maps, and targeted their prescription-opioid marketing campaigns to areas with below-average educational levels and underperforming economies — basically targeting and flooding areas where they anticipated higher demand. So do you want to call that demand-driven or supply-driven?
Less-educated workers are having a tough time in all rich countries, though they benefit from much stronger safety nets outside the US. But it is also pretty clear that our prescription-opioid epidemic would not have grown as severe without certain corporate behaviors being permitted, licensed, and politically protected in the US, while outlawed in other countries. Jaw-dropping evidence reveals the institutional failures that allowed essentially heroin in pill-form to saturate and ravage many of our most ailing communities. Congress did worse than look the other way. It hamstrung agencies whose remit includes the oversight of scheduled drugs. Behavior that other societies would treat as a criminal conspiracy was tolerated and even encouraged. Sam Quinones’ splendid book Dreamland explores this parallel between the legal and illegal dealers.
We might struggle to pinpoint precisely where pain- and opioid-driven despair shades into death by suicide. But deaths by suicide do offer their own clear statistical trends in your book (rising today in specific US populations while falling across much of the world, occurring at historically unprecedented rates among working-class Americans relative to their wealthy counterparts, concentrated in a low-population-density Suicide Belt stretching north from Arizona to Alaska). Could you say more about which complex convergences of individual, interpersonal, and/or collective turmoil seem, in your research findings, to pose the most predictable conditions for suicide?
Suicide is very hard to predict and understand. It amazes us how much of the little that social scientists do know about suicide still comes from Durkheim. America’s Suicide Belt, which runs along the Rocky Mountains, commonly gets explained by social isolation in sparsely populated areas, and while social isolation has increased, we doubt that’s the only force at work. America has a lot more guns than it used to have. But we know too little on this topic, because Congress (or really the NRA) prevents data collection and analysis. Pain often gets implicated in suicide. But again, we just don’t fully understand the year-on-year increases in pain that our data show. We suspect, but have not seriously researched, that some of this rise in suicides comes from addiction — though suicide actually started rising before the opioid epidemic.
Durkheim considered less-educated people less likely to kill themselves, and that supposition has endured ever since. Our own data break that historical pattern, which to us offers further powerful evidence of the disintegrating life for many less-educated Americans.
Then to build toward a broader social diagnostic of the institutional failings prompting this despair epidemic, our dysfunctional healthcare system definitely stands out, with you describing this system as “a cancer at the heart of the economy.” Here could we start from your two basic points that free markets tend not to function well for distributing high-quality healthcare (with, for instance, an overload of circumstantial factors impeding informed and rational consumer decisions), and that our healthcare sector by no means operates as a free market anyway (with Big Pharma’s lavish lobbying and protectionist rent-seeking making its complaints of “anti-free-market regulation” absurd)?
That is a good place to start. And it’s not just Big Pharma that lobbies. Healthcare has become the largest employer in most Congressional districts, giving this industry enormous power. It also spends huge sums in D.C. There are five healthcare lobbyists in D.C. for every member of Congress. Without revitalized private-sector unions, we see little hope for any countervailing power.
So could you describe some broader economic consequences by which America’s healthcare industry here emerges as the “leading villain”: dragging on overall growth through its bureaucratic inefficiencies and parasitic profiteering, pushing down workers’ wages while undermining prospects for good jobs, siphoning off public financing for essential education and infrastructure investments?
Well again, we arrived at this perspective through a process of differential diagnosis. Many features of our capitalist economy of course exist in other rich countries as well, with US-style healthcare the outstanding exception. And healthcare is big enough to explain a lot. According to findings by the National Academy of Medicine and others, America’s healthcare system wastes around a trillion dollars a year, so the waste alone is 50 percent more than our military budget — just an amazing statistic, given how often the military gets cited by Americans arguing that we should spend our money in different ways. We outspend most wealthy countries by 50 percent per-capita on healthcare, yet have the lowest life expectancy in the rich world.
At the same time, employers’ costs for an individual or family policy have grown large enough to significantly reduce their ability to hire low-skilled workers. So America’s healthcare system really has become the elephant in the room. While everyone knows it costs too much, many Americans perhaps have grown inured to hearing the huge numbers and the tut-tutting — without really thinking through all that this wasteful spending deprives us of, both as individuals and as a nation. We try to push forward that thinking in this book.
American healthcare today also exemplifies a scenario in which, to provide universal high-quality outcomes, we don’t necessarily need to find vast new sources of funding, so much as to reallocate resources. But US healthcare also offers very clear examples of entrenched rent-seekers fighting for their lives to fend off any such sensible (and globally tested, proven, popular) policy agenda. So here could you outline your call, in an imperfect world, to allow such shameless rent-seekers themselves to continue benefiting for some time, even as we phase in systemic reform that will recoup these (more or less wasted) expenses over the longer term?
That may be necessary. Our book argues that this happened in Britain after World War Two. Obamacare attempted something similar, by paying off all the problematic actors. But the broader cost-control mechanisms that a public option could have catalyzed were defeated by one man, Senator Joe Lieberman of Connecticut (home to much of the insurance industry). Perhaps we can try again.
COVID already has changed everything. It seems possible that, when the coronavirus pandemic ends, with so many Americans financially crippled and personally enraged by healthcare charges and failures of performance, we’ll see a new opportunity for real change. For that change to happen, people in the middle of the economic and political distribution will have to join this conversation. The change we need won’t happen if we only have left-of-center Americans calling for change. But the medical bills and costs of drugs (and possibly vaccines) imposed on the millions of Americans who fall ill with COVID may make that conversation imperative.
Dysfunctionalities within our healthcare system also point to this book’s more general proposition that epidemics of despair don’t inevitably derive from a free market imposing its brutal whims — but sometimes reflect in fact a lack of free markets (as manifest in today’s concentrated consumer sectors, in labor-market monopsony conditions facilitating corporate exploitation of workers, in localized restrictions to occupational entry and professional licensing). So how else might we combat such despair less through dramatic tax increases, and more through dramatic reductions in corporate stealing, evasion, predation, stifling of market entry and competition?
You put it a little more strongly than we do. Many firms that get identified as predators, or that have taken over large shares of whole industries (like Amazon and Big Tech platform companies), have also brought huge benefits. Sorting out these benefits and costs poses an intellectual challenge that economists and other social scientists haven’t yet fully met. This will likewise require deep thought about antitrust policy and enforcement, topics which have become much more urgent with COVID causing so many businesses to fail, while certain tech firms keep getting larger.
And for improving American workers’ well-being, we also would bring in educational reform, which will require its own heavy lift. For America today, a four-year college degree serves as the great divide — in work, in health, in home life. The labor-market earnings premium, for those with a BA relative to those with a high-school diploma, soared from 40 percent to 80 percent between 1980 and 2000. That kind of “price” signal should have driven a lot more young people to finish college. It didn’t (although college completion has started nosing up now). So what biggest barriers do many American students face? Cost is one. We also believe that K-12 education, which in much of this country prioritizes college-bound students, while ignoring or underserving all other students, needs significant revamping.
Finally, in more overt political terms, given the palpable sense of despair your research has traced, how might you recommend pursuing some of these technocratic reforms while simultaneously making clear to despairing populations that their pain is being felt, that their concerns are being heard? What most concrete initiatives could help, for example, to get a vast majority of working-class Americans believing that our democratic institutions have their own best interests at heart?
We suppose some of our solutions might sound technocratic. But we basically believe that, in the long run, working people need more political power, and more control over their lives. That is for them to make happen, or not. Donald Trump’s election perhaps offers a failed attempt by working people to gain influence over the educated elite — a group they have, with reason, come to despise. Yet we only see more political change ahead.
Portrait of Anne Case and Angus Deaton courtesy of Rebecca Wilcox, Purdue University