Deaths from Despair and the Future of Capitalism by Anne Case and Angus Deaton

Deaths from Despair and the Future of Capitalism, published in March, is yet another in the growing list of books examining increasing social and economic divisions in the United States. The co-authors Anne Case and Angus Deaton – a married couple who are both Economics professors in Princeton University – focus their work on America’s growing mortality crisis: what is happening, why it is happening and how the problem could potentially be fixed.

Case and Deaton coined the phrase “deaths from despair” in 2015 to describe the growing number of fatalities from alcoholism, drug overdoses (including those caused by opioid addiction) or suicide being recorded in the US. Even in a country as populous as America, the death toll is remarkable. In 2017, there were 157,000 of these deaths nationwide.

Case and Deaton focus in particular on American whites, a group which has historically been privileged compared to other groups, but who are far from immune to the growing despair afflicting less affluent parts of the country. So great has been the carnage that overall death rates among middle-aged people have been increasing, a trend which runs contrary to what occurred in the twentiety century, an era in which medical advances helped to save huge numbers of younger people from cancer, heart disease and other ailments.

Shockingly, as a result of this increase in deaths from alcohol and drug addiction and suicide, life expectancy at birth fell year-on-year for the America population as a whole between 2014 and 2017. A decline like this has not taken place for one hundred years. The fact that death records include details on the educational attainments of the deceased allows Case and Deaton to come to another unsurprising yet stark conclusion: deaths from despair are far, far more common among those Americans who have not graduated from college.

In every respect, this cohort of the population is suffering.

The widening gap between those with and without a bachelor’s degree is not only in death but also in quality of life; those without a degree are seeing increases in their levels of pain, ill health, and serious mental distress, and declines in their ability to work and to socialize.

“The gap is also widening in earnings, in family stability, and in community,” Case and Deaton write. “A four-year degree has become the key marker of social status, as if there were a requirement for nongraduates to wear a circular scarlet badge bearing the letters BA crossed through by a diagonal red line.

Case and Deaton draw the attention of readers to the dark side of modern America, which is somewhat meritocratic, but which has grown more stratified and divided as well. The gap between highly-educated people, particularly those working in high-tech and knowledge-based industries, and those with a high school education or less has widened greatly. This gap is not just educational or professional – its effects are felt in all areas of life.

There are many explanations for why this has come about.

Globalisation and technological developments have dramatically reduced the demand for America’s low-skilled workers. A case in point: of the sixteen million new jobs created in the US between January 2010 and January 2019, fewer than three million were for workers without a four-year degree. Even for those fortunate enough to have work, the outlook is bleak. Labour-intensive services required by large companies are increasingly being outsourced, either to companies based overseas or to small outside firms whose employees enjoy few of the benefits offered to employees of successful multinationals.

In this environment, wages have stagnated for those without the skills to compete for high-paying jobs in the growth sectors of the economy. Millions of other able-bodied men and women have checked out of the labour force completely and no longer look for work. A core contention within this book is that America’s much-criticised healthcare system has played a central role in creating these problems.

America’s unique healthcare system – where health insurance coverage is provided by employers – is uniquely flawed when it comes to providing security to workers in an increasingly precarious economy where long-term employment at the same firm is increasingly uncommon. Pharmaceutical companies and the broader healthcare industry invest vast sums in buying political influence, and Case and Deaton believe that this has contributed to the epidemic of opioid addiction most noticeable in economically-distressed areas, due to the over-prescribing of painkillers. Excessive medication has not made the patient better: instead, ill health is plaguing Americans. Right now, 100 million Americans suffer from chronic pain, and 98 million Americans were prescribed with opioids in 2015.

As with everything else, social inequality is clearly reflected in the basic health indicators. Economic and physical breakdown has also gone hand-in-hand with a social breakdown. As the authors make clear, marriage rates for the less educated have fallen compared to their college graduate peers, and this trend has far-reaching implications for broader society. Case and Deaton also lament the growing secularisation of America’s lower classes.

Once more, this is not a process which is unique to people who tend not to have a college education or a highly-paid job. But abundant quantities of data from the social sciences show that secularisation, out-of-wedlock births and the disintegration of family units are far more common at the base of America’s socio-economic structure than at its apex. Faced with poor economic outlooks and bereft of the familial ties and religious commitments which once gave meaning to life, despair has set in to a frightening degree. A bottle of alcohol or an extra prescription of opioids is a dangerous temptation in such an environment, and so is a loaded gun.

If the book sounds familiar, you may have read something similar in recent years.

• In 2015, the well-known sociologist Robert Putnam wrote Our Kids: a book which focused on the massive opportunity gap between American children born into different circumstances.

• JD Vance’s beautiful Hillbilly Elegy became a best-seller the following year, and in 2019, Tim Carney’s Alienated America examined how social capital has collapsed in many parts of America, while being retained in others.

The most important book on this subject, however, was published long before this, way back in 2012. Charles Murray’s Coming Apart described the bifurcation of American society: economically, geographically and culturally. Just like Case and Deaton, Murray focused his analysis on white working-class Americans, but he came to very different conclusions to those reached by Case and Deaton.

The fact that much of the ground has been covered before by Murray and other authors does not take away from the merits of this thought-provoking work, which poses a number of questions, one of which is – could a similar epidemic of deaths from despair occur in Europe?

Statistics as grim as those recorded in America have not yet been replicated on this side of the Atlantic, although Case and Deaton (a Scotsman) do point to rising numbers of similar deaths and slow rises in household earnings in the UK as possibly representing storm clouds on the horizon.

Their suggestion that Europe’s stronger safety nets and healthcare systems have prevented similar outcomes from coming to pass sounds slightly premature.

After all, many of the same processes have been playing out across Europe for many years.

• Declining industrial and manufacturing bases? Check.

• Increasing disillusionment with the political class and rising support for radical alternatives? Check.

• Decreasing faith in traditional institutions such as churches? Check.

• Growing social dysfunction and family breakdown, particularly among poorer people? Check.

The special circumstances of the United States – and the nature of the health system – may have accelerated the process of societal breakdown in the US, which could turn out to be a trend-setter rather than an outlier.

There are two other core strengths of this book.

Unlike the libertarian Charles Murray, Case and Deaton believe that legislative reforms can help to fix the serious problems they all see. Their policy recommendations – universal healthcare and reforms to limit the power of the pharmaceutical industry, wage increases and a possible move towards adopting more apprenticeship-based third-level education – can be accepted or disputed, but at the very least they demonstrate an open-mindedness when it comes to finding policy solutions.

Secondly, and as importantly, unlike many commentators in academia or elite policy circles, the co-authors recognise that what is underway in the United States is not merely an economic problem, in the same way that man is not merely an economic creature. “Declining wages are part of the story, but we believe that it is impossible to explain despair through declining material advantage,” they write.

We believe that much more important for despair is the decline of family, community, and religion. These declines may not have happened without the decline in wages and in the quality of jobs that made traditional working-class life possible. But it was the destruction of a way of life that we see as central.

That way of life had religion and the nuclear family at its heart, and its destruction has paved the way for the despair which has afflicted tens of millions of Americans. Secularisation and atomisation did not come about by accident, and the passing of the old order was heralded by many as representing liberation.It still is heralded, in spite of the mounting evidence of the price which has been paid by the most vulnerable in society.

If European leaders and influencers – be they in the political, educational or media spheres – do not stop to consider what is being done in the name of progress, then the present misery of America could be our future too.