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Stronger safety nets and health care reform could help mitigate “deaths of despair”

Deaths of Despair and the Future of Capitalism

Anne Case and Angus Deaton
Princeton University Press
324 pp.
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Life expectancy in the United States declined for 3 years in a row between 2014 and 2017. This is surprising in a world where we have grown accustomed to rising life expectancy. Anne Case and Angus Deaton’s new book, Deaths of Despair, deals with three questions: Who is dying, why are they dying, and what can we do about it?

Case and Deaton have been rightly celebrated for identifying the large rise in U.S. deaths due to suicide, drugs, and alcohol, particularly among white males aged 45 to 54 who have not completed a 4-year degree. Here, they argue that a key social divide exists in America between those who have a bachelor’s degree and those who do not and that deaths of despair also occur in white women. Furthermore, they suggest that the problem is more widespread; the stalled decline in heart disease mortality in the United States, against a backdrop of improvements in other countries, may be due, in part, to drugs and alcohol. Such deaths, they argue, are hidden “deaths of despair,” and deaths are just the most visible manifestation of a broader crisis of widespread pain, addiction, and misery among the less educated.

Deaths of despair are not an exclusively American phenomenon. Similar deaths occurred in Russia after the fall of communism, and there is evidence that the recent decline in life expectancy in the United Kingdom is attributable to a rise in deaths of despair. Such deaths are the result of a breakdown in social systems that give people a sense of respect and meaning. America, however, may be particularly vulnerable to this phenomenon, because of its emphasis on individualism and its tendency to equate economic success with social value.

When it comes to the factors driving despair, the book rejects a simple economic argument about poverty, jobs, immigration, globalization, automation, and the Great Recession. Case and Deaton note a decline not just in incomes for the less educated in the United States but also in a sense of purpose and a way of life that once included social bonds forged through trade unions, church, and marriage.

American adherence to the idea of meritocracy is, they believe, particularly undermining for the less educated. Despite overwhelming evidence of low intergenerational mobility in education and income levels in the United States, there is a strong cultural belief that poverty reflects personal shortcomings rather than a rigged economic system. Such beliefs may be preposterous, but they have proven difficult to overcome.

Case and Deaton also offer a scathing indictment of the U.S. health care industry, calling it a cancer at the heart of the economy. They describe the rise of the prescription opioid OxyContin, arguing that pharmaceutical companies put profits above people, leading to widespread addiction.

The authors place the blame squarely on corporations that use political lobbying to create market power and exploit the poor. Case and Deaton’s solution for the failures of capitalism, however, is more capitalism, in the form of more-perfect markets. While they are undoubtedly right that it would be possible to reform the U.S. health care industry so that it provides both better and more accessible care at substantially lower costs, the pervasive and perverse role of money and lobbying in this industry makes it hard to see why they are optimistic about such a solution.

Case and Deaton see benefits in globalization and automation, although they recognize the need for policies to ensure that these benefits are equally distributed. They are in favor of a somewhat stronger safety net and modestly higher minimum wages. However, they oppose greater wealth redistribution through taxes as well as more radical ideas such as a universal basic income. Their proposed solutions may be insufficient if the underlying causes are indeed structural.

A criticism that has been leveled against Case and Deaton’s work is that their focus on the rise in white midlife mortality downplays the much higher rates of mortality among black Americans. I have sympathy for the position that the scientific analysis of one issue does not imply a disparaging of the importance of other issues, and the book does cover the black-white mortality differential. However, a race-based analysis opens questions not just of science but of justice.

Indeed, the policies that the authors advocate not only would address deaths of despair, they would improve the health and welfare of the American people more generally. A clearer articulation of this point would have helped to assuage the view that the authors are focused only on policies that will improve the health of the white population.

About the author

The reviewer is at the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA 02115, USA.