Magazine May 4, 2020, Issue

What’s Behind the Rise in Deaths of Despair?

From the cover of Deaths of Despair and the Future of Capitalism (Princeton University Press)
Deaths of Despair and the Future of Capitalism, by Anne Case and Angus Deaton (Princeton University Press, 312 pp., $27.95)

In 2015, economists Anne Case and Angus Deaton garnered a lot of media coverage for an academic paper documenting a rise in “deaths of despair” — from alcohol, suicide, and drugs — among American whites, especially middle-aged whites without a college degree. Now they have fleshed out their thoughts on the issue in a book. Their argument is that in order to combat this plague, the U.S. needs to boost wages, bring back unions, fight crony capitalism, and deeply reform the health-care system.

If that strikes you as a preexisting wish list that’s been tacked on to a problem that happened to present itself but is only tangentially related, you’re not alone. Case and Deaton’s arguments linking deaths of despair to their proposed remedies are far from airtight, and as a result the book is underwhelming.

Let’s start by taking a look at the scope of the problem. In their definition, “deaths of despair” comprise three different categories. Drug deaths are overdoses that, according to the medical examiners and coroners who fill out death certificates, were either accidental in nature or of an “undetermined” intent. Alcohol deaths have several causes, including cirrhosis and other liver diseases. And suicides consist of all intentionally self-inflicted deaths, including intentional drug overdoses.

Case and Deaton note that drug overdoses make up by far the biggest share of deaths of despair, but, bizarrely, they don’t provide a clear breakdown of how all three categories have changed over time. Fortunately, Senator Mike Lee’s Social Capital Project released a report late last year with the relevant data, most pertinently this chart tracking deaths of despair among Case and Deaton’s main demographic focus, middle-aged whites:

(Source: Social Capital Project analyses of CDC data. Prior to 1998, the trend includes Hispanic whites.)

Here we see some very important things. First of all, while all three causes of death have been rising since the turn of the century, two of them, suicide and alcohol, are not too far above the levels they hit as recently as the 1970s, while the third — drugs — is continuing a very long-running and long-accelerating increase. Even when we limit our focus to the current century, maybe two-thirds of the death increase is from overdoses. The story here is overwhelmingly about drugs, and this would be even more the case if we counted addiction-related suicides as drug deaths rather than as generic suicides.

In a sense, then, Case and Deaton haven’t really discovered much that’s new. They’ve mainly drawn more attention to the already well-documented opioid epidemic, and in the process pointed out that suicide and alcohol deaths are trending upward too, which is undeniably an important problem but plays only a supporting role in the spectacular explosion of deaths of despair.

The book-length treatment of this observation could be saved, of course, by a compelling argument about what to do about it, rooted in an accurate diagnosis of why these deaths are rising. But the arguments here are mostly lacking.

Case and Deaton do get the origin story mostly right on drugs, even if they are too dismissive of the benefits that opioids provide for pain patients who don’t respond to anything else. In 1996, Purdue Pharma released OxyContin, an opioid chemically similar to heroin that released its dose over the course of many hours. Some patients became addicted to the drug they were prescribed, and thanks to lax prescribing practices and corrupt doctors who ran “pill mills,” the drug flooded onto the black market too. Some addicts crushed the pills up and snorted them, defeating the time-release mechanism.

We should absolutely hold those guilty of this atrocity responsible and try to prevent a repeat. But that doesn’t amount to any kind of fix for the epidemic today, as Case and Deaton note. The abuse of prescription painkillers began to subside years ago, as Purdue reformulated Oxy to make it harder to crush and doctors started prescribing opioids less — but addicts turned instead to heroin and fentanyl. The problem to be solved now involves illegal drugs more than legal ones.

So what to do? The most obvious way to combat drug, alcohol, and suicide deaths would be a full-court press, backed by massive federal funding, against drug abuse, alcoholism, and depression. But Case and Deaton have only muted comments to make about such approaches. The medication-assisted treatments for opioid abuse that many find promising — the medications work by satisfying an addict’s cravings without getting him high — are “likely being oversold” because many addicts either don’t seek help or they relapse. Stepping up law-enforcement efforts against heroin and fentanyl traffickers? Not really on their radar. Alcoholics Anonymous? “The scientific evidence is more positive than not.” Suicide prevention? Case and Deaton direct any struggling readers to call a hotline but have rather little to say about whether expanding mental-health treatment could reduce suicide rates.

Instead, they spend the bulk of their time making a “root causes” type of argument that pins deaths of despair on the economic misfortunes of the white working class. Oddly enough, this argument begins with a chapter called “False Trails: Poverty, Income, and the Great Recession,” laying out the reasons that economic explanations don’t really fit the data. There was no increase in poverty that began at the turn of the century, making the timing all wrong for poverty to be the explanation, and at the state level there is little correlation between whites’ poverty rates and their overdose rates. The Great Recession greatly affected incomes and employment but did little to bend the upward trajectory of deaths in either direction. One might add that the longer-term patterns in deaths of despair pictured above bear little obvious relationship to economic trends either.

Then they offer a theory that’s vague enough to be hard to test in a rigorous way. (As they put it, “readers will have to decide whether our account is persuasive without the benefit of controlled trials or anything of the sort.”) The idea is that the white working class gradually lost its status and way of life starting in maybe 1970 or so, and this problem didn’t become bad enough to noticeably affect mortality until the turn of the century — when people who’d been in their twenties at the start of the process reached middle age and their lives were not as good as they’d expected, having grown up in the idyllic (for white people) ’50s and ’60s.

This narrative is essentially economic, though part of it is social and spiritual too. In all these ways, higher- and lesser-educated Americans are “coming apart,” to use Charles Murray’s term.

Economically, as overall growth has fallen off from the highs the U.S. enjoyed decades ago, more and more of capitalism’s rewards are being directed to the best-off, owing to globalization, the end of union bargaining power, and the scourge of wage-suppressing cronyism. Wages for non-college workers have stagnated completely, indeed declined somewhat, thanks in part to the fact that our dysfunctional health-care system diverts so much compensation to insurance premiums before workers even see it. Labor-force participation has been falling among working-age males for decades.

On the social side, the decline of marriage, the rise of chaotic family structures, and the weakening of organized religion and other sources of social capital have been especially dramatic among those with less education. (Papers from the Social Capital Project and the sociologist Phil Cohen, which aren’t cited in the book, have confirmed that deaths of despair are concentrated specifically among unmarried whites.) Case and Deaton also report widening gaps in self-reported well-being between whites with and those without college degrees. Oddly, lower-educated whites are also reporting higher pain levels than previous generations did, despite the fact that jobs have become less physically demanding.

This overarching narrative is solid to a large extent, but lots of the particulars are highly debatable. For one thing, many of the data analyses here involve trends stretching back 50 years or more, and the authors are fond of analyzing those with B.A.s separately from those without. However, the no-B.A. category represents an increasingly disadvantaged group over time, because more people have acquired B.A.s in more-recent years. (Hardly anyone had a B.A. in 1950, but now about a third of Americans age 25–54 do.) Another big problem is that Case and Deaton rely on an inflation-adjustment method that’s well known to overstate inflation, meaning that wages have grown far more strongly than their numbers suggest. They also arguably shortchange the roles of the safety net and women’s economic progress in making work less necessary for men and marriage less necessary for women who want to have kids, and the growing role of the safety net in supplementing the incomes of people who make low wages.

Yet it’s in connecting these half-century trends — especially the economic ones — to deaths of despair that Case and Deaton are on their weakest footing. “If we are to stop deaths of despair, we must somehow stop or reverse the decline of wages for less educated Americans,”  they declare, noting that both minimum-wage hikes and wage subsidies could achieve this. They want to bring back unions and fix the health-care system so that it costs far less too, though they don’t give many specifics as to what that would entail. Broadly speaking, they think American capitalism has stopped working correctly and needs to be fixed.

Of course, this makes sense as a remedy for deaths of despair only if Case and Deaton are correct that a bunch of economic trends dating to 1970 or so caused a mortality problem that started around 2000, a proposition for which they admit to having no concrete proof. And even if they are completely correct, one wonders whether the problem will wear itself out long before their solutions can have an effect. After all, if the issue is high, unsatisfied expectations formed in an earlier time, then future generations who grew up in later decades presumably won’t be so shocked by what they find in middle age. As it happens, overdose deaths dropped in 2018 for the first time in nearly three decades, and fixing capitalism could take a long time.

Some of Case and Deaton’s proposed changes, including health-care reform and higher wages for the working class, are good goals in their own right, of course. But the path from these efforts to meaningful declines in the death rate is blurry, especially when so much of the problem comes from opioid addictions that higher wages will not treat. Given how much uncertainty there is about whether Case and Deaton have identified the right underlying causes, and if so how quickly their solutions could work, attacking the problems of substance abuse and suicide directly seems like a much more promising approach.

Editor’s note: This piece has been emended since its original publication.

This article appears as “What Drives Deaths of Despair?” in the May 4, 2020, print edition of National Review.

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