Throughout the 20th century, mortality rates have declined worldwide. The improvements in life expectancy are so impressive that Princeton economist and Nobel Laureate Angus Deaton dedicated a whole book, The Great Escape, to how it happened. But the richest country in world history has seen a reversal of fortune. In the past few years, life expectancy in the United States has declined. It’s against this concerning background that the coronavirus pandemic hit.

In a groundbreaking 2017 paper, Deaton and fellow Princeton economics professor Anne Case explored the trends behind the life expectancy decline. They found that middle-aged white Americans are dying in increasing rates from suicide, drug overdose, and alcohol-related liver disease, and labeled these “deaths of despair.” In their new book Deaths of Despair and the Future of Capitalism, Case and Deaton explore the root causes — and find that the trend reflects structural problems in the American economy. Decades of stagnant wages, decimated unions, outsourced labor, and the decreasing social and economic value of a high school diploma contribute to a sense of isolation and generate pain.

Case and Deaton talked to The Inquirer about deaths of despair, and the potential impact on America’s despair crisis from the coronavirus and the social distancing measures it requires. Responses were edited lightly for clarity and length.

The cover of Death of Despair and the future of Capitalism by Anne Case and Angus Deaton
Princeton University Press
The cover of Death of Despair and the future of Capitalism by Anne Case and Angus Deaton

What drives deaths of despair? Is it simply just economic downturns?

Case: Current economic conditions can’t explain this. It might not just be the loss of a paycheck or that you can’t get as good a job as the one you lost, but that without a good job, you can’t get married or have a stable home life, your community is falling apart, your sense of connection with other people is gone.

The return on having gone to college has skyrocketed, while simultaneously the wages of people who did not go to college started to decline.

[Looking at the opioid crisis] we think that the scourge of oxycodone just being handed out in jelly jars — it would have been a serious problem, but the fact that they were falling into a community that was looking for a way to numb itself made the drug epidemic much, much worse.

You write that despair is tied to the kind of job someone has, and the sense of belonging the comes with it, not just the earnings.

Deaton: I grew up in Scotland, we were not very well off. For ordinary people, people who are not very well-educated, getting a job with a large company was just a wonderful thing. Even if it was really menial, like sweeping the floors or working in the mailroom, or guarding the door — you belong to this thing that mattered. And you might have a lifetime career there.

What happens to belonging and despair in a time, like now, that requires social distancing and poses a new health threat?

Deaton: A lot of people are going to be socially isolated. Things that were important for them, like sports games, which feed a sense of solidarity, are going to go away. So it would not be an unreasonable prediction that suicide rates and drinking and drug overdose would go up during this pandemic. The big question, of course, is how long people will put up with that.

Case: Deaths of despair were rising before the Great Recession, during it, and after it was over. There is a structural problem that won’t go away anytime soon. Even had there been no COVID-19 epidemic, we would have anticipated that about 150,000 Americans would die from suicide, drug overdose, and alcoholism in 2020. The problem will be there after this epidemic sweeps through. How much the epidemic adds to that total is unclear.

The mortality rate from suicide, drug overdose, and alcoholic liver disease mortality in Kentucky by educational attainment, for white non-Hispanics age 45-54 who have a bachelor's degree compared to those who don't. From Death of Despair and the Future of Capitalism by Anne Case and Angus Deaton.
Princeton University Press
The mortality rate from suicide, drug overdose, and alcoholic liver disease mortality in Kentucky by educational attainment, for white non-Hispanics age 45-54 who have a bachelor's degree compared to those who don't. From Death of Despair and the Future of Capitalism by Anne Case and Angus Deaton.

Deaton: Let’s say the best case comes, President Trump’s hopes are validated, and when it gets warm, the virus goes away. We’re pretty sure that won’t happen, but let’s say it did. Then we have a short sharp recession and a big bounce back, with a lot of deaths from COVID. Deaths of despair will go on. For COVID, the best case is it’s a one-time event, like the great flu pandemic [of 1918 that was] gone by 1920. So that would be the best case. The worst case is [that COVID-19 is] gone eventually but leaves behind devastation to the economy. And that will add to the distress of the people we’re writing about, so the deaths of despair will go on.

What is the path out of despair?

Case: If we don’t the handle the structural problems caused, for example, by trying to finance the healthcare system through one’s employer, we don’t anticipate that these deaths of despair are just magically going to disappear.

Deaton: Funding healthcare through employers is a disaster for less educated people ... Workers with low education and low salaries have, one way or another, to pay almost as much as CEOs for their healthcare. That’s eliminating jobs and starting off the social catastrophes we’ve dealt with.

What can be done on the local level?

Deaton: Our education system is sort of a scandal because from kindergarten you’re trained to go to college. If you don’t go to college there’s not a lot left for you, except to be branded as a failure and facing a worse labor market. We’ve got to do a lot of local experimentation with finding ways for people who can’t or don’t want to go to college to [have status and prospects]. Something more like the German system, where we valorize things other than going to a four year college.