Review: Benjamin M. Friedman on Deaths of Despair

“Albany, Kentucky, 2016,” by photographer Stacy Kranitz. A small community fights legal sales of alcohol in a dry county overwhelmed by the opioid epidemic. Kranitz’s book of photographs of Appalachia, As it Was Give(n) to Me, will be published by Twin Palms next year

Well before the covid-19 pandemic ravaged the American population and undermined our economy, alarming statistics were showing gaping holes in our public health system. Black Americans, especially including pregnant Black women, persistently registered as underserved. But the system’s failures were not limited to them. Each year more than 150,000 Americans were killing themselves, either intentionally by suicide, or by drug overdoses where it’s hard to know what was intended, or by alcohol-triggered liver disease. The appearance of the synthetic opioid fentanyl has brought some increase in fatal drug overdoses among Black Americans, but these self-inflicted “deaths of despair”—nearly four times the annual number of traffic fatalities—were mostly occurring among young and middle-aged non-Hispanic Whites. What most of them had in common is that they lacked a college education

Anne Case and Angus Deaton, two Princeton economists, were among the first to identify this alarming trend and they have led the way in seeking to understand its implications. In their excellent and important book, aptly titled Deaths of Despair and the Future of Capitalism, they have made their analysis and their painstaking research available to a general audience.

Roughly half of these untimely deaths have been from drugs, with the other half about evenly split between suicide and alcohol. The rise in self-inflicted mortality among less-educated non-Hispanic Whites has been substantial enough to cause the first drop in overall US life expectancy in a century. Moreover, the problem is uniquely American. It has not occurred elsewhere, even in countries whose pre-covid economic experience closely tracked ours.

Case and Deaton suggest three causes. The most familiar is that wages have shrunk and job opportunities have narrowed for workers without a college education. Americans increasingly compete with foreign workers, both those in factories abroad and those who come here to fill jobs that cannot be shifted offshore. Rapidly advancing technology is replacing many workers and lowering skill requirements—and therefor wages—for many who still have jobs. Millions have accepted lower pay and less fulfilling work or simply stopped working altogether.

Second, Case and Deaton point to what they see as a social failure. Eroding labor markets, they argue, are not sufficient to explain why so many people are killing themselves. Other countries have lost industrial and agricultural jobs to mechanization and globalization yet have not seen this spike in premature death. Historically, only during the Great Depression of the 1930s has labor-market shrinkage correlated in this way with premature mortality. Case and Deaton argue that today family life is also crumbling for these Americans, with marriage rates down and out-of-wedlock births up among working-class Whites. Other traditional social institutions, like churches and unions, are failing them too. They have lost not just their jobs but their way of life.

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And third, the blanket of bigotry in which so many once wrapped themselves has frayed. Case and Deaton do not dwell on this element of the story, but they quote Martin Luther King’s remark that low-income Whites have lost the feeling of superiority they once derived from the color of their skin. A half-century after the Civil Rights movement of the 1960s, the increasing heterogeneity of American society and the rising material success of African Americans and other non-White groups have challenged the economic and social advantage these less-educated Americans could once attach to their racial, or religious, or nativist identification. Widespread calls to further racial equality continue to challenge the sense of security these long-held attitudes may once have afforded.

Case and Deaton identify America’s health care system as the most egregious failure behind citizens’ decline and despair. The combination of private insurance and government regulation has insulated doctors, hospitals, and pharmaceutical manufacturers from meaningful competition on price, allowing the cost of health care to escalate while absorbing an ever-greater share of our economy’s resources: health care in America now costs $10,739 each year per person (as of 2017). Without the drag from such rapidly rising health care costs, wages paid to American workers could have risen instead of fallen over the past few decades, and American firms could have kept more of them employed. Further, losing a job can terminate a family’s coverage, in many cases driving them into poverty from medical expenses. Much of that enormous cost, Case and Deaton argue, is waste. Most toxically, for years some pharmaceutical companies aggressively marketed deadly opioids to precisely this group of Americans, generating billions in profits for the companies and their owners and along the way addicting millions of patients, many of whom died. Other countries, with different health care systems and different drug regulation, were spared.

Stopping the opioid crisis may well turn out to be the easy part. Restructuring American health care would offer great gains, but political and economic impediments continue to stall its advancement. Enhanced education, from pre-kindergarten to better structured high school curricula to adult job training (and retraining), is probably the most effective single policy direction, although for many of the citizens whom Case and Deaton have in mind such reforms come too late. Visions for fundamental change in the economy— job sharing, universal income, taxing robots, reforms to corporate governance—may hold promise for improving these Americans’ prospects, but they face formidable obstacles and are too far off to address the immediate health crisis. Meanwhile expanding access to affordable day care, and affordable housing, would contribute to making existence on a limited income manageable. Such gains would benefit both the Americans about whom Case and Deaton write and other workers, including many of the non-Whites whose plight has been the focus this year’s popular agitation.

But any real solution for these struggling Americans will have to extend beyond government. Under any set of policies, the coming decade or two will not be a good time to be a working-age American with limited education. The challenge is to provide these citizens a life worth living, one consistent with American consciences if not aspirations. Beyond government programs, a supportive environment for our country’s full panoply of social institutions—churches, unions, social clubs, athletic leagues, regional arts groups—will be needed for a society that does not drive many thousands of its citizens to self-destruction.

Deaths of Despair and the Future of Capitalism will be out in paperback this winter. Preorder here.


Benjamin M. Friedman is the William Joseph Maier Professor of Political Economy at Harvard University. His most recent book is The Moral Consequences of Economic Growth. His new book, Religion and the Rise of Capitalism, will be published in January and is available for preorder.


Book notes
President Barack Obama’s long-awaited memoirs received a surprise announcement this morning (hinted at on Monday in the New York Post): the first of two volumes, A Promised Land, itself weighing in at a hefty 768 pages, will arrive in bookstores on November 17, two weeks after the election. (According to a spokesperson, the former President did not want to pull attention away from the campaign by publishing earlier.) The book enters a packed publishing season (see our Book Notes of September 4) already threatened with printing shortages and scheduling delays, but independent booksellers were nevertheless jubilant at the prospect of another Obama offering for the holidays in the midst of all the strains of 2020. Anticipating the crunch, the publisher has ordered one million of its three-million print run to be printed in Germany, whence they will come, like some sort of caravan, on “three ships, outfitted with 112 shipping containers.” Michelle Obama’s half of their record-breaking two-person contract, Becoming, carried the 2018 publishing season, as well as producing a grammy-winning audiobook and a tour that become the subject of an Emmy-nominated documentary. Said Vulture, “Best-selling author Michelle Obama’s husband is releasing a new book of his own. Good for him!” (To be fair, all three of their self-narrated audiobooks have won Grammies.)

The publisher promises that the book will be “extraordinarily intimate and introspective,” “frank about the forces that opposed him at home and abroad,” “open about how living in the White House affected his wife and daughters,” and “unafraid to reveal self-doubt and disappointment.” If the former president’s record as an author is any indication, they do not have much to worry about.  Obama’s first book, Dreams From My Father, written when he was still an unknown law professor, was bought out from Simon and Schuster for a $40,000 advance after the author missed too many deadlines and went on to sell more than 3.3 million copies. Chicago bookseller Brad Jonas told a Hyde Park Historical Society panel on independent bookselling last fall how he had bought 4,000 copies of the remaindered edition of Dreams From My Father (22 cents each) after being impressed that then-State-Senator Obama, whom he had met at a daughter’s fourth-grade assembly, later remembered his name encountering him at a Chicago chamber of commerce meeting. Jonas made a big display of his stash of remaindered Dreams From My Fathers in the front of his store, Chicago offshoot of Portland’s venerable Powell’s, but didn’t sell that many copies; he sheepishly offered some to Obama’s campaign when copies became scarce. Years later, after Obama became famous for his keynote address at the 2004 Democratic convention and was being spoken of as a presidential contender, Jonas went to Obama’s local shop, 57th Street Books to get a copy of his new book The Audacity of Hope signed. Obama stood up, “shook my hand, turned to the Random House guys, and said, ‘This is the guy who bought the remainders of my book.’” (The Audacity of Hope went on to sell more than 4.2 million copies itself.) Jack Cella, owner of 57th Street Books when Obama became President, told the panel that his staff was honorable in never answering questions from the press about what books the Obamas bought. That Obama was a “member” of the cooperative Chicago bookstore was a source of puzzlement to snoopers.

The date for the second volume has not yet been set. Please do your local indie a favor and order your copy of A Promised Land well in advance. (For Obama completists: he revealed his annual summer playlist a couple of weeks ago.)

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