Why the White Working-class Mortality and Morbidity Is Increasing in the United States: The Importance of the Political Context

Current Studies on the Topic

These and other related questions have triggered a lively discussion, enriched by valuable studies. One that has generated a very interesting debate is the well-known report “Mortality and Morbidity in the 21st Century,” written by Anne Case and Angus Deaton, 2 professors from Princeton University, and published in the spring 2017 edition of the Brookings Papers on Economic Activity. (It should be noted that this study built on a previous study they conducted in 2015 ¹ ). This study (which specifically focuses on people 45–54 years old) and the majority of other similar studies have followed the positivist and empiricist methodology, which is characteristic of most social analyses in the United States. This methodology employs a statistical approach to try to explain the dependent variables: the evolution of mortality and morbidity among the working class in the United States. This is done by looking at how it correlates with the independent variables, some of which are acquired at birth (such as age, race, and gender) and others by social conditions (such as places people live or levels of education or income). The number of independent variables is impressive: the study “Mortality and Morbidity in the 21st Century” has collected an extensive dossier of information that, no doubt, will generate many more studies.

I applaud the authors for the task they have achieved. It has contributed to present information that can help to open up a range of possibilities in the search to understand what is happening with the health of a critical component of our population: whites in the working class, a social class much forgotten in the United States. The widely held assumption that the United States is a “middle-class society” explains why little attention is being paid to the working class in the United States. It is assumed that the working class has disappeared or has become the middle class. Many current events have shown that neither of these 2 assumptions reflects the reality of U.S. society.

Limitations of the Current Studies, Including “Mortality and Morbidity in the 21st Century”

The applause to the authors of this study needs to be accompanied, however, with a critique of its deficiencies. Many authors have already shown several methodological flaws in the study. ² Another limitation of this study is the choice of the independent variables used to explain the increase of mortality and morbidity in the white working class of the United States. The authors use, for example, the level of employment as an indicator of the quality of the labor market, assuming that a high level of unemployment speaks poorly of that labor market. Since unemployment in the United States has been low (the lowest among the OECD countries), it is assumed that the conditions in the labor market are good and cannot explain the increase of mortality. But this assumption ignores that the decline in unemployment may be achieved at the cost of the increasing level of precariousness and therefore stress in the workplace, as many articles in the International Journal of Health Services have shown.^3,4 Plenty of evidence (not cited in the study “Mortality and Morbidity in the 21st Century”) suggests that the U.S. labor market has been deteriorating since the late 1970s and beginning of the 1980s, a deterioration that could not be measured by just looking at levels of unemployment.

But the most important limitation of these types of studies is not so much the type of variables chosen but the conceptual model in which the variables relate to each other. Nowhere in this study, or any other study that has analyzed mortality and morbidity in the working class, has the concept of social class and how it has evolved in relation to other classes been described or analyzed. Social class in the United States appears almost as an un-American variable: it rarely appears. Most of the social research in the United States focuses on race and gender inequalities and rarely on class inequalities, although class inequalities are larger than race and gender inequalities. Moreover, race mortality inequalities have little to do with race itself, but rather with racism, which puts black citizens at the bottom of the class structure. ⁵

The Forgotten Issue of Class in the United States

In other words, the part missing in all of these studies is the conceptualization of the study, starting with the analysis of the class structure of the United States, how it has evolved, and how it has affected the health, quality of life, and well-being of the population. Indeed, the increase of mortality and morbidity described in Case’s and Deaton’s studies is not as new as it appears. As several authors have shown, this rise of mortality caused by the “diseases of despair”—suicide and drug addiction, among others—among white age groups of the working class occurs within a trend of increased mortality in all age groups, races, and genders of the U.S. population (that explains a decline of life expectancy) since the early 1980s. This trend is the most important event that should have been the center of attention. ⁶ However, the majority of these studies have not sufficiently analyzed the key question of why this situation has been occurring. An essential element of these studies should be the analysis of how the class structure of and class relations in the United States have evolved and why.

Class Structure in the United States

Today, the U.S. class structure is characterized by the existence of (1) at the top, the upper class or the corporate class, which includes the owners and managers of large corporations, who have enormous financial, economic, and political influence in the United States; (2) a large middle class, defined by access to higher and middle education that, due to the wide access to educational institutions in the United States, is one of the largest middle classes in the western world; (3) and a working class, which has evolved significantly, changing its composition from industrial (the majority men and white) to services (the majority women, with the black population being a large growing minority). This working class is the majority of the adult population. ⁷

What Has Occurred to This Class Structure: Why Is the White Working Class the One That Has Seen More Changes in Its Health Situation?

The most important factor for answering this question is the change in the class power relations. The period post-WWII (1945–1980), known as the golden age of capitalism, was interrupted by a series of public policy interventions (initiated by the Thatcher government in the United Kingdom in 1978 and by President Reagan in the United States in 1980) that aimed to reduce the power of the working class. The policies implemented included (1) a concerted attack on labor’s negotiating power, (2) cutbacks in the social safety net, (3) the creation of a business-friendly environment, and (4) deregulation of labor and capital markets, among others. These policies negatively affected the living and working conditions of the popular class (particularly the working class) and, for the most part, were continued by Presidents Bush Sr., Clinton, and Obama and magnified by Trump.

As a consequence, the unionization rates within the private sector have declined from 15% in 1983 to less than 7% in 2017; wages have remained stagnant over this period, forcing households to borrow extensively, doubling their debt relative to their income, which has increased profitability for the financial sector. The top 10% of households who own 90% of all financial assets have benefited enormously, while inequalities have increased dramatically. The share of income going to the bottom 90% in aggregate has declined from 20% to 12% since 1980, while the aggregate share of income going to the top 1% has increased from 12% to 20%.^8,9

The Decline of the Quality of Life of the Working Class

The result of these policies was a decline of the quality of life and well-being of the working class as well as a significant decline in the standard of living of a large sector of the middle class, in a process known as the “proletarianization.” This decline had a more significant effect on those who were higher up within the working class: industrial workers. I emphasize that I am speaking about the rate of decline rather than the absolute level of well-being (in terms of life and working conditions). Black people generally have worse life and working conditions than white people, but the rate of decline has been higher among the white working class. Their fall has been from higher levels of prosperity and well-being.

As I have just mentioned, the fall was largest among the most privileged groups of the working class. An example is the decline of the industrial working class, affected primarily by the diminishing power of the trade unions and the exportation of industrial jobs to other countries as part of the process of globalization. The high wage—$20 to $32 per hour—sector of the labor market constituted 41% of the 2008–2010 losses, compared with 22% from the low wage sector ($9 to $13 per hour). The labor movement has been losing power considerably since the 1980s, when neoliberal policies were initiated by President Reagan and followed by his successors. The working class’s loss of power was a consequence of the growing power of the corporate class. This reality appears very clearly when we analyze the distribution of income during this post-1980 period. While income derived from property (as a percentage of all income) has increased significantly, from around 30% in the 1970s to around 40% in 2012, income derived from labor (as a percentage of all income) has declined since 1978, from 70% in the 1970s to 63.6% in 2012. This evolution of income distribution is the major cause of current income polarization in the United States. In fact, this income redistribution is a symbol of the class polarization of the United States and is the primary cause of the decline in the quality of life, social well-being, and health of the white working class. ¹⁰ And this decline of the working class was more substantial for the well-paid white sector (the majority of the working class) than for the black working class: the latter group was already at the bottom economically. Members of the white working class were the ones whose income fell more rapidly and more dramatically.

Why Did This Not Happen in Western Europe?

The decline of labor has also occurred in most Western European countries but to a lesser extent. And the primary reason for this is that, even today, the institutions of labor in Western Europe—such as trade unions and labor-friendly political parties—have more power than they do in the United States. For any student of class-power relations, the weakness of labor in the United States is quite remarkable (today, only 2% of the labor force in the private sector is unionized). Consequently, labor, social, and political rights are much less developed in the United States than in Western Europe. These types of variables, however, are rarely studied in the social analysis of mortality and morbidity in the United States. And this is where the roots of the problem reside.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.