Abstract
In Deaths of Despair and the Future of Capitalism, Anne Case and Angus Deaton present a bleak picture of American life. From 1999 to 2017, they tell us, six hundred thousand people between the ages of forty-five and fifty-four died from alcoholic liver disease, drug overdose, and suicide, which contributed to the decline in life expectancy from 2014 to 2017. While these phenomena are unique to the United States, they suggest what may come to pass elsewhere if capitalism is left unchecked. Case and Deaton’s earnest analysis evokes the comment by the late public health advocate Irving Selikoff that “statistics are people with the tears wiped away.” Their recommendations for reducing this pain—the Future of Capitalism part of the title—are both moderate and radical considering the reforms that will be necessary to change such a profoundly unfair system.
The thesis of this monograph is that white working-class Americans have experienced the “destruction of a way of life” (254). A catastrophe like the 2008 financial crisis did not inflict the damage; rather, “[r]ising despair is a cumulative process that has taken many years to develop” (224). Much has been written about the white working class since the 2016 elections, including Joan C. Williams’s White Working Class (2017), Robert Wuthnow’s The Left Behind (2018), and Jonathan Metzel’s Dying of Whiteness (2019). Deaths of Despair contributes to this field by focusing on capitalism’s erosion of the structures of working-class life. Thus, in contrast to political scientist Charles Murray who decries the loss of virtue, Case and Deaton write “primarily about the external forces that have eaten away the foundations that characterized working-class life as it was half a century ago” (7). One of Case and Deaton’s methods for assessing how far working-class whites have fallen is contrasting them with African Americans who presently rank below whites without bachelor’s degrees on several measures. African Americans were “last hired, first fired” in the 1960s–1970s, and drugs and the carceral state devastated their communities in the 1980s, but recent data show that “black lives are improving on many dimensions while the lives of less educated whites are worsening” (183). Although working-class whites are the primary subject of this study, this troubling contrast reminds readers that the legacies of racial oppression are endemic to American life.
Deaths of Despair consists of sixteen chapters divided into four sections. As the quote above suggests, Case and Deaton find that education is a variable in many measures of despair. College-educated people tend to be healthier than those with a high school diploma or less; among other things, the former smoke less and have lower rates of hypertension, obesity, and suicide than the latter. Case and Deaton use charts developed from Centers for Disease Control and Prevention data to illustrate the rise of mortality for the less educated. A comparison of birth cohorts from 1935 to 1985 indicates that mortality for white non-Hispanics by alcohol, drugs, and suicide has steadily increased for those without bachelor’s degrees, while rates for those with bachelor’s degrees or more have changed little. The less educated experience more mental and physical pain, too: “for those without a bachelor’s degree, pain increases with age, but those born later have more pain throughout their lives” (90).
Case and Deaton draw on Emile Durkheim’s Suicide (1897) to emphasize the social and economic roots of the despair. Alcohol, drug overdose, and suicide are diseases that afflict people who are without hope and “doing this to themselves” (38). There is no shortage of literature describing the social consequences of the economic dislocation that leads to these conditions. To take one example, in his memoir about the decline of the steel industry in Homestead, Pennsylvania, in the 1980s, author Mike Stout recalls the death of a way of life: “Not a week went by that someone didn’t die prematurely of a heart attack, stroke, cancer, or suicide—usually two or three people” (Stout 2020: 253). Case and Deaton also find that binge drinking and suicide are more common among people with less than a bachelor’s degree, once again raising the issue of education as a point of division in American society.
Deaths of Despair puts opioids under a microscope. Case and Deaton condemn pharmaceutical companies, doctors, and lawmakers for the scourge of “legalized heroin” (128). Indeed, from 2000 to 2017, more Americans died from opioid overdoses than perished in World Wars I and II combined. Although used in American medicine during the Civil War, opioids were criminalized in 1914. The convergence of new theories of pain management and new drugs in the 1990s, particularly Oxycontin, had devastating results. Doctors had little understanding of opioids’ potency and pharmaceutical companies pushed them as much as legally possible, sometimes bribing doctors to prescribe them when they were unnecessary. Members of Congress, including those from areas affected by opioids, blocked legislation to regulate them. Meanwhile, working-class whites suffering physical and mental pain, unemployment, and isolation offered a lucrative market.
In a truly despicable move, pharmaceutical companies (including Purdue, the manufacturer of Oxycontin) are now promoting medication-assisted treatment for people addicted to opioids; and more recently, a study found that many for-profit residential treatment programs charge high rates, practice aggressive recruiting, and have dubious accreditations (Beetham et al., 2021). The unequal power relationship between pharmaceutical companies and ordinary people illustrates one of Case and Deaton’s key arguments: “the use of market power to bring about upward distribution, from a large number of people with little, to a smaller number with a great deal, is symptomatic of the industry and, more arguably, of American capitalism more generally” (127). Here it’s instructive to compare Case and Deaton with another pair of critics, Paul Baran and Paul Sweezy. While Case and Deaton express concern over the market power of the health-care and airline industries, they are less concerned with monopoly and concentration than they are with employers’ power in labor markets. Baran and Sweezy describe monopoly capital as an “irrational system” that “has utterly failed to provide the foundations of a society capable of promoting the healthy and happy development of its members” (1966: 285). For them, such conditions are not aberrations but intrinsic to capitalist exploitation. However, Case and Deaton neither anticipate nor demand capitalism’s demise; it can be reformed for the commonweal—“we believe that capitalism is an immensely powerful force for progress and for good, but it needs to serve people and not have people serve it” (262).
The most persuasive chapters in Deaths of Despair are explanatory instead of diagnostic. In chapter 13, “How American Healthcare Is Undermining Lives,” Case and Deaton document the failures that cause “indirect harm to people’s lives and work” (191, original emphasis). Clearly, the American health-care system is flawed and inefficient; the strength of this chapter is how it highlights its relationship with the labor market that now favors the college educated. Most Americans obtain health insurance through their employers, who are increasingly shifting health-care costs to workers, reducing their workforces, and then outsourcing to firms that pay less and provide fewer benefits. As sociologist Ruth Milkman has written, employers often hire immigrant workers to perform these degraded jobs, thereby fomenting nativism among working-class whites (2019). Case and Deaton call attention to other aspects of this vicious cycle in chapters 11 and 14, “Growing Apart at Work” and “Capitalism, Immigrants, Robots, and China,” respectively. To be sure, college-educated workers are not immune to the consequences of a disastrous health-care system, but they have generally fared better than the less educated.
The final chapter (“What to Do?”) will inspire debate. Instead of articulating a comprehensive vision of a good society, Case and Deaton recommend reducing the despair and confronting its causes and symptoms. For example, they call for limiting the use of opioids, implementing universal health insurance, and reining in health-care costs, the latter two of which would disincentivize employers from lowering wages and outsourcing jobs. Notably, Case and Deaton are skeptical of universal basic income, an idea that has gained some currency on the Left and Right, because of its cost and potential for displacing established benefits. Likewise, they do not consider other instances of radical political economy, such as full employment or the socialization of production.
The other reforms that Case and Deaton discuss—modernizing antitrust law, changing corporate governance, increasing the minimum wage, and stopping rent-seeking—have the potential to mitigate the worst effects of the despair, but they do not directly confront the power imbalance between capital and labor. In fact, it is surprising that Case and Deaton have little optimism unions will play much of a role in the future. On the one hand, their recommendations are good for markets but, on the other hand, they are politically impossible without the power organized workers can bring to bear on policy making. Indeed, the absence of unions from reform efforts suggests the adage “if you’re not at the table you’re on the menu.” Working-class institutions are essential for working-class people to wrestle concessions from capital and the state.
Scholars who want to reach lay readers should look to Deaths of Despair for inspiration. It is an excellent synthesis of original research and secondary texts that is accessible to nonspecialists. It also complements several recently published works. In We’re Still Here, Jennifer M. Silva uses ethnographic investigation in Pennsylvania’s anthracite region to ask how working-class residents negotiate the struggles of everyday life. Its index abounds with entries for “alcohol abuse and alcoholism,” “drug abuse and addiction,” “pain and pain management,” “suffering,” and “suicide” (Silva 2019). In Worked Over, Jamie K. McCallum examines the consequences of the increase in working hours and their intensification. In particular, he notes that American workers spend more time working than Japanese workers who are eligible for a compensable form of death from overwork known as karoshi (McCallum 2020: 10). Finally, as this review neared completion, the National Academy of Sciences, Engineering, and Medicine issued a report, High and Rising Mortality Rates among Working-Age Adults, which analyzed the decline in life expectancy in the United States, much of it informed by Case and Deaton’s work (National Academies of Sciences, Engineering, and Medicine 2021).
Deaths of Despair will interest scholars across disciplines, including economics, sociology, and public health and public policy. It is a good counterpart to literature that dwell on the cultural grievances and disaffection of working-class whites. Perhaps the most striking point is that its preface is dated October 2019. Just a few months later COVID-19 laid bare the unfairness that Case and Deaton write about so eloquently. Despair exists in the absence of hope, but emerging social movements are organizing around positive visions of the future.
