Abstract
While they were researching their book, Deaths of Despair and the Future of Capitalism, a physician tells authors Anne Case and Angus Deaton that “biographies matter.” This physician, Ken Thompson, is referring to the need to understand the social and economic conditions in which people who use drugs live to fully understand and ultimately address their drug misuse. My biography is that of an epidemiologist—a noneconomist—writing a review of a book written by economists for an audience of economists. I am also charged with reviewing a book that already has a Wikipedia page, was listed by the New York Times as one of its notable books of 2020, and was shortlisted for Book of the Year by the Financial Times. It would be foolhardy of me to critique its economic assumptions, even if I were so inclined.
What I can offer, however, are insights about how this book is useful for preventing suicide, or more aptly preventing premature mortality, a field I have contributed to for over a decade. Most recent research on suicide can be characterized as identifying individual attributes that increase risk, often portrayed as determinative. These individual-level characteristics, however, are more accurately population-level “risk factors.” The findings from this research inevitably lead to identifying interventions largely delivered in health care settings directly to individuals, many of whom are already feeling suicidal. Most fatal attempts at suicide, however, are first attempts. And while some of those who die have a history of mental health treatment, many have never sought such help. Thus, although such an approach is useful, it has been inadequate for mitigating the increasing trend of suicide and overdose mortality in the United States. Rather than focusing on how to stop suicidal people from taking their lives, Case and Deaton offer evidence about the social forces that drive people’s thoughts of suicide in the first place. This emphasis has been, by and large, missing from our field: We focus on individual portraits, not the landscape.
In contrast to this individual-centered approach, Deaths of Despair begins with the authors’ observation of a plateauing in life expectancy in the United States that began in 1998 among non-Hispanic middle-aged White men and women. This slowing of the steady, post–World War II increase in life expectancy was unique in the United States. By the second decade of the 21st century, U.S. life expectancy began to fall. These changes coincided with increasing rates in “deaths of despair”—overdose fatalities, suicides, and alcohol-related diseases—most notably among middle-aged White men, particularly those without a bachelor’s degree. The authors also observe changes in other metrics, including morbidity, marriage, and community participation, signifying to them increased evidence of heightened despair. These trends represent to the authors a “destruction of a way of life (p. 183),” and more specifically the “decline of family, community, and religion” (p. 183). For those without high school degrees, good-quality jobs have become scarcer and wages have decreased, all the while steadily increasing for those with a college degree. These conditions are brought about, according to the authors, from capitalism gone awry: enormous wastes in health care spending that keep wages low and that do not produce improved health outcomes; lost representation of workers’ interests in Washington; increased concentration of market power among a limited number of large corporations; and lack of enforcement of antitrust laws that collectively result in “persistent upward redistribution through manipulation of markets” (p.188). They acknowledge that such forces are acting globally, but that the United States has uniquely decided not to invest (and even disinvest) in an adequate social safety net. As a result, the “costs” of being jobless (or in low quality jobs) in the United States are graver than in comparable nations.
Deaths of Despair adds to the burgeoning field of “social epidemiology,” a field that examines how social-structural factors affect health and that uses interdisciplinary methods and theories from epidemiology, economics, sociology, and demography. Anne Case and Agnus Deaton deserve credit for their interdisciplinary approach. [This quote resonated with me: “economists seek to explain why people choose to commit suicide, while sociologists explain why they have no such choice” (p. 98).] What is unique and noteworthy about Deaths of Despair is that Case and Deaton identify some of the most common explanatory variables examined in the field (e.g., poverty, income inequality, income) and offer explanations as to why these are themselves inadequate for fully understanding the rise in suicide, overdose, and alcohol-related mortality. They argue, . . . deaths of despair and income inequality are indeed closely linked, but not, as is often argued, with a simple causal arrow running from inequality to death. Instead, it is the deeper forces of power, politics, and social change that are causing both the epidemic and the extreme inequality. (p. 134)
This framing results in recommendations common in social epidemiology to improve the social safety net. But Case and Deaton go further by identifying reasonably specific economic, legal, and political forces that are driving people to despair. They offer policy recommendations aimed at more than mitigating the consequences of these forces. Their goal is to reduce the influence these forces have in the first place.
Readers looking to pull apart econometric models that associate these social and economic forces with increases in deaths will not have the opportunity. Although each author previously has demonstrated mastery of such methods, they anticipate the critique and preclude it, arguing, Such techniques have their uses, but they are of little use to us here in describing a slowly evolving and large-scale disintegration that involves a historically contingent set of forces, many of which interact. (p. 190)
This approach reflects a refreshing departure from the research community’s increasing valuation of causal inference from innovative econometric models to one that uses tools and methods common in economic history—a forgotten, abandoned, or at least deprioritized discipline. Case and Deaton’s emphasis lies on tying legislated social policies and unregulated corporate practices, determined by what I might call the “controlling classes,” to their economic consequences and their ultimate fatal effects—an approach rarely seen in social epidemiology.
Nonetheless, one may still find opportunity to question the authors’ approach and conclusions. For example, in a very striking analysis, the authors show how the combined alcohol, drug, and suicide mortality rate among White non-Hispanics without a college degree has increased dramatically by birth cohort from 1935 to 1985. But during this time, the college completion rate also increased for White men nearly fivefold, from 5% in 1940 to nearly 25% in 1991 (Snyder, 2001). The people who comprise the group not attending college have likely changed over time. Perhaps it increasingly represents a population more susceptible to alcohol and drug misuse and suicide for reasons that similarly influence their educational outcomes. Or, these individuals may be more susceptible for reasons other than education to the adversarial social and economic forces directed toward them. These alternative perspectives are not considered.
There are other strengths of the book, but also areas where the authors fell short. The 20-page chapter on the failure of American health care is a pointed and a scathing rebuke of the health care industry, an urgent condemnation that targets likely candidates, such as health insurers and pharmaceutical companies, while also offering compelling examples of hospital systems colluding to suppress nurses’ wages, the American Medical Association’s lobbying to limit medical school class sizes to ensure higher wages for physicians, and other mechanisms by which the industry redistributes wealth upward. Yet, while on the one hand chastising the American health system, the authors, on the other hand, call upon it to help solve the opioid epidemic, urging it to “explore better options” for chronic pain. This may be an opportunity for American health care to prove its worth. Or more pessimistically, after reading Deaths of Despair one might question whether the industry should even be trusted to solve a problem that it helped create.
Although the authors are highly critical of the U.S. health care system, they give the similarly flawed U.S. education system a pass. They write, We think that many of those who do not have a bachelor’s degree today could have obtained one, or could obtain one now, and that they, and the rest of us to a lesser extent, would be better off as a result. That is especially true of those who have talent and cannot go to college, either for financial reasons or, even worse, because they do not realize that people like them can go on to tertiary education. (p. 257)
But students’ motivation to attend college and their likelihood of success are linked to the quality of the preparatory K-12 education they receive. The authors highlight regional variability in job quality and wages, and how these are correlated geographically with the concentration of deaths of despair. But they fail to connect these social and economic disparities to the lack of K-12 educational opportunities available to the children in these same communities. The repercussions of such educational disparities feed directly into the book’s foundational premise. Without changes to create a more equitable K-12 education system, we can be assured that the disparities between those with and without a college degree will only become further exaggerated.
The authors also do the field a service by following the direction of epidemiologists who combine suicide and overdose fatalities together, questioning the “accidental” designation given to overdoses with insufficient overt evidence of a person’s intention to die. With some notable exceptions, researchers tend to operate in silos that separate suicide from addiction: Suicide prevention trials may exclude patients with substance use disorders, whereas experiments for addiction treatments may exclude persons with thoughts of suicide. However, Case and Deaton’s inclusion of liver disease caused by heavy alcohol use in the triad of deaths of despair is more concerning. As opposed to death from overdose or suicide, which result from an immediate behavior, liver cirrhosis results from cumulative drinking behaviors from the past and the present. One must question whether heavy alcohol consumption not only increases the risk of liver disease but also contributes to an individual’s educational attainment, work prospects, wages, family discord, and community disengagement—thus making alcohol as suitable a culprit as the social and economic forces that form the basis of the authors’ arguments.
The phrase “biographies matter” has proven to be prescient beyond the material covered: It is impossible to read Deaths of Despair, which the authors completed in October 2019, and not consider its implications in the context of the COVID-19 pandemic. The virus itself has disproportionately impacted certain populations, and there is little doubt that factors like crowded housing, limited transportation options, the ability to telework, and other socio-structural factors played a contributing role in creating these differences. There are also disparities in the pandemic’s effects on labor: Most notably, the April-May “rebound” in employment was not experienced by those without a high school degree and even got worse (Dey et al., 2020). While we will not fully understand the pandemic’s effects on deaths of despair for some time, Case and Deaton offer a lens for forecasting those people likely to be most impacted and, critically, the policies that will be required to alter an already discouraging trend.