If past is a prologue, observations regarding impact of economic conditions on mortality in Deaths of Despair and the Future of Capitalism by Anne Case and Angus Deaton has sobering implications for of dilemmas facing policymakers in the midst of COVID-19 pandemic. In balancing public health needs versus those of the economy, saving lives through social distancing and economic shut down has won, regardless of its economic consequences. Case and Deaton, offer an eerie vision of health and mortality consequences of economic decline, which suggests that this simplistic calculation of tradeoffs may also need to incorporate health consequences of bring the wheels of the economy to a grinding halt. Anne Case and Angus Deaton, noted economists and professors emerita and emeritus at Princeton University, challenge one of the canons of demographic faith, the inexorability of mortality decline over time. In the United States, mortality for white population aged 45–54 was 1,500 per 100,000 population in 1900 declining to 400 per 100,000 population by 2000. This pace of decline—about 2 percent per annum—was shared by other industrial societies. However, the twenty-first century brought a rupture in this trend; not only did mid-life white mortality in the United States stop falling, it began to rise. Most of this increase is attributable to what Case and Deaton dub “deaths of despair”—deaths through suicide, drug overdose and liver disease associated with alcohol. This increase was largely concentrated among the non-Hispanic white population while mortality among African American population continued to fall, reducing the gap between black and white mortality. When Case and Deaton first published this finding in 2015, it set off a flurry of responses, particularly from demographers who found this incomprehensible. Could it be an artifact of age distribution? Higher fertility among the African American half a century earlier may have led to lower average age among the black population in 45–54 age group and an older age distribution among the whites. However, age-adjusted data continue to show this divergence, prompting Case and Deaton to explore causes of this turn-around in white midlife mortality. The book argues that the white non university-educated population of the United States is now going through what African Americans experienced earlier in the twentieth century when the arrival of crack cocaine and HIV/AIDS precipitated a black mortality crisis. However, since the 1990s, black mortality has continued to decline while the white mortality stopped falling and the gap between the two narrowed. Case and Deaton stress that, regardless of the closing of this gap, black mortality continues to be higher than that for the whites and that they are talking about the rate of change in mortality and not levels. What led to this surprising reversal of decades of mortality decline for white Americans in midlife? These two distinguished economists, one a Nobel prize winner, conclude that it is the economy that has left the white Americans behind. Not all whites, just those without a university degree. While university-educated individuals have always earned more than those without a degree, the premium doubled in the later part of the twentieth century; what had been a 40 percent pay difference became 80 percent. It is not simply a reward for higher skills, as the literature on skill-biased technological change would suggest, the authors argue. The widening gap has come not just through an increase in the earnings of the university graduates, but also through a reduction in the earnings of those without a four-year university degree. While women without a university degree escaped this penalty in the early part of this trend, female members of the cohorts born after 1965 have, too, experienced real wage decline. If declining wages were not enough, individuals without a university degree also find it progressively more difficult to get and hold a job. Deaths of Despair argues that there is another division in American society, not just between people but between historical epochs. From the end of the Second World War to 1970, the economy grew rapidly and individuals were on a moving escalator, gaining economic rewards as they gained experience. After 1970, one escalator became two escalators. Those with college degree were on the escalator that was moving up, those without a degree were stuck on an escalator that was going nowhere, resulting in a slowly unfolding calamity for the working class. The manufacturing jobs that formed the core of the American working class declined, unions that brought stability to the workers and policed their health and safety lost power and membership. As the manufacturing jobs declined, workers had to move to less desirable, precarious jobs with little potential for individual productivity, attachment to the employer, and long-term stability. In a manner reminiscent of William Julius Wilson's Truly Disadvantaged, Case and Deaton argue that this economic decline is responsible for myriad outcomes that add to the pain and the loss suffered by nonuniversity-educated whites. Without a job to provide for a family, they become less marriageable and one of the pillars of stable life escapes their reach. As sociologists like Andrew Cherlin and Sarah McLanahan have observed, university- and nonuniversity-educated individuals now follow different paths in life. For those with a university degree, there awaits a job with health benefits accompanied by a stable marriage and childbearing along with a house in the suburbs. For those without a university degree, life may come with childbearing outside marriage or high likelihood of divorce or failure to attract a spouse in the first place. The psychological pain of being part of a precarious economy brought physical pain with it. Using data collected by the Gallup polling organization that asks individuals whether they experienced pain during a lot the day “yesterday,” Case and Deaton find that members of the nonuniversity white population report more pain than university-educated individuals. Moreover, while we generally expect pain to increase with age, members of the nonuniversity-educated white population aged 40–50 report more pain than individuals above age 60. As many as 35 percent of the 40- to 50-year-old whites without college education report experiencing pain in the preceding day, setting a stage for the opioid epidemic. Prescription pain killers turn into an addiction, addiction turns into overdose and leads to deaths of despair. In 2017, 158,000 Americans died from deaths of despair. All three kinds of death—suicide, drugs, alcohol—involve actions of those who die. Following Emile Durkheim's seminal work Suicide, Case and Deaton argue that, to understand these self-inflicted deaths, we must look beyond the individual to the society. An economy that has left behind middle-aged whites and led to alienation from work, family, and society created a situation in which life has little meaning. Individuals seek oblivion either immediately, via suicide, or on the installment plan, via substance abuse. The most interesting part of the book emerges in the final section where Case and Deaton provide an analysis of the processes that brought about this perfect storm. Their analysis of the trends that brought the nonuniversity-educated white population to this impasse rests on two pillars. First, they argue that it is not the secular trends in the economy that have left less-educated individuals behind, but rather deliberate choices made by the society. Second, they suggest that economic decline, coupled with social and historical processes that robbed the less-educated white population of their historical advantages have created a pain that can only be annihilated by suicide or numbed through addiction. The post-1970s economy has been turbulent. Notably, the Great Recession worsened poverty, inequality, and income stagnation. However, Case and Deaton do not attribute deaths of despair to economic events and trends. They meticulously work through each explanation and show that they do not account for the rising midlife white mortality they document. They note that trends in national poverty rates do not match the striking increase in deaths of despair. From the early 1980s through the start of the Great Recession, midlife white poverty rates were roughly constant at 7 percent, 9 percent for those with less than a bachelor's degree while the deaths of despair among whites increased year by year. They also note that while West Virginia and Kentucky are centers of drug overdose and have high rates of poverty, the match between poverty rates and death is imperfect. Drug overdoses are also prevalent in less economically deprived states such as Maryland, New Jersey, Connecticut, and Rhode Island. In contrast, states with high poverty such as Arkansas and Mississippi are much less affected by drug overdose. Similarly, inequality is not directly correlated with rising rates of suicide or overdose. For 20–30 years, when inequality was rising, mortality continued to decline. It is only since the 1990s that we have begun to see the increase in mortality. It is the nature of inequality, rather than its existence, that is responsible for the deaths of despair. When the inequality grew, it did not simply come about because of the skyrocketing income of those at the top of the income distribution; those in the knowledge, information, and technology economies. It also came about because the real incomes of nonuniversity-educated whites fell. Rising health care costs and declining power of the unions led to reduction in social protection for people at the bottom, while processes that kept income growth at the top, for example, antitrust enforcement, control of monopsony, and progressive taxation, weakened. One might argue that the Great Recession may have led to increasing overdose and suicides. History provides us with a precedent. The Great Depression of 1929 was directly responsible for a sharp increase in suicides; the peak in suicides that has never been attained in the United States since then. However, the deaths of despair documented by Case and Deaton began rising in 1990, long before the onset of the Great Recession. So, what happened? Case and Deaton hold the nature of the American capitalism responsible for devasting the lives of individuals without a college degree. They argue that the loss of good jobs and falling real wages over the last half century have made life difficult, not just by lowering living standards but also by undermining the lives of working-class people. For many individuals, the social institutions that historically provided support and sustenance—marriage, family, church, community—no longer do so. Their identity and status have been challenged, meaning of life has been lost. Case and Deaton suggest that we are now living a society that is characterized by redistribution from the poor to the rich, from those without university degrees to those with university degrees. Thus, the rich are not simply getting richer, they are getting richer at the expense of the poor. Immigration, mechanization, and outsourcing in a global economy add to the bewilderment of the working class. They see no way in which they can come out ahead. Their only solace lies in drugs, alcohol, and suicide. Deaths of Despair comes of an age in an era where intellectuals are struggling to make sense of a society that elected Donald Trump. Through a lens of addiction and suicide, it complements Arlie Hochschild's Strangers in Their Own Land: Anger and Mourning on the American Right and Andrew Cherlin's Labor's Love Lost: The Rise and Fall of Working Class Family in America in chronicling the tsunami that brought a billionaire president to power with support from the white population at the bottom of the economic totem pole. The challenge all of these books face, though, lies in distinguishing race from class. The economic forces that Case and Deaton document affect both white and black Americans without a university degree. Why is it that, while black mortality continued to fall, at least until 2013, white mortality increased? This is where the book relies on the trope of relative privilege. It argues that the crisis experienced by less-educated white population since 1990 afflicted the black population 20 years ago, resulting in high levels of mortality due to drug abuse and HIV/AIDS infection. However, recent years have seen reduction in racial animus toward blacks as characterized by election of a black president, increase in college education among African Americans, and emergence of black middle class. Nonmaterial improvement in their lives has shielded them from the psychological impact of economic forces that devastated white Americans, who also suffered the added injury of reduction of white privileges. This part of the argument is arguably less convincing compared to the solid empirical evidence presented in other chapters and is likely to be a matter of considerable debate.
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Mar 31, 2024
Marianna Kudlyak + 1