Why Americans Are Dying from Despair

The unfairness of our economy, two economists argue, can be measured not only in dollars but in deaths.

By Atul Gawande

March 16, 2020

It all started with a bad back. For more than a decade, the Princeton economist Anne Case had suffered from chronic lower-back pain, and nothing seemed to help. She’d made her name studying the connections between health and economic patterns in people’s lives; her research showed, for instance, a connection between your health in early childhood, or even in utero, and your economic status later in life. So she decided to research the patterns of pain in the population. And as she pulled on this thread she found a bigger, more alarming story than she ever expected.

The question she began with, in 2014, was whether pain had grown more or less prevalent in the United States over the past few decades. Given advances in labor-saving technologies and in pain treatments, she expected that the prevalence reported in population surveys would have fallen. Instead, it had gone up. Some hundred million Americans now suffer from chronic pain—that is, they’ve been in pain on most days for the past three months. And the rates are especially high in middle age: Americans in their fifties, unlike their counterparts in other countries, have higher rates of chronic pain than those in their seventies and eighties.

Case’s husband, Angus Deaton, is also an economist at Princeton. In 2013, he published a sweeping economic history, “The Great Escape,” which traced the way people had become healthier and wealthier in the past couple of centuries, though at a cost to economic equality. During his research, he’d noticed that people’s happiness was largely disconnected from this story. As wealth rose, so did health and quality of life; happiness did not necessarily follow. He was struck, then, when his wife told him that pain rates had not declined, either.

Was there a link? They combed through survey data together and found that communities with higher rates of chronic pain also had higher rates of suicide. What’s more, rates of both had risen markedly for middle-aged, non-Hispanic white Americans—but not for black or Hispanic Americans. And the data grew only more curious and concerning the further they looked. As Case and Deaton recount in their new book, “Deaths of Despair and the Future of Capitalism” (Princeton), they dug deeper into national vital statistics and compared rates of suicide with those of other causes of mortality. “To our astonishment, it was not only suicide that was rising among middle-aged whites; it was all deaths,” they write.

This was nearly unfathomable. Outside of wars or pandemics, death rates for large populations across the world have been consistently falling for decades. Yet working-age white men and women without college degrees were dying from suicide, drug overdoses, and alcohol-related liver disease at such rates that, for three consecutive years, life expectancy for the U.S. population as a whole had fallen. “The only precedent is a century ago, from 1915 through 1918, during the First World War and the influenza epidemic that followed it,” Case and Deaton write. Between 1999 and 2017, more than six hundred thousand extra deaths—deaths in excess of the demographically predicted number—occurred just among people aged forty-five to fifty-four. Case and Deaton first wrote about the rise in deaths from suicide and self-poisoning—what they came to call “deaths of despair”—in a 2015 paper. The editors at JAMA and The New England Journal of Medicine, the two most prominent medical journals, somehow missed the paper’s significance and rejected it without even a formal review; it was eventually published in a more technical journal, the Proceedings of the National Academy of Sciences, in November of that year. A few weeks before it appeared, Deaton was named the winner of the Nobel Prize in Economics, for his earlier work in development economics. But he considered this new paper to be as important as anything he’d done in his life. Sure enough, when the paper came out it was discussed on television, talk radio, and social media, drawing the sort of public response that seldom greets economic research. It had put numbers on a long-simmering but inchoate sense among many people that something had gone profoundly wrong with the American Dream.

But what, exactly? Why was this happening here and not elsewhere? Case and Deaton’s original paper offered no explanation, but their new book does. And their explanation begins by dismantling several others.

Was the source of the problem America’s all-too-ready supply of prescription opioids? For decades, drug companies notoriously played down their addictive properties, and we physicians, to our lasting shame, gave out the drugs like lollipops. Looking back, I am aghast at the glib reassurance I gave patients who hesitated about taking oxycodone after surgery. “Don’t worry,” I’d say. “Addiction is unusual after surgery.” But it wasn’t, and I should have known. Studies revealed that three to eight per cent of surgery patients who took narcotics for the first time after brief hospital stays were still taking the drugs as much as twelve months later. Abuse became widespread in the early years of this century. After regulations tightened the legal supply of opioids, users turned to other sources. About a million Americans now use heroin daily or near-daily. Many others use illicitly obtained synthetic opioids like fentanyl.

Yet white Americans with bachelor’s degrees have accounted for only about nine per cent of overdose deaths in the past quarter century. Such deaths are even rarer among black Americans. As Case and Deaton note, most people who abuse or become addicted to opioids continue to lead functional lives and many eventually escape their dependence. The oversupply of opioids did not create the conditions for despair. Instead, it appears, the oversupply fed upon a white working class already adrift. And, although opioid deaths plateaued, at least temporarily, in 2018, suicides and alcohol-related deaths continue upward.

Could deaths of despair be related to the rising incidence of obesity? Obesity is known to increase chronic illness and joint pain, and its regional and demographic patterns track with deaths of despair. But Case and Deaton report that we’re seeing the same troubling health trends “among the underweight, normal weight, overweight, and obese.”

Is the problem poverty? Death rates for the white working class have seen no decline for nearly three decades, even as poverty rates fell during the nineteen-nineties, rose during the Great Recession, and fell again in the years afterward. Overdose deaths are most common in high-poverty Appalachia and along the low-poverty Eastern Seaboard, in places such as Massachusetts, New Hampshire, Delaware, and Connecticut. Meanwhile, some high-poverty states, such as Arkansas and Mississippi, have been less affected. Black and Hispanic populations are poorer but less affected, too.

How about income inequality? Case and Deaton have found that patterns of inequality, like patterns of poverty, simply don’t match the patterns of mortality by race or region. California and New York, for instance, have among the highest inequality levels in the country and the lowest mortality rates.

A consistently strong economic correlate, by contrast, is the percentage of a local population that is employed. The numbers have undergone a long decline nationally. In the late nineteen-sixties, Case and Deaton note, all but five per cent of men of prime working age, from twenty-five to fifty-four, had jobs; by 2010, twenty per cent did not. In 2018, well into the recovery from the Great Recession, fourteen per cent were still not at work. Of that fourteen per cent, only a fifth reported that they were looking for work and were therefore counted in official statistics as “unemployed.” The rest were not in the labor force. What Case and Deaton have found is that the places with a smaller fraction of the working-age population in jobs are places with higher rates of deaths of despair—and that this holds true even when you look at rates of suicide, drug overdoses, and alcohol-related liver disease separately. They all go up where joblessness does.

Conservatives tend to offer cultural explanations. You see this in J. D. Vance’s “Hillbilly Elegy” and Charles Murray’s “Coming Apart: The State of White America, 1960-2010,” not to mention a raft of state initiatives that would impose work requirements on Medicaid recipients. People are taking the lazy way out of responsibilities, the argument goes, and so they choose alcohol, drugs, and welfare and disability checks over a commitment to hard work, family, and community. And now they are paying the price for their hedonism and decadence—with addiction, emptiness, and suicide.

Yet, if the main problem were that a large group of people were withdrawing from the workforce by choice, wages should have risen in parallel. Employers should have been pulling out the stops to lure people back to work. But they haven’t. Wages have stayed flat for years.

So what does explain the rise of deaths of despair among white Americans without college degrees? Case and Deaton argue that the problem arises from the cumulative effect of a long economic stagnation and the way we as a nation have dealt with it. For the first few decades after the Second World War, per-capita U.S. economic growth averaged between two and three per cent a year. In the nineties, however, it dipped below two per cent. In the early two-thousands, it was less than one per cent. This past decade, it remained below 1.5 per cent.

Different populations have experienced this slowdown very differently. The earnings advantage for those with college degrees soared. Anti-discrimination measures improved earnings and job prospects for black and Hispanic Americans. Though their earnings still lag behind those of the white working class, life for this generation of people of color is better than it was for the last.

Not so for whites without a college education. Among the men, median wages have not only flattened; they have declined since 1979. The work that the less educated can find isn’t as stable: hours are more uncertain, and job duration is shorter. Employment is more likely to take the form of gig work, temporary contracting, or day labor, and is less likely to come with benefits like health insurance.

Among advanced economies, this deterioration in pay and job stability is unique to the United States. In the past four decades, Americans without bachelor’s degrees—the majority of the working-age population—have seen themselves become ever less valued in our economy. Their effort and experience provide smaller rewards than before, and they encounter longer periods between employment. It should come as no surprise that fewer continue to seek employment, and that more succumb to despair.

The problem isn’t that people are not the way they used to be. It’s that the economy and the structure of work are not the way they used to be. This has had devastating effects on the family and on community life. In 1980, rates of marriage by middle age were about eighty per cent for white people with and without bachelor’s degrees alike. As the economic prospects of those two groups have diverged, however, so have their marriage prospects. Today, about seventy-five per cent of college graduates are married by age forty-five, but only sixty per cent of non-college graduates are. Nonmarital childbearing has reached forty per cent among less educated white women. Parents without bachelor’s degrees are also now dramatically less likely to have a stable partner for rearing and financially supporting their children.

Religious institutions previously played a vital role in connecting people to a community. But the number of Americans who attend religious services has declined markedly over the past half century, falling to just one-third of the general population today. (The rate is lower still among non-college graduates.) Union membership has declined even more precipitously. Case and Deaton see a picture of steady economic and social breakdown, amid over-all prosperity. Physicians like me attend to the individual circumstances of illness and mortality. We see the seeds of suicide in pain, depression, or addiction, perhaps germinated by a life event, such as a breakup, a financial crisis, or a new health problem. But climate—the amount of social and economic instability not only in your life but also in your family and community—matters, too. Émile Durkheim pointed out more than a century ago that despair and then suicide result when people’s material and social circumstances fall below their expectations. The connection appears to be just as powerful for other forms of self-harm, such as drug and alcohol abuse.

Yet why has the steep rise in deaths of despair been so uniquely American? Case and Deaton identify a few factors. The United States has provided unusually casual access to means of death. The availability of opioids has indeed played a role, and the same goes for firearms (involved in more than half of suicides); we all but load the weapons of self-destruction for people in misery. The U.S. has also embraced automation and globalization with greater alacrity and fewer restrictions than other countries have. Displaced workers here get relatively little in the way of protection and support. And we’ve enabled capital to take a larger share of the economic gains. “Economists long thought that the ratio of wages to profits was an immutable constant, about two to one,” Case and Deaton point out. But since 1970, they find, it has declined significantly.

A more unexpected culprit identified by Case and Deaton is our complicated and costly health-care system. There is, to be sure, a strong correlation between lack of health coverage and increased risk of suicide (not to mention over-all mortality), but the problem doesn’t end with the plight of the uninsured. The focus of Case and Deaton’s indictment is on the fact that America’s health-care system is peculiarly reliant on employer-provided insurance.

As they show, the premiums that employers pay amount to a perverse tax on hiring lower-skilled workers. According to the Kaiser Family Foundation, in 2019 the average family policy cost twenty-one thousand dollars, of which employers typically paid seventy per cent. “For a well-paid employee earning a salary of $150,000, the average family policy adds less than 10 percent to the cost of employing the worker,” Case and Deaton write. “For a low-wage worker on half the median wage, it is 60 percent.” Even as workers’ wages have stagnated or declined, then, the cost to their employers has risen sharply. One recent study shows that, between 1970 and 2016, the earnings that laborers received fell twenty-one per cent. But their total compensation, taken to include the cost of their benefits (in particular, health care), rose sixty-eight per cent. Increases in health-care costs have devoured take-home pay for those below the median income. At the same time, the system practically begs employers to reduce the number of less skilled workers they hire, by outsourcing or automating their positions. In Case and Deaton’s analysis, this makes American health care itself a prime cause of our rising death rates.

It also means that, in order to revive the American Dream for people without college degrees, we must change the way we pay for health care. Instead of preserving a system that discourages employers from hiring, retaining, and developing workers without bachelor’s degrees, we need to make health-care payments proportional to wages—as with tax-based systems like Medicare. Democrats are split over whether our health care should involve a single payer or multiple insurers. But that’s not the crucial issue. In other advanced economies, people pay for health care through wage-based taxes. In some countries, such as Germany and Switzerland, the money pays for non-government insurance; elsewhere, the money pays for Medicare-like government insurance. Both strategies work. Neither undermines the employment prospects of the working class.

So far, the American approach to the rise in white working-class mortality has been to pour resources into addiction-treatment centers and suicide-prevention programs. Yet the rates of suicide and addiction remain sky-high. It’s as if we’re using pressure dressings on a bullet wound to the chest instead of getting at the source of the bleeding. Meanwhile, people whose life prospects have deteriorated respond, publicly, with anger (sometimes cynically inflamed) toward nonwhites and immigrants, whose prospects, though worse than their white counterparts’, may have improved compared with those of their forebears. But Case and Deaton want us to recognize that the more widespread response is a sense of hopelessness and helplessness. And here culture does play a role.

When it comes to people whose lives aren’t going well, American culture is a harsh judge: if you can’t find enough work, if your wages are too low, if you can’t be counted on to support a family, if you don’t have a promising future, then there must be something wrong with you. When people discover that they can numb negative feelings with alcohol or drugs, only to find that addiction has made them even more powerless, it seems to confirm that they are to blame. We Americans are reluctant to acknowledge that our economy serves the educated classes and penalizes the rest. But that’s exactly the situation, and “Deaths of Despair” shows how the immiseration of the less educated has resulted in the loss of hundreds of thousands of lives, even as the economy has thrived and the stock market has soared. To adapt the old Bill Clinton campaign motto, it’s the unfair economy, stupid.

“We are not against capitalism,” Case and Deaton write. “We believe in the power of competition and of free markets.” But capitalism, having failed America’s less educated workers for decades, must change, as it has in the past. “There have been previous periods when capitalism failed most people, as the Industrial Revolution got under way at the beginning of the nineteenth century, and again after the Great Depression,” they write. “But the beast was tamed, not slain.”

Are we capable of again taming the beast? In earlier eras, reform involved child-labor laws, worker-safety protections, overtime requirements, social security, a minimum wage. Today, the battles are over an employer-based system for financing health care, corporate governance that puts shareholders’ interests ahead of workers’, tax plans that benefit capital holders over wage earners. The dispiriting politics of stasis and scapegoating can prevail for a very long time, even as the damage comes into clearer view. We are better at addressing fast-moving crises than slow-building ones. It wouldn’t be surprising, then, if we simply absorbed current conditions as the new normal. We are good at muddling along.

But unexpected things happen, as the coronavirus pandemic demonstrates. One reality in particular will surely fester. Because economic policy is inseparable from health-care policy, the unfairness of the health system is inseparable from the unfairness of the economy—an unfairness measured not only in dollars but in deaths. The blighted prospects of the less educated are a public-health crisis, and, as the number of victims mounts, it will be harder to ignore. ♦