Deaths of Despair and the Future of Capitalism

Book Title: Deaths of Despair and the Future of Capitalism

Authors: Anne Case and Angus Deaton

Publication Information: Princeton, NJ, Princeton University Press, 2020, 312 pp., $27.95 (hardcover), $10.99 (audiobook)

“Capitalism does not have to work as it does.” (p. ix)

Is capitalism in the United States an engine of general prosperity, or a racket for upward redistribution? In Deaths of Despair, Princeton economists Anne Case and Angus Deaton explore the relationships between economic inequality, health status, and increasing rates of death and suicide among middle-aged White Americans.

The authors (a husband and wife team) relate that the book “was born in a cabin in Montana in the summer of 2014” (p. 1). Their discovery that suicide rates in their rural summer retreat were four times greater than in their home on the East Coast prompted further research into increasing rates of pain and ill health among middle-aged White Americans, and increasing mortality from what they labeled “deaths of despair”—deaths from suicide, drug overdose, and alcoholism. They justify this combined outcome by arguing that all three types of death have in common an underlying degree of intentional or unintentional self-harm, which in most situations can be attributed to a lack of hope.

The book combines meticulous analysis of data with comprehensive historical and social analysis. Its four sections explore historical antecedents of today’s economic conditions (Part I: Past as Prologue”), analysis of social data (“Part II: The Anatomy of the Battlefield”), economic realities (“Part III: What’s the Economy Got to Do With It?”), and the nature of 21st century capitalism in the United States (“Part IV: Why Is Capitalism Failing So Many?”).

Throughout the book, Case and Deaton return time and again to the argument that recent history in the United States has been particularly harsh to Whites without a bachelor’s degree. This argument may sound insensitive after 2020 has thrust the realities of racism to greater prominence in our national conversation. However, Case and Deaton point out that while mortality disparities persist between Blacks and Whites, mortality rates for middle-aged Blacks have continued to improve yet mortality rate improvements for middle-aged Whites have stalled. Indeed, they argue that while racial disparities are diminishing for many outcomes, “class divisions are widening, at least if we think of class in terms of education” (p. 185).

Among the causes they identify for increasing deaths of despair among middle-aged Whites without a bachelor’s degree are the decline of social and religious institutions, increasing disparity between rural and urban economies, the weakening of unions, and increased outsourcing of work. Most significantly, especially for those of us in medicine, they attribute much of the blame for deaths of despair to the structure of health care in the United States—a “cancer at the heart of the economy” that steals “from the poor on behalf of the rich” (pp. 10-11). Case and Deaton argue that the structure of employer-paid health insurance drives down wages and curtails job growth, that the power of professional medical associations means that medical legislation more often favors the interests of lobbyists over those of the population, and that the protection of corporate and business interests means that rent-seeking (p. 11) is built into the very essence of health care in the United States. They also argue that the recent opioid epidemic has been a particularly insidious manifestation of the combined effects of these influences.

The breadth and depth of the economic analysis in this book is impressive—the authors clearly know their stuff! By contrast, some of the medical analysis (including discussions of addiction, pain management, and the structure of medical practice) would seem to have benefited from attention to the same level of exploration. At times the book offers critique and recommendations that seem to fall short in their understandings of the nuances of clinical practice. At the same time, this is the first book on health care economics I have encountered that includes advice on calling the family doctor—“If you (are) suffering from addiction to drugs or alcohol, talking to a trusted family doctor or spiritual advisor is a good first step” (p. x).

Case and Deaton clearly care about bringing in-depth analysis to bear on addressing the epidemic of deaths of despair, and their recommendations are aimed at solutions they hope might address some of the injustices currently robbing from Whites without a bachelor’s degree and benefiting those at the top. It can seem deceptively easy to focus on problems within individual silos of society; Case and Deaton offer an analysis that cuts across disciplines both in making a diagnosis, and proposing steps towards a cure.