At his presidential inauguration three years ago, Donald Trump looked out at America and saw not the “shining city on a hill” once conjured by Ronald Reagan but “carnage”. A great nation, the new president argued, had been brought low by joblessness, crime and a pervasive malaise.
Trump’s dark rhetoric, on what is traditionally a hopeful occasion, was shocking for many. But perhaps not to members of America’s white working class — or to the Princeton economists Anne Case and Angus Deaton.
In 2015, the wife-and-husband team had uncovered a kind of Rosetta Stone for our age that had somehow gone overlooked by other observers: from the early 1990s onwards, a century of steadily increasing life expectancy had suddenly begun to reverse for middle-aged white Americans. Not only was their risk of dying in mid-life higher than that faced by their parents, but they were living sicker and more afflicted lives.
It was a development that was unique among wealthy nations. Case and Deaton attributed it to a trio of killers stalking those without university degrees: suicide, drug overdoses from a flood of opioids and diseases arising from alcoholism. Or, as Case would later dub these: “deaths of despair”.
The findings caused a stir, quantifying the morbid decline of communities that tended to be described as “left behind” — if they were described at all. For those puzzled by Trump’s rise, the economists’ research moved beyond the familiar charges of racism or ignorance to explain why so many white working-class voters might embrace the promise of renewal offered by a reality-TV star.
“He got on a wavelength that really spoke to a lot of people who are suffering,” Case tells me as we sip coffee in the home she and Deaton share near Princeton. “The Democratic candidates in 2016 kind of went out there and said, ‘Look, things are getting better and we’re going to be doing more of the same.’ And that did not play well in communities where things were not getting better, and the last thing they wanted to think was there was going to be more of the same.”
Case and Deaton live at the end of a cul-de-sac in a wooded area a few miles from campus — a universe away from the misery they chronicle. A lone orchid greets visitors in the foyer. The couple bought the house from an Orthodox Jewish family a few years ago and opted to leave the mezuzahs affixed to its many doorways. “I guess you could say I believe in taking blessings when they are offered,” she says.
For someone who spends her days studying despair, Case, 61, laughs easily and is determined to keep some optimistic flame alive — even as her day job repeatedly douses it. “After the gilded age came the progressive era, and we made real changes and we got things back on the rails. Maybe there’ll be another progressive era. Maybe?” she says, when asked about some cause for optimism. “That’s about as hopeful as I can be.”
She brightens when talking about teaching. “I love the classroom. I love the students. I teach masters students, who want to go out and do good. And they’re very smart and talented.”
When discussing her work, Case speaks not in the revved-up tones of this partisan era but deliberately, and almost reluctantly, like a doctor sharing sobering news. And the news is sobering. With Trump’s re-election campaign in full swing — and the plight of the white working class a topic of obsessive national discussion — Case and Deaton have returned with a new book, Deaths of Despair and the Future of Capitalism.
It is an attempt to make sense of the economic and social forces that lie behind the rising mortality rates they first uncovered and offer some possibilities to address them.
One might hesitate to open an academic book called Deaths of Despair. It turns out to be both gloomy and gripping. The authors do not merely rehearse decades of mortality and wage statistics. Rather, they seek to catalogue how an entire way of life first frayed and then fell apart over the past half-century, and the cruelty of an American meritocracy that heaps lavish rewards on the winners while increasingly leaving others to rot.
Globalisation, automation and financial shocks are all part of the tale. There is also a large dose of opioids — essentially, legalised heroin — added to the mix. Yet the authors see the real problem as America’s failure to deal with these forces. “Other rich countries, in Europe and elsewhere, face globalisation and technical change but have not seen long-term stagnation of wages nor an epidemic of deaths of despair,” they write. “There is something going on in America that is different, and that is uniquely toxic to the working class.”
The daughter of a civil engineer and a teacher, Case grew up in Binghamton, an upstate New York town near where IBM began life in the early 20th century. The company sold its campus there in 2002, so she understands the feel of a once-proud town that has seen jobs disappear and educated residents leave.
On first contact with economics, as an undergraduate student at the State University of New York at Albany, she found the subject tedious. “This is just blackboard work. I want to go help people,” she remembers thinking. So she studied for a masters degree in public affairs at Princeton, and gradually came to see what a useful tool economics could be.
It was while earning her doctorate that she first met Deaton, a Cambridge University-educated Scot who had been widowed when he was 29 and who had two children. “I was a PhD student, and he was a faculty member, and we got along well,” she recalls. “But it was only many years later — I graduated with my PhD from Princeton, went off to be an assistant professor at Harvard . . . came back to Princeton and taught for several years — [that] we got together.” They married in 1997.
Early on, she and Deaton collaborated on some research papers, with mixed results. “We fought over every word,” Case recalls, smiling. “So we decided at that point we would divide up the world: Angus went to India and I went to Africa.” Who’s smarter, I ask — her or her Nobel-Prize-winning husband? “Oh, it depends on the day!” she replies.
In South Africa, she focused on the relationships between healthcare and income and status, documenting the collateral damage inflicted upon children whose mothers died prematurely from the Aids virus: worse education, unstable homes, earlier introduction to sex. “Burying people in mid-life is just absolutely devastating to families, to communities, to children,” Case says. That is as true for Kentucky as it is for Johannesburg.
After a dozen or so years travelling back and forth, Case shifted her focus to the US to study rising reports of physical pain — backaches and other maladies that might keep a person out of work. (It turns out that areas with high incidences of physical pain neatly correlate with support for Trump.) “Can’t you for a change just work on something a little more cheerful?” she recalls a colleague asking at the time.
Meanwhile, Deaton was puzzling over rising suicide rates. It was in 2014, in a cabin in Montana, where they spend each August, that they realised they were tugging at different strands of a common thread: rising mortality rates for middle-aged white Americans.
“We thought, ‘If we’ve found this, other people must have seen it.’ And what we found was that everyone seemed to be surprised,” Case says. One reason others might have missed the trend, she speculates, is that researchers tended to focus on disparities in mortality, and the fact that African-Americans have always had — and continue to have — higher death rates than white Americans (though the gap is closing).
Their first paper revealing the shift in mortality rates not only prompted newspaper headlines and debate, it also brought an outpouring of emails and letters from ordinary people recounting their losses. Case keeps these close at hand. “They help me enormously in understanding what’s happened,” she says.
“Even though it’s something that’s hit people with less education harder, it is still the case that there’s not a family in Princeton that I know well enough that hasn’t had a brother, a sister, a mom — someone who’s either had an opioid-use disorder or alcohol-use disorder, or a family where someone has killed themselves. It has actually reached the kind of bubbles that you and I both live in.”
One avid reader was then in the White House, as Case and Deaton discovered when they paid a visit in 2015 after Deaton was awarded the Nobel Prize for his earlier work on consumption and welfare. To their surprise, President Obama not only had a copy of their paper but had read it to the footnotes and was keen to discuss it.
“He said to us, ‘This has a lot of resonance with what happened in the African-American community in the late 1960s and early 1970s.’ And the more we looked into that, the more we realised he was dead on,” Case says.
In those decades, US manufacturing had begun to decline and black people were first to lose their jobs. They were forced to take worse ones — or none at all. Soon marriage rates began to plunge because men no longer had prospects. Out-of-wedlock births and drug addiction shot up. Professionals with means moved out, stripping neighbourhoods of talent. A working class became an underclass.
Many conservatives blamed inner-city African-Americans for their own plight — finding fault with their “culture” and ignoring the role of economics. Thirty years later, as working-class white people have begun to succumb to a similar fate, some commentators are making familiar accusations — to Case’s disgust. “It’s not black culture, it’s not white working-class culture,” she argues. “We really think if you treat people shabby enough, for long enough, bad things happen to them.”
There are signs that workers are suffering in other western countries too. The latest data shows that deaths of despair also began to tick up in Britain in the early 1990s. But the levels — while rising — remain well below those in the US. One reason, Case suspects, is that “opioids have never been unleashed in the UK the way they have been in the US. So it’s a much more muted crisis.”
Oxycontin, a controlled-release form of the powerful opioid oxycodone, was approved in 1995 for pain relief and then vigorously marketed by pharmaceutical companies and their lobbyists. By 2017, OxyContin and other prescription opioids were responsible for nearly a third of the record 70,237 overdose deaths that year in the US. The toll from that year alone is greater than the number of Americans killed in Vietnam.
“If things were going well, those opioids may land on soil that’s not very fertile,” Case says. “But when things are going badly, those opioids are landing on a place where people are looking for ways to numb themselves, and here comes this drug — and my doctor even says it’s OK. And it’s helping me cope with a life that I can’t find other ways to cope with.”
Another factor that distinguishes America, in Case and Deaton’s view, is its uniquely burdensome healthcare system. In 1960, it absorbed 5 per cent of national income. The figure has since grown to 18 per cent, and rising. In the book, they liken it to “a tapeworm that Americans accidentally swallowed long ago”.
The Democratic candidates seeking to unseat Trump have talked about “Medicare for all” and how best to expand health insurance. But, to Case’s frustration, they have largely overlooked costs.
“To date, there’s been very little reaction to us ringing the bell on healthcare costs,” she says. “I certainly would say that I think everyone should be covered. But what’s really killing us is the fact that costs are now so high that it’s eating our economy from the inside out. And the people who are paying the price for that are people with less education.”
Any European system would be an improvement, Case and Deaton suggest. Just switching to a Swiss system — the world’s next most expensive after the US — would free up more than $8,300 per household, or more than $1,000bn in annual savings. That is money that could be spent on pay rises, education, infrastructure or on providing some semblance of the social safety net that has protected European workers from deaths of despair.
As history demonstrates, reforming American healthcare is a gargantuan challenge. The sorts of fixes Case and Deaton recommend would mean fighting battalions of well-funded lobbyists for hospitals, insurance companies and even doctors, who are better paid than their foreign counterparts. At the moment, Congress cannot even agree how to stamp out the scourge of “surprise medical bills” — often sent by hospitals owned by private equity firms — that are bankrupting families.
“Cost controls are going to be really, really hard,” Case acknowledges. “That’s a heavy, heavy lift . . . [But] if we don’t do it, then we have to wait for something to break very badly before we make a change. I’m hoping we can get there before things break very badly.”
In the meantime, there is more to study. As she did with Aids in South Africa, Case would like to examine how deaths of despair will shape communities for years to come.
“What happens to the next generation?” she asks. “What happens to kids who grew up with a mom who was addicted to OxyContin or whose dad committed suicide, or has bounced around between relatives because they don’t have a stable home life, don’t know their dads? I think that for people whose lives were unstable as children, they’re at much higher risk for bad things happening. They’re on trajectories that are going to lead to some pretty difficult circumstances.”
‘Deaths of Despair and the Future of Capitalism’ is published by Princeton University Press on March 17. Joshua Chaffin is the FT’s New York correspondent
This article has been revised to reflect the fact that OxyContin, rather than oxycodone, was approved in 1995.
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