USA. Kerrville. September 19, 2017 Steven Been, (Terri Been's husband) at the Gas station where Jeff was arrested.
© Jerome Sessini/Magnum Photos

An epidemic is sweeping the US, taking lives on an unprecedented scale and threatening the future of the world’s biggest economy. But this is not a new virus, dangerous and contagious yet likely to blow over with only a temporary hit to economic growth.

The epidemic documented in a timely and important new book by Anne Case and Angus Deaton has been savaging America for two decades. So far, many hundreds of thousands of lives have been lost to what the authors, two eminent economists, label the “deaths of despair” — death by suicide, accidental drug overdose or alcoholic liver disease.

Like all good economics, the argument in Deaths of Despair starts from an observation — rising suicide rates among working-class Americans in the first decades of the 21st century. The authors then use data to describe the problem before trying to diagnose, understand and prescribe.

As you might expect from a Nobel Prize winner (Deaton) and, in Case, one of America’s best empirical economists, the picture they paint is painstaking in its detail and vivid in its importance. The victims of this new epidemic, they demonstrate, are white, non-Hispanic middle-aged Americans without a degree-level education qualification — a group that overwhelmingly voted for President Donald Trump in 2016 and has stuck with him since. Over the past 25 years, deaths from suicide, drug and alcohol abuse among this group have tripled.

As a result, and after a century of falling mortality rates, the death rate for 45-54-year-old white Americans began to rise in 2000 and has continued to do so — while rates among Hispanic and black Americans, as well among Europe’s working populations, have continued to fall. If the downward trend of the 20th century had continued between 1999 and 2017, 600,000 more people would be alive today.

What is going on? Poor economic outcomes must be part of the answer. These deaths of despair have been rising only among Americans whose relative earning and job prospects have deteriorated sharply in recent decades. Those with degrees have seen no such rise. Yet the authors find no correlation between rising death rates and either poverty or rising inequality. And why have mortality rates for older and less-educated black Americans — who have also experienced declining employment prospects and relative wages — continued to fall?

United States of America. Philadelphia. April 4, 2018. St. Francis Inn. The Franciscan shelter has been serving meals to the neediest persons in Philadelphia since 1979. Most of them are addicted to opioids. credit Jerome Sessini / Magum Photos
Outside a Franciscan shelter that serves meals to the neediest people in Philadelphia, many of them addicted to opioids © Jerome Sessini/Magnum

Case and Deaton heap blame on the US healthcare system and, in particular, the decision to liberalise the prescription of opioid-based painkillers in the 1990s. It was “the carelessness of doctors, without a flawed approval process at the FDA, or without the pursuit of profits by the industry at whatever human cost” that led to the return of mass opioid addiction to America for the first time since the aftermath of the civil war. Universal health insurance and better regulation to control costs and drug availability is the answer — although, as usual, these US economists are doubtful about directly importing the public provision of the UK’s National Health Service.

But why has white America been hit so hard? At this point, the authors rely less on data and evidence, more on conjecture and sociological speculation. First, they pin the blame for this growing pain and unhappiness — or “carnage” as Trump famously labelled it — not on rising material deprivation but on the decline in trade union membership, churchgoing and marriage rates, with rising numbers of children growing up with single parents.

They argue that black working Americans experienced a similar decline in relative economic prospects and community cohesion in the 1980s — “decades later, less educated whites, long protected by white privilege, were next in line”. And they assert that the wellbeing of the previously privileged white community has been additionally undermined by the loss of social status relative to their black fellow citizens: “more than half of white working class Americans believe that discrimination against whites has become as big a problem as discrimination against blacks and other minorities”. My own experience of working and travelling in the US suggests this is all far too narrow and simplistic. There is far more to current alienation than Trumpian racial envy. And while the strength of the earlier part of Deaths of Despair lies in its statistics and evidence, it is here, where analysis is replaced by speculation, that the book is less satisfactory.

The final policy section feels muddled — the authors slip into corporation, bank and politico-bashing with rather a Trumpian tone but little analysis or policy to back it up. Large parts of the US economy, they claim, “have been captured to serve the wealthy with the consent and connivance of government”; and that “the sheriff of Nottingham has taken up residence in Washington DC and the good cops have left town. Robin Hood is nowhere to be seen.”

Yet the authors are also at pains to stress that capitalism remains the answer and that inequality is a byproduct of economic incentives — “the problem is not that we live in an unequal society but that we live in an unfair society”.

As a result, the gap between their rhetoric and policy prescriptions feels achingly wide. They reject an increase in progressive taxation or a more generous “band-aid” welfare state. They predict that a rebirth of trade unionism or comprehensive reform of corporations is “unlikely”. Education reform is given little weight and public infrastructure investment doesn’t get a mention.

The result is disappointing. Not only do their calls for a “modest” rise in the minimum wage and weaker patent protection seem insufficient, none of the policy discussion even tries to address the cultural arguments about community cohesion and pride upon which the authors pin so much earlier in the book.

Yet while I ended the book feeling worried that economics still doesn’t seem to have answers to the economic and cultural dislocation faced by so many working people in the US and across Europe too, I did feel cheered that we in Britain still at least have an NHS that should be the envy of any sane American.

Deaths of Despair and the Future of Capitalism, by Anne Case and Angus Deaton, Princeton, RRP£20, 312 pages

Ed Balls, a former UK cabinet minister, is a research fellow at the Harvard Kennedy School

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