28 The New York Review
Left Behind
Helen Epstein
Deaths of Despair
and the Future of Capitalism
by Anne Case and Angus Deaton.
Princeton University Press,
312 pp., $27.95
We’re Still Here:
Pain and Politics in
the Heart of America
by Jennifer M. Silva.
Oxford University Press,
206 pp., $24.95
The United States is in the throes of
a colossal health crisis. In 2015 life
expectancy began falling for
the first time since the height
of the AIDS crisis in 1993.
The causes—mainly suicides,
alcohol- related deaths, and
drug overdoses—claim roughly
190,000 lives each year.
The casualties are concen-
trated in the rusted-out factory
towns and depressed rural areas
left behind by globalization, au-
tomation, and downsizing, but
as the economists Anne Case
and Angus Deaton demonstrate
in their new book, Deaths of
Despair and the Future of Cap-
italism, they are also rampant
in large cities. Those most vul-
nerable are distinguished not
by where they live but by their
race and level of education.
Virtually the entire increase
in mortality has been among
white adults without bachelor’s
degrees—some 70 percent of
all whites. Blacks, Hispanics,
college- educated whites, and
Europeans also succumb to
suicide, drug overdoses, and
alcohol-related deaths, but at
much lower rates that have
risen little, if at all, over time.^1
The disparity is most stark
in middle age. Since the early
1990s, the death rate for forty-
five-to-fifty-four-year-old white
Americans with a BA has fallen
by 40 percent, but has risen by
25 percent for those without
a BA. Although middle-aged
blacks are still more likely to
die than middle-aged whites, their mor-
tality has also fallen by more than 30
percent since the early 1990s. Similar
declines occurred among middle-aged
French, Swedish, and British people
over the same period.
Case and Deaton show how this
crisis worsened over generations,
beginning with the Baby Boomers.
College- educated whites born before
World War II were slightly more vul-
nerable to suicide, drug overdoses,
and alcohol- related deaths than non-
college- educated whites, but these
trends reversed among those born after
the war, and then the fates of those with
and without a BA continued to diverge.
Growing economic insecurity is a
major cause of the problem. White
manual workers once expected that
the American Dream would come
true for them. In Kathryn Newman’s
remarkably prescient study of downsiz-
ing, Falling from Grace (1988), older
people recalled that Elizabeth, New
Jersey—where 18 percent of residents
now live in poverty—was once a “place
of grandeur, where ladies and gentle-
men in fine dress promenaded down
the main avenue on Sunday.” The
Singer Sewing Machine company em-
ployed over 10,000 workers, roughly a
tenth of the city’s population. The com-
pany awarded scholarships to children,
sponsored baseball games, and hosteddances and bar mitzvahs in its recre-
ation hall. Each sewing machine had a
label, and if returned with a defect, the
man who’d made it would fix it himself.
The last American Singer plant closed
decades ago, along with thousands of
other factories. There were 19.5 million
decently paying US manufacturing jobs
in 1979, compared to around 12 million
today, when the population is almost 50
percent larger. Over the same period,
the wages of workers with a high school
degree or less have fallen by about 15
percent, while the earnings of college-
educated workers have risen by around
10 percent and of those with higher de-
grees by nearly 25 percent.Today, what’s available to those with-
out a BA are mostly poorly paid ser-
vice jobs without health or retirement
benefits, let alone baseball games and
scholarships. The demise of unions
means that these workers have virtu-
ally no bargaining power. One in fiveUS workers is subject to a noncompete
clause, meaning they can’t easily move
from one company to another without
switching fields completely. Until re-
cently, even chain restaurant workers
could be subject to such rules, so that a
burger flipper at Carl’s Jr. who was of-
fered higher pay at Arby’s couldn’t ac-
cept it without risking a lawsuit.
Andrew Cherlin and Timothy Nel-
son recently interviewed dozens of
American men without BAs, most of
whom bounced from one dead-end job
to another. One unemployed man had
started out as an editorial assistant at alocal newspaper but was laid off when it
downsized; he became a parking atten-
dant, but that job was eliminated by au-
tomation; he then worked for a catering
company until it went out of business.^2
The personal lives of those without a
BA mirror this instability. The vast ma-
jority of women with a BA have all their
children in marriage, but most women
without one have at least some, if not all,
of their children out of wedlock, often
with different men. American children
experience more changes in stepfathers,
stepmothers, and residences than chil-
dren in any other wealthy country,
and Cherlin maintains that American
families may be the most unstable in
the world. This no doubt contributes
to many child development problems
that are also common in the US, in-cluding difficulties sitting still and pay-
ing attention in school, disobedience,
and destructive behavior. Children
with these issues often find it difficult
to enter, let alone finish, college, per-
petuating an intergenerational cycle of
thwarted potential.
Some conservatives, such as Charles
Murray and J. D. Vance, the author of
the wildly popular memoir Hillbilly
Elegy, attribute these economic and
social upheavals to moral decline. If
only poor whites would embrace reli-
gion, adopt the family values of their
better- educated peers, stop blaming the
government, and work harder,
they’d be fine, they say. But as
Case and Deaton point out, if
it were really true that work-
ers without BAs were slacking
off, wages would have risen
for those who weren’t, but this
hasn’t happened. The jobs just
aren’t there—or if they are, they
don’t pay enough to support a
dignified existence. About half of
those who patronize America’s
food banks live in households
with a full-time worker—per-
haps a janitor, Uber driver, ca-
shier, nanny, or caregiver—who
doesn’t earn enough for grocer-
ies. According to the Urban In-
stitute, about a quarter of adults
in homeless shelters have jobs.
But while poverty in America
is all too real, it’s not the only
reason for the epidemic of
deaths of despair. Poor states
like Arkansas and Mississippi
have seen smaller increases in
overdose deaths than wealthier
Florida, Maryland, Delaware,
New Jersey, Connecticut, New
Hampshire, and Maine. Deaths
of despair continued their steady
rise right through the 2008
financial crisis, when many
Americans lost homes and jobs,
and didn’t jump in frequency,
as we’d expect if economic
circumstances alone were the
cause. Blacks without a BA
earn between 20 and 27 percent
less than whites without a BA,
but even though addiction re-
mains a problem in African- American
communities, non-BA blacks are never-
theless 40 percent less likely than non-
BA whites to die from suicide, alcohol,
or drug overdoses.If poverty alone can’t explain this epi-
demic, what’s going on? Case and Dea-
ton suggest that it may have something
to do with the ways in which non-BA
whites have responded to the radical
changes that have upended their world
over the past century or so. The post-
1970s economy inflicted suffering on
non-BA people of all ethnicities, but the
psychological toll on whites might have
been worse because their expectations
were so much higher. Financial hardship
has long been part of historical reality
for black Americans, often attributed,
rightly, to discrimination. Perhaps for
this reason, blacks are more likely to
sympathize with poor and unemployed
friends and relatives, and help out when
possible. Europeans are similarly likely(^1) Although this may be changing, as
deaths of despair seem to be increasing
among people of color in the US and
in the UK.
(^2) Andrew J. Cherlin, Labor’s Love
Lost: The Rise and Fall of the Working-
Class Family in America (Russell Sage
Foundation, 2014), p. 154.