Science - 27.03.2020

in the form of more-perfect markets. While

they are undoubtedly right that it would

be possible to reform the U.S. health care

industry so that it provides both better

and more accessible care at substantially

lower costs, the pervasive and perverse

role of money and lobbying in this indus-

try makes it hard to see why they are opti-

mistic about such a solution.

Case and Deaton see benefits

in globalization and automa-

tion, although they recognize

the need for policies to ensure

that these benefits are equally

distributed. They are in favor

of a somewhat stronger safety

net and modestly higher mini-

mum wages. However, they

oppose greater wealth redis-

tribution through taxes as well

as more radical ideas such as

a universal basic income. Their

proposed solutions may be

insufficient if the underlying

causes are indeed structural.

A criticism that has been

leveled against Case and Dea-

ton’s work is that their focus on

the rise in white midlife mortal-

ity downplays the much higher

rates of mortality among black

Americans. I have sympathy

for the position that the scientific analysis

of one issue does not imply a disparaging

of the importance of other issues, and the

book does cover the black-white mortality

differential. However, a race-based analy-

sis opens questions not just of science but

of justice.

Indeed, the policies that the authors ad-

vocate not only would address deaths of

despair, they would improve the health and

welfare of the American people more gener-

ally. A clearer articulation of this point would

have helped to assuage the view that the au-

thors are focused only on policies that will

improve the health of the white population. j

10.1126/science.aba3036

When it comes to the factors driving de-

spair, the book rejects a simple economic

argument about poverty, jobs, immigra-

tion, globalization, automation, and the

Great Recession. Case and Deaton note

a decline not just in incomes for the less

educated in the United States but also in a

sense of purpose and a way of life that once

included social bonds forged through trade

unions, church, and marriage.

American adherence to the idea of

meritocracy is, they believe, particularly

undermining for the less educated. De-

spite overwhelming evidence of low in-

tergenerational mobility in education and

income levels in the United States, there

is a strong cultural belief that poverty re-

flects personal shortcomings rather than a

rigged economic system. Such beliefs may

be preposterous, but they have proven dif-

ficult to overcome.

Case and Deaton also offer a scathing

indictment of the U.S. health care indus-

try, calling it a cancer at the heart of the

economy. They describe the rise of the pre-

scription opioid OxyContin, arguing that

pharmaceutical companies put profits above

people, leading to widespread addiction.

The authors place the blame squarely on

corporations that use political lobbying to

create market power and exploit the poor.

Case and Deaton’s solution for the failures

of capitalism, however, is more capitalism,

27 MARCH 2020 • VOL 367 ISSUE 6485 1433

PHOTO: ISTOCK.COM/VALENTINRUSSANOV

L

ife expectancy in the United States

declined for 3 years in a row between

2014 and 2017. This is surprising in

a world where we have grown accus-

tomed to rising life expectancy. Anne

Case and Angus Deaton’s new book,

Deaths of Despair, deals with three ques-

tions: Who is dying, why are they dying,

and what can we do about it?

Case and Deaton have been rightly cel-

ebrated for identifying the large rise in

U.S. deaths due to suicide, drugs, and alco-

hol, particularly among white males aged

45 to 54 who have not completed a 4-year

degree. Here, they argue that

a key social divide exists in

America between those who

have a bachelor’s degree and

those who do not and that

deaths of despair also occur in

white women. Furthermore,

they suggest that the prob-

lem is more widespread; the

stalled decline in heart dis-

ease mortality in the United

States, against a backdrop of

improvements in other coun-

tries, may be due, in part,

to drugs and alcohol. Such

deaths, they argue, are hid-

den “deaths of despair,” and

deaths are just the most visi-

ble manifestation of a broader

crisis of widespread pain, ad-

diction, and misery among the

less educated.

Deaths of despair are not an

exclusively American phenomenon. Simi-

lar deaths occurred in Russia after the fall

of communism, and there is evidence that

the recent decline in life expectancy in the

United Kingdom is attributable to a rise in

deaths of despair. Such deaths are the re-

sult of a breakdown in social systems that

give people a sense of respect and meaning.

America, however, may be particularly vul-

nerable to this phenomenon, because of its

emphasis on individualism and its tendency

to equate economic success with social value.

ECONOMICS

By David Canning

Reversing the rise in midlife mortality

Stronger safety nets and health care reform could help mitigate “deaths of despair” in America

Deaths of Despair and the

Future of Capitalism

Anne Case and Angus Deaton

Princeton University Press,

2020. 324 pp.

Originally documented in white men, deaths of despair occur in white women too.

The reviewer is at the Department of Global Health

and Population, Harvard T.H. Chan School of Public

Health, Harvard University, Boston, MA 02115, USA.

Email: [email protected]

SCIENCE