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,
- 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