American dream or nightmare? Deaths from despair and the future of capitalism

CASE, Anne; DEATON, Angus. . Deaths of Despair and the Future of Capitalism. Princeton University Press: Princeton, NJ, 2020. 312p.

In the past decade, there has been an increase in evidence about the relationship between economic insecurity and increased suicides, chronic liver disease and drug and alcohol intoxication. This group has been called “despair deaths” (Knapp et al., 2019). Some American studies have described increases in mortality rates from these causes in the past five years, especially among white men of middle age and low education. The most famous of these is the study by Case and Deaton (2015), which received comprehensive coverage in the American media. It also induced collateral research that discussed poor whites’ situation in the American economy, whose peak was the launch of the work “Deaths of Despair and the Future of Capitalism” (Case & Deaton, 2020).

Renowned economist Anne Case is one of the leading experts in the links between economic and health status. Simultaneously, Angus Deaton won a Nobel Prize in 2015 for his work on family poverty and well-being. Princeton professors bring in this work a robust empirical basis for arguing (and conclude) in a harshly critical way the fragility of American democracy. Using language accessible to non-economists, the authors seek to connect the phenomenon of deaths from despair and the context of social and economic inequality.

Anne Case and Angus Deaton observed that, throughout the 20th century, mortality rates decreased steadily in the United States (USA). However, in the past 20 years, there has been a dramatic change: between 1999 and 2017, contrary to the trend, mortality rates in middle-aged American men and women in non-Hispanic white people aged 45-54 years have grown. As a result, life expectancy in the US, which had been steadily increasing, has stagnated and then dropped in recent years (down from 78.9 years to 78.6 years between 2014 and 2016) (Woolf & Schoomaker, 2019). It means that the increase in middle-age mortality, led by these “deaths from despair,” was significant enough to offset the mortality gains of children and the elderly. The causes associated with this increase were intoxications, mainly by opioids, suicides, and alcohol-related deaths. What happened and why for this specific subgroup in the United States is Deaths of Despair. The authors point out that if the twentieth-century trend of progress had been maintained equitably for the American population, the US would have been spared approximately 600,000 deaths - the equivalent of AIDS deaths since the epidemic began 1980s.

Despair deaths reflect a loss of a long-term and slowly developing way of life. In this respect, the increase in middle-age mortality results from cumulative disadvantages that have occurred over decades. The America that Case and Deaton write about is a place linked to the class. The less educated experience higher rates of severe mental illness have more problems with “instrumental activities of daily living” (p. 79) like walking and report more pain. In contrast, Americans with degrees live longer, have more stable families, report happier lives, and abuse opioids and alcohol less often. Deaths of despair and the future of capitalism portrays, in this sense, the fall of the American dream, the failure of American capitalism to provide welfare to many.

Our story is primarily about the external forces that have eaten away the foundations that characterized working-class life as it was half a century ago. (...). It is the loss of meaning, of dignity, of pride, and of self-respect that comes with the loss of marriage and of community that brings on despair, not just or even primarily the loss of money. (p. 8)

The work reinforces the theory that self-destructive health behaviors can be associated with social and economic factors underlying life’s context. Social and economic circumstances are likely to be the main contributors to the increase in deaths from observed despair. Case and Deaton specifically target white men and women without college degrees. In fact, for the white working class, the United States has become a land of broken families with little prospect of survival. The authors link the crisis to weakening employment links and organized movements - such as unions - and corporations’ growing power.

The role of the social determinants of health is highlighted by the observation of a social gradient in deaths from despair: the fewer years of schooling, the greater the risk of death. However, Case and Deaton have an exciting view of income inequality, reinforced by the work, arguing that there is no causal relationship between income inequality and deaths from despair. Instead,

it is the deeper forces of power, politics, and social change that are causing both the epidemic and the extreme inequality. Inequality and death are joint consequences of the forces that are destroying the white working class. (p. 134)

According to Case and Deaton, the distortion of wealth and income towards wealthier Americans and educated elites over the past half-century with government policies and legislation has slowly eroded the foundations of working-class life. The answer, they point out, requires redoing the system. They argue that the profound changes in this system are in the taxation of fortunes and tax increases of the most privileged classes and the guarantee of tough measures that prevent corruption.

Case and Deaton also do a careful analysis of the US health system, characterizing it as a health industry. The authors explicitly denounce the American health care system as a perversion of capitalism, made possible by lobbyists and legislators’ alliances. They describe their extraordinary and inadequate costs and classify the health system as partly responsible for workers’ layoffs. It occurs by reducing employee payroll, relieving employers’ accounts with employee health insurance. It is a politically protected profit. For example, they cite the relatively recent epidemic of opioids in the American population and claim that corporations have explicitly profited from death. Thus, it is not just opioids invading working-class Americans’ lives: it is the political system that harms them.

It is tempting to draw quick conclusions from these findings. However, this analysis requires a more complex theoretical model precisely because it has this contextual effect as a central element (Diez-Roux, 2017). For example, Anne Case and Angus Deaton propose that the increase in middle-age mortality results from cumulative disadvantages over decades. This effect has become more noticeable in recent years because it has generally occurred in the population with low education but white. However, despite increases in whites and declines in blacks, in 2015, whites’ mortality rates are substantially lower than in blacks in all categories and social strata (including income, education and social class).

Case and Deaton hypothesize that blacks in the US have always suffered disproportionately from these and other threats to working-class life, providing a ready explanation for blacks’ higher death rates than whites in the US over the century 20 and still today. On this point, it is essential to note that when whites in the US working class had stable jobs, supported by unions, and relatively well paid in the industry, stable family and social life, they had considerably better conditions for healthy living than black people. These advantages have deteriorated, but not completely undone, hence the reduction, but not the elimination, of the white population’s advantage in mortality indicators. The fact is that the black community was the first to suffer from changes in the economic system when there was a displacement of jobs in factories for the less educated white population or when gentrification processes closed the doors of small family businesses of the income population in large cities (Marmot, 2020). It is no coincidence that the black population was also the group most affected by the social cost of the first significant drug overdose epidemic caused by crack use in the late 1970s. Almost 40 years passed before this pattern of illness and addiction reached the white population. The message here, quoting writer Lucy Nicholas, is that “When you’re accustomed to privilege, equality feels like oppression.” (Nicholas, 2017, p. 9). The rest, literally, is history.

Another issue is that, despite all their criticisms, the authors wrote about capitalism’s future, not just about its failure. Looking at the evidence from several American states, they show that “poverty is not the source of the increase in deaths from despair.” (p. 137). On the other hand, the financial crisis may be one factor responsible for this economic instability.

If poverty is not primarily responsible for the scenario of despair deaths, the idea of - inequality linked to the flattening of the living conditions of the population of greatest socioeconomic vulnerability over time certainly is. Since inequality and class formation are the foundations of capitalism, what way is possible within this bubble?

Superficially, the authors defend guidelines such as universal health insurance, reforms in corporate governance and the use of alternative non-opioid treatments for chronic pain. However, the dimension given to these solutions does not seem to correspond to the scale and complexity of the problems described by the authors. That said, it is essential to contextualize the position of the authors. Case and Deaton are sympathetic to the progressive perspectives. However, they reticently attribute the economic system a cause, even if partial, for this phenomenon. Thus, in the view shared by the authors, capitalism can be “better monitored and regulated” and should not “be replaced by some fantastic socialist utopia in which the state takes control of the industry because democracy can face the challenge.” (p. 162).

Socialism is a view on democracy. At best, it is uninteresting to conclude that any alternative to capitalism brought about by socialism is utopian or fantastic. The authors take for granted the idea of “democracy” with which they feel comfortable, strongly tied to capitalism. Furthermore, in an unpretentious (but not naive) way, they disregard any form of isonomic social practice and outside of the private property possible for the current world.

Ultimately, the book’s evidence helps scientists and politicians recognize that health is affected by much more than medical care. The social and economic context conditions even behaviors. However, it is essential to realize that there is a specific context that legitimizes this observation. The authors, economists, succinctly present public health issues from the health system’s perspective and do not advance in the social determination of the health-disease process - although they did not intend to explore this dimension, not social analysts. The discrepancy between the diagnostic robustness traced throughout the work and the proposition in its final comments is remarkable. The analysis of this phenomenon in other realities must consider different world views, social structure, health system context and political-economic organization.

Referências

• CASE, Anne ; DEATON, Angus. Deaths of despair, and the future of capitalism Princeton University Press: Princeton, Nova Jersey, EUA, 2020. 312 p.
• CASE, Anne ; DEATON, Angus. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. PNAS, v. 112, n. 49, p. 15.078-15.083, 2015. DOI: 10.1073/pnas.1518393112. Disponível em: https://www.pnas.org/content/pnas/112/49/15078.full.pdf Acesso em: 10 jan. 2021.
  » https://doi.org/10.1073/pnas.1518393112» https://www.pnas.org/content/pnas/112/49/15078.full.pdf
• KNAPP, Emily A. et al Economic insecurity and deaths of despair in US counties. American Journal of Epidemiology, v. 188, n. 12, p. 2.131-2.139, 2019. DOI: 10.1093/aje/kwz103.
  » https://doi.org/10.1093/aje/kwz103
• MARMOT, Michael G. Despair, democracy, and the failures of American capitalism. The Lancet, v. 395, n. 10.229, p. 1.027-1.028, 2020. DOI: 10.1016/S0140-6736(20)30640-1.
  » https://doi.org/10.1016/S0140-6736(20)30640-1
• NICHOLAS, Lucy. Beyond quiet tolerance to diversity perspectives: when you’re accustomed to privilege, equality feels like oppression. Ethos, v. 25, n. 4, p. 9-11, 2017. Disponível em: https://search.informit.org/doi/10.3316/informit.325212638376085 Acesso em: 24 ago. 2021.
  » https://search.informit.org/doi/10.3316/informit.325212638376085
• ROUX, Ana V. D. Despair as a cause of death: more complex than it first appears. American Journal of Public Health, v. 107, n. 10, p. 1.566-1.567, out. 2017. DOI: 10.2105/AJPH.2017.304041. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607706 /. Acesso em: 9 jan. 2021.
  » https://doi.org/10.2105/AJPH.2017.304041» https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607706
• WOOLF, Steven H.; SCHOOMAKER, Heide. Life expectancy and mortality rates in the United States, 1959-2017. JAMA, v. 322, n. 20, p. 1.996-2.016, 2019. DOI: 10.1001/jama.2019.16932. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146991 /. Acesso em: 10 jan. 2021.
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Publication Dates

• Publication in this collection
  04 Oct 2021
• Date of issue
  2021

History

• Received
  10 Feb 2021
• Accepted
  19 Aug 2021