Book Review: Deaths of Despair and the Future of Capitalism
Introduction
America is a land of hope for many people. Unfortunately, the tale of optimism is fading out. In today’s US society, there are millions of working-age Americans, mostly white, without four-year college degrees were dying due to suicide, drug overdoses, and alcohol-related disease. Anne Case and Angus Deaton coined the term “deaths of despair” to describe this three causes of death: suicide, drug overdoses, and illnesses arising from alcoholism. In their book, Deaths of Despair and the Future of Capitalism, Case and Deaton have drawn public attention to the deteriorating well-being of less-educated working-class white Americans, presenting the uncomfortable fact that the great story of America is not as beautiful as it has been told. They also link the deaths of despair as a consequence of the country’s modern capitalism.
The book provides answers to three questions of the deaths of despairs epidemic: who are the dying people, why are they dying, and how to solve this dying problem? The authors write the explanations in non-technical prose, yet a strong message providing solid evidence. While the descriptive empirical facts are coherently presented, several arguments are still dubious. This review article questions three flaws that are worth emphasising in this book: (i) the failure to recognise the consequences of inequality; (ii) over-criticism on the healthcare industry; and (iii) lack of policy discussion on the root cause of misery.
Summary
Deaths of Despair and the Future of Capitalism deserves particular attention for three reasons. First, this book makes us aware that there was a silent epidemic run rampant in the US. Second, it implicitly states that there is a compelling impact of the role of higher education on decent life well-being, both in terms of economics and sociological aspects. Third, this book forces the US healthcare system, as a part of unfair capitalism, to be quickly re-evaluated.
Case and Deaton start the book by introducing the deaths of despairs — the cause of mortality related to suicide, drug overdoses, and alcoholism — as the major contributors to this high number of deaths in America. While the death rates continue to decline in other high-income countries, it has been going on in the opposite direction in the United States, particularly among less-educated white American people.
The authors divide the book into four main parts. In Part I, Case and Deaton examine the various group of population aged between 45–54 year. They highlight this midlife cohort because those people should have been living longer and enjoying a better quality of life. In the beginning, they provide the 20th-century background, the time of tremendous technological advances improved life expectancy throughout the world. Over the sweep of the 20th century, the mortality rate, defined by the number of deaths per hundred thousand people at risk, continued to fall at 2% per year from 1970 to 2000 (2020, p. 30).
However, this was not the case when we look closer at the midlife white American group. The authors present the declining trend of mortality rates of midlife Americans without university degrees stopped and has, in fact, risen since the late 1900s, being primarily driven by deaths of despair. Deaths of despair in the midlife age then started to increase and tripled from 1990 to 2017. The evidence, moreover, does not indicate that another cohort is going to be fine once they leave this stage. The truth is that the younger generation could end up facing the worse trajectory (2020, p. 45). The epidemic is getting worse, and the death patterns are not only exclusive for the middle age group.
In Part II, Case and Deaton answer the question of how differences in educational attainment and races shaped the deaths of despairs in the 21st century. Due to skill-biased technological change, there has been a growing earning gap between two main groups: American people with bachelors’ degree and those without the degree. The “earnings premium” of people with a university degree had doubled from 40% in the 1970s to 80% in 2000 (2020, p. 51). They correlate this economic issue into profound non-material outcomes. Many people without university degrees experienced a decline in well-being; that they are less content, less healthy, and live with more daily pain.
In Part III, there is a fuller discussion on the major causes of the deaths of despair. Notably, The Great Recession, along with poverty and inequality exacerbated life outcomes. Case and Deaton, however, do not attribute deaths of despair to these economic events. The authors examine that one main factor that causes the problem is the loss of wealth due to the worsening of the labour market. There is a little wage change within a job, and there is a lower labour participation force from losing and replacing jobs. Since American people do not have a decent job, they decided to cohabit but not get married. As a result, the loss of good jobs and declining real wages have undermined the lives of working-class people, such as the decline of social bonds through family, trade union, and religious community.
Case and Deaton also argue that the death of despairs are experienced by today’s white Americans as the sequel of a similar tragedy in the 1970s for black Americans, which many blacks died due to cocaine and HIV. Over the decades, whites Americans had a special privilege over African Americans. However, white privilege has diminished due to black progression in the country. The authors point out a survey finding, in which more than 50 percent of white working-class Americans believe that discrimination against whites has become as big a problem as discrimination against other minority groups (2020, p. 66). Combine with declining in wages and social life, a loss of white privilege has contributed more to the despairs. Here, the loss of white privilege somewhat related to the winning of Donald Trump, who exploited the white supremacy campaign in the 2016 presidential election.
In their final part, Case and Deaton blame the American capitalism that has made the condition worsen. They argue that American capitalism is similar to the Sheriff of Nottingham with redistribution upwards (2020, p.193). Going into more detail about capitalism, Case and Deaton mainly put the healthcare industry as a supervillain, which is analogous to cancer that is consuming the US economy from the inside out (2020, p.10). Employers must pay for their workers’ health insurance; thus, it leaves fewer wages for the workers. The contacting out of low-skilled jobs is a result of high healthcare cost. The unfair process generates despairs for some people, while at the same time, health care corporations hurt low-income people through inefficient political lobbying to increase their market power. Therefore, despair and inequality are joint outcomes of forces working underneath this issue.
To add more complication, they also see globalisation, automation, and financial crisis as all part of the story. Furthermore, even though capitalism provides the gross and unfair system, Case and Deaton still believe in capitalism. However, they think that capitalism needs to be repaired by delivering better monitored and regulations in the system.
Case and Deaton propose a set of policy initiatives to remedy the failures of this capitalism, such as the need of US healthcare industry reform and more vigorous enforcement of America’s antitrust law. They propose such a form of European’s universal income provision and a decreased supply of highly addictive drugs. They also support a stronger safety net and higher minimum wages for workers to deal with the uncertainty brought by globalisation and automation.
Critical Review
The central argument of the book is that today’s American capitalism is not working well for those without a university degree, which is two-thirds of the US population. Altogether with the total number of deaths, the books provide us with the increasing of reports of severe mental distress and pain in the society. The strength of this book is coming from the empirical evidence. On the other hand, some parts of arguments are less convincing, and the policy section feels muddled, thus could be a matter of considerable debate.
The failure to recognise the consequences of inequality
First, readers should give pause while reading the inequality chapter in the book. Case and Deaton believe that income inequality simply is a consequence of growth under unfair capitalism, as are deaths of despair. They argue “if inequality makes a society unhealthy, everyone’s health suffers, rich as well as poor” (2020, p. 139). While it seems convincing, the author ignores the psychosocial causes, which are interrelation of psychological and social factors that influence mental health. They appear to be unaware of how chronic stress raises the risk of health problems, resulting in more rapid ageing and death. Evidence shows that higher inequality undercuts social cohesion and capital and increases chronic stress, including in the US (Inequality.org, 2020; Burkhauser et al., 2016)
Moreover, Case and Deaton believe that “those in despair are in despair because of what is happening to their own lives and to the communities in which they live, not because the top 1 per cent got richer” (2020, p. 140). This may not be the case. Material inequities have powerful psychological effects: when the gap between rich and poor increases, so does the tendency to define and value ourselves and others in terms of superiority and inferiority (Wilkinson and Pickett, 2018). People worry about how they are seen and judged, mainly because income and status are so often seen as marks of personal worth.
The fact that they are not aware that this issue is intriguing since they had mentioned the consequences of inequality in the black-white status difference’s discussion. Case and Deaton recognise a similar psychological impact due to inequality. When they argue that whites privilege over blacks has diminished or vanished, their statement implies that white Americans are now insecure about their self-worth (2020, p.166). A loss of sense of racial privilege is practically speaking in the same battleground with widening inequality.
Given the title of the book: ‘death of despairs’, and the background profile of both authors, the reader may expect the authors are well-grounded with the psychosocial issue, resulting in more rich exploration on this inequality chapter. In the end, low-income people feel they are worthless when living in unequal societies. Inequality attack people’s insecurity about their self-worth. Unfortunately, it seems that the authors were reluctant to explore this complicated yet very crucial issue. It might explain why among many graphs in the book, there is no single one that is showing the story of US inequality, even though the gap has increased substantially over the past decade. Another thing, when they talk about the success of Scandinavian countries health care system to mitigate deaths of despair, could the equal society influence it, rather than just by the policy per se? It is an inequality arena that I wish they had explored further.
Over-criticism on the healthcare industry
Case and Deaton argue that despairs cannot explain only by declining in material well-being, but more importantly, destruction in the American way of life, such as family, trade union, and religious community (2020, p. 879). However, instead of pointing at this direction, Case and Deaton put a healthcare system as a lead villain. This is the part where my second critical begin.
One bias about the health care system is on the lobbying argument. Indeed, it is satisfying to know that the authors mention the greediness of big pharma industries in the broken US system. However, I am still questioning how too many lobbyists in healthcare industries can affect the increase of deaths of despairs? It contradicts with the authors’ statement that argues “there is too much competition and too many lobbyists on all sides of the big issues. Lobbying is important, but it has not rigged the system so that it only works for the paymasters” (2020, p. 242). If lobbyists do not always prevail and there are no effective lobbyists, why so bother to explore it in long pages, but avoid discussing the intertwined things related to deaths of despair, such as inequality?
To be fair, not only the healthcare industry, they also put little blame to other sectors, such as financial and real-estate, even though they seem to overlook the healthcare industry. They worry about the excessive power that would expand in those industries. Therefore, promote more competition through antitrust policy is needed, even though they do not elaborate more in a fuller discussion. Moreover, if the deaths of despairs are mainly caused by healthcare industries, why such a similar tale will not hold for the financial industry? In the Great Recession, the banking sectors contributed to the loss of trillion dollars from the economy, resulting in the growing social disparity and economic insecurity (Glei et al., 2019). Then, why they still believe that competition proposal, which mainly focuses on the healthcare industry, will not repeat the same old story in future capitalism?
Furthermore, how about other industries in America, such as social media and internet companies in Silicon Valley that create an increasing number of hopeless despairs, anxiety, and even radicalism? This industry has a “dark side” that is hard to avoid, such as cyberbullying, trolling, fake news, and privacy abuse (Madison et al., 2019). Also, can we blame the alcohol industry that produces substances which contribute to a quarter of deaths of despair? It is also interesting if the book can also challenge the lobbying practise from other sectors, particularly the powerful processed and fast food industry that had shape public-health related policies at the expense of public health and their lifestyle (Gostin 2016).
Another bias on the healthcare industry; the authors tend to see immoral pharma companies targeted only to the less-educated white Americans. This raises a question whether another different group of people in the race and educational level seems immune to this excessive profit-seeking actions. Do the greedy doctors only take care of white people’s pain or decide to prescribe opioid drugs only to white Americans? Alternatively, are black and Hispanics less likely to visit over-prescribing doctors? The authors leave this issue unexplored. The authors already recognise that opioid painkillers were given to arthritis illness, which associated with the older age of population regardless of their races. However, it is strange if only less-educated white Americans are somewhat addictive into drugs. This part should be discussed more.
In a nutshell, I agree that the healthcare system must change. However, it seems that rather than trying to understand holistically on deaths of despairs, the authors prefer to make a differentiation with other books that has a similar theme in challenging capitalism today, such as The Future of Capitalism by Paul Collier or the Third Pillar by Raghuram Rajam. The unique twist that they put in this book, perhaps, is putting the healthcare industry into the spotlight.
Lack of policy discussion on the root cause of misery
The third critical, the set of the proposed solution is fairly general, and again, with respect to the authors’ expertise, the prescription is quite disappointing. For instance, they are optimistic about curing American capitalism by reforming the US health care industry. While it is true that the reform would lower costs in the industry that is associated with vigorous rent-seeking activities, the preserve role of money makes it hard to see why this proposed solution is politically feasible.
They also reject an increase in progressive tax and prefer to extend the safety net and a mild rising in minimum wages. However, given the deeper structural problems of the US economy, their proposed solution is not sufficient. Evidence shows that the economy needs more substantial wealth redistribution to build a more stable US economy, even though the primary justification for such policies is not economic. (Papadimitriou et al., 2019).
Apart from the healthcare system, another crucial issue that education reform is given a little weight, although the despairs revolve around educational aspects. High academic level, which is represented by a four-year university degree, sharply divides the white Americans into two groups: those are prone to deaths of despair, and those are resilient. Evidence shows that educational attainment in society is one of the most critical factors for social and economic outcomes of a country (Riddell, 2006). Although they mention why the K-12 educational system is wasteful and unjust (p 259), which is also a consequence of unfair capitalism, they do not explore how and why it needs reform. For instance, an alternative proposal that they can offer is to provide more educational access to people. Piketty & Goldhammer (2014) argue that a government can use a progressive tax to fund higher education to every young adult, particularly in low-income families. That instrument will help transform the ability of children from poor households to move up and fix their future lives.
Finally, the debate on the policy plan does not even try to answer the cultural arguments regarding social cohesion and self-pride problems which are mentioned so much earlier in the book. An alternative version of this book might address how the public policy to address the cause of despairs from social aspects. Some propose solutions might resonate with Timothy P. Carney’s explanation in the book Alienated America (2019), which explore proposals to overcome the erosion of community in working-class Americans. Case and Deaton could also explore the absence of strong “middle institutions” such as churches and trade union, and the challenge in a more secular society and rapid technological advance. I believe that such a comprehensive social analysis in this issue will be an excellent insight in seeing the current American political and social issue.
Conclusion
The book successfully sounds an alarm, making the readers pay attention to the deterioration of well-being of white working-class Americans. Not only portrays the economic and social forces that have made midlife white working-class Americans without university degree much more miserable, they also offer possible solutions to the chronic epidemic. This book also provides some lessons for specialists, including economists, to dare to touch interdisciplinary discussions and connect the dots in a more complex world.
However, readers of the book may disagree with anecdotal story and policy recommendations in the book. The authors tend to blame the healthcare industry rather than providing comprehensive policy proposal to address the rising rate of death of despairs. As a result, they fail to see the US inequality issue as a necessary consequence of socioeconomic distress among Americans.
In light of the Covid-19 pandemic, a less-educated working-class people around the globe now are at even higher risk of dying of despairs. The book draws attention so that our government, at every level, can begin to realise the connections between psychological pain, economic distress, and an appropriate set of policies to overcome the misery. Moreover, as a part of society, we need to learn that our strength lies in cooperation and altruism, that we can prevent deaths of despairs by taking meaningful and comprehensive actions as a nation.
References
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Carney, TP 2019, ‘Alienated America: why some places thrive while others collapse’, HarperCollins, California.
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Gostin, LO 2016, ‘“Big Food” is making America sick’, The Milbank Quarterly, vol. 94, no. 3, pp 480–484.
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< https://inequality.org/facts/inequality-and-health/#us-inequality-health >.
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Piketty, T & Goldhammer, A 2014, ‘Capital in the twenty-first century’, Harvard University Press, Cambridge.
Papadimitriou, DB, Nikiforos, M & Zezza, G 2019, ’Can redistribution help build a more stable economy?’ Strategic Analysis, April 2019, Levy Economics Institute.
Riddell, W 2006, ‘The impact of education on economic and social outcomes: an overview of recent advances in economics’, Canadian Policy Research Networks, viewed 17 Oct 2020, <http://oaresource.library.carleton.ca/cprn/44362_en.pdf>.
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