Current Affairs

‘Deaths of Despair’ and the Failure of Capitalism

When McKinsey praises your book, it’s a sign—and not a particularly good one.

It would be difficult to overstate the volume and intensity of the public discourse on the white working class over the last half decade or so. While the lineage of this discussion might be traced back at least half a century to the desegregation campaigns and political realignments of the 1960s and 1970s, the most recent chapter in this saga began with Donald Trump’s enthusiastic courting of working-class white voters during the 2016 presidential election. Trump’s overtures to this constituency included talk of reviving domestic manufacturing, railing against globalization, decrying corporate bosses for selling out American workers, and vilifying immigrants for (among a variety of displaced or fabricated grievances) “taking our jobs.” While Trump’s rhetoric was largely political theatre—including everything related to actually improving the lives of workers—these efforts seemingly paid off, with Trump increasing Mitt Romney’s 25-point margin among white voters without a college degree in 2012 to a whopping 39 points in 2016.*

This trend may have been relegated to a historical footnote had Trump not won the 2016 election, a prospect the political punditry widely considered borderline impossible at the time. But Trump’s improbable victory imbued his strong showing among working-class whites with a salience that has largely defined the conversation about this population within the liberal-progressive media milieu. Discussions therein tend to center on questions like: How could working-class whites vote so clearly against their own interests? How could they possibly vote for a candidate as viscerally repulsive as Trump? Why are they so reactionary? Do they really only care about racism and xenophobia?

In a nutshell: what the hell is wrong with working-class white people?

Though not focused on Donald Trump or electoral politics, Deaths of Despair and the Future of Capitalism explores in great detail some variation of this last question, sans the implied pathology. Specifically, the book details and attempts to make sense of the remarkable increase in mortality among middle-aged white Americans without a bachelor’s degree over the last two decades or so, a period that has seen around 600,000 more middle-aged whites die than would have been expected based on both historical domestic trends and prevailing global patterns. That is nearly as many people as the total number of Americans who have died from HIV/AIDS in the roughly four decades since the onset of that epidemic in the early 1980s.

In fact, the increase in white middle-age mortality has been so pronounced in recent years that life expectancy among all Americans actually decreased between 2013 and 2017 (the last year of data included in the book). Outside of major wars and pandemic disease outbreaks, such a reversal in life expectancy has no precedent in recorded history. “Constantly falling death rates were one of the best and best-established features of the twentieth century,” the authors point out. “All-cause mortality is not supposed to increase for any large group.”

Deaths of Despair is written by Anne Case and Angus Deaton, distinguished professors emerita at Princeton University who have earned global acclaim for their individual and collective work: Case is a member of the prestigious National Academy of Sciences; Deaton is a Nobel Prize winner in economics and has been knighted by the British government. Given the collective clout of its authors and the broad popularity of the white working class as a subject of public discourse, it is perhaps unsurprising that Deaths of Despair has made a rather large splash since its publication in March of 2020. The book made various bestseller lists and was a New York Times Editors’ Choice and Notable Book of 2020. A promotional sticker on the front cover advertises that it was shortlisted for “Business Book of the Year” by Financial Times and McKinsey & Company.

Whether or not you are swayed by these endorsements (clearly, you should not be), Deaths of Despair explores urgent topics that have important implications for egalitarian politics. While the book offers a compelling portrait of the economic devastation that has befallen the white working class over the last few decades and its harrowing consequences, Case and Deaton’s self-professed commitment to capitalism renders them incapable of producing a clear-eyed account of the forces responsible for this devastation or of advancing solutions capable of addressing it.

Deaths of Despair

Deaths of Despair opens by describing the remarkable increase in life expectancy over the course of the 20th century. In the United States, average life expectancy rose by nearly three full decades, from 49 to 77 years, and mortality rates across the age spectrum plummeted. For middle-aged whites, mortality decreased by nearly three quarters, from 1.5 percent to 0.4 percent annually over the course of those 10 decades. Similar declines were seen in what the authors call “wealthy countries” across the world. Yet while middle-aged mortality rates continued a steady decline in those other countries into the 21st century, mortality among middle-aged whites in the United States plateaued and then began to rise beginning in 1999. This trend has begun affecting both younger and older adult whites as well. Mortality rates among middle-aged African Americans and Latinos, on the other hand, have (mostly) continued to decline.

In the most immediate sense, the increase in mortality among middle-aged whites is almost entirely attributable to three closely related causes: drug overdoses, suicides, and cirrhosis and other alcoholic liver diseases. These deaths tripled among this demographic between 1990 and 2017, a trend driven entirely by increases among those who lack a bachelor’s degree, whom Case and Deaton define as “working class.” Drug overdoses, primarily from opioids, represent both the largest and fastest-growing category of such deaths. Though white middle-aged men are nearly twice as likely as their female counterparts to die from these various causes, the upward trajectories of both genders mirror one another. “These kinds of death are all self-inflicted,” Case and Deaton point out. “All the deaths show great unhappiness with life, either momentary or prolonged.” This reality brought the authors to discuss these phenomena collectively as “deaths of despair.”

Middle-aged working-class whites are also reporting dramatically worse health, deepening mental distress, declining levels of happiness, a diminishing capacity to perform basic daily functions, and intensifying levels of pain, Case and Deaton inform us. Overall health and quality of life, in other words, have conspicuously deteriorated for this group as well. While increasing numbers of middle-aged working-class whites are dying deaths of despair, many more are also living lives of despair.

To their credit, Case and Deaton are not satisfied with explaining these trends solely within their most immediate context, which would almost certainly have the effect of pathologizing the subjects of their study. Indeed, notions of the white working class as inherently and irredeemably poor, dumb, angry, bigoted, and self-destructive have been perhaps the defining feature of the recent discourse on this group. In some ways, Deaths of Despair might be understood as a sort of 21st century Moynihan Report or The Truly Disadvantaged for the white working class, for better and worse. If the book shares with these works a penchant for moralizing the lives of inequality’s victims, it also shares their emphasis (however imperfect) on the political-economic roots of that inequality. Thus, Deaths of Despair generally avoids the more antagonistic gaze of recent books like Hillbilly Elegy, which explains white poverty as a cultural phenomenon, or Dying of Whiteness, which points to poor whites’ ostensible commitment to racism as the cause of their own ruin.

Instead, Case and Deaton attribute these deaths of despair to “the external forces that have eaten away at the foundations that characterized working-class life as it was half a century ago,” arguing firmly “against the view that workers brought the calamity on themselves.” The story that they tell about these external forces is, by now, a largely familiar one: millions of good-paying, low-skilled, unionized jobs liquidated by a combination of automation, intensifying global competition, and offshoring; increasing numbers of working-age adults who have dropped out of the workforce entirely; a shift toward increasingly precarious, meaningless, and poorly paid jobs for those who are still working; a steady decline in real wages for large segments of workers; and an ever-greater share of national income and wealth being swallowed by capital. These shifts have had disastrous effects on people’s individual and familial finances. But they have also destroyed once-thriving communities and towns wholesale, as plants and mines closed, the esteem and meaning derived from dignified work disappeared, familial bonds strained and unraveled, and social institutions collapsed.

On this note, the authors productively link these trends with the similar implosion of working-class Black urban communities beginning in the 1960s. In fact, much of the industry that has recently disappeared from smaller, predominantly white towns and cities throughout the country initially emerged during the postwar era as manufacturers abandoned central cities for the suburbs and hinterlands in search of cheap land, low taxes, lax regulations, and a more pliable workforce. Then, as now, the relatively stable, unionized industrial jobs that formed the bedrock of working class life disappeared by the millions, rates of unemployment and poverty skyrocketed, community life deteriorated, despair set in, and substance abuse exploded. Indeed, the phrase “rust belt,” which has been invoked in recent years mostly to describe small, predominantly white towns and cities ravaged by industrial decline, once referred to larger cities with large Black populations devastated by similar forces decades earlier, like Detroit, St. Louis, Cleveland, Milwaukee, Buffalo, Flint, Michigan, and Gary, Indiana.

To clarify, then, it’s not that working-class whites are doing worse than their Black counterparts today—only that the immiseration of working-class Black people is longer-standing and largely (and racistly) accepted as a matter of course. The immiseration of the white working class, on the other hand, is more recent and, in a society in which whites are generally considered to have a “fair shake” in life, more novel.

A veritable library’s worth of scholarship and social commentary over the last half century has sought to make sense of the devastation wrought by deindustrialization and the collapse of Black working-class life in these places. Like the discourse on the white working class today, however, much of the work on the gutting of the urban Black working class is marred by a tendency to pathologize the dispossessed as well as a basic misreading of the political-economic forces ultimately responsible for their plight.

In more than one way, what’s past is very much prologue.

Detours, Deflections, and Scapegoats

In summary, Case and Deaton argue that deaths of despair are best understood as a product of “the breakdown and turmoil in a society that can no longer provide its members an environment in which they can live a meaningful life.” The first two-thirds of the book offer a detailed overview of the nature of this collapse and the acute toll that it has taken on increasing numbers of working-class white Americans. This account is largely insightful and persuasive. The final section of the book, “Why Is Capitalism Failing So Many?,” attempts to illuminate why these things have happened and what might be done to address these issues. It is here that the analysis falls apart.

The “leading villain” in the story of why this has happened, Case and Deaton argue, is the U.S. healthcare system. Pharmaceutical companies, they point out, functioned as predatory cartels in pushing as many addictive opioids into the hands of as many Americans as possible in their pursuit of profits. The U.S. healthcare system, moreover, is not only the most expensive in the world, but routinely delivers outcomes that are vastly inferior to those of cheaper systems and leaves tens of millions of Americans uninsured. This system, the authors rightfully declare, “is a cancer at the heart of the economy.”

Nonetheless, as inhumane as the U.S. healthcare system is, it is miscast as the leading villain in this particular story. Deaths of Despair vastly overstates its centrality in explaining white working-class dislocation, blaming the healthcare industry for “bringing down wages, destroying good jobs, and making it harder and harder for state and federal governments to afford what their constituents need.” On one level, these claims are rooted in premises for which the authors provide no evidence. Who’s to say that, if employers were not paying so much for healthcare coverage for their employees, that money would be translated into higher wages for workers and greater numbers of good-paying jobs? Given the prevailing balance of class power, it seems more likely that capital would simply usurp those savings into quarterly profit margins and shareholder dividends. Likewise, who’s to say that, if governments were not wasting billions of dollars subsidizing the private healthcare industry, that money would necessarily be redirected to addressing the pressing daily needs of constituents? The authors provide no evidence for their presumption that political priorities would shift toward downward distribution simply because of an aggregate increase in government budgets.

These issues are never seriously addressed because they’re never seriously considered. And, more to the point, they are entirely tangential to Case and Deaton’s own analysis. The healthcare industry is not responsible for the disappearance of manufacturing jobs, the decline of labor unions, structural unemployment, falling wages, increasingly precarious work, and the like. That is, the healthcare industry cannot be blamed for the destruction of white working-class life that has precipitated skyrocketing levels of deaths of despair. At most, one segment of this industry, pharmaceutical companies, helped fuel opioid addictions—though, as the authors themselves note, even this predation must be situated within the broader context of working-class dislocation and immiseration, which provided the “fertile ground” within which addiction and overdoses might flourish. In short, their extensive discussion of the healthcare industry is a complete detour from the central themes of the book and functions as a deflection from examining what should be the principal explanation in their narrative.

Deaths of Despair then runs through a laundry list of other potential culprits—immigration, hegemonic corporate power, the anemic U.S. welfare state, the decline of organized labor—only to conclude that none of them had very much to do with the destruction of the white working class. So, for example, Case and Deaton “are not persuaded that there is a general issue of monopoly;” in fact, they claim, increasing market concentration can be largely credited for the “ever-lower prices” for goods and services that we enjoy. And not only is there “no smoking gun that links deaths of despair to a lack of safety nets,” the authors inform us, but it would also “be unwise to rely too heavily on stronger safety nets.” Labor unions, meanwhile, simply “faded in importance” over time, as people ostensibly found declining “value” in membership.

Yet when Case and Deaton do link specific factors to working-class dislocation, as they do with automation and globalization, they conclude that these things were both inevitable and, on the whole, much more good than bad, anyway. “Globalization and technological progress [read: automation] are good. Both enable us to have collectively higher incomes because they expand the productive capacity of the economy. Yet,” they acknowledge, “even the most Panglossian assessment recognizes that trade and innovation bring losers as well as winners.” These “collectively higher incomes,” then, are really only higher incomes for certain segments of society. Other, much larger segments of society have their livelihoods directly undermined or utterly destroyed. These higher incomes, it turns out, are not really “collective” at all. Here, the incoherence of framing macroeconomic growth as a universal good—a well-worn tactic in the elite playbook—is laid bare, as the immiseration of untold millions is readily accepted as a tradeoff for increasing the “productive capacity” and “trade and innovation” that benefit society’s “winners.”

With automation and globalization thus vindicated, Case and Deaton feebly offer up a handful of abstractions about “rent-seeking,” “crony capitalism,” and “ill-gotten” profits as the ostensible forces (along with the healthcare industry’s avarice) to blame for the deaths of despair epidemic. Yet the authors fail to present even a cursory argument that these phenomena are linked to the destruction of working-class life or, by extension, to deaths of despair. In short, these buzzwords function as obvious scapegoats. Nonetheless, they provide an essential pretext for exonerating Case and Deaton’s ideological commitment to capitalism and their raft of (non-)solutions to redress working-class suffering that flow from that commitment.

The Failure of Capitalism

 “We would like to see an America that is more just,” begins the final chapter of Deaths of Despair, titled “What to Do?” According to the authors, “The problem is that different people have very different and mutually incompatible ideas of justice. But we can go a long way focusing instead on obvious injustices, features of society on whose wrongness many people can agree.” After spending 200 pages detailing the immiseration of the white working class and the deaths of despair epidemic, Case and Deaton shrug off the notion that they might use their considerable platform to make a bold case about just what should be done to address these issues based on the facts of their analysis. In limiting their discussion to issues on which “many people can agree,” a consideration of the potential effects of strategies for redress is explicitly subordinated to a strategy’s ostensible level of agreeability among “many people.” (Who these people are is never clarified. Are they the working class? Policymakers? Ivy League economists?) Equally problematic, in shifting their focus from addressing deaths of despair, specifically, to vague notions about creating “an America that is more just,” the authors suggest upfront that their discussion may have little bearing on the actual topic of their book.

Further preempting any possibility that a meaningful program of redress might be advanced, Case and Deaton declare, “We believe that those in distress deserve priority, but not that there should be any decline in priority with income or wealth among those who are not in distress.” This is, simply put, an incoherent position. By definition, “priority” involves regarding or treating something as more important than something else: If the distress of the working class deserves greater political priority than it currently receives, this necessarily requires deprioritizing other things. For the authors, however, the structurally imposed anguish driving tens of thousands of people to deaths of despair every year is important—but ultimately no more important than anything else. This is an argument that nothing should fundamentally change, couched in more polite and less coherent language.

Case and Deaton deliver emphatically on this premise, as their proposals for addressing deaths of despair amount to, essentially, nothing. Despite framing the entire book against the backdrop of the college educated versus non–college educated, for example, they are against “free college for everyone,” since they claim, without evidence, that this “would distribute most of the benefits to those who need them least.” (The reality that financing is the biggest barrier to attaining a bachelor’s degree for millions of Americans—especially those from the working class—is apparently lost on them.) They dedicate nearly two pages to the prospect of a universal basic income (UBI), only to conclude that they “are not in favor of a UBI under current circumstances.” They are also firmly against raising taxes on the wealthy, a position that, on its own, would seem to preclude any robust redress via the public sector. For all of their handwringing about rent-seeking, the authors ultimately conclude that “there is nothing to stop trade associations or corporations from lobbying elected officials for protection.” The only policy reform that they clearly endorse is “gradually” raising the federal minimum wage to $15 an hour.

The limitations of Case and Deaton’s perspective, however, are most conspicuous in their discussion of healthcare reform. As a reminder, they spend scores of pages throughout the book lambasting the healthcare system, going so far as to declare that “free-market competition does not and cannot deliver socially acceptable healthcare.” So what do they ultimately conclude is needed to reform the healthcare system?

Not much. Case and Deaton encourage health providers to “explore better options” and “alternative treatments” for pain in lieu of prescribing so many opioids, whatever that might mean. They argue that there should be more intentional oversight for drug approvals “to prevent the adoption of treatments whose benefits fail to exceed their costs”—apparently, economist-speak for “maybe don’t approve drugs that are likely to kill hundreds of thousands of people.” Most egregiously, while they argue that “America should follow other rich countries in providing universal insurance and in controlling healthcare costs,” they fail to debate the merits of nationalized healthcare or a single-payer system, the two options most capable of accomplishing these goals. Instead, they mention these possibilities in passing for the sole purpose of summarily dismissing them. Hence, “it is not true… that the only alternative to what currently exists is the British system” of nationalized healthcare, and “there are also many alternatives to the extremely expensive idea that the federal government should provide Medicare for all.” By contrast, they spend three sentences promoting an obscure voucher proposal “that is not a single-payer system.” (That proposal is co-authored by Ezekiel Emanuel, who openly promotes the idea that older people should die because diminished economic “productivity” makes life worthless.)

This is market fundamentalism masquerading as rigorous scholarship.

To reiterate, however, Case and Deaton’s discussion of healthcare functions primarily as a distraction from the basic fact that capitalism itself is responsible for the deaths of despair that they so painstakingly detail. The authors open and close Deaths of Despair by proclaiming their allegiance to capitalism, a commitment they reaffirm periodically throughout the book. Certainly, they are entitled to their beliefs. The problem is that those beliefs have seemingly left them without the capacity to adequately and honestly assess the forces that have caused the deaths of despair epidemic or to propose anything approximating an adequate raft of solutions. Rather, by propping up abstractions like “rent-seeking” and “unfairness” as scapegoats, Case and Deaton enable themselves to frame a “better monitored and regulated” capitalism as the solution. (As the foregoing discussion indicates, they are rather light on the specifics of what that would actually entail.)

Nonetheless, we should be clear that the gutting of the white working class, as with the Black working class before that, is directly attributable to the basic workings of capitalism—technological development, global trade, free markets, profit maximization—and not to the scapegoats that Case and Deaton invoke. Replacing manufacturing jobs with machines, shuttering factories and moving production abroad, and globalizing markets are in the interests of ownership; they increase productive output, reduce labor costs, and extend the domain of markets. They are against the interests of workers, as the fallout detailed in Deaths of Despair so clearly attests to. Indeed, it is no coincidence that the immiseration of white workers has intensified to such an extreme degree over the last few decades, when the wealth and power of capital have reached new heights. In the end, there is simply no getting around the basic fact that structural unemployment and worker precarity are endemic to capitalism and good for capital. 

These fundamental contradictions, and not a cherry-picked smattering of capitalism’s alleged excesses (presented as Not Really Capitalism, no less) are at the root of working-class ruin.

Yet Case and Deaton inform us that they remain “optimistic” about capitalism. “We considered using the phrase ‘the failure of capitalism’ in our title,” the authors write, “but opted instead for ‘the future of capitalism,’ a future we hope will be better.” Ultimately, it is unclear if their optimism is a matter of ideology or misunderstanding. After all, on at least two occasions in Deaths of Despair, they claim that “upward redistribution is not an inherent feature of capitalism,” when this is arguably its single most defining feature. Either way, for anyone who actually cares about alleviating the suffering of the working class and reversing the deaths of despair epidemic, Case and Deaton have provided no reason to share in their optimism.

The Future of Egalitarian Politics

With these lessons in mind, it is worth returning to some of the political questions that opened this piece and to consider their relationship to socialism and egalitarian politics more broadly.

From the perspective of electoral politics, the question of why many poor and working-class whites cast ballots for Republicans typically lays at the heart of this discourse. Clearly embedded in this question is the view that these whites are voting against their own interests, a perspective that is accepted as common sense among liberals and many progressives and leftists. Actually, to frame this discourse as a question is rather inaccurate, since the ostensible explanation for this phenomenon is clear: racism. That is, poor and working-class whites are thought to enthusiastically reject a political program rooted in class solidarity and racial egalitarianism that would serve their own material interests in favor of a politics of white supremacy that directly undermines those interests. This received wisdom, however—which is routinely read into the past as an explanation for the broader trajectory of American history—is in need of serious reconsideration on a number of fronts.

Most recently, Donald Trump electoral victory in 2016 is commonly attributed to the ostensible racism of his supporters. CNN commentator Van Jones explained it as a “whitelash against a changing country” and “against a Black president.” Writer Ta-Nehisi Coates insisted that Trump’s victory was attributable to the irresistible “power of whiteness” and a transcendent “white tribalism.” Why the tens of millions of whites who cast ballots for Hillary Clinton (or Joe Biden) were apparently unmoved by the whitelash or by the ostensible power of whiteness is unexplained. These explanations lose even more of their luster when juxtaposed with the fact that as many as 9.2 million overwhelmingly white voters who cast a ballot for Trump in 2016 voted for Barack Obama in 2012. If a commitment to racism was decisive for these voters in 2016, when they voted for a racist demagogue, why was it apparently not decisive in 2012, when they voted for a Black man? A perspective that presumes that racism is the principal, if not sole, force animating the political behavior of white voters is simply incapable of explaining these dynamics.

Weighing in on Trump’s support among working-class whites following the 2016 election, Bernie Sanders lamented, “I come from the white working class and I am deeply humiliated that the Democratic Party can’t talk to the people where I came from.” Coates and other liberals chastised Sanders for his comments, with one commentator expressing “real concern that people of color will get left behind again.” But the fact is the Democratic Party left working people of color behind decades ago—at the same time that it left white workers behind. After all, the decline of industrial employment, the gutting of organized labor, the shift to monetary policies designed to promote unemployment and suppress wages, the passage of worker-crushing trade policies, the hollowing out of the U.S. welfare state, and the rise of the carceral state—that is, the forces that have destroyed working-class life for Black people, whites, and everyone else in the United States over the last half century—have been decidedly bipartisan political projects.

The Democratic Party’s engagement with African Americans, Latinos, and other people of color in recent decades, then, has been a largely identitarian affair, rooted in appeals to racial and ethnic identities, as opposed to class position or material interests. Indeed, as historian Touré Reed notes, the former are often treated as proxies for the latter, with “racial justice”—in the form of symbolic representation and proportional inequality—being divorced from and substituted for broader agendas aimed at transforming the political economy for working people. When the alternative is an openly chauvinistic GOP, the potential appeal of this limited brand of politics to many voters is readily apparent. But that should not preclude a sober, critical assessment of its substantive and strategic shortcomings: If what the Democrats have offered Black people and other constituents of color are symbolic representation and a commitment to basic nondiscrimination, and, simultaneously, an intensification of inequality and precarity for working people of all identities, what have they had to offer working-class whites, who are in need of neither symbolic representation nor nondiscrimination? The deficiency of this politics forms the essential context for low levels of political engagement among the more submerged strata of both whites and Black people (and almost certainly other groups as well), many of whom see little reason to vote at all.

In the end, we should recognize that people’s perceptions and actions are historically contingent and shaped by a wide range of factors that play out within the context of the broader social order. As political scientist Cedric Johnson points out, the notion that “working-class interests are already self-evident, unified and simply waiting to be advanced” is erroneous and “fail[s] to capture how particular class interests are congealed, articulated and advanced.” And many features of our current social order no doubt hinder the development of a clear-eyed discernment of working-class interests and the building of broad-based working-class solidarity—unprecedented inequality and growing artificial scarcity, a battered labor movement, increasingly precarious and contingent forms of employment, geographic divisions, an elite discourse that alchemizes material inequality into racial grievances, the widespread notion that the state can’t do anything productive for its citizenry, and—yes—racist resentments, which should be understood against this backdrop, not as a primordial compulsion.

But as inhumane as these features of our political economy are, such conditions also provide openings for exposing the contradictions that lay at the heart of capitalism. They provide a foundation of shared experiences, felt needs, and interests, and the possibility of building solidarity around these commonalities across ascriptive identities and other ostensible divides. This isn’t easy work, and these commonalities are not necessarily self-evident. But for anyone who cares about advancing egalitarian politics, this is the basic task with which we are confronted. As the longstanding immiseration of working-class Black people and other communities of color and the deepening devastation of the white working class detailed in Deaths of Despair make clear, there is no alternative.

* Both these political pundits and the authors of Deaths of Despair define the working class as comprising those who lack a bachelor’s degree. Though this definition may be largely rooted in the limitations of survey data, we should recognize its limitations as a general proxy for people’s relations to economic production. This is particularly true with regard to the small towns and rural hinterlands where Trump drew strong support and where people without a college degree include many small businesspersons, landlords, building trade contractors, cattle ranchers, and other proto-entrepreneurs and wannabe millionaires.

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