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Deaths of despair

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Joshua Cohen talks to Angus Deaton in the Boston Review:

Angus Deaton, Dwight D. Eisenhower Professor of Economics and International Affairs Emeritus at Princeton University, has been widely recognized for his work on capitalism and inequality. Awarded the Nobel Prize in 2015 for “his analysis of consumption, poverty, and welfare,” the British American scholar was knighted by Queen Elizabeth II the following year for “for his services to research in economics and international affairs.” In the mid 2010s, he and economist Anne Case turned their attention to what seemed to be a startling trend: the reversal of declines in mortality rates for white working-class Americans in middle age. That research culminated in the March 2020 publication of their book Deaths of Despair and the Future of Capitalism. Last month, Boston Review editor Joshua Cohen spoke with Deaton about this new work—the narrowing economic horizons for the U. S. working class, the relationship between culture, financial hardship, and health, and prospects for change.


Joshua Cohen: In mid-March you and Anne Case published Deaths of Despair. As the book appeared, much of the country was shutting down because of COVID-19. But the book is about a terrible problem that significantly predates COVID-19, will almost certainly outlive COVID-19, and in all likelihood will be made worse by COVID-19. We’ll come back to the COVID-19 connection at the very end, but I want to focus the conversation on the terrible problem that the book identifies. What were the initial reasons that led you to what you call “deaths of despair”?

Angus Deaton: Like many things that surprise you, you fall over it accidentally. We were working together on suicide, and discovered a remarkable increase in suicides among white non-Hispanics in midlife. We were going to present that at a conference, and it seemed like a good idea to put it in the context of all-cause mortality.

When we pulled that data from the Centers for Disease Control (CDC), we were astonished to find that the long-term decline in mortality in the twentieth century for all racial groups—a trend I’d written about for my previous book, The Great Escape (2013)—had stalled or reversed for white non-Hispanics in midlife. That seemed extraordinary. I should note that African Americans, who have historically had higher all-cause mortality rates, and indeed still do, were making real progress in terms of falling mortality rates.

At the same time, Anne was working on pain—she suffers from very severe lower back pain herself—and she knew there’d been an increase in pain and other morbidity in the same group. And we saw very quickly that this was happening to both men and women, and, most importantly, that this decline was only happening to white people who didn’t have college degrees. Those of us with at least a bachelor’s degree, the educational elite, were somehow exempted from these horrors.

So first we wrote about it in a 2015 paper. When we saw the rise or cessation of fall in all-cause mortality rates, we did what seems like a reasonable thing: we looked at what other things were rising really rapidly and found three that Anne later christened “deaths of despair”: suicide, drug overdose, and alcoholic liver disease. What we got wrong at the time—as Jon Skinner and Ellen Meara picked up very quickly—was that even the rapid rise in these three things could not account for the increase in all-cause mortality. Deaths from heart disease, which had been falling rapidly in the last quarter of the twentieth century, had stopped declining. Lots of people die from heart disease; adding that to the deaths of despair that were going up very fast accounted for the all-cause mortality rates. We had missed that.

We also missed—and the book is clear about this—that these deaths of despair are getting worse not just for white people in middle age (45–55 years old), but for younger people as well. When we wrote in 2015, it was also too early to see the increase in drug overdose among African Americans once fentanyl reached the inner cities after 2013.

JC: In the book you focus on these deaths of despair: 158,000 in 2018, about 100,000 of which are above and beyond what we would normally expect, an excess that is almost entirely among white non-Hispanic men and women without a college degree. The category covers three different causes of death: alcohol, opioids, and suicide. Could you talk about why you group them together?

AD: Initially, “deaths of despair” was a label of convenience. It helped express the sense that these deaths were sort of caused by your own hand—unlike COVID-19, say. We had this sense that you have to look at what’s happening to people in their lives, rather than some fault in the medical systems. Anne thought up that term in an interview, I think. And that led us back to Durkheim, whose thinking about suicide proved very useful and provided some intellectual framework—not something that economists are brought up on.

JC: Yes, it’s not exactly a common American Economic Review reference, but it’s important. To what extent is this fundamentally an opioids issue, rather than an issue of alcohol and suicide as well?

AD: Some have taken the position that . . .

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Written by Leisureguy

13 May 2020 at 3:21 pm

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