Deaths of despair: the unrecognized tragedy of working class immiseration

Given the socioeconomic effects of the ongoing Covid-19 pandemic, it should have come as no surprise that the Centers for Disease Control and Prevention recently reported more than 100,000 drug overdose deaths during the 12-month period ending in April 2021, a 28.5% increase over the prior year. Most of these deaths were attributed to the use of synthetic opioids by middle-aged white men. The question immediately begged is: What is the U.S. Department of Health and Human Services (HHS) doing about these so-called deaths of despair?

The answer is sobering.

The term deaths of despair comes from Princeton economists Anne Case and Angus Deaton, who set out to understand what accounted for falling U.S. life expectancies. They learned that the fastest rising death rates among Americans were from drug overdoses, suicide, and alcoholic liver disease. Deaths from these causes have increased between 56% and 387%, depending on the age cohort, over the past two decades, averaging 70,000 per year.

Case and Deaton learned that these deaths disproportionately occurred in white men who had not earned college degrees. In their 2020 book, “Deaths of Despair and the Future of Capitalism,” they argued that a key driver of these deaths is economic misery.

The phenomenon was first examined more than a century ago. In 1897, French sociologist Émile Durkheim defined these deaths as “anomic suicides” — anomic meaning alienated — in his book “Le Suicide.” These deaths, he argued, result from a breakdown in social equilibrium or social norms, or when individuals believe there is a lack of communal spirit or conclude the government is indifferent to their needs.

This psychological state is largely the result of economic hardship or the loss of work or wages, something that today is disproportionately experienced by approximately 66 million white workers without college degrees between the ages of 25 and 64 years, or 38% of working-age people. As Case and Deaton showed, this population has seen the purchasing power of their wages decline by 13% since 1979 while per capita income increased 85% over the same period.

The resulting health effects are altogether predictable. Insecurity, deprivation, the loss of possibilities, the lack of belonging, hopelessness, and social maladjustment lead to negative emotions including loneliness, unhappiness, worry, and stress that in turn lead individuals to, in part, experience more pain and pain sensitivity both physical and psychological. Over approximately the past three decades, survey data show that Americans, particularly middle-aged white people, report more pain than respondents in 30 other wealthy countries. Pain, especially chronic pain, can become a gateway to opioid use and addiction.

Factor in the Covid-19 pandemic, and it’s no wonder that 911 calls for opioid-related use increased 250% between 2019 and early 2020.

Echoing Durkheim, Case and Deaton concluded, “Jobs are not just the source of money; they are the basis for the rituals, customs, and routines of working-class life. Destroy work and, in the end, working-class life cannot survive. It is the loss of meaning, of dignity, of price, and of self-respect that comes with the loss of marriage and of community that brings on despair.”

Brian Alexander’s recent account of a hospital in Bryan, a small town in Ohio’s northeast corner, offers a glimpse into how destructive anomie can be. Particularly noteworthy is Alexander’s discussions of Keith Swihart, who experiences the worst outcomes from uncontrolled diabetes, including blindness and amputation; his wife, Stephanie, dead at age 46 from cervical cancer; and several of his friends who kill themselves by handgun, rifle, rope, or overdosing on fentanyl and amphetamines. One friend, Zach Rhinard, before fatally shooting himself in the head, wore a baseball cap that read, “ich bin innerlich tot.” Translation: “I am dead inside.”

As sobering as Alexander’s account is, the reality of deaths of despair is far more insidious.

Steven Woolf, a physician and lead author of the 2013 landmark Institute of Medicine report, “Shorter Lives, Poorer Health,” has for several years documented that U.S. life expectancy has not kept pace with that of comparable countries since the 1980s, about the time wages began stagnating. Life expectancy stopped increasing in 2010 and has fallen since 2014. This decline has not been caused just by epidemics in drug and alcohol abuse and suicides. Woolf and his colleague Heidi Schoomaker also found significant increases in excess deaths among white men and women in their midlife years from 35 other causes of death. These include infectious, neurological, and organ system diseases, mental and behavioral disorders, obesity, and injuries. In sum, the all-cause mortality rate, which should never significantly increase for a large population, increased for working-age white men without college degrees by approximately 25% over the past two decades.

While there are nuances to the relationship between economic conditions and mortality, the fact remains that the health status of 38% of working-age Americans has been significantly compromised over decades of economic hardship. The response to this fact by HHS has been beyond muted, something that is hard to understand since there is a well-documented correlation between income and health. This means health care policy and economic policy are inseparable.

As Woolf bluntly stated in opening his testimony before Congress on the 2013 “Shorter Lives, Poorer Health” report, “The lower people’s income, the earlier they die and the sicker they live.” To pretend otherwise is like, as Atul Gawande has analogized, treating a bullet wound with a pressure dressing.

In late October 2021, likely in anticipation of the CDC’s update on overdose deaths, HHS Secretary Xavier Becerra announced a “new overdose prevention strategy.” The department’s new, reactive strategy mirrored its old, reactive strategy, both of which ignored context. To his credit, Becerra attempted to express support for harm reduction via safe consumption sites. The department, however, immediately walked backed the comment.

Leaving aside what 38% of the workforce population with horrible health markers means relative to nativist politics and an ability to secure the nation’s defense, one might think that HHS would be concerned regarding labor-force effects on health care funding, spending, and staffing, as well as health care’s own contributory effects.

Even before the pandemic, approximately 20% of men between their early 20s and early 60s, or roughly 20 million men, had left the labor force. That is three times the percentage in 1960, and worse than the depths of the recent Great Recession in the late 2000s. Beyond excessive rates of illness and death, working-age men also have high rates of disability, with about 20% of men ages 25 to 54 saying they are disabled.

Add to this the Great Resignation that includes the health care labor market. Over the past two years, 18% of health care workers have quit their jobs and 31% are considering doing so. The cost of this economic time bomb is currently estimated at roughly $1 trillion in gross domestic product. This economic hit will worsen because of a rapidly aging workforce which, in turn, means that demands on Medicare and Medicaid, already on unstable financial ground, will be even greater.

The indefensible excessive cost of health care is largely absorbed by employer-based plans that insure approximately 160 million Americans. That these health plans are funded by employees’ lost wages (“lost” because this money would otherwise be paid to workers), Case and Deaton argue, substantially explains decades of lost jobs and stagnant wages particularly hard felt among lower-wage workers. Beyond the negative effect excessive costs have on care, the burden on low-wage workers constitutes a reverse Robin Hood effect that exacerbates already substantial economic inequality. As Case and Deaton conclude, “the industry that is supposed to improve our health is undermining it” and “our government is complicit.”

It would be encouraging if HHS leadership, along with the White House and the Congress, would publicly recognize deaths of despair, however they want to define them. But it appears that federal health care policy makers can neither bring themselves to use the phrase nor investigate the problem. A search of HHS’s website for the phrase yields no results. Searching the website of the Centers for Medicare and Medicaid Services similarly yields no results. The Biden White House has yet to use the phrase in a speech, remark, statement or release. Woolf has not been invited to testify before Congress since 2013. Deaton, a Nobel Prize economist, did testify in 2020 but before the House Budget Committee, where he discussed Covid-19. None of the four Congressional health committees have addressed deaths of despair.

The federal government’s public acknowledgment of the existence and impact of deaths of despair would be good. Better still would be for HHS leadership to recognize the relationship between socioeconomic stratification and health or sociomedical status. Still better would be for Becerra to borrow a page from Rudolf Virchow, the founder of social medicine, and recognize that “disease is an expression of individual life under unfavorable conditions,” and that epidemics, by which I mean here deaths of despair, “must be indicative of mass disturbances of mass life.”

Becerra and the rest of HHS need to put the social back into medicine and combat deaths of despair broadly defined using both medical and social policy. The lives of 38% of working-age Americans are in the balance.

David Introcaso is a vice president for regulatory policy at Strategic Health Care in Washington, D.C., and host of The Healthcare Policy Podcast.