Before 2015, few people would have thought of not finishing college as a public-health issue. That changed because of research done by Anne Case and Angus Deaton, economists at Princeton who are also married. For the past six years, they have been collaboratively researching an alarming long-term increase in what they call “deaths of despair” — suicides, drug overdoses, and alcoholism-related illnesses — among white non-Hispanic Americans without a bachelor’s degree in middle age.
Change any one of those attributes (race, nationality, education), and the trend disappears. Mortality has not increased among white Americans with a bachelor’s degree, nor American people of color, nor non-Americans without a bachelor’s degree. (Indeed, all-cause mortality among those groups has continued to go down, as usual.) Something about not having a bachelor’s degree in America, especially when white, can be deadly.
The term “deaths of despair” has taken on a life of its own, becoming ubiquitous in newspapers, magazines, and op-eds. It has been the subject of think-tank panels, conferences, and even government inquiry. “America Will Struggle After Coronavirus. These Charts Show Why,” proclaims a New York Times article that visualizes some of their research. This past fall, Congress’s Joint Economic Committee issued its own report on “Long-Term Trends in Deaths of Despair.”
Case and Deaton’s new book, Deaths of Despair and the Future of Capitalism (Princeton University Press), takes their message even further. Capitalism itself, they argue, needs serious reform if it is to make good on its potential to improve the lives of all Americans. In particular, as Case pointedly observed in a lecture last year at Stanford University, “We don’t think [American capitalism] is working for people without a four-year college degree — and that’s two-thirds of Americans between the ages of 25 and 64.” The coronavirus outbreak, the dire economic forecast, the millions of newly unemployed — all of these recent events raise the stakes of their research.
What difference does education make to a life?
It was an accident of government record-keeping that first allowed Case and Deaton to recognize that change in mortality among white Americans in middle age could be accounted for almost entirely by education level. Since 1989, U.S. death certificates have collected information on the highest level of education attained by the deceased. Mortality from all causes among middle-aged white Americans appeared steady at first, but then, they realized, the fates of the more- and less-educated were actually diverging. When they separated the groups, they saw that white middle-aged college graduates’ mortality had dropped 40 percent from 1990 to 2017, while those without a college degree became 25 percent more likely to die in middle age. The result: By 2017, those who hadn’t finished or never went to a four-year college were four times as likely to die between age 45 and 54 as those who did.
It’s too simple to say that college inoculates people against deaths of despair, and Case and Deaton do not say so. But their research on this mortality gap does raise the stakes on postsecondary education. If college helps produce not just creative and flexible thinking or higher lifetime earnings, but also greater average health and happiness for those who graduate, what should the role of college in American life look like? Should college enrollments grown ever higher, producing as many graduates as possible? Or should we instead focus on producing better job training and opportunities for people without a college degree? Now that the pandemic has once again plunged the world into an economic recession, these questions grow more urgent and less likely to be addressed anytime soon, while the gap between the experiences of those with and without undergraduate degrees continues to widen in the United States.
Consider the difference education has made in the lives of Case and Deaton, which they discussed recently in their tidy, spare offices at Princeton, just down the hall from each other. Case grew up in Binghamton, N.Y., where her mother (a teacher) and her father (an engineer) had moved, partly because of the quality of the area’s schools. They were strict Irish-American Catholics who supported the civil-rights movement and social justice in general. They also believed strongly in the importance of education, celebrated their four daughters’ good grades with spaghetti dinners out, and always presumed that their children would go to college.
Only after leaving home for the State University of New York at Albany, where she graduated first in her class, did Case feel her life had truly begun. She realized it was campuses she loved, and so she stayed: first by going to Princeton for a public-policy degree and then a Ph.D. in economics. She did not, in her words, “want to make money for rich people”; she wanted to help ordinary people “keep body and soul together.” Despite the boot camp-like, ego-flattening asperities of early-stage graduate training, as well as raw sexism from faculty members, her love for research and teaching led her to turn down a chance to work for the World Bank, and her career took her to Harvard and then back to Princeton.
Deaton was born in a Scottish town south of Edinburgh just months after the end of the Second World War. His father came from a coal town where schools served the mines and only one child a year received much education beyond age 12. Deaton’s father never really learned how to write, which led him to covet a solid education for his children. By a small miracle, he persuaded local schoolteachers to coach Deaton free in advance of an exam that won him a scholarship to Fettes College, an Edinburgh boarding school. From there, Deaton went to the University of Cambridge, where he studied economics and earned a Ph.D. He taught at the University of Bristol and then Princeton, eventually winning a Nobel Prize.
Deaton is very tall, and very large; Case is also tall, but seems almost wispy next to him. (At one point in the book, they describe themselves as being “beyond obese” and “on the cusp of being underweight,” respectively.) His suit jackets billow about him like cloaks, and he has a fondness for bow ties, a number of which he inherited from his mentor, the Cambridge economist Richard Stone. Both love fly-fishing (Deaton taught Case and calls her the better angler); for 20 years, they have spent as much of the summer as they can in the Montana town of Varney Bridge, known for its excellent rivers, where the research leading to their current book unexpectedly began.
Case keeps her posture very upright; like many of her subjects, she suffers from sciatica, a chronic back condition that causes intense pain in certain positions. In the summer of 2014, Case wondered about others’ experiences of chronic pain, so for vacation reading she brought along decades of data collected by the National Health Interview Survey, an annual study of medical problems in 35,000 households across the United States. It turned out that, year after year, Americans kept experiencing more and more pain in middle age. In fact, middle-aged Americans were reporting more pain than the elderly.
Education is at once a potential cause of and partial remedy for deaths of despair.
As Case pondered this mysterious increase in midlife pain at a table at the front of their cabin, Deaton sat in a comfortable armchair near the back, working on a presentation of their findings. The behavioral economist Daniel Kahneman had for some time encouraged them to think seriously about happiness as a topic of research, and they were now sifting through Gallup data to see if there were any connection between states’ average happiness and suicide rates. (Conclusion: no.)
It has been well established that suicide rates are generally low among black and Latinx Americans in comparison with whites, and also decline steadily with age. As Deaton looked through the data, he found an odd parallel with Case’s pain statistics: In contrast to minorities, suicide rates among white Americans were peaking in middle age. They decided they should compare the suicide rate among middle-aged white Americans to mortality rates from all causes — cancer, heart disease, everything else — in the same age group, expecting to find a decrease in mortality over time. So they downloaded a huge data set from the Centers for Disease Control and Prevention, ran the numbers, and arrived at the anomaly that would shape the next chapter of their careers.
Before their research, one of the best-established trends in the social sciences had been that in the modern world, mortality rates always go down. That trend held in any large population over time, regardless of country, gender, or any other variable, with rare, brief exceptions like the 1918 influenza pandemic, the AIDS crisis, and the immediate aftermath of the Soviet Union’s dissolution. Finding other counterexamples to this pattern was supposed to be impossible, so when Case and Deaton did, in 2015, they were at first convinced they had made a mistake. No one could have missed such a huge number of unexpected deaths. They estimated that since the late 1990s, some 600,000 people had died who would otherwise have lived longer, healthier lives. Five years on, the mortality trend shows no sign of reversing.
Shock and consternation greeted Case and Deaton’s first paper on these deaths, published in 2015 in the Proceedings of the National Academy of Sciences. When they presented it, Deaton recalls, “The reaction was always the same: People’s jaws just dropped. And no one could say, ‘Well, you made this mistake.’” The Dartmouth economists Ellen Meara and Jonathan Skinner wrote a dismayed comment alongside Case and Deaton’s article: “It is remarkable that it took more than a decade to bring this reversal to the attention of the scientific community.”
Fellow social scientists occasionally brought up issues of method or interpretation, but few disputed the basic finding. The Harvard economist David Cutler told The New York Times that deaths the profession had previously written off as blips due to the opioid epidemic seemed, in light of the article, “more like incoming missiles.” At that point, the commentary about the political implications of their research often struck a tone of unhurried, if sincere, concern — the 2016 primaries were still months away.
After Donald Trump’s election, Case and Deaton’s research took on a new significance. In March 2017 they published a much longer paper, “Mortality and Morbidity in the 21st Century,” that looked for potential causes of deaths of despair. They rejected the idea that despair was simply due to poverty, as well as the idea that income inequality was to blame. Rather, they suspected, different kinds of setbacks — declining wages, the loss of jobs requiring only a high-school education, family breakdown, weak social bonds, frequent illness — had piled on top of one another as far back as the early 1980s, increasing the pain on each successive generation of white Americans who didn’t finish college.
Political commentators seized anew upon “deaths of despair” — the very words struck a long, resounding chord. Their idea seemed to lend empirical support to a narrative of political backlash by less-educated white Americans against minorities and elites. “Americans are dying ‘deaths of despair.’ Will Trump help?” asked The Washington Post’s editorial board. “This may help explain Trump, according to economists studying mortality,” posited The Huffington Post. (Neither Case nor Deaton claimed their work had anything to do with Trump.) Others projected racial motivations onto their work, contending they were peddling narratives about white decline tailored to draw media attention. “Why is the story more dramatic or attractive when it’s about white people?” asked the journalist Malcolm Harris in Pacific Standard. “In 2017 the narrative that sells involves white workers who are unemployed, suffering, ignored, dying.”
In an early 2018 working paper published by the National Bureau of Economic Research, Christopher J. Ruhm, a professor of economics and public policy at the University of Virginia, suggested that “the ‘deaths of despair’ framing, while provocative, is unlikely to explain the main sources of the fatal drug epidemic.” He continued: “The fatal overdose epidemic is likely to primarily reflect drug problems rather than deaths of despair.” Case and Deaton responded that they had explicitly tested and rejected his hypothesis, and that in their work “despair” was meant to be “a label, not an explanation.”
As the phrase “deaths of despair” became more popular, Case and Deaton found themselves frustrated by a number of recurrent misunderstandings. Critics often seemed to them to be replying to points entirely different than the ones they intended to make. Regarding race, they think it is perfectly reasonable that the still-higher black mortality rate deserves every bit as much attention and concern as the rate among whites in their study. (Mortality among Latinx and Asian Americans is lower than that among whites.) Others incorrectly said their work focused on rural areas or particular regions of the country, perhaps conflating it with popular books like J.D. Vance’s memoir Hillbilly Elegy, when in reality deaths of despair were hitting metropolitan areas just as hard.
Lastly, they did not think the underlying problem was simply poverty. Money alone, in the form of aid or wages, would not fix matters, although they did believe higher wages were a necessary step toward a remedy. More and more, they found themselves turning to sociology — Durkheim’s Suicide, Andrew Cherlin and Sara McLanahan’s work on family dynamics, Robert Putnam’s Bowling Alone — for insight. In this light, problems like a lack of social connection, a sense of purposelessness in one’s work, and doubt that the future would improve underlay the mortality trends. Unemployment, income inequality, and other ills might be part of that problem, but the center of their story had broadened into something like the slow unraveling of a way of life.
Education is only one of the three central categories defining the main population of concern in Case and Deaton’s work. But education is at once a potential cause of and partial remedy for deaths of despair in ways that race and nationality, being fixed, are not.
The record unemployment caused by the Covid-19 epidemic has only intensified anxieties about the economic vulnerability of American workers without B.A.s. “Less-educated Americans are either essential, which puts their lives at risk, or nonessential, which puts their livelihoods at risk,” noted Deaton in a recent online talk, emphasizing that social distancing is harder to maintain the less money one has. Case said in a recent New York Times roundtable, “Eventually, when the time comes for people to go back to work, I worry that some large fraction of working-class people won’t have work to go back to.”
She and Deaton argue in Deaths of Despair and the Future of Capitalism that capitalism requires serious reform if it is to make good on its potential to improve the lives of all Americans rather than just a privileged few. Education, particularly postsecondary education, plays an important, recurring role: Neither savior nor villain, it offers all manner of protections to those who have it, yet leaves behind those who don’t.
“The four-year college degree is increasingly dividing America,” they write in the book. “A four-year degree has become the key marker of social status, as if there were a requirement for nongraduates to wear a circular scarlet badge bearing the letters BA crossed through by a diagonal red line.” Mortality from deaths of despair since 1995 continues to decline among college graduates across race and gender, but nongraduates have not seen a similar decrease. Drinking is more common among graduates, but binge-drinking more common among nongraduates. The incidence of debilitating physical and mental pain has grown since the late 1990s among young and middle-aged white nongraduates, while graduates are one-third less likely than the general population to experience chronic pain.
In the late 1970s, college graduates made about 40 percent more than those with just a high-school diploma; by 2000, that gap had doubled. It’s not awful that college graduates make more money; after all, people should have incentives to pursue education, Case and Deaton reason. And if the only trend were college graduates’ rising earnings, the situation would not be so bad. But on top of that, the earnings of people who did not graduate from college have been declining. Moreover, the pay gap has not proven an effective incentive to finish college: College-enrollment and college-completion rates have not followed the swelling difference in earnings. Roughly two-thirds of Americans over 25 do not have a bachelor’s degree: That is a lot of scarlet badges.
Case and Deaton’s account of the employment outlook for those with a high-school education or less is grim. In the past, an employee might have worked from the mailroom or janitorial closet upward through on-the-job training. Today, companies offer fewer opportunities for internal advancement. Case and Deaton scathingly denounce the practice of domestic outsourcing — replacing roles like security guards by contracting with big security firms that can offer cheaper (because non-unionized) labor. They also lament stagnant wages and lay much blame upon the American health-care industry — the book’s principal villain.
Health care soaks up money that could have gone to wages — nearly $11,000 per worker — and consumes 18 percent of the U.S. economy (Switzerland, at 12 percent, is a distant second), yet offers worse health outcomes per dollar than every other rich country’s health system. Deaton calls it “a very expensive system that’s not delivering much.” Estimated waste in health care totals around $1 trillion per year. The American health-care system also conditions employees to feel grateful for securing health care at all. “Economists would say they’re ‘pinning [employees] to their participation constraint,’” Case notes with disapproving irony, using air quotes, “paying them as little as possible to get them to continue to show up.”
In the midst of the pandemic, with mass unemployment jeopardizing coverage for many as a disease ravages the country, this state of affairs seems particularly explosive. Deaton thinks that the pandemic will result in either a “hero scenario” or a “villain scenario” for the health-care industry. In the hero scenario, pharmaceutical companies find a vaccine quickly and make it available widely and cheaply while doctors and nurses work bravely; insurers waive copays and deductibles, and they or the government provide free testing. In the villain scenario, drugs are expensive and rationed by price, ordinary people with infections are crushed under massive unexpected medical debt, and insurance premiums skyrocket in coming years.
“Now there are people who are going to face tens of thousands of dollars of medical bills for having been put on a ventilator,” Case noted at the New York Times roundtable. “There are predictions that health-insurance premiums could rise by as much as 40 percent. I think something is going to break. And when it breaks, we may think about real reform.”
“We do not accept the basic premise that people are useless to the economy unless they have a bachelor’s degree.”
Among the difficult questions raised by Case and Deaton’s research are these: Should we try to send as many Americans to college as possible (potentially changing the point of higher education in the process)? Should we try to build more and better careers and futures that don’t require college? And do most of the jobs that require a degree do so out of necessity, or merely to winnow an applicant pool?
Case and Deaton are not specialists in the economics of American higher education. They are wary of speculating, and quick to defer to the expertise of others. “I’ve written two books now in which I came out at the end of the book thinking I need to know more about education than I do know, and I don’t think either of us are really specialized in that … Your readers are going to know a lot more than we know!” Deaton admits. They didn’t start out working in education, but as they wrote the book, the topic of education became hard to avoid, even as, Case admits, “we’re on thin ice here.”
That said, they advance a few general beliefs. Case worries that, at present, most high schools focus too much on providing an education to students headed to college, with curricula for everyone else merely a watered-down form of college prep: “We need to be doing more up through age 18 for people who are not collegebound, so that we don’t end up with a bimodal society.” She continues: “I’ve flip-flopped as we’ve written the book on whether I think that everyone who can should go to college.”
She started out thinking that was ridiculous. “Not everyone has to go to college. We just need to rewrite the social contract between capital and labor in a way that gives people who haven’t been to college a say in their workplace and dignity in their workplace and a living wage.” But, at the same time, she thinks, the education system needs to change in a serious way, and that “will be a really heavy lift.”
Case and Deaton write jointly in their book about the attractiveness of a German model that gives greater resources to more flexible forms of vocational training. Deaton finds it puzzling that the model hasn’t yet caught on in the United States: “People have been saying for years that the German system would be good here … but somehow it never happens. And I don’t know what the institutional blocks to that are.”
They note that at Montana State University at Bozeman, near where they spend their summers, the economics major includes agricultural aspects — “Students are learning economics, but they’re learning economics that’s going to help them when they’re out working,” Case says. Deaton adds, “If everybody went to college, it would make sense that you’d have to have a much wider range of colleges than you have now. Many of us in Britain were upset when they made technical colleges into universities because they turned very good technical schools into bad liberal-arts universities.”
Throughout their book, they return with skepticism to the idea of meritocracy. Deaton notes that for much of the 20th century, people like himself, who came from humble backgrounds, had opportunities to do amazing things with their lives, things their parents might not have thought possible. “Equality of opportunity” rings hollow in his ears now. The people who use it as a rallying cry tend to do so as a justification: “‘Well, if there’s equality of opportunity, we don’t have to worry about the people who don’t succeed because they had their chance.’ And that’s not a satisfactory answer.”
Case and Deaton often cite the British sociologist Michael Young, best known for coining the term “meritocracy” in 1958 — which, they point out, was originally meant to describe a kind of dystopia. American life at present is, Deaton says, “the worst of Michael Young’s predictions in some sense. We’ve created an underclass, or what he called ‘the populists’ — and the rest of us he called ‘the hypocrisy.’”
“We would like to see a world in which everyone who can benefit from going to college, and wants to go to college, should be able to do so,” they write. “But we do not accept the basic premise that people are useless to the economy unless they have a bachelor’s degree. And we certainly do not think that those who do not get one should be somehow disrespected or treated as second-class citizens.”
“If people who get a B.A. think, ‘We’re the winners, and if we’re the winners, they’re the losers,’ that’s a really destructive setup,” Case says. Deaton mentions the work of Kwame Anthony Appiah, who argues that too often “winners” are all on a single track, whereas different tracks would allow several ways to excel. “The person who decides to be an engraver,” Deaton adds, “doesn’t have to be seen as a failed mathematician.”
In other words, people should not have to feel like losers in the great social lottery for choosing the level of education appropriate to their own sense of their abilities. Income is important, but only part of the social problem. It is not material envy, but rather a sense of being mocked or blamed for one’s own life outcomes that Case and Deaton think makes the mix of pain or illness, low pay, and lack of a college degree so dangerous for individuals and so corrosive to society. The salves for amorphous “despair” may be just as slippery as despair itself: belonging, dignity, meaning.
Correction (4/19/2020, 11:25 a.m.): This article originally said that Angus Deaton did not receive a Ph.D. In fact, he did. The text has been corrected accordingly.
Spencer Lee-Lenfield is an assistant editor at The Yale Review, contributing editor at Harvard Magazine, and doctoral student in comparative literature at Yale University.