It all started with a bad back. For more than a decade, the Princeton economist Anne Case had suffered from chronic lower-back pain, and nothing seemed to help. She’d made her name studying the connections between health and economic patterns in people’s lives; her research showed, for instance, a connection between your health in early childhood, or even in utero, and your economic status later in life. So she decided to research the patterns of pain in the population. And as she pulled on this thread she found a bigger, more alarming story than she ever expected.

The question she began with, in 2014, was whether pain had grown more or less prevalent in the United States over the past few decades. Given advances in labor-saving technologies and in pain treatments, she expected that the prevalence reported in population surveys would have fallen. Instead, it had gone up. Some hundred million Americans now suffer from chronic pain—that is, they’ve been in pain on most days for the past three months. And the rates are especially high in middle age: Americans in their fifties, unlike their counterparts in other countries, have higher rates of chronic pain than those in their seventies and eighties.

Case’s husband, Angus Deaton, is also an economist at Princeton. In 2013, he published a sweeping economic history, “The Great Escape,” which traced the way people had become healthier and wealthier in the past couple of centuries, though at a cost to economic equality. During his research, he’d noticed that people’s happiness was largely disconnected from this story. As wealth rose, so did health and quality of life; happiness did not necessarily follow. He was struck, then, when his wife told him that pain rates had not declined, either.

Was there a link? They combed through survey data together and found that communities with higher rates of chronic pain also had higher rates of suicide. What’s more, rates of both had risen markedly for middle-aged, non-Hispanic white Americans—but not for black or Hispanic Americans. And the data grew only more curious and concerning the further they looked. As Case and Deaton recount in their new book, “Deaths of Despair and the Future of Capitalism” (Princeton), they dug deeper into national vital statistics and compared rates of suicide with those of other causes of mortality. “To our astonishment, it was not only suicide that was rising among middle-aged whites; it was all deaths,” they write.

This was nearly unfathomable. Outside of wars or pandemics, death rates for large populations across the world have been consistently falling for decades. Yet working-age white men and women without college degrees were dying from suicide, drug overdoses, and alcohol-related liver disease at such rates that, for three consecutive years, life expectancy for the U.S. population as a whole had fallen. “The only precedent is a century ago, from 1915 through 1918, during the First World War and the influenza epidemic that followed it,” Case and Deaton write. Between 1999 and 2017, more than six hundred thousand extra deaths—deaths in excess of the demographically predicted number—occurred just among people aged forty-five to fifty-four. Case and Deaton first wrote about the rise in deaths from suicide and self-poisoning—what they came to call “deaths of despair”—in a 2015 paper. The editors at JAMA and The New England Journal of Medicine, the two most prominent medical journals, somehow missed the paper’s significance and rejected it without even a formal review; it was eventually published in a more technical journal, the Proceedings of the National Academy of Sciences, in November of that year. A few weeks before it appeared, Deaton was named the winner of the Nobel Prize in Economics, for his earlier work in development economics. But he considered this new paper to be as important as anything he’d done in his life. Sure enough, when the paper came out it was discussed on television, talk radio, and social media, drawing the sort of public response that seldom greets economic research. It had put numbers on a long-simmering but inchoate sense among many people that something had gone profoundly wrong with the American Dream.

But what, exactly? Why was this happening here and not elsewhere? Case and Deaton’s original paper offered no explanation, but their new book does. And their explanation begins by dismantling several others.

Was the source of the problem America’s all-too-ready supply of prescription opioids? For decades, drug companies notoriously played down their addictive properties, and we physicians, to our lasting shame, gave out the drugs like lollipops. Looking back, I am aghast at the glib reassurance I gave patients who hesitated about taking oxycodone after surgery. “Don’t worry,” I’d say. “Addiction is unusual after surgery.” But it wasn’t, and I should have known. Studies revealed that three to eight per cent of surgery patients who took narcotics for the first time after brief hospital stays were still taking the drugs as much as twelve months later. Abuse became widespread in the early years of this century. After regulations tightened the legal supply of opioids, users turned to other sources. About a million Americans now use heroin daily or near-daily. Many others use illicitly obtained synthetic opioids like fentanyl.

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Yet white Americans with bachelor’s degrees have accounted for only about nine per cent of overdose deaths in the past quarter century. Such deaths are even rarer among black Americans. As Case and Deaton note, most people who abuse or become addicted to opioids continue to lead functional lives and many eventually escape their dependence. The oversupply of opioids did not create the conditions for despair. Instead, it appears, the oversupply fed upon a white working class already adrift. And, although opioid deaths plateaued, at least temporarily, in 2018, suicides and alcohol-related deaths continue upward.

Could deaths of despair be related to the rising incidence of obesity? Obesity is known to increase chronic illness and joint pain, and its regional and demographic patterns track with deaths of despair. But Case and Deaton report that we’re seeing the same troubling health trends “among the underweight, normal weight, overweight, and obese.”

Is the problem poverty? Death rates for the white working class have seen no decline for nearly three decades, even as poverty rates fell during the nineteen-nineties, rose during the Great Recession, and fell again in the years afterward. Overdose deaths are most common in high-poverty Appalachia and along the low-poverty Eastern Seaboard, in places such as Massachusetts, New Hampshire, Delaware, and Connecticut. Meanwhile, some high-poverty states, such as Arkansas and Mississippi, have been less affected. Black and Hispanic populations are poorer but less affected, too.

How about income inequality? Case and Deaton have found that patterns of inequality, like patterns of poverty, simply don’t match the patterns of mortality by race or region. California and New York, for instance, have among the highest inequality levels in the country and the lowest mortality rates.

A consistently strong economic correlate, by contrast, is the percentage of a local population that is employed. The numbers have undergone a long decline nationally. In the late nineteen-sixties, Case and Deaton note, all but five per cent of men of prime working age, from twenty-five to fifty-four, had jobs; by 2010, twenty per cent did not. In 2018, well into the recovery from the Great Recession, fourteen per cent were still not at work. Of that fourteen per cent, only a fifth reported that they were looking for work and were therefore counted in official statistics as “unemployed.” The rest were not in the labor force. What Case and Deaton have found is that the places with a smaller fraction of the working-age population in jobs are places with higher rates of deaths of despair—and that this holds true even when you look at rates of suicide, drug overdoses, and alcohol-related liver disease separately. They all go up where joblessness does.