AMERICAN workers without college degrees have suffered financially for decades—as has been known for decades. More recent is the discovery that their woes might be deadly. In 2015 Anne Case and Angus Deaton, two (married) scholars, reported that in the 20 years to 1998, the mortality rate of middle-aged white Americans fell by about 2% a year. But between 1999 and 2013, deaths rose. The reversal was all the more striking because, in Europe, overall middle-age mortality continued to fall at the same 2% pace. By 2013 middle-aged white Americans were dying at twice the rate of similarly aged Swedes of all races (see chart). Suicide, drug overdoses and alcohol abuse were to blame.

Ms Case and Mr Deaton have now updated their work on these so-called “deaths of despair”. The results, presented this week at the Brookings Institution, a think-tank, are no happier. White middle-age mortality continued to rise in 2014 and 2015, contributing to a fall in life expectancy among the population as a whole. The trend transcends geography. It is found in almost every state, and in both cities and rural areas. The problem seems to be getting worse over time. Deaths from drugs, suicide and alcohol have risen in every five-year cohort of whites born since the 1940s. And in each group, ageing seems to have worse effects.

You might think that rising mortality is the flipside of falling incomes. Recent trends in median per-person income for households headed by white 50- to 54-year-olds mirror their mortality rate. Income rises in the 1990s and then falls in the 2000s, ending up roughly where it started. But split people out by education, and the reflection fades. The income of college graduates has followed a similar pattern (most of the surge in the value of a college education happened before 1990). But their mortality has steadily fallen. And deaths of despair are much rarer among blacks and Hispanics, whose incomes have been on similar paths.

The authors suspect more amorphous, long-term forces are at work. The fundamental cause is still a familiar tale of economic malaise: trade and technological progress have snuffed out opportunities for the low-skilled, especially in manufacturing. But social changes are also in play. As economic life has become less secure, low-skilled white men have tended towards unstable cohabiting relationships rather than marriages. They have abandoned traditional communal religion in favour of churches that emphasise personal identity. And they have become more likely to stop working, or looking for work, entirely. The breakdown of family, community and clear structures of life, in favour of individual choice, has liberated many but left others who fail blaming themselves and feeling helpless and desperate.

Why are whites the worst affected? The authors speculate that their misery flows from their crushed aspirations. Blacks and Hispanics face worse economic circumstances, but may have had lower expectations to begin with. Or they may have taken hope from progress against discrimination. Low-skilled whites, by contrast, may find many aspects of their lives perennially disappointing. That may push them towards depression, drugs and alcohol.

American exceptionalism

The theory, however, does not explain why misfortune is so lethal in America. It is hardly the only place where manufacturing jobs have disappeared and the social fabric has frayed. In other English-speaking countries—Australia, Britain, Canada and Ireland—deaths of despair have risen, but not by as much. More research is needed to find out precisely what is going on. But it is not hard to see ways in which Americans are particularly vulnerable.

One example is the easy availability of opioid painkillers. Deaths from opioids more than doubled between 2002 and 2015. The epidemic is primarily found in North America. Another is access to guns, which are used in around half of suicides. However, although both these factors probably increase deaths, they cannot fully explain them. Alcohol, which kills many of those who despair, is readily available across the West.

A more likely root cause for despair is the absence of a safety net for swathes of Americans, particularly in health care. Before Obamacare financed an expansion of Medicaid (government-provided health insurance for the poor), few states provided any coverage at all for adults without dependent children. (Today, of the 19 states that did not expand Medicaid, only Wisconsin covers any childless adults.) A lack of health insurance has obvious implications for mortality when illness strikes. But it causes the healthy anguish, too. A randomised trial in Oregon found that Medicaid reduces depression rates by a third; researchers have found more personal financial strain in states that did not expand the programme. In other rich countries, people in dire straits need not worry about paying for health care.

Broader social insurance is also lacking. The help available for workers who lose their jobs is paltry compared with their lifetime income losses. As a percentage of GDP, America spends only one-fifth of the average in the OECD, a club of mostly rich countries, on training workers. It spends only a quarter of the average on financial help for the jobless. Yet Americans do not seem to build their own safety nets: 46% say they could not cover an unexpected $400 expense and would have to sell something or borrow to pay for it. A perilous economic existence and a culture which almost indiscriminately holds people responsible for their circumstances are toxic for mental well-being.

Life is unlikely to become more secure for the low-skilled. In fact, policy may soon make it more perilous. The health-care bill that lawmakers were due to vote on as The Economist went to press would vastly increase costs for the older, poorer people who are suffering the most. One avenue for reducing despair may lie in future generations of low-skilled Americans curbing their aspirations. Indeed, some of the jobless young already seem content to spend much of their leisure time playing video games. But America can surely do better than to hope for less hope.

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