iStock

In early January last year, the Fox News host Tucker Carlson took to the airwaves with a 15-minute rant about the way that American capitalism was crushing families and decimating white working-class communities. He blamed small government conservatives and liberal elites alike for ignoring the economic cause of the collapse of the working class. Conservatives, he complained, blame the problem solely on the breakdown of the traditional family. “Like the libertarians they claim to oppose, many social conservatives also consider markets sacrosanct,” Carlson said. “The idea that families are being crushed by market forces seems never to occur to them. They refuse to consider it.”

His indictment of American capitalism went viral and set off a familiar, if heated, debate, mostly on the right, where conservatives weren’t used to hearing such an assault on free market economics from one of their own. Yet Carlson’s assessment was rooted in solid academic research. In fact, his monologue could have served as the prologue for Deaths of Despair, a new book written by the married Princeton economics duo Anne Case and Nobel Prize winner Angus Deaton. They’re the academics who first shocked the country in 2015 with a new study finding that the mortality rates of white people, particularly those without college degrees, had spiked, after nearly a century of sustained decline.

At the time, they were hard pressed to explain exactly why white people were suddenly dying in such large numbers when everyone else—African Americans, Hispanics, and white working-class people in other countries—seemed to be doing better. Five years later, with Deaths of Despair, they’ve returned with a book-length investigation of the trends they first identified in 2015. Their updated data points are stark: Deaths from suicide, drug overdoses, and alcohol-related disease among middle-aged white men and women skyrocketed from 30 per 100,000 in 1990 to 92 per 100,000 in 2017. The spike in these deaths is almost exclusively confined to white Americans, both men and women, without a college degree. Mortality rates among college-educated Americans have continued to fall. Mortality rates for white-working class people in other wealthy countries are similarly in decline.

Case and Deaton note that these premature deaths are the reason that American life expectancy at birth has fallen for three straight years. Such a drop is unparalleled in modern U.S. history. The only comparable disaster came during the First World War and the flu epidemic that followed. The authors compare what’s happening with the American white working class to what happened after the collapse of the former Soviet Union, where the resulting countries saw radical change and dire economic straits. “It is no exaggeration to compare the long-standing misery of these Eastern Europeans with the wave of despair that is driving suicides, alcohol, and drug abuse among less educated white Americans,” they write.

Deaths of Despair is an academic book, laden with charts and facts and figures, and the authors devote a significant amount of ink to shooting down things they think are not causing the crisis—problems like obesity, for instance. But after dismissing a variety of possible causes for increasing mortality rates, they essentially come to the same conclusion Carlson did: that rapacious capitalism and predatory corporations, protected by politicians indebted to them, have destroyed the white working class. American capitalism, they write, is uniquely toxic and often looks “more like a racket for redistributing upward than an engine of general prosperity.” They believe that the way capitalism has run amok in the U.S., without much regulation or a safety net for those caught up in its creative destruction, is literally killing people.

Deaths of Despair features a battery of distressing statistics about the state of the white working class. For white men without a college degree, the average growth in median wages between 1979 and 2017 was a negative number (−0.2 percent a year), even as median hourly earnings for all white workers grew by 11 percent in the same period. This wage deflation has had well-documented cultural ripple effects, depressing marriage rates as men’s appeal as partners fell along with their earnings. Without a stable family life, these men are more isolated, with fewer of the sorts of social buffers that might inoculate them against suicide or drug abuse. As a result, the rates for both have gone up.

Women without college degrees are also suffering. Both men and women are now experiencing record levels of disability and stalled progress against heart disease. Women have always had lower rates of suicide, alcoholic liver disease, and drug overdoses, whether or not they have a four-year degree. But that has changed since the late 1990s. Working-class women without college degrees are dying from despair in about equal numbers as men. Case and Deaton don’t tease this out, but recent data suggests that white middle-aged women are now drinking themselves to death at a shocking rate. Between 1999 and 2015, alcohol-related deaths in this group soared by 130 percent.

But Case and Deaton argue that the deaths are far more than a product of stagnant wages or economic distress. If that were the case, African Americans would surely be leading the uptick, but they aren’t. White working-class people are much less likely to be poor than black Americans are, and while African Americans still have higher overall mortality rates, those rates have been falling for the past 20 years even as they’ve risen for white people without college degrees.

Instead, Case and Deaton point to something much broader at work in these numbers: the collapse of communities and the end of a way of life. Black communities experienced the ravages of deindustrialization decades before white communities did, along with an increase in mortality. These groups have since stabilized. But now, as rapid technological change and globalization have more thoroughly destroyed U.S. manufacturing, the community networks that kept the white working class together are collapsing.

That means that, just as 1980s Detroit or Baltimore was a ripe environment for the crack epidemic, white working-class areas of Kentucky or Ohio were uniquely primed for the opioid epidemic. Of the drug overdose deaths since the introduction of OxyContin, 90 percent have been among those without college degrees. “The people who used the opioids, the many millions who became opioid abusers or became addicted, who became zombies walking the streets of once-prosperous towns, were those whose lives had already come apart, whose economic and social lives were no longer supporting them,” the authors write.

But Case and Deaton also offer a harsh indictment of the pharmaceutical industry, which made obscene profits from getting vulnerable people hooked on deadly drugs. Indeed, they offer a harsh indictment of the health care system in general. American health care is stripping away fully 18 percent of the gross domestic product—nearly $11,000 per person in 2017. They describe the system as “a cancer at the heart of the economy, one that has widely metastasized, bringing down wages, destroying good jobs, and making it harder and harder for state and federal governments to afford what their constituents need.”

Out-of-control health care costs have helped turn good jobs into bad ones as companies outsource work to shift the cost of care elsewhere, keep wages down to compensate for rising health care costs, or eliminate many jobs entirely. Once, it was possible for janitors to work their way up into C-suite positions at major companies. That’s no longer true, because janitors now rarely work for the same company as the people in the offices they clean. Corporate managers have shunted these workers off to contractors that offer low wages, few benefits, and little opportunities for advancement. Meanwhile, all that health care spending is draining public investment on other important things, like education and infrastructure. It shows. U.S. roads are so dilapidated that FedEx trucks need new tires twice as often as they did 20 years ago, Case and Deaton write.

One key policy question that the authors don’t address is whether or not the Affordable Care Act has impacted mortality rates, which seems like a glaring oversight for a book like this. It would stand to reason that a law that extended decent health insurance to millions of people, many of them white working class, might have staunched the bleeding. But from the national numbers they present, Obamacare doesn’t seem to have been much of a salve. In fact, the death rate has accelerated since Obamacare passed in 2010. The problem with American health care, Case and Deaton say, is less insurance coverage than the enormous cost of the system that’s dragging the economy down with it. “The industry is not very good at promoting health, but it excels at promoting wealth among healthcare providers,” they write.

But while Obamacare may not have helped prevent deaths of despair, Case and Deaton’s research suggests that attacks on social safety programs have made the problem worse. The authors steer clear of partisan politics, but the death trends they’ve identified dovetail almost perfectly with conservatives’ decades-long assault on the nation’s social programs. Starting with the 1994 Republican revolution in Congress, both the federal government and many GOP-dominated states have made it much harder for people suffering a job loss or other calamity to access everything from Medicaid to food stamps, a trend that has likely exacerbated the current misery of white working-class people today. Thirty percent of people living on an income that’s half the poverty line—about $12,000 a year for a family of four with two kids—get no help from the government of any sort.

The lack of a safety net is one reason why Case and Deaton suggest that the working class in the U.S. is suffering in a way that those in other wealthy countries are not, even though the same forces of globalization and inequality are buffeting their citizens as well. Without a cushion for their fall in the midst of massive change, America’s white working-class communities are coming apart.

While Deaths of Despair does an admirable job of describing the scope of this epidemic and some of its causes, apparently not even a Nobel Prize–winning economist can figure out what to do about it. Case and Deaton throw up one or the other idea kicking around in politics in recent years—a universal basic income or higher marginal tax rates on the rich—only to dismiss the proposed solutions as ineffective, too expensive, or politically unpalatable.

Take the safety net—the same thing they identified as being helpful in protecting European people during the Great Recession and through 40 years of globalization. They argue that a bigger welfare state might have helped Americans when globalization first exploded, but that it would now be too little, too late. That’s especially true so long as the well-being of Americans is dependent on whether or not they have a college degree. “The safety net is something of a Band-Aid,” they write, “useful but incapable of addressing the fundamental problem”—the loss of good jobs for people without college degrees.

So if a college degree protects against much that ails the working class, maybe the government should embrace Bernie Sanders’s idea of free college for everyone? Eh, sorry, they declare. That would be too expensive, and most of the benefits would go to people who don’t need them. Besides, unless the American form of capitalism is reformed in a meaningful way, Case and Deaton warn, a bachelor’s degree is “not a suit of armor that protects you against change.” Just as African Americans suffered mass casualties 50 years ago with the decline in manufacturing jobs, and the white working class is suffering now, the authors conclude that it is entirely possible that “many of those with a college degree will be next in line.”

They see universal health care as critical, but only if it’s accompanied by significant cost controls, something likely to be stiffly opposed by big monied interests in the health care system, like doctors and pharmaceutical companies. To get around that problem, they advise giving some of the richest people in America the sort of soft landing that has never been available to the subjects of their book. “The healthcare lobby is the most powerful in Washington, and it is almost certainly impossible to have reform without paying them off at the time of the reform,” they note. “The alternative is to keep paying them off forever, and a well-designed reform, with cost control, will slowly reduce the tribute we have to pay them.”

Case and Deaton do suggest some simpler, more palatable solutions, such as increasing the minimum wage and expanding apprenticeship programs like those in Germany to help train workers who don’t go to college. And they champion better antitrust enforcement to increase competition and level the business playing field. But they lament that such efforts would require a functioning democracy, which the U.S. currently does not have, strangled as it is by “lobbying and by legislators’ need for deep-pocketed backers.”

In a rare moment of optimism, the authors argue that these political problems are solvable. “Democracy can rise to the challenge,” they write. “Democracy in America is not working well, but it is far from dead and it can work again if people push hard enough, just as it was made to work better in the Progressive Era a century ago and in the New Deal of the 1930s.”

But there’s not much evidence that the ship of American democracy can be turned in time to save working-class people, in large part because they themselves don’t think it’s possible. In 2016, the enterprising Washington Post reporter Jeff Guo discovered that in counties where white people were dying the fastest, Trump performed best in the GOP primary. Since assuming office, President Trump and the GOP-controlled Senate have single-mindedly pursued policies that will harm white working-class voters, through cuts in social welfare programs like food stamps and Medicaid and by allowing huge corporate mergers. Yet these same sick and dying white working-class voters want nothing to do with the Democratic Party, whose platform at least offers some meaningful assistance.

“It is easy to be pessimistic,” Case and Deaton concede. “The election of Donald Trump is understandable in the circumstances, but it is a gesture of frustration and rage that will make things worse, not better. Working-class whites do not believe that democracy can help them; in 2016, more than two-thirds of white working-class Americans believed that elections are controlled by the rich and by big corporations, so that it does not matter if they vote.”

They’re probably right. Even Tucker Carlson sees that the problem goes far beyond Trump. In his viral monologue last year, he said, “At some point, Donald Trump will be gone. The rest of us will be gone, too. The country will remain. What kind of country will it be then? How do we want our grandchildren to live? These are the only questions that matter.”