May 1, 2020 / 1:13 PM / 2 months ago

Breakingviews - Review: A grim look at bad American exceptionalism

LONDON (Reuters Breakingviews) - Each suicide has its own sad story, as does every death from alcohol and drug abuse. When the number of these tragic endings increases dramatically, something bigger is going on: a social failure. “Deaths of Despair and the Future of Capitalism” recounts the multifaceted communal neglect which has poisoned the lives of far too many vulnerable Americans – in many cases, literally. The spread of Covid-19 only reinforces the thesis.

A man who is living in the New York subway system sleeps in a relatively empty station as the outbreak of the coronavirus continues in New York, U.S., April 13, 2020.

Anne Case and Angus Deaton are senior economists at Princeton with expertise in public health and poverty, respectively. The combination, plus clear writing and ample doses of caution and open-mindedness, makes “Deaths of Despair” a compelling book.

The first half is factual. It traces the leading causes of the alarming divergence in the rate at which middle-aged people die in the United States, compared with other developed economies. To be precise, if white Americans between 45 and 54 years old had followed the same mortality trend as their European peers, 600,000 fewer of them would have died between 1999 and 2017. That is close to the 675,000 premature deaths caused by AIDS since the 1980s. 

Case and Deaton focus on the triple scourge of suicide, drink and drugs, especially opioids. In their middle-aged cohort, the recorded rate of death from these causes tripled. The toll would be higher with an accurate count of diseases worsened by substance abuse and near-suicidal recklessness.

The despair correlates with lack of formal education. Death rates for people with undergraduate degrees in this age group have hardly increased. Poorly educated people are also more likely to report having poor health, despite, or perhaps because of, taking vast quantities of painkillers. The division is largely new in the United States and unique to it. Similarly educated Europeans are much less wretched.

Case and Deaton are particularly skilled at summarising vast amounts of data. They investigate alternative hypotheses and take account of criticisms of earlier presentations of their thesis. The methodical approach makes the conclusion all the more chilling. Something has gone badly wrong with the American way of life, compared to both the nation’s past and the rest of the developed world. 

The second half of the book provides the authors’ explanation for the distinctly American rise in deaths of despair. The challenge is to find weaknesses in the American system which are fairly new there and not present, or not as pronounced, in Europe. 

The long list of potential explanations starts with unusually bad healthcare for poor people and goes on from there. Networks of social protection are particularly weak. Skilled workers have suffered an unusually steep decline. There’s been an unmatched rise in fatherless families. The financial system is especially exploitative. The government is more susceptible to corporate lobbying. Organised religion and community support have declined.

In Case and Deaton’s analysis, all these forces have combined to diminish both the social standing and the economic prospects for poor whites. Many of them have responded with antisocial, escapist and self-harming behaviour.

It’s a reasonably persuasive narrative, although there are so many distinctly American problems that it is easy to weave them together with different emphases. Indeed, while “Deaths of Despair” does not engage in cultural jeremiads, the high mortality rate of the most vulnerable group seems to be a particularly clear example of a much broader national loss of economic, social and political health.

The authors are particularly scathing about the excess cost of the U.S. healthcare system. They point out that if “a fairy godmother were somehow to reduce the share of healthcare in American GDP” to the level of Switzerland, the second most profligate county, there would be $8,300 more for the average household each year. That is a lot of money to fight against the forces of despair.

Though the book was written before Covid-19 struck America, the pandemic seems to be following a too-familiar pattern. The poor are suffering more than the rich, the government’s response is inadequate, and the healthcare system is not fit for purpose.

“Deaths of Despair” joins a burgeoning literary genre of American laments. In these studies, economists, sociologists and political commentators explain how and why the United States has moved from being world leader in pretty much everything to falling behind several European countries in many important indicators. When it comes to combating Covid-19, it has proven less capable than South Korea.

Like most of these books, “Deaths of Despair” ends with a chapter called “What to Do?”. Case and Deaton’s wish list will be familiar to American liberals: better healthcare, taxes, governance, corporate regulation, welfare provisions and education, plus higher minimum wages and more willingness to copy best practice elsewhere.

The list is long and the authors are not very optimistic. As they point out, the negative health trends in the United States have been getting steadily worse since the early 1990s. It takes a great deal of energy to overcome a malaise which has been deepening for that long. There are few signs that Americans are culturally well enough to face the challenge.


Reuters Breakingviews is the world's leading source of agenda-setting financial insight. As the Reuters brand for financial commentary, we dissect the big business and economic stories as they break around the world every day. A global team of about 30 correspondents in New York, London, Hong Kong and other major cities provides expert analysis in real time.

Sign up for a free trial of our full service at and follow us on Twitter @Breakingviews and at All opinions expressed are those of the authors.

0 : 0
  • narrow-browser-and-phone
  • medium-browser-and-portrait-tablet
  • landscape-tablet
  • medium-wide-browser
  • wide-browser-and-larger
  • medium-browser-and-landscape-tablet
  • medium-wide-browser-and-larger
  • above-phone
  • portrait-tablet-and-above
  • above-portrait-tablet
  • landscape-tablet-and-above
  • landscape-tablet-and-medium-wide-browser
  • portrait-tablet-and-below
  • landscape-tablet-and-below