1932

Abstract

Deaths of despair, morbidity, and emotional distress continue to rise in the United States, largely borne by those without a college degree—the majority of American adults—for many of whom the economy and society are no longer delivering. Concurrently, all-cause mortality in the United States is diverging by education in a way not seen in other rich countries. We review the rising prevalence of pain, despair, and suicide among those without a bachelor's degree. Pain and despair created a baseline demand for opioids, but the escalation of addiction came from pharma and its political enablers. We examine the politics of despair, or how less-educated people have abandoned and been abandoned by the Democratic Party. Whereas healthier states once voted Republican in presidential elections, now the less-healthy states do. We review deaths during COVID-19, finding that mortality in 2020 maintained or exacerbated existing relative mortality differences between those with and without college degrees.

Loading

Article metrics loading...

/content/journals/10.1146/annurev-economics-051520-015607
2022-08-12
2024-04-24
Loading full text...

Full text loading...

/deliver/fulltext/economics/14/1/annurev-economics-051520-015607.html?itemId=/content/journals/10.1146/annurev-economics-051520-015607&mimeType=html&fmt=ahah

Literature Cited

  1. Achen CH, Bartels LM. 2016. Democracy for Realists: Why Elections Do Not Produce Responsive Government Princeton, NJ: Princeton Univ. Press
  2. Alsan M, Chandra A, Simon K 2021. The great unequalizer: initial health effects of COVID-19 in the United States. J. Econ. Perspect. 35:325–46
    [Google Scholar]
  3. Autor D, Dorn D, Hanson G, Majlesi K. 2020a. Importing political polarization? The electoral consequences of rising trade exposure. Am. Econ. Rev. 110:103139–83
    [Google Scholar]
  4. Autor D, Goldin C, Katz LF. 2020b. Extending the race between education and technology. AEA Pap. Proc. 110:347–51
    [Google Scholar]
  5. [Google Scholar]
  6. Blanchflower DG, Oswald AJ. 2004. Well-being over time in Britain and the USA. J. Public Econ. 88:1359–86
    [Google Scholar]
  7. Blanchflower DG, Oswald AJ. 2019. Unhappiness and pain in modern America: a review essay, and further evidence, on Carol Graham's Happiness for All?. J. Econ. Lit. 57:2385–402
    [Google Scholar]
  8. Blanchflower DG, Oswald AJ. 2020. Trends in extreme distress in the United States, 1993–2019. Am. J. Public Health 110:101538–44
    [Google Scholar]
  9. Bor J. 2017. Diverging life expectancies and voting patterns in the 2016 US presidential election. Am. J. Public Health 107:101560–62
    [Google Scholar]
  10. Case A 2015.. “ Deaths of despair” are killing America's white working class. Quartz Dec. 30. https://qz.com/583595/deaths-of-despair-are-killing-americas-white-working-class/
    [Google Scholar]
  11. Case A, Deaton A. 2015. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. PNAS 112:4915078–83
    [Google Scholar]
  12. Case A, Deaton A. 2017a. Mortality and morbidity in the 21st century. Brook. Pap. Econ. Act. Spring397–476
    [Google Scholar]
  13. Case A, Deaton A 2017b. Suicide, age, and well-being: an empirical investigation. Insights in the Economics of Aging DA Wise 307–34 Chicago: Univ. Chicago Press
    [Google Scholar]
  14. Case A, Deaton A. 2020. Deaths of Despair and the Future of Capitalism Princeton, NJ: Princeton Univ. Press
  15. Case A, Deaton A 2021a. Life expectancy in adulthood is falling for those without a BA degree, but as educational gaps have widened, racial gaps have narrowed. PNAS 118:11e2024777118
    [Google Scholar]
  16. Case A, Deaton A 2021b. Mortality rates by college degree before and during COVID-19 NBER Work. Pap 29328
  17. Case A, Deaton A, Stone AA. 2020. Decoding the mystery of American pain reveals a warning for the future. PNAS 117:4024785–89
    [Google Scholar]
  18. CDC (Cent. Dis. Control Prev.) 2021a. Monthly provisional counts of deaths by select causes, 2020–2021 Dataset, Natl. Cent. Health Stat. Washington, DC: accessed Aug. 18. https://data.cdc.gov/NCHS/Monthly-Provisional-Counts-of-Deaths-by-Select-Cau/9dzk-mvmi
  19. CDC (Cent. Dis. Control Prev.) 2021b. Health disparities: provisional death counts for coronavirus disease 2019 (COVID-19) Dataset, Natl. Cent. Health Stat. Washington, DC: accessed Aug. 14. https://www.cdc.gov/nchs/nvss/vsrr/covid19/health_disparities.htm#RaceHispanicOrigin
  20. CDC (Cent. Dis. Control Prev.) 2022. CDC WONDER Database, Cent. Dis. Control Prev., US Dep. Health Hum. Serv. Washington, DC: http://wonder.cdc.gov
  21. Cherlin AC. 2014. Labor's Love Lost: The Rise and Fall of the Working-Class Family in America New York: Russell Sage Found.
  22. Chetty R, Stepner M, Abraham S, Lin S, Scuderi B et al. 2016. The association between income and life expectancy in the United States, 2001−2014. JAMA 315:161750–66
    [Google Scholar]
  23. Cornia GA, Paniccià R, eds. 2000. The Mortality Crisis in Transitional Economies Oxford, UK: Oxford Univ. Press
  24. Couillard BK, Foote CL, Gandhi K, Meara E, Skinner J 2021. Rising geographic disparities in US mortality. J. Econ. Perspect. 35:412346
    [Google Scholar]
  25. Currie J, Schwandt H. 2018. Inequality in mortality decreased among the young while increasing for older adults, 1990–2010. Science 352:6286708–12
    [Google Scholar]
  26. Currie J, Schwandt H. 2020. The opioid epidemic was not caused by economic distress but by factors that could be more rapidly addressed NBER Work. Pap. 27544
  27. Cutler DM, Glaeser EL. 2021. When innovation goes wrong: technological regress and the opioid epidemic. J. Econ. Perspect. 35:417196
    [Google Scholar]
  28. Deaton A. 2012. The financial crisis and the well-being of Americans. Oxf. Econ. Pap. 64:11–26
    [Google Scholar]
  29. Deaton A. 2018. What do self-reports of wellbeing say about life-cycle theory and policy?. J. Public Econ. 162:18–25
    [Google Scholar]
  30. Economist. 2016. Illness as indicator: local health outcomes predict Trumpward swings. The Economist Nov. 19
    [Google Scholar]
  31. Geronimus AT, Bound J, Waidmann TA, Rodriguez JM, Timpe B. 2019. Weathering, drugs, and whack-a-mole: fundamental and proximate causes of widening educational inequity in U.S. life expectancy by sex and race, 1990–2015. . J. Health Soc. Behav. 60:2222–39
    [Google Scholar]
  32. Goldman N, Glei DA, Weinstein M. 2018. Declining mental health among disadvantaged Americans. PNAS 115:287290–96
    [Google Scholar]
  33. Goldsmith SK, Pelimar TC, Kleinman AM, Bunney WE, eds. 2002. Reducing Suicide: A National Imperative Washington, DC: Natl. Acad. Press
  34. Graham C. 2017. Happiness for All? Unequal Hopes and Lives in Pursuit of the American Dream Princeton, NJ: Princeton Univ. Press
  35. Grol-Prokopczyk H. 2017. Sociodemographic disparities in chronic pain, based on 12-year longitudinal data. Pain 158:2313–22
    [Google Scholar]
  36. Hendi A. 2017. Trends in education-specific life expectancy, data quality, and shifting education distributions: a note on recent research. Demography 54:31203–13
    [Google Scholar]
  37. Hollingsworth A, Ruhm CJ, Simon K. 2017. Macroeconomic conditions and opioid abuse. J. Health Econ. 56:222–33
    [Google Scholar]
  38. James J. 2012. The college wage premium Econ. Comment. 2012–10 Res. Dep. Fed. Reserve Bank Cleveland Cleveland, OH: https://www.clevelandfed.org/newsroom-and-events/publications/economic-commentary/economic-commentary-archives/2012-economic-commentaries/ec-201210-the-college-wage-premium.aspx
  39. Jemal A, Ward E, Anderson RN, Murray T, Thun MJ. 2008. Widening of socioeconomic inequalities in U.S. death rates, 1993–2001. PLOS ONE 3:5e2181
    [Google Scholar]
  40. Kates J, Tolbert J, Orgera K. 2021. The red/blue divide in COVID-19 vaccination rates. KFF Sep. 14. https://www.kff.org/policy-watch/the-red-blue-divide-in-covid-19-vaccination-rates/
    [Google Scholar]
  41. KFF (Kaiser Fam. Found.) 2020. 2020 employer health benefits survey Rep., KFF San Francisco, CA: https://www.kff.org/report-section/ehbs-2020-section-1-cost-of-health-insurance/
  42. Koob GF, Powell P, White A. 2020. Addiction as a coping response: hyperkatifeia, deaths of despair, and COVID-19. Am. J. Psychiatry 177:111031–37
    [Google Scholar]
  43. Kuziemko I, Washington E 2018. Why did the Democrats lose the South? Bringing new data to an old debate. Am. Econ. Rev. 108:102830–67
    [Google Scholar]
  44. Leive A, Ruhm CJ. 2020. Has mortality risen disproportionately for the least educated? NBER Work. Pap. 27512
  45. Lovell J. 2014. The Opium War: Drugs, Dreams, and the Making of Modern China New York: Overlook Press
  46. Mackenbach JP, Kulhánova I, Artnik B, Bopp M, Borrell C et al. 2016. Changes in mortality inequalities over two decades: register based study of European countries. BMJ 353:i1732
    [Google Scholar]
  47. Mackenbach JP, Valverde JR, Artnik B, Bopp M, Brønnum-Hansen H et al. 2018. Trends in health inequalities in 27 European countries. PNAS 115:256440–45
    [Google Scholar]
  48. Macy B. 2018. Dopesick: Dealers, Doctors, and the Drug Company That Addicted America New York: Hachette
  49. Masters RK, Tilstra AM, Simon DH. 2018. Explaining recent mortality trends among younger and middle-aged White Americans. Int. J. Epidemiol. 47:181–88
    [Google Scholar]
  50. McCarthy MA. 2017. Dismantling Solidarity: Capitalist Politics and American Pensions Since the New Deal Ithaca, NY: Cornell Univ. Press
  51. Meara ER, Richards S, Cutler DM. 2008. The gap gets bigger: changes in mortality and life expectancy, by education, 1981−2000. Health Aff. 27:2350–60
    [Google Scholar]
  52. Metzl JM. 2019. Dying of Whiteness New York: Basic Books
  53. Miller S, Wherry LR, Mazumder B. 2021. Estimated mortality increases during the COVID-19 pandemic by socioeconomic status, race, and ethnicity. Health Aff 40:81252–60
    [Google Scholar]
  54. Monnat SM. 2016. Deaths of despair and support for Trump in the 2016 presidential election Res. Brief, Pa. State Univ University Park: https://smmonnat.expressions.syr.edu/wp-content/uploads/ElectionBrief_DeathsofDespair.pdf
  55. Monnat SM, Brown DL. 2017. More than a rural revolt: landscapes of despair and the 2016 presidential election. J. Rural Stud. 55:227–36
    [Google Scholar]
  56. Montez JK, Hummer RA, Hayward MD, Woo H, Rogers RG. 2011. Trends in the educational gradient of US adult mortality from 1986 through 2006 by race, gender, and age group. Res. Aging 33:145–71
    [Google Scholar]
  57. Montez JK, Zajacova A. 2013. Trends in mortality risk by education level and cause of death among US white women from 1986 to 2006. Am. J. Public Health 103:473–79
    [Google Scholar]
  58. Moynihan DP. 1965. The Negro family: the case for national action Rep., Off. Policy Plan. Res., US Dep. Labor Washington, DC:
  59. Mulligan CB. 2020. Deaths of despair and the incidence of excess mortality in 2020 NBER Work. Pap 28203
  60. Nahin RL, Sayer B, Stussman BJ, Feinberg TM 2019. Eighteen-year trends in the prevalence of, and health care use for, noncancer pain in the United States: data from the Medical Expenditure Panel Survey. J. Pain 20:7796–809
    [Google Scholar]
  61. NASEM (Natl. Acad. Sci. Eng. Med.) 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: Natl. Acad. Press
  62. NASEM (Natl. Acad. Sci. Eng. Med.) 2021. High and Rising Mortality Rates Among Working-Age Adults. Washington, DC: Natl. Acad. Press
  63. Novosad P, Rafkin C, Asher S. 2021. Mortality change among less educated Americans. Am. Econ. J. Appl. Econ. In press
    [Google Scholar]
  64. Olfson M, Cosgrove C, Altekruse SF, Wall MM, Blanco C. 2021. Deaths of despair: adults at high risk for death by suicide, poisoning, or chronic liver disease in the US. Health Aff. 40:3505–12
    [Google Scholar]
  65. Olshansky SJ, Antonucci T, Berkman L, Binstock RH, Boersch-Supan A et al. 2012. Differences in life expectancy due to race and educational differences are widening and many may not catch up. Health Aff. 31:81803–13
    [Google Scholar]
  66. Pethokoukis J. 2021. 5 questions for Ed Glaeser on the economics of the opioid crisis. AEI July 30. https://www.aei.org/economics/5-questions-for-ed-glaeser-on-the-economics-of-the-opioid-crisis/
    [Google Scholar]
  67. Pethokoukis J, Glaeser E. 2021. A supply-side explanation of the opioid crisis: my long-read Q&A with Ed Glaeser. AEI July 29. https://www.aei.org/economics/how-did-entrepreneurs-respond-to-covid-19-my-long-read-qa-with-ed-glaeser/
    [Google Scholar]
  68. Phillips JA, Nugent CN. 2014. Suicide and the great recession of 2007–2009: the role of economic factors in the 50 states. Soc. Sci. Med. 116:22–31
    [Google Scholar]
  69. Pirkis J, John A, Sangsoo S, DelPozo-Banos M, Arya V et al. 2021. Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countries. Lancet Psychiatry 8:57988
    [Google Scholar]
  70. Platt SM. 2018. Imperial Twilight: The Opium Wars and the End of China's Last Golden Age New York: Knopf
  71. Radler BT, Ryff CD. 2010. Who participates? Accounting for longitudinal retention in the MIDUS national study of health and well-being. J. Aging Health 22:3307–31
    [Google Scholar]
  72. Reeves A, Stuckler D, McKee M, Gunnell D, Chang S-S et al. 2012. Increase in state suicides in the USA during economic recession. Lancet 380:98561813–14
    [Google Scholar]
  73. Ritchie H, Roser M, Ortiz-Ospina E. 2021. Suicide. Our World in Data https://ourworldindata.org/suicide
    [Google Scholar]
  74. Robbins LN. 1993. Vietnam veterans’ rapid recovery from heroin addiction: a fluke or a normal expectation. Addiction 88:1041–54
    [Google Scholar]
  75. Rossen LM, Hedegaard H, Warner M, Ahmad FB, Sutton PD. 2021. Early provisional estimates of drug overdose, suicide, and transportation-related deaths: nowcasting methods to account for reporting lags NVSS Vital Stat. Rapid Release Rep. 011, Natl. Cent. Health Stat. Hyattsville, MD: https://www.cdc.gov/nchs/data/vsrr/vsrr011-508.pdf
  76. Rostron BL, Boies JL, Arias E. 2010. Education reporting and classification on death certificates in the United States. Vital Health Stat 2:1511–21
    [Google Scholar]
  77. Ruggles S, Flood S, Foster S, Goeken R, Pacas J, Schouweiler M, Sobek M. 2021. IPUMS USA: version 11.0 Dataset, IPUMS Minneapolis, MN:
  78. Ruhm CJ. 2021. Living and dying in America: an essay on Deaths of Despair and the Future of Capitalism. J. Econ Lit. In press
    [Google Scholar]
  79. Sandel M. 2020. The Tyranny of Merit: What's Become of the Common Good New York: Farrar, Straus and Giroux
  80. Sasson I. 2016a. Diverging trends in cause-specific mortality and life years lost by educational attainment: evidence from United States Vital Statistics Data, 1990−2010. PLOS ONE 11:10e0163412
    [Google Scholar]
  81. Sasson I. 2016b. Trends in life expectancy and lifespan variation by educational attainment: United States, 1990−2010. Demography 53:269–93
    [Google Scholar]
  82. Sasson I, Hayward M. 2019. Association between educational attainment and causes of death among white and black US adults, 2010−2017. JAMA 322:8756–63
    [Google Scholar]
  83. Schwandt H. 2016. Unmet aspirations as an explanation for the U-shape in wellbeing. J. Econ. Behav. Organ. 122:75–87
    [Google Scholar]
  84. Siddiqi A, Sod-Erdene O. 2021. Invited commentary: Do small cause-of-death correlations throw into question the notion of a collective “deaths of despair” phenomenon?. Am. J. Epidemiol. 190:61172–74
    [Google Scholar]
  85. Siddiqi A, Sod-Erdene O, Hamilton D, Cottom TM, Darity W. 2019. Growing sense of status threat and concomitant deaths of despair among whites. SSM—Popul. Health 9:100449
    [Google Scholar]
  86. Simon DH, Masters RK. 2021. Do deaths of despair move together? County-level mortality changes by sex and urbanization. Am. J. Epidemiol. 190:61169–71
    [Google Scholar]
  87. Stuckler D, Kling L, McKee M. 2009. Mass privatization and the post-communist mortality crisis. Lancet 373:9661399–407
    [Google Scholar]
  88. Thomas K, Gunnell D. 2010. Suicide in England and Wales 1861–2007: a time-trends analysis. Int. J. Epidemiol. 39:1464–75
    [Google Scholar]
  89. UNESCO (UN Educ. Sci. Cult. Organ.) 2006. International Standard Classification of Education—ISCED 1997. Paris: UNESCO New ed. http://uis.unesco.org/sites/default/files/documents/international-standard-classification-of-education-1997-en_0.pdf
  90. US Census Bur 2021. CPS historical time series tables Tables, US Census Bur. Washington, DC: https://www.census.gov/data/tables/time-series/demo/educational-attainment/cps-historical-time-series.html
  91. US Congr. Joint Econ. Comm 2019. Long-term trends in deaths of despair SCP Rep 4–19 US Congr. Joint Econ. Comm. Washington, DC: https://www.jec.senate.gov/public/index.cfm/republicans/2019/9/long-term-trends-in-deaths-of-despair
  92. Wilkerson I. 2020. Caste: The Origins of Our Discontents. New York: Random House
  93. Woolf SH, Chapman DA, Buchanich JM, Bobby KJ, Zimmerman EB et al. 2018. Changes in midlife death rates across racial and ethnic groups in the United States: systematic analysis of vital statistics. BMJ 362:k3096
    [Google Scholar]
  94. Woolf SH, Schoomaker H. 2019. Life expectancy and mortality rates in the United States, 1959−2017. JAMA 322:201996–2016
    [Google Scholar]
  95. Woolhandler S, Himmelstein DU, Ahmed S, Baily Z, Bassett MT et al. 2021. Public policy and health in the Trump era. Lancet 397:10275705–53
    [Google Scholar]
  96. Young M. 1958. The Rise of the Meritocracy London: Thames & Hudson
  97. Zajacova A, Grol-Prokopczyk H, Zimmer Z. 2021. Pain trends among American adults, 2002–2018: patterns, disparities, and correlates. Demography 58:2711–38
    [Google Scholar]
  98. Zimmer Z, Zajacova A. 2020. Persistent, consistent, and extensive: the trend of increasing pain prevalence in older Americans. J. Gerontol. B. Psychol. Sci. Soc. Sci. 75:2436–47
    [Google Scholar]
/content/journals/10.1146/annurev-economics-051520-015607
Loading
/content/journals/10.1146/annurev-economics-051520-015607
Loading

Data & Media loading...

  • Article Type: Review Article
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error