Reviewed by Roger Keeran

June 2020


Deaths of Despair and The Future of Capitalism by Anne Case and Angus Deaton. Princeton, New Jersey: Princeton University Press, 2020. $27.95. Pp. 312.


In 1845, Frederick Engels published The Condition of the Working-Class in England, a study based on his own experience working in the textile mills in England as well as on his research into government and private reports. Engels began with the most eloquent passage ever penned about workers under capitalism.


When an individual inflicts bodily injury upon another such injury that death results, we call the deed manslaughter; when the assailant knew in advance that the injury would be fatal, we call his deed murder. But when society places hundreds of proletarians in such a position that they inevitably meet a too early and an unnatural death, one which is quite as much a death by violence as that by the sword or bullet; when it deprives thousands of the necessaries of life, places them under conditions in which they cannot live—knows that these thousands of victims must perish, and yet permits these conditions to remain, its deed is murder just as surely as the deed of the single individual; disguised, malicious murder, murder against which none can defend himself, which does not seem what it is, because no man sees the murderer, because the death of the victim seems a natural one, since the offense is more one of omission than of commission. But murder it remains.


In 2019 two Princeton University economists, Anne Case and Angus Deaton, published a study on the condition of the American working class. Though lacking Engels’ practical experience and literary power, Case and Deaton discovered conditions as shocking and damning as Engels found 175 years ago. Today, white American blue collar workers, those with a high school education, are dying in staggering and unprecedented numbers from alcohol related disease, drug overdoses, and suicides, what the authors call “deaths of despair.”


Since 1999, these three causes have produced 600,000 “excessive deaths” of mainly white working class Americans.   Workers elsewhere in the world have avoided this scourge. Moreover, American Blacks and Hispanics, who have always suffered from deaths at greater rates than whites, have not experience the recent spike in deaths of despair that has been concentrated in the white working class.   Indeed, mortality rates for workers in the rest of the world and for Hispanic and Black Americans have been falling, while mortality for white, non-Hispanic workers has been rising.


The authors delineate the contours of this plague in jaw dropping detail. In 2017 alone 158,000 deaths of despair occurred. Of these, 70,000 were from drug overdoses; 47,000 from suicides. Drug overdoses are the “largest and fastest growing” cause of death.   These deaths are a direct result of opioids pushed by the pharmaceutical companies. The drugs include fentanyl (approved by the Federal Drug Administration in 1968), Vicodin, and OxyContin (manufactured by Purdue Pharmaceutical and approved by the FDA in 1995).


By 2015 one third of all adults, 98 million people, had prescriptions for opioids. The Sackler family, the owners of Purdue, sold between $30 and $50 billion worth of OxyContin, spent millions on advertising and promotion, and made between $12 and $13 billion in profits. In Kermit, West Virginia, a town of 406, during a two-year period, a single pharmacy dispensed nine million pills. Of course, the greed of Purdue and the complicity of the FDA constitute only part of the explanation.   The use opioids and the deaths by overdose is caused by the same problems that are leading to the growing number of deaths by alcohol and suicide.


Case and Deaton’s “main argument” is “that the deaths of despair reflect a long-term and slowly unfolding loss of a way of life for the white, less educated working class.” For vast numbers of workers, a way of life that once revolved around good jobs, decent income and benefits, marriage, family and social connections is disappearing.  Ultimately, Case and Deaton argue, “it is some features of American capitalism that is failing so many.”


Central to the disappearing way of life has been economic decline: the loss of good jobs and good wages. Median wages of American men have stagnated for fifty years, a phenomenon unequaled in any other industrial country. This reflects the loss of well-paid often unionized, manufacturing jobs. Five million such jobs disappeared between 1979 and 2007.   By 2019 only 12 million Americans worked in manufacturing compared to 18 million twenty years before.   Paralleling this decline has been the decline of working class health.


Today, more and more workers suffer from illness, pain, and an inability to work. More working age adults than senior citizens report living in pain. Areas of the country where workers experience the most bodily pain are also those with the highest unemployment rates, the greatest poverty, and largest number of votes for Donald Trump. Meanwhile, economic inequality has steadily grown. CEO earnings that averaged 20 times those of the average worker in 1965 now out-number the wages of the average worker by 278 times.


For Case and Deaton the economic hardships represent the root of a more destructive malignancy, the unraveling of family and social life and the growing alienation or anomie in working class communities   Marriage among white working class whites has declined.   Between 1980 and 2017, nonmarital childbearing among white women without college degrees has more than doubled.   The increase in social alienation is reflected in the decline of church membership, union membership, political engagement and voting.


Case and Deaton also describe the myriad features of American capitalism that are failing working people, including growing monopolization of the economy, the increasing political power of the rich and corporations, and the weakening of the social welfare.   High on their list of failures stands the American health care system. Even after Obamacare, 27 million Americans lack health insurance. Case and Deaton’s numbers on health care are eyepopping.   About half of working Americans have health insurance through their employers that averages about $10,739 per person. This amounts to a direct reduction of workers’ wages. The U.S spends more on healthcare and has higher mortality than twenty-five other countries. America has fewer doctors per head, and they are paid twice as much as in other countries. Prescription drugs are three times more expensive in the U.S. than elsewhere. Pharmaceutical companies spend more on marketing than on research.


The top ten pharmaceutical executives made salaries ranging from $38 million for Ari Bousbib of Iqvia to $18 million for Kenneth Frazier of Merck. Hospitals are becoming monopolized and are increasingly owned by private equity firms, whose primary interest is not health care but profits, and in 2017 hospitals spent $450 million on advertising. In 2018 the healthcare industry as a whole employed 2,829 lobbyists, more than 5 for each member of Congress. These conditions contribute to increased inequality of wealth and political power, to declining working class economic and social conditions, and worsening physical and mental health.


This book provides an immense amount of telling data on the current state of the blue collar working class and the dysfunction of American capitalism. The authors, however, utterly fail to provide an effective explanation of the root cause of these problems or to propose a realistic solution. The key to this failure resides in their main argument that “some features of American capitalism” are failing.   For these economists, who enjoy privileged positions in one the country’s leading universities, the problem is not capitalism but only “some features” of “American capitalism.” As if trying to shield themselves from the accusation of being wild-eyed radicals, the authors affirm several times, “We are not against capitalism.” For them, the answer to the grave and deadly problems facing workers are trifling reforms and modest tinkering to restore a social safety net, to improve the health care system, and to make markets free and competitive. As laudable as these reforms are, they are laughably insufficient to address the catastrophe they take the pains to describe.


The similarities and the contrasts between Case and Deaton and Engels could not be sharper.   Like Case and Deaton, Engels saw the deaths of despair suffered by workers. Like them, he found the terrible toll of alcohol, drugs, and suicide. Death from alcohol is not new. Engels found that the health of workers was enfeebled by “intemperance most of all.” Opioids are not new. Engels observed: “[T]he English working-people now consume patent medicines to their own injury and the great profit of the manufacturer. One of the most injurious of these patent medicines is a drink prepared with opiates, chiefly laudanum, under the name Godfrey’s Cordial.” Nor is working class suicide new. Engels said: “For suicide, formerly the enviable privilege of the upper classes, has become fashionable among the English workers, and numbers of the poor kill themselves to avoid the misery from which they see no other means of escape.”


Engels, however, did not call this carnage “deaths of despair,” which sounds more like a psychological diagnosis than a social analysis.   He called these deaths “murder.” And Engels did not shrink from naming the perpetrator of this murder—capitalism itself.   Nor did he delude himself with fanciful solutions of returning back to a more competitive capitalism but rather saw clearly that the way forward was a revolution that would entirely replace a system of exploitation, private ownership and profit seeking with socialism.


-Roger Keeran is an American historian and university professor who taught successively at Cornell, Princeton, Rutgers and the New York State University (SUNY). A specialist of Labor and Policy studies, he published, in 1980, The Communist Party and the Auto Workers’ Unions and, in 2004, with co-author Thomas Kenny, Socialism Betrayed: Behind the Collapse of the Soviet Union (a book translated into several languages), as well as various articles in history or sociology journals. He is now Professor Emeritus of the Empire State College at SUNY after retiring in 2013.