The 20th century was an era of rapid and unprecedented improvement in public health all over the world.
In the United States alone, a person born in 1900 could expect to live to 49; by 2000, that person's great grandchildren were likely to see their 77th birthdays. Reaching old age is no longer an anomaly, and that is true for people of every race, ethnicity and social class.
Around 2000, however, came a stark and dramatic reversal of that trend, one documented in the disturbing book Deaths of Despair and the Future of Capitalism, by the husband-and-wife team of Anne Case and Angus Deaton, who won the 2015 Nobel Prize for Economics. For white Americans between 45 and 54, average life expectancy was no longer increasing; in fact, it was actually declining — in a pattern seen almost nowhere else on Earth. If increases in life expectancy had continued at the same rate, some 600,000 more Americans would now be alive, Case and Deaton write.
This reversal has come almost entirely among white Americans without a four-year college degree, who make up 38 percent of the U.S. working-age population. "Something is making life worse, especially for less educated whites," Case and Deaton write.
Much of the decline stems from higher rates of suicide, opioid overdoses and alcohol-related illnesses — the "deaths of despair" that Case and Deaton refer to. Americans "are drinking themselves to death, or poisoning themselves with drugs, or shooting or hanging themselves."
They're also no longer making progress against heart disease, due to higher rates of obesity and tobacco use. While U.S. smoking rates have declined precipitously over the years, they remain stubbornly high in states such as Mississippi, Kentucky, Alabama and Tennessee. Smoking rates are actually rising among middle-aged white women who lack a Bachelor's degree.
The America that Case and Deaton write about is an intensely class-bound place, where the less-educated experience higher rates of severe mental disease, have more trouble with the "instrumental activities of daily life," such as walking, and report more pain. Chronic pain is now more common among the middle-aged than the elderly, they write.
By contrast, Americans with a Bachelor's degree live longer, enjoy more stable families, report happier lives and abuse opioids and alcohol less often. They even vote more. Once, suicide was more common among the educated; today, the reverse is true.
Case and Deaton don't shy away from the likely cause of this public-health scandal: The collapse of the steady, decently paid manufacturing jobs that once gave meaning and purpose to working-class life. They write:
"Destroy work and, in the end, working-class life cannot survive. It is the loss of meaning, of dignity, of pride, and of self-respect that comes with the loss of marriage and of community that brings on despair, not just or even primarily the loss of money."
Men without good jobs make lousy husbands and poor fathers. "They may have children from a series of relationships, some or none of whom they know and some of whom are living with other men. Such fractured and fragile relationships bring little daily joy or comfort and do little to assure middle-aged men that they are living a good life," Case and Deaton write.
In such a world, marriages break up, and social bonds fray. The institutions that once provided ballast to working-class life — unions and mainstream churches — have proven largely ineffectual against the tectonic forces now reshaping the global economy.
Case and Deaton do a great job making the case that something has gone grievously wrong. The solutions they propose, such as repairing the U.S. safety net and overhauling the broken U.S. health-care system, are worthy ones, but somehow don't feel up to addressing the gargantuan social problems they spell out so well.
Something more will be needed to address the steady erosion of working-class life, with all the heartbreak and despair it's engendered.