Anne Case and Angus Deaton present a compelling and harrowing description of one of the United States’ most severe public health crises in recent history. The life expectancy of the average American has declined continuously for the past few years. Non-college educated whites have been driving this trend. This population has been dying at alarming rates from suicides, alcoholism, and “accidental poisonings” from opiates. Many of these preventable deaths are occurring among prime working-age adults. The opiate epidemic, deindustrialization, and declining economic fortunes for those without college degrees have coalesced into a slow-burning wildfire throughout U.S. communities.

Growing up in rural Ohio I have observed firsthand what Case and Deaton describe and am perhaps predisposed toward their arguments. I have peers who have died from opiate overdoses, I have witnessed the depopulation and decline of rural towns, and am one of the educated elites privileged enough to have migrated to better opportunities. I am writing this review during one of the worst pandemics in recent history and cannot help but recognized that the public health crisis afflicting less educated whites is driven by the same forces propelling the coronavirus crisis. Like the HIV epidemic under Ronald Reagan and COVID-19 pandemic under Donald Trump, the epidemic in Deaths of Despair is the result of deliberate policy actions or rather inactions. Case and

Deaton provide a thorough accounting of the current employment, health, and social conditions of the white working class and how said factors contribute to the mortality crisis. The authors show that the experience of this population differs from their peers in other nations and African Americans of the same economic strata. While the authors focus on the economic factors driving the mortality crisis and offer policy recommendations, they tend to avoid discussing the historical institutional factors and political intransigence that hamstrings policy making and prevents efforts to alleviate the crisis.

The first three chapters introduce the mortality crisis among less-educated white adults. The next six chapters elaborate upon the unique patterns in mortality, health, pain, and addiction experienced by these people. Chapter 9 stands out as an exemplary and comprehensive summary of the opiate crisis in the United States and its causes. Case and Deaton parallel the current crisis started by Purdue Pharma and the Sackler Family with the transgressions of profiteering British merchants against the Chinese two centuries earlier. From the FDA’s approval of Oxycontin without regarding the potential societal implications of the drug (pp. 127-28) to Congress undercutting the DEA’s efforts to pursue pill mills in 2016 (pp. 120, 124), the authors lay out the history of policy decisions that created the opiate epidemic.

Chapter 13 describes the market failures in U.S. healthcare and the social burden these market failures create. The historical account of why these failures arose and have been allowed to persist appears in Chapter 14. The authors note how employer-based healthcare emerged accidentally from price control policies enacted by the Federal Government during WWII and how racial politics played a role in blocking national health insurance (p. 224). As an economic historian, I wish the authors had shown the history of the U.S. health insurance system the same deference they did to the opiate crisis. The history of the U.S. healthcare system illustrates how policies actions by the Federal government, such as tax deductions, can create or reinforce rent-seeking lobbies.

It may be impossible to fully account for the multitude of factors feeding into the United States’ epidemic of suicide, alcoholism, and opiate addiction in a single book. The authors focus on how the burdens of the U.S. healthcare system, the decreasing bargaining power of laborers, and market consolidation among fewer firms put many in positions of precarity and poverty. Nevertheless, this is not a complete picture of the underlying causes of the current mortality crisis. The United States’ peculiar racial politics, fragmented political institutions, and decades of disinvestment in public goods all have contributed towards the conditions of the current crisis. Case and Deaton touch on the contributing issues such as the perceived loss of racial privilege and growing racial resentment (pp. 166, 190). They hint at broader political problems in Chapter 10 when stating the “policy response to the financial crisis in the US was less than it should have been” (p. 135). Still, the authors avoid discussing the elephant in the room, namely the growing intransigence towards legislative action in the United States. The predominant political ideology viewing “government is the problem” has helped contribute to the economic conditions driving deaths of despair. This same force has driven decades of public disinvestment and the malign neglect witnessed during the COVID-19 pandemic. The authors admit that the provision of public goods such as childhood education or basic road infrastructure has waned (though in the context of Medicaid expenditures crowding out other public goods, pp. 206-207). Price Fishback, Michael Haines, and Shawn Kantor (“Births, Deaths, and New Deal Relief during the Great Depression.” The Review of Economics and Statistics 89, no. 1 [2007]: 1-14.) have shown how major targeted fiscal interventions such as the New Deal can reduce mortality and improve the material well-being of the public. Notably absent from Chapter 16’s policy prescriptions are broad fiscal interventions such as a renewed effort in investing in decaying infrastructure, financing basic research, and developing nascent industries.

Even though the authors do not explicitly focus on the historic political and institutional forces that contributed to the current crisis, the book is deeply informative and persuasive. Economic historians will notice the potential parallels between the current crisis and displaced cottage industry workers of the first industrial revolution or the distress of the Great Depression. Aspects of the U.S. culture and institutions as detailed in Werner Troesken’s The Pox of Liberty: How the Constitution Left Americans Rich, Free, and Prone to Infection (Chicago: University of Chicago Press, 2015) lie behind the policy and economic failings highlighted by Case and Deaton. The historical consequences of healthcare policies made over half a century ago as described by Melissa Thomasson (“The Importance of Group Coverage: How Tax Policy Shaped U.S. Health Insurance.” American Economic Review 93, no. 4 [2003]: 1373-84.) echo throughout the text. Deaths of Despair and the Future of Capitalism highlights a relatively silent epidemic driven by economic precarity and provides a key description of the anatomy of the United States’ broader economic and social upheavals.