Despair: The plague of the white working class

The great social and medical mystery of the early 21st century in America is this: What is killing the white working class?

The leading detectives on the case, indubitably, are two Princeton economists who happen to be married to each other, Ann Case and Angus Deaton, winner of the 2015 Nobel Prize in economics. They in fact were the first to detect the condition.

Two years ago they published an academic study that you probably remember because it garnered so much attention. They discovered that from 1998 to 2013, the mortality rate got worse for one and only one demographic group in America: non-Hispanic, middle-aged whites.

It was a stunning and disturbing finding because for generation after generation, mortality rates — the most basic measure of public health — steadily fell for all Americans of all demographic description.

Some groups clearly fared better than others; whites have had lower mortality rates than blacks, for example, and still do. But all groups' got better year after year — except middle-aged whites early in the 21st century. Their death rates from cancer and heart disease, "the two biggest killers," declined as with the rest of the population. But they were offset by sharp increases in suicide, drug overdoses (mostly opioids) and alcohol-related liver disease.

Deaton and Case called these "deaths of despair." The phrase stuck.

The Deaton and Case duo published a troubling follow-up paper recently that showed that mortality rates continued to go up through 2015 for non-Hispanic whites, men and women, without college degrees of all ages, not just for the middle-aged. Mortality rates for everyone else continued to move in the right direction — for blacks, Hispanics and educated whites.

Deaton and Case found this to be an American phenomenon, not a "white" or Western one. In Europe, mortality rates are falling for everyone and even faster for people with less education than for their better-educated compatriots.

Deaton and Case have discovered the "what" in the mystery: opioids, alcohol and suicide. The real mystery is "why?"

The case of the white "deaths of despair" has taken on a life of its own, like a grand metaphor that could unlock what ails America and even explain the election of Donald Trump. So there has been a natural temptation to come up with vast, metaphoric explanations.

One follows the standard explanation of Trump's rise. Because of globalization and automation, employments and wages have declined since the 1980s for a white working-class Americans who previously could expect to earn good livings without higher education. While this might be a pat accounting for why Trump won, Deaton and Case didn't find evidence this caused more disease and mortality.

Another take is that those in the white working class came of age expecting that they would (and should) do better than their parents doing the same kinds of jobs and imbibe in the classic American dream. That expectation has been dashed by economic reality. "Deaths of despair" arise from that sense of loss, not just unemployment or underemployment. Historically unprecedented economic inequality aggravates all these wounds.

Deaton and Case are suspicious of single-concept explanations.

Instead, they propose a tentative, combination theory: For many years, poorly educated white men and women entering the labor market faced worse and worse economic prospects, which triggered a vicious cycle of "cumulative disadvantage" over the rest of their lives — "dysfunctions" in employment, marriage, religiosity, parenting and social life.

In the short hand of social science, the expectation of declining economic capital triggers behavior that diminishes social capital (meaningful connection to family, community, value traditions and institutions).

"Traditional structures of social and economic support slowly weakened," they write. "Marriage was no longer the only way to form intimate partnerships, or to rear children. People moved away from the security of legacy religions or the churches of their parents." With that came illness and the "deaths of despair."

Minorities, especially blacks, must think "yes, obviously" when they hear this kind of thinking. White mortality rates might be getting worse, but they're still better than black mortality rates. Dysfunction in black families and communities was a hot academic topic in the 1960s and a worsening problem today, as are their economic disadvantages.

Politics makes for an especially depressing subplot of the current mystery. In the last election, Donald Trump preyed on losses experienced by the white working class, offering no honest prescriptions and no realistic course of treatment. Instead, Trump and his party exploited the pain of the white working class — and of some better-educated, wealthier whites who feel and remember their pain — and channeled it into resentment and anger at blacks, Mexicans, Muslims, immigrants as well as the "establishment" elite who rig the system.

That is a prescription that ensures no one will get better.