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Book Review-Deaths of Despair and The Future of Capitalism

Suicide is, unfortunately, not the only death of despair.  In Deaths of Despair and the Future of Capitalism, the argument is made that we’re getting crushed by suicide, drug overdoses, and alcohol related deaths.  These are, the authors assert, the deaths of despair – and that they’re uniquely being amplified by the American system of capitalism.  In fact, they argue that there’s a class difference between those with bachelor’s degrees and those without them.

Education’s Protection

The basic argument – backed by a mountain of data – is that those who have at least a bachelor’s degree are protected from much of the despair.  They’re not immune to problems or even a death of despair, but the prevalence is lower.  Paul Tough in The Years that Matter Most explains that not only does going to college matter, but so does which college you go to.  He’s speaking about the high end of opportunities unlocked by both the education and the network that you develop.  What happens below the line – when you can’t get into any college?  That’s what concerns Anne Case and Angus Deaton.  Why is it that people who don’t get a degree do so poorly?

The answer may be a cascade of factors.  First, jobs have become increasingly more complex and have required greater technical skill.  While there’s an argument that too few people go into the field in which they earned their degree, there’s a belief that a bachelor’s degree proves a general acumen.  In any case, the unemployment numbers indicate that unemployment is higher without a bachelor’s degree than with them.  In short, there’s a greater likelihood of employment with a degree.

Second, the prospects of marriage are much better with a job than without.  There’s an expectation that especially men should be able to support their spouse and ultimately their families.  Without a job, that’s not possible.  So not only does a degree convey better job prospects, where many get their self-worth and socialization, but it conveys better opportunities for marriage.

Third, marriage means, on average, a better economic picture.  Two people working together – both of whom are likely to have a degree – is much better financially than two people working alone.  The result is that the person with a bachelor’s degree is likely to be even better financially than just the degree implies.

Thus, the degree allows for a set of conditions that lead to several protective factors: the belief in self-worth, the engagement of social connections, an intimate partner, and financial resources.  It’s a keystone marker that had a large impact on future outcomes.

Put Out the Fire


What few people realize is that substance use disorder – a drug addiction – isn’t just a problem.  It’s a solution, too.  It’s the way that people have learned to cope with their life’s circumstances.  There is a lot of mythology with drugs that makes it difficult for people to accept that people with substance use disorder aren’t bad people – and it’s not that drugs are so addictive.  Even Bruce Alexander’s work about Rat Park is misrepresented as saying that even rats become addicted to morphine.  (See Chasing the Scream, and The Globalization of Addiction for more.)  We’ve been sold a bill of goods that people who use drugs are bad, and even one attempt at drugs will addict everyone.  It’s just wrong.

The painful truth about drug use is that people use drugs because of some other pain they’re facing that they don’t know how to handle.  There’s something that they don’t know how to resolve, and the drugs make it go away – at least for a while.  That’s why including drug use as a death of despair makes so much sense.

Another tricky aspect of drug use as it pertains to suicide is that it’s very difficult to distinguish a suicide death by drugs from an unintentional one.  Intent to die is the only thing that separates the suicide from the accidental overdose, and there’s no clear, bright line.  Ambivalence and not protecting oneself from overdose death is only a matter of degrees different than intentional overdose.  Even those who survive may not be certain themselves.

There was a real problem that was created by pharmaceutical companies, particularly Purdue Pharma, where powerful opioids were sold as non-addictive.  The result of continued overuse led to addiction.  Oxycontin was massively overprescribed for pain.  When controls started to be placed on opioid prescriptions, and they became both harder and more expensive to get, many people switched to heroin, because it was a similar but cheaper option.  (See the book Dreamland for this transition and the opioid crisis in general.)

The number of deaths due to drug overdose is estimated at 107,000 in 2021.  This is roughly double the number of deaths that are categorized as suicide in the United States.  More than that, these startling numbers are a key indication that many people are suffering.


Drugs are at least illegal.  Deaths by overdose are necessarily criminal when the drugs themselves are outside the law.  However, what about the deaths that center around alcohol?  We tried prohibition in the United States, and it ended quite poorly with the rise of crime.  We won’t attempt eliminate consumption of alcohol again, but it does take a huge toll on us.  The CDC estimates over 140,000 people die through excessive alcohol consumption – that’s roughly three times as many people as die by suicide each year.  It’s appropriate to focus on the mortality associated with alcohol.  However, we can’t ignore that alcohol – like drugs – causes suffering in other ways as well.

Alcohol consumption differs between those with and without a bachelor’s degree.  People without a degree are more likely to drink heavily, less likely to drink in moderation, and less likely to abstain from drinking.  Alcohol is really a drug – a legal one – that people use to help them numb the pain of their daily lives.


The most addictive substance is nicotine.  Decades ago, the tobacco industry’s chokehold on information about the harmful effects of smoking was broken.  Despite this, we still find that 11.4% of adults with bachelor’s degrees smoked – as compared to 19.8% of people without a degree.  It would be practically impossible to smoke without awareness of the long-term health impacts.  If nothing else, the on-package warnings are a solid clue.

This is a powerful indicator that simply having knowledge of something doesn’t mean that we’ll change behavior.  Everett Rogers in Diffusion of Innovations explains that we must change knowledge, then attitudes, to get to a change in practice – or behavior.  (See Knowledge-Attitudes-Practices for more.)  An official strategy for combatting tobacco use is called the Transtheoretical Model – or Stages of Change.  It’s important to recognize that this model accepts that some people aren’t even open to changing their behavior, and engaging them in a discussion about the change may cause them to dig in their heels.

Deaths and the Economy

Though suicides are correlated with economic hardship, deaths generally fall during economic hardship.  The reason for this is that, though suicide deaths increase, other types of deaths fall.  Whether the core of that is because people don’t have the money to do riskier things or they’re not stressed by their jobs, the odd relationship means that there is often more than meets the eye when we’re looking at societal changes.

Unable to Work

One of the difficult parts of addressing deaths of despair is the degree and type of support to offer.  We see that countries that have better social support programs have fewer suicides when unemployment increases, but the concern is that we’re demotivating people from working.  In fact, we’ve seen a general decline in the percentage of men of working age that are in the workforce.  That’s a troubling statistic.

Part of the issue is that there’s a greater participation in higher education, but that’s not enough to explain the decrease.  Investigation of the numbers notes that there is a troubling trend that people exit the employment market during downturns – perhaps through no fault of their own – but they don’t always return to the work force.  This is irrespective of the social supports in place.  They’re just not coming back.

It’s also true that the decline in the rates of working people in the United States involves an increase in reported pain.  Pain makes work less tolerable, particularly for those whose jobs involve manual labor.

Sex and Marriage

Above, I shared that marriage prospects are decreased for those without a bachelor’s degree, but there’s more to this story.  As I mentioned in my review of America’s Generations, the advent of the contraceptive pill and the availability of abortion radically reorganized our views about sex, particularly sex outside of marriage.  No longer was there a real risk that one would face an unwanted pregnancy after sexual relations.  With appropriate precautions and with a failsafe, sex felt safer for casual fun.  It’s a startling revelation that, using the data from 2014 rates, one in four women will have an abortion by forty-five.  The recent Supreme Court decision to overturn Roe v. Wade will certainly have an impact on this – but to what degree isn’t known.

This meant that women no longer needed to marry early to ensure support of a baby.  They were free to be choosier.  More than that, it changed the sense that women had for their careers.  They had more flexibility to decide when they wanted to take a break to have a baby.

Religion and Politics

Marx called religion “the opiate of the masses.”  However, as Churchless, The Great Evangelical Recession, Bowling Alone, and other books have noted, people are attending church less regularly.  We ended up using opioids as religion lost its hold on society.  But what happened to cause the gap is more challenging.  Ezra Klein in Why We’re Polarized explains that we’re more focused on our political identity than we have been in the past.  We’re seeing it in church attendance: instead of people first picking a church community and adapting their politics to suit their friends, they’ve switched it.  Now, it seems people pick their spirituality to fit their politics.

The Assault on Healthcare

The book ends with an assault on healthcare.  It asserts, “Sixteen percent of those in the top 1 percent of incomes in 2015 were physicians; 6 percent among the top tenth of 1 percent.”  The implication is that doctors are soaking up the work of the people through higher than appropriate fees.  However, if we look at Robert Pearl’s work, including Uncaring and Mistreated, we see that there is a problem, but the doctors probably aren’t the core issue.

There is lots of profiteering to be sure.  However, the truth is that our system doesn’t prioritize or reward preventative care.  We know that preventative medicine is good medicine.  Not only do people not suffer, but it’s more effective.  Yet most preventative care isn’t done, because it doesn’t make sense for an insurance plan that is likely to change in the next year.  We don’t fix problems, but instead subject patients to long-term pharmaceutical interventions.  We operate a medical system that is paid to perform services – and so that’s what we get whether those services are needed or not.

Scanners and Scammers

Making it even harder is that the new technologies that are supposed to improve care may not really do that.  For instance, I took Scott Warrick to task for supporting SPECT rather than the more broadly accepted fMRI.  (See Solve Employee Problems Before They Start.)  Both are expensive, but SPECT is less expensive and much less common.  SPECT has some uses, but fMRI provides more robust data.  The tricky part here is that SPECT can be useful – but in a narrower set of circumstances.  Figuring out whether a cheaper scanner will do what you need or whether you need a more expensive scanner with more robust data is a difficult decision that invariably will be wrong.

One of the reasons that our healthcare costs are spiraling upwards is because these expensive pieces of equipment sit idle too frequently.  In the service of faster access, we reduce utilization and therefore must amortize the cost of the unit across fewer procedures.

Sorting out the solution to The Deaths of Despair and the Future of Capitalism isn’t easy – but it’s important.

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