This review will be published in Political Quarterly in February 2021, and is the subject of the Health Foundation's January podcast.

Back in 2016 the shock win for Donald Trump in the US presidential election prompted much soul searching and hard analysis. A number of books have given clues as to why some traditionally blue collar areas flipped red, and supported Trump in droves.

Among them, Joan C. Williams’ White working class: Overcoming class cluelessness in America, JD Vance’s Hillbilly elegy: A memoir of a family and culture in crisis, and Amy Goldstein’s Janesville: An American story. Williams set out why working class communities feel devalued by a professional managerial elite caught up in the belief of a meritocracy that is self-serving (re-examined recently by Michael Sandel). JD Vance gave testimony to his own family’s story of economic insecurity, family breakup, drug addiction and violence. Goldstein meanwhile carefully chronicled the impact of economic collapse on workers and their families following the 2008 closure of a General Motors plant in a Rust Belt town. The added terrible human cost of the US opioid epidemic – a public health disaster – was set out by Chris McGreal in American overdose. The time arc traced by these authors expands beyond the 2016 election, and further back from the financial crash in 2008.

The common themes across these books are working class communities reeling in plain sight from economic shocks and social disintegration, middle class blindness (at best) to their plight, and with government too often looking the other way. The result: deep despair, humiliation, rage, premature illness and death. In today’s divided America, the issues have clearly not gone away. Biden is the victor in the 2020 election, but Trump consolidated support, particularly among white voters without a college education, in small towns and rural areas.

In the must-read book of the year, two very distinguished economists [...] set out not just what has happened to health in the US, but the economic and social story underpinning it.

The impact on health

Unsurprisingly, all this is reflected in health statistics. In the must-read book of the year, Deaths of despair and the future of capitalism, two very distinguished economists – Anne Case and Angus Deaton – set out not just what has happened to health in the US, but the economic and social story underpinning it.

In dissecting aggregate statistics, Case and Deaton home in on one group where health has deteriorated fastest – middle-aged (45–54-year-old) white Americans. In this population, death rates from all causes are actually rising, in contrast to the established trend across developed nations since the beginning of the 20th century. The biggest increases are in deaths from suicide, accidental poisonings (for example from opioids and other drugs), and alcoholic liver disease – so called ‘deaths of despair’. And furthermore these deaths are almost all concentrated in Americans without a college degree (which comprises almost two-thirds of all US workers). While the health of some groups in the US may be worse, the trend among middle-aged white people is highly unusual. For example, in black populations 2000–2015 mortality rates among those aged 45–54 improved, and in non-Hispanic white people they noticeably worsened. As well as the death data, Case and Deaton also show deteriorating health in this group, in particular depression, other mental illness and distress, and chronic pain and disability.

But it is the human story that resonates most. One woman explained on national public radio what happened to her husband and his friends: ‘One died with a heart attack, but drug use and alcohol use played all the way through his life. Another one died of cancer, drank up to the very end. And my husband actually had his G-tube in, a feeding tube in, and poured alcohol down his feeding tube until he died.’

Economic stagnation

Health is only one part of the story – Case and Deaton carefully chart the underlying economic picture, which is no less stark. Median wages for men have stagnated for half a century. A combination of outsourcing, the decline of large industries as jobs have moved abroad, and long run reductions in unionisation (from 33% of workers in the 1950s to 10% today) has meant with job decline has come wage decline. Weakening US antitrust laws have boosted corporate power to raise prices and depress wage growth. Case and Deaton also reserve special comment for the US health care system, whose unchecked costs over decades have eaten into employer profits, contributing to stagnating wages, low investment, and reducing the competitiveness of US industry – features underlying plant closures.

The result writ large is some communities are losing ground, crushed by mounting insecurity. A secure job for life, towns with civic amenities and where social life is built on the corporate responsibility of the local big employer, the ability to work up from the shop floor over many years into management – all declining or long gone. As Case and Deaton argue, with little economic stability, men in particular become detached from the labour force, less marriageable, less rooted in family and rearing their kids particularly in middle and older age. This plus the downward trend in marriage rates, and in organised religion, combine to put the ‘pillars of stable life’ out of reach. Case and Deaton summarise the situation bleakly as ‘a slowly evolving and large scale disintegration that involves a historically contingent set of forces, many of which interact’.

It isn’t just the US…

Clearly it is not just America that is hurting. Somewhere around 2011 something big happened to the health of the populations across many developed nations. Growth in life expectancy began stalling, with the slowdown greatest in the US, followed by the UK. Not since 1900 was this growth so low.

The question is, why? Several careful investigations in the UK have concluded there is no one factor. The slowdown in gains from drugs treating heart disease, some excess deaths due to a few bad winters, the prolonged squeeze on public sector spending that bit deeply into investment in education, housing, welfare, health and social care services following the financial crash of 2008. In a high-profile analysis, Professor Michael Marmot pointed the finger at public sector fiscal ‘austerity’ since 2011 in England being the likely chief culprit of the patterns observed. Others noted that while fiscal belt tightening was a feature across many western nations since 2008, stalling life expectancy was also seen in countries only mildly affected by austerity.

Further analyses within England, by Marmot and others, have shown the slowdown disproportionately affects people living in socioeconomically deprived areas, in particular in the North East, North West and West Midlands. Life expectancy actually reversed in some of these areas for women. Not only did the life expectancy gap grow between people living in the most deprived relative to the least deprived areas, but so did the years a person can expect to live in good health (‘healthy life expectancy’). This gap is now nearly 19 years, meaning that a person living in the most deprived parts of England can on average expect to be healthy until aged 52 (a full 14 years before current state retirement age), compared with 71 for a person living in the least deprived.

Will things get worse?

Further beneath the aggregate national data others have been documenting concerning trends in the most deprived areas in England. Three journalists won the Orwell Prize for their widely acclaimed story in the Financial Times about the impact of globalisation on small town populations. These effects included higher levels of chronic pain, depression, unemployment, and dependency on welfare and painkillers – a combination described by GPs in Blackpool as ‘shit life syndrome’. In the House of Lords, a Committee noted the many issues faced by seaside towns have their roots in the decline of their core industries. In trying to understand why so many had voted leave in the Brexit referendum, particularly in working class areas, Goodheart chronicled the increasing gulf between the ‘anywheres’ (in short a cognitive-professional elite at home anywhere) and the ‘somewheres’, rooted in the places they grew up, and less likely to be college educated.

It is difficult to argue with Case and Deaton’s thesis that these trends are rooted in ‘a historically contingent set of forces, many of which interact’, that are different in each country. While this cannot be a surprise to governments across the world, what is daunting is the complexity, scale, and long run nature of the forces at play. This must be set alongside the ability of governments not only to make a comprehensive diagnosis of the challenges, but to chart out a strategy to address them that will stick politically in the longer term, and then deliver on them.

Case and Deaton make a start on this strategy, by chunking up broad themes US policymakers should focus on first. Big ticket areas include: addressing the opioid crisis properly; ensure affordable health care to all, while curbing its cost growth; reverse the decline in unionisation and worker representation; strengthen antitrust law and enforcement; consider wage subsidies or a higher minimum wage; expand skills in those who do not go to college; create more transparency in corporate lobbying. Clearly these elements are part of a much bigger picture – economic, social, democratic – that has been examined by many others and needs attention.

Published just before the pandemic hit, Case and Deaton were not able to show either COVID-19’s impact on widening existing disparities in health between population groups, or the disproportionate immediate (and likely longer term) economic impact on the lower skilled workforce. But the need to make change now, as outlined by Case and Deaton, is surely all the greater now.

Jennifer Dixon (@JenniferTHF) is Chief Executive of the Health Foundation.

Case A, Deaton A. Deaths of despair and the future of capitalism. Princeton Press; 2020.

Goldstein A. Janesville: An American story. Simon & Schuster; 2017.

Goodheart D. The road to somewhere. The new tribes shaping British politics. Penguin; 2017.

McGreal C. American Overdose. The opioid tragedy in three acts. Faber and Faber; 2018.

Sandel M. The tyranny of merit. Why the promise of moving up is pulling America apart. Macmillan USA; 2020.

Vance JD. Hillbilly elegy: A memoir of a family and culture in crisis. Harper Collins USA; 2016.

Williams J. White working class: Overcoming class clueslessness in America. Harvard Business Review Press; 2017.

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