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Deaths of Despair Are Soaring. A Unified Response is Needed.

Race reductionism impairs the response to our deaths of despair crisis.

Key points

  • Deaths of despair, from suicide, alcohol-related liver disease, and drug overdose claim the lives of 160,000 Americans annually.
  • These deaths are intimately linked to declining material conditions that have disadvantaged Americans without college degrees.
  • Reducing despair-related deaths to a racialized phenomenon precludes a unified response to a growing crisis.
Daniel George
Steelton, Pennsylvania is one of many post-industrial towns that have seen rising rates of despair-related illness
Source: Daniel George

The ascendancy of antiracism in the last decade has helped illuminate the social structures, institutions, and processes that have cumulatively disadvantaged people of color across the country’s history. Especially in the wake of the 2020 Black Lives Matter protests, antiracism has provided a framework for analyzing persistent health disparities (e.g., maternal mortality) and public health phenomena (e.g., vaccine hesitancy) that have disproportionately affected the Black community.

However, as with any ideological movement, antiracism discourse sometimes misses the mark, and its approach has not always been helpful when applied to contemporary medical issues, a hard truth that has emerged with respect to the growing deaths of despair (DoD) crisis.

What Are Deaths of Despair?

Deaths of despair refer to rising mortality first observed last decade among rural white middle-aged working-class adults with low educational attainment, specifically driven by increases in suicide, drug overdose, and alcoholism (see figure 1).

Figure 1. All-cause mortality, ages 45–54 for US White non-Hispanics (USW) (red line)
Source: Rising midlife morbidity and mortality, US whites Anne Case, Angus Deaton Proceedings of the National Academy of Sciences Dec 2015, 112 (49) 15078-15083; DOI: 10.1073/pnas.1518393112

Since these deaths were first noted in economically-distressed regions reshaped by decades of globalization, deindustrialization, job outsourcing/automation, deunionization, and falling real median wages/incomes, the researchers who discovered this trend in 2015—economists Anne Case and Sir Angus Deaton of Princeton—chose a descriptor (“despair”) that reflected escalating hardship in peoples’ lives.

Long-term labor market decline has, in turn, weakened job security, fragmented traditional family/community structures, limited access to high-quality healthcare, reduced participation in social organizations, and engendered loneliness, physical/mental pain, and loss of future-oriented hope in ways that have increased the likelihood of lethal self-injury and substance abuse for working-class Americans. These cascading circumstances have been particularly damaging in the Rust Belt, Appalachia, and other hollowed-out post-industrial regions where those with high school educations (or less) struggle to adjust to service- and knowledge-based economies.

In 2019 the nation saw 164,000 annual despair-related deaths, according to Case and Deaton, with the crisis contributing last decade to the longest sustained life expectancy decline since 1915-1918.

More recent studies, including two analyses I have collaborated on at Penn State College of Medicine, have established that rising excess mortality and morbidities from DoD extends across racial, ethnic, gender, age, and geographic lines. Case and Deaton have also noted upticks in DoD in other Western countries like Canada, the UK, and Australia that have undergone major neoliberal restructuring over the past 50 years but also managed to mitigate despair-related mortality with stronger welfare states and safety nets. Their most recent paper in PNAS showed life expectancy declining for both Black and White Americans who lack bachelor’s degrees, and rising for members of those groups who are college-educated (see figure 2).

PNAS March 16, 2021 118 (11) e2024777118
Figure 2. Expected years of life from 25 to 75 by sex, race, and BA status.
Source: PNAS March 16, 2021 118 (11) e2024777118

What we are witnessing is a class-based crisis that places less-educated citizens at a major material disadvantage.

Blinded by “Whiteness”

However, because DoD were initially regarded as endemic to the “White working-class," and absorbed into the fractious, identity-obsessed culture-war discourse of the Trump era, there has been a tendency to interpret the phenomenon through an antiracist lens, focusing on the independent causal force of “Whiteness” driving despair-related deaths. Proponents of this interpretation argue that the DoD crisis is interwoven with the toxic effects of White privilege, White supremacy, and racial resentment.

For instance, last year in the Lancet pediatrician Rhea Boyd argued that, due to poor Whites voting in favor of “white racial dominance” rather than broader material gain, it would be more appropriate to conceptualize the DoD crisis as “white self-destruction.” Viewing “white privilege/white racism” as causal mechanisms, Boyd rejected the concept of DoD altogether, proposing it be replaced with “diseases of disproportionate opportunity (to wield firearms) and access (to prescription opiates).” In her words, “whiteness impairs health.”

Paradoxically, this antiracist perspective harmonizes with right-wing perspectives that have used “Whiteness” as shorthand for self-defeating pathologies of rural working-class culture. In his book Coming Apart, Charles Murray expressed this sentiment, writing: “White males of the 2000s were less industrious than they had been 20, 30, or 50 years ago…the decay in industriousness occurred overwhelmingly in [white working-class towns]."

In 2016, Kevin Williamson advanced an even more visceral argument in the conservative National Review:

Economic changes of the past few decades do very little to explain the dysfunction and negligence—and the incomprehensible malice—of poor white America. The truth about these dysfunctional, downscale communities is that they deserve to die. Forget your sanctimony about struggling Rust Belt factory towns…The white American underclass is in thrall to a vicious, selfish culture whose main products are misery and used heroin needles.

Besides being jarringly dehumanizing, race-reductive arguments linking poor health outcomes to an essentialized “Whiteness” obfuscate the material conditions underpinning the crisis and the empirically-established role of class position as a mediator of risk for despair-related deaths. Each author thus avoids confrontation with an imbalanced political-economic system (i.e., neoliberalism) that has, since the 1970s, aggressively operationalized policies serving the needs (capital accumulation/growth) of the ruling class, justifying the economic decline and abandonment of whole regions and foreclosing the possibility of meaningful, dignified, secure lives for millions, especially those lacking higher educations. As the protective stability of jobs/benefits and social services has eroded, there has been a rupture in the promise that subsequent generations of working-class families will do better than those preceding them.

Americans live increasingly precarious lives.

In 2018, a Federal Reserve report on the economic well-being of U.S. households found that 40% of Americans wouldn’t be able to cover an unexpected $400 expense without going into debt. As of July 2021, less than a third of labor force participants held secure jobs (i.e., annual income of $40K<, predictable earnings, steady hours, and health benefits); among workers without college degrees, that figure fell to one in five. The resulting precarity, anguish, alienation, anomie, and loss of hope for a better future are pushing desperate, hurting people from varied racial/ethnic backgrounds to seek numbness and escape in ways that are killing them, either slowly through alcohol, or swiftly with guns and lethal drugs (e.g., fentanyl, oxycodone) that have flooded into economically-distressed regions.

Flawed explanations render accurate diagnosis of the problem impossible while simultaneously scapegoating the white working-class. When Boyd argues that White access to “firearms” and “opiates” is driving the epidemic and Williamson focuses on “misery and used heroin needles," they are narrowly fixating on symbols at the end of a cascade of failing societal systems that have, over decades, compounded distress, dislocation, and purposelessness for the working-class.

In reality, structural failures help load the gun, syringe, and bottle of the despairing, regardless of skin color.

That so many Americans are seeking numbness and escape from the pain of their lives must be viewed as an indictment of the way we have organized society—and specifically a consequence of the hyper-capitalist economic reordering of the last 50 years—rather than a congenital flaw within a racially-discrete group. This is as true today as it was during a prior wave of capital disinvestment from U.S. cities in the 1960s and ‘70s that degraded material conditions for urban Blacks, laying the groundwork for the devastating crack-cocaine epidemic.

Attributing that crisis to a reified ontological quality (i.e., “Blackness”), which was invoked by misguided politicians and media at the time, is just as repugnant as deploying “Whiteness” as an explanatory model for DoD in 2021.

How a Race-Reductive Analysis Fails Us

Analytic errors mystify causation of DoD, effectively depoliticizing the situation and confounding appropriate social action.

Indeed, for Boyd, Murray, and Williamson, the despair crisis is one of moral decadence. Thus, the authors "responsibilize" working-class individuals, offering that poor Whites either check the racial privilege, supremacy, and resentments entangled with their self-inflicted suffering (Boyd) or optimize their personal industriousness (Murray/Williamson). A broader perspective, as embodied by Martin Luther King’s 1968 Poor Peoples’ Campaign, might attempt to build unity around the shared suffering and exploitation of the working class and change the underlying material conditions driving despair/precarity through redistributions of wealth and power.

But because proponents like Boyd apply a racial-reductionist lens rather than invoking a solidaristic class-based approach, muscular universalist responses to DoD and other public health crises of our era feel untenable. When we view DoD through a prism of “Whiteness," we fail to interrogate falling life expectancy as a structural problem most affecting an exploited working class. When we regard police shootings as a problem for only one racial community we fail to recognize that, while police violence disproportionately affects Blacks, the most reliable risk factor for being killed by police is being poor. When we racialize COVID-19 vaccine hesitancy, we fail to see the phenomenon rooted in distrust shared by poor urban Blacks and poor rural Whites based in legitimate historical grievances often linked to political-economic marginalization and the failures of our public institutions and political/“expert” class.

(Indeed, to the latter point, it was just a few decades ago that the FDA, which has overseen vaccine approval, failed to properly regulate the approval, labeling, and marketing of opioids that subsequently flowed into the fertile soils of despair-riddled rural towns.)

A Bridge Out of Despair

Antiracism remains a righteous goal. However, advocates must reckon with the fact that, as King voiced in his 1968 “Drum Major Instinct” speech, common forces oppress the American underclass. Insofar as an antiracist analysis diverts us from potential unity and interdependence and toward sectarian interpretations of crises like DoD that could otherwise be addressed through popular mobilization, we ought to offer constructive pushback—especially when lifespans are tragically falling for so many disadvantaged Americans.

Powerful interests want our working-class divided. Those of us in healthcare should not oblige.