Despair & Early Death

(Originally published November 2015)

The increase in mortality rates for White Americans, 45-54, described in a recently published article by Anne Case and Angus Deaton came as a surprise to many public health experts.  According to Case and Deaton, mortality rates in the U.S. and other developed countries had fallen by about 2% annually for more than 20 years prior to the late 1990s, in part because of medical advances in prevention and treatment of heart disease and strokes. Despite the apparent inability to reduce child maltreatment related deaths and school shootings (in the U.S.), the child death rate from all causes declined by more than 40% during the past 15-20 years (see Anna E. Casey’s Kids Count 2014). Given these long term positive developments, it was easy for health experts to overlook a small unexpected increase (0.5%) in the mortality rate for middle aged White Americans.


An annual increase in a mortality rate of one half of one percent from 1999-2013 may at first glance seem like a curious but minor anomaly; but Case and Deaton point out that a small increase in a mortality rate applied to a large population over more than a decade can lead to a substantial increase in the number of early deaths. These scholars assert that if the mortality rate for White Americans, 45-54, had remained at the 1998 level, there would have been 96,000 fewer deaths in this age group from 1999-2013; and, if the mortality rate had continued to decline at 2% per year (as it has for other age groups and racial/ethnic groups in the U.S. and in Western European countries), there would have been almost 500,000 fewer deaths of middle aged Americans during this 15 year period. Through careful examination of mortality statistics, Case and Deaton have identified a public health crisis for a demographic group often viewed as privileged and in the prime of life. What causal factors can explain the increase in early deaths of White middle aged Americans?


Causes of Early Death


Case and Deaton identify three main causes of the increase in deaths of White Americans, 45-54:


  • Alcohol and drug poisoning

  • Cirrhosis of the liver

  • Suicide


They point out that increases in deaths from these causes has been concentrated among middle aged Americans with limited education, i.e., high school degree or less.  Both Case and Deaton, and several commentators, have referred to “deaths of despair” in hypothesizing a causal relationship between economic decline, i.e., the loss of well–paying jobs (especially manufacturing jobs) for Americans lacking a college education, and deaths resulting from alcohol and/or drug abuse and suicide. These speculations seem plausible, though these authors have emphasized that mortality rates for the elderly and for African Americans have continued to decline at about 2% annually even though these groups are worse off economically than White middle aged Americans. If, indeed, the increase in deaths of middle aged Whites in the U.S. is due to despair that has economic roots, it is not unemployment rates, annual incomes and material hardship per se that have led to life endangering behaviors.  Psychological factors, e.g., the difference between expectations and reality and hopelessness regarding future economic prospects, are clearly implicated. Understanding the surprising increase in mortality rates for White middle aged Americans can help to illuminate the social determinants of health, and how poverty, the lack of economic opportunities, substance abuse and mood disorders combine to undermine confidence in a social group’s ability to shape their future.


Factors that lead to hopelessness


Individuals, racial/ethnic groups, communities, regions and countries are extraordinarily sensitive to losses of jobs, cultural traditions/identities, status and power, especially when these losses appear to be long term or permanent. The loss of manufacturing jobs has had an enormous impact on many American communities, and on both Whites and African Americans, because these jobs not only paid well and supported middle class lifestyles, but because they were the basis of personal identity, social respect and a sense of belonging to a thriving community. The loss of income, social standing, cultural traditions and whole communities, combined with the lack of economic prospects for poorly educated Americans, is embittering and fuels the rage and cultural divide between educated elites and low paid service workers that has become a defining feature of modern America. In addition, when large areas of whole regions have been abandoned by state and local governments, corporate America and even philanthropies (as described in Paul Theroux’s Deep South) political leaders should not be surprised to encounter an angry electorate that wants to clean house, or which is so alienated that voting is not even a consideration.


The French sociologist Emile Durkheim (1857-1917) pointed out that suicide rates decline during times of national emergency (such as war) and increase when collective bonds are weakened in the aftermath of emergencies. I applied this idea to understanding the delayed effects of recessions on child welfare in a past Sounding Board, Post-Recession Blues (September, 2014). Following Durkheim, the increase in suicide rates among White middle aged Americans is not an indicator of extreme economic hardship, but rather the extent to which poorly educated Whites feel disconnected from their extended families, neighborhoods and communities. In Coming Apart: The State of White America 1960-2010 Charles Murray described the steady decline in rates of labor force participation, churchgoing and marriage for Whites with low educational achievement. Low income Whites have been hemorrhaging social capital for decades. Case and Deaton’s research suggests that a deterioration in the strength of familial and community connections has had a dramatic effect on health and mortality; the only surprise is that the increase in mortality rates is limited to a single middle aged group of the population.


Hopelessness and helplessness are emotionally connected: each feeds and strengthens the other. The belief that loss of jobs and a way of life cannot be undone or compensated for, is self-fulfilling: why engage in persistent effort, or political action, or community initiatives if there’s no hope of a better future?  Furthermore, the devastating loss of personal agency, i.e., self-efficacy resulting from depression and other mood disorders and from drug/alcohol addiction, along with the weakening of community bonds, can leave individuals and families feeling powerless and isolated. The experience of powerlessness confirms beliefs that give rise to hopelessness.  These dysfunctional beliefs in turn often create a deep resistance to offers of help and undermine the ability to cope with everyday challenges, much less generate spirited resistance to formidable challenges. This is the dynamic that affects families chronically referred to child welfare systems, and other traumatized populations as well. Case and Deaton speculate that low income middle aged Whites may be a “lost generation” due to the power of drug/alcohol addiction and their dismal economic prospects. However, “throwing in the towel” is premature when a public health problem has just been recognized. It is foolish to believe that a small increase in middle aged White mortality rates is a bigger challenge than the AIDS epidemic was during the 1980s and 90s in the U.S. and Africa. Once hopeless/helpless beliefs and attitudes are overcome, there is much that can be done both to combat drug/alcohol addiction and to mobilize affected  groups and communities.  



There are two broad avenues to restoring self-efficacy and collective efficacy to persons and communities that feel powerless: (1) the strengthening of collective bonds and (2) the experience of effective and persistent effort repeated over and over again in ways both large and small. Collective bonds in a community can be strengthened in ways that are both benign or destructive – through a winning sports team, through a shared religious faith or strongly shared values, through political action and through violence, war, national emergencies, xenophobia, scapegoating. It is a remarkable that hundreds of thousands of people from all social classes will stand in packed groups for hours in cold weather to celebrate a Super Bowl or World Series winning team; or that sustained non-violent protests can lead to fundamental changes in a nation’s civil rights laws; or that war can generate instantaneous political support for unpopular leaders; or that gang violence can lead to dozens or even hundreds of deaths of youth and young men in a single American city. Strong collective bonds bring power to political leaders and community leaders who can mobilize them for good or ill, especially during periods of economic decline and uncertainty.


Nothing overcomes hopelessness more quickly than effective action, especially actions that have been freely chosen. However, cultural beliefs and a strongly felt social identity sometimes stand in the way of making even a minimal effort.  Many, probably most, middle aged White Americans were raised with the idea that adults will either be a success or failure; winners or losers, in economic terms. This is a denuded cultural story which, nevertheless, is a source of despair for those middle aged adults who have fallen in the world, and the basis of a sense of entitlement for the rich and powerful. Americans need a better cultural story of what it means to lead an admirable life; or the country needs to make an ideal such as “equal opportunity for all” more credible than it currently is. 


The Long Shadow


The main idea in recent decades for how to cope with economic decline, the loss of manufacturing jobs, thinning out of the American middle class, deepening income inequality and the gap in educational achievement between children from affluent families and low income families has been to reform educational systems, require standardized measures of educational achievement, fund early childhood education for low income children, support the development of charter schools and other educational experiments, equalize funding between schools in well off neighborhoods and poor neighborhoods, increase teachers’ salaries based on merit rather than seniority, and prepare all students with the skills needed to successfully compete in a global economy. Despite huge investments in education in some localities and states, federal legislation mandating use of standardized tests, a powerful charter school movement, the gap in educational achievement between low income children and children from more affluent families has widened instead of narrowing in recent decades.


In The Long Shadow: Family Background, Disadvantaged Urban Youth, and the Transition to Adulthood (2014) Karl Alexander, Doris Entwisle and Linda Olson discuss the findings of a longitudinal study (1982-2010) of 709 children, age 6 and in the first grade when the study began and in their late 20s at the study’s end. These children were a probability sample of first graders in Baltimore, Maryland; 25% of the children were from high SES families; 45% were White while most of the remaining children were African American.


According to the authors, Baltimore lost 75% of its manufacturing jobs between 1950 and the mid-1990s; the city’s population declined from about 940,000 to 733,000 between 1950 and 1990. A main finding of the study is the persistence of socioeconomic advantages/disadvantages for both White and African American children evident in the first grade. The authors comment “that the reproduction of disadvantage can be forecast with some fidelity even before children reach age six.”  59% of low SES boys in the sample were held back in the first grade and fewer than half completed school with a high school diploma. Schooling in Baltimore, the authors believe, contributed more to consolidating the reproduction of social advantages for high SES children than providing a means for children from low income families to escape poverty.  They comment about educationally advantageous placements that “Being easily observed and appearing to be meritocratic, that visibility has the effect of both preserving and legitimating the high standing attained by children of privilege and the low standing of those less well off.” Less than 5% of young people from low income families had graduated from college by age 28. Most of the youth who had dropped out of high school had returned to school to obtain a GED or enroll in community college, “but their failed attempts at higher education outnumber their successes and the successes mostly are in certificate and licensure programs, which benefit them little,” the authors state.


Low SES White youth benefited substantially in job seeking from social networks that African American youth largely lacked. For Low SES youth in this Baltimore study it was social connections rather than education that lifted them out of poverty, when this occurred. Low SES African American in this study often spent large amounts of time neither working or in school, and long bouts of idleness damaged their future employment prospects, the authors believe.


The Long Shadow is a bleak story of how social advantages and disadvantages are transmitted from one generation to the next in a city that has experienced long term economic decline and powerful racial tensions. However, The Long Shadow provides a framework for understanding why many low income adults of all races/ ethnicities might be feeling pessimistic regarding their future economic prospects and the prospects of their children.




Case, A. & Deaton, A., “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century,” Proceedings of the National Academy of Sciences, published online November2, 2015.


Kids Count 2014, Anna E. Casey Foundation, 2015.


Allexander, K., Entwisle, D. & Olson, L., The Long Shadow: Family Background, Disadvantaged Urban Youth and the Transition to Adulthood, Russell Sage Foundation, 2014.


Murray, Charles, Coming Apart: The State of White America 1960-2010, Random House, 2012.

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