Illustration by Emma Kumer

Other People’s Despair | Mending the Social Fabric Won't Fix the Suicide Crisis

Erik Baker

Last March, in the early weeks of the Covid-19 pandemic, Donald Trump issued a warning: in what would soon become an incessant refrain among opponents of lockdowns and mandatory social-distancing measures, he claimed that unless the country was swiftly opened back up, there would be “suicides by the thousands.”

Trump’s particular prophecy was clearly ridiculous, and it became more so with each passing month. But it was by no means unreasonable to be concerned about the effects of the pandemic on Americans’ already-fragile mental health. By the time shelter-in-place orders began to proliferate, suicide rates in the United States had already increased by 30 percent since 2000. A major 2019 study found that the suicide rate for people aged 10 to 24 had increased by fifty-six percent from 2007 to 2017. As staggering as these figures are, they are almost certainly underestimates, because of pervasive problems with the U.S.’s protocols for monitoring and reporting suicide.

Nonetheless, liberal commentators eager to counteract the president’s histrionics tended to downplay the possibility that the pandemic could exacerbate this disturbing trend. Two of the most prominent voices urging calm were Princeton economists Anne Case and Angus Deaton. Case and Deaton are eminent scholars — Case is a member of the American Academy of Arts and Sciences, the American Philosophical Society, and the National Academy of Medicine, and Deaton received the Nobel Prize in economics in 2015. That same year, he and Case published a paper coining the phrase “deaths of despair,” which encompasses both suicide and alcohol- and drug-related deaths. While not every single death from drug and alcohol use is best understood as a “death of despair,” the economists showed that these substance-related deaths have tracked the rise in suicides closely. Together, “deaths of despair” almost single-handedly explain an unprecedented decline in the overall U.S. life expectancy in recent years. As Atul Gawande remarked in a glowing profile in The New Yorker, the paper received “the sort of public response that seldom greets economic research.”

In the spring of 2020, Case and Deaton embarked on a virtual book tour in support of their new book, Deaths of Despair and the Future of Capitalism. Asked to prognosticate about how the pandemic would affect the trends they had analyzed, their response was unequivocal: it wouldn’t. Since “short-term fluctuations, even quite severe short-term fluctuations, are not what’s causing people to die,” Deaton told Vox in April 2020, the pandemic was “not going to cause a mass harvesting of deaths of despair.” He repeated the prediction in a Boston Review interview the following month. “The problem of deaths of despair is a fifty-year process, not something that happens in fifty days,” he said. Instead, their book posits that the recent surge is due to the slow decay of the “social fabric” in white working-class communities, where they claim the epidemic is almost entirely concentrated. In their account, people are killing themselves because they have lost the sense of meaning and belonging that the noble institutions of “work, family, and church” once provided. If, as they argue, deaths of despair are primarily a consequence of the gradual erosion of traditional meaning-making institutions, it’s true that even an entire year of acute hardship would seem unlikely to move the needle.

Early last summer, preliminary data from Connecticut and Massachusetts, two states with above-average suicide monitoring, substantiated Case and Deaton’s sanguine prediction, showing flat or decreasing rates in the first months of the pandemic. But the picture soon darkened. The CDC announced in August that a quarter of young adults surveyed had experienced suicidal ideation in the previous thirty days, and a patchwork of other local reports offered glimpses of the picture that national data failed to reveal. By the end of the summer, suicides in Oregon’s Columbia County, outside Portland, had already outstripped the 2019 total. In November, a suburban Chicago county projected a 23 percent spike in suicide for the year as a whole. National hospital data reported by the CDC in the winter showed that the share of emergency room visits accounted for by adolescent suicide attempts had risen in the second half of 2020.

Late this March, researchers released provisional 2020 cause-of-death data from the National Center for Health Statistics’ National Vital Statistics System (NVSS), although a final accounting remains at least a year away. The NVSS statistics project that the suicide rate remained relatively constant in 2020, even registering a slight decline. But while this new batch of data clearly proves the most apocalyptic predictions wrong, it actually underscores the inadequacy of Case and Deaton’s optimistic prediction as well. First, the NVSS data shows a stunning 11.1 percent increase in deaths from “unintentional injury.” The vast majority of deaths in this category are drug overdoses, some of which include misclassified suicides. Every year, other sorts of accidental deaths that fall into this category also include unrecognized suicides, and due to the strain the pandemic has placed on coroners nationwide, the likelihood of misclassification in the provisional data seems especially high. Deaths of despair as a whole, in other words, unequivocally rose. Second, if the initial state-level reports were right that suicide declined slightly in the early months of the pandemic, a stable rate for the full year implies a worse-than-normal rate for the remainder — consistent with the warnings of clinicians who have long expressed concern that the suicide toll of the pandemic would likely worsen with time.

In recent months, we’ve also acquired more fine-grained county-level data showing that aggregate totals fail to capture an alarming divergence between the pandemic-era suicide rates of white people and people of color, tracking the well-documented racist discrepancy in the impact of both the pandemic and its economic fallout. A survey of the data from nine of the most populous counties in the U.S. revealed that the suicide rate in these places increased in 2020 by 17 percent among Black people, 14 percent among Latinos, and 9 percent among Asians, while it fell for white people by 15 percent. Contrary to the predictions of anti-lockdown activists, the suicide surge was concentrated in communities where people were disproportionately likely to have no choice but to continue working in person.

Case and Deaton and Republican lockdown critics share the assumption that deaths of despair are ultimately a symptom of weak social ties. People take their own lives, they all believe, when the bonds that tether them to other people in their communities come undone. The only disagreement is about how quickly social bonds can fray: whether it takes decades of decline, or whether a single shelter-in-place order may suffice. But what if this underlying assumption is wrong to begin with?

 

In Deaths of Despair, Case and Deaton take pains to make clear exactly what they are and are not claiming. “We believe that it is impossible to explain despair through declining material advantage,” they write in a summary section near the end of the book. “Much more important for despair is the decline of family, community, and religion.” In case you didn’t get the message, they continue: “It was the destruction of a way of life that we see as central, not the decrease in material wellbeing.” The confidence with which they press their argument makes it all the more puzzling that they never make a case for it directly. 

Though they claim that deaths of despair are almost exclusively concentrated among middle-aged white people without college degrees, they never actually prove that point, and in fact provide data that contradict it. It is true that in the 21st century, the epidemic has been far more severe among white people without a BA. But a number of their own graphs show an unmistakable rise in suicide and drug and alcohol mortality among white BA-holders since 2000 and among Black people without a BAs since the early 2010s. Astonishingly, the explosion in suicide among young people nationwide receives only a single vague mention. Case and Deaton insist that deaths of despair are surging in “white working class” communities because “there is something about these people that makes them susceptible.” Such a claim requires far more stringent statistical evidence than they supply.

Summoning a bevy of statistics that conjure an image of typical “white working class” communities, Case and Deaton rely on their readers’ intuitions to do the rest of the work. In the text as well as in their promotional interviews, the authors invoke an existing discourse of white-working-class decline to draw readers into their portrait of a world where “the institutions that provided support … no longer do so, identity and status have been challenged, and the meaning of life has been lost.” In the rush to explain Donald Trump’s 2016 electoral victory, many upper-middle-class liberals adopted the premise of this argument as conventional wisdom. They propelled J.D. Vance’s Hillbilly Elegy to bestseller status, drawn to its portrait of the “social rot” allegedly at the core of Appalachian poverty. Even Bell Curve author Charles Murray got a new hearing from liberal pundits thanks to his 2012 book Coming Apart, a warning about the degradation of moral norms in white working-class communities and the ensuing social pathologies.

Early in the book, with statistics and a map, Case and Deaton explain that “white working class” deaths of despair are on the rise in nearly every state, and then proceed to open the next chapter with a vignette of despair in Kentucky, the setting of Hillbilly Elegy. There is an element of sleight-of-hand here. When Case and Deaton present statistics showing that deaths of despair disproportionately afflict middle-aged white people without college degrees, and then more statistics showing that church attendance has declined as divorce rates have surged among this same demographic, they can expect their own educated liberal readers to fill in the blanks.

Throughout the book, Case and Deaton go to incredible lengths to sidestep even very obvious material causes for despair. Chronic pain is a well-known driver of suicide that has been on the rise across the United States for years, but Case and Deaton argue that it is primarily psychosomatic — that even “the increase in pain among less educated Americans can be traced back to the slow disintegration of their social and economic lives.” The loss of a way of life also turns out to explain the opioid epidemic. Case and Deaton don’t exactly let manufacturers or physicians off the hook, but they argue that wrongdoers simply exploited a preexisting hunger for hard drugs that, in turn, can only be explained by the decay of traditional communities. “As religion faltered,” they quip, “opioids became the opium of the masses.” Following a dubious process of elimination, they conclude that since poverty rates, income inequality coefficients, and household incomes do not correlate well with the trends in deaths of despair, they can proceed as if they have shown definitively that the dissolution of a “way of life” is really to blame. But there’s plenty of reason to think that Case and Deaton have chosen the wrong metrics of “material wellbeing” to eliminate. They completely ignore other factors with a much better-established relationship to suicide and drug and alcohol mortality, all of which have been exacerbated by the Covid crisis. 

One is debt. Contemporary social science has confirmed the folk wisdom of the postwar generation’s great debt movie, It’s a Wonderful Life: debt takes a unique psychological toll compared to other forms of financial insecurity, and Americans’ total household debt has doubled in the twenty-first century. According to one 2013 study, people who die from suicide are eight times more likely to be net negative on their balance sheets. Other studies have found a similarly strong relationship between debt and drug and alcohol abuse. Given the role of the opioid epidemic in fueling drug-related mortality in recent years, it is also significant that debt is associated with various forms of chronic pain. Twenty-seven percent of respondents reporting high debt stress in one survey had ulcers or other forms of digestive pain, and nearly half had migraines or chronic headaches. Over the course of the Covid-19 pandemic, fifty million Americans have seen their credit card debt worsen, tracking surging unemployment and the increased financial burden on caregivers. Meanwhile, the word “debt” does not appear in the index of Deaths of Despair and the Future of Capitalism.

Case and Deaton do not overlook work as egregiously, but they still mangle its relationship to deaths of despair. Back in the good old postwar days, they argue, even “cleaners, janitors, drivers, and customer service representatives ‘belonged’ when they were directly employed by a large company.” Now, due to deindustrialization and outsourcing, low-wage workers lack that sense of belonging and shared purpose. They no longer get “invited to the holiday party.” In turn, male workers deprived of the esteem and possibility for advancement that came with big-company industrial employment don’t “make good marriage partners.” Women don’t want to marry men working for a subcontractor rather than for the “Generous Motors” (seriously) of yore, prompting the decay of the traditional family. Even if this were true, it would suggest a straightforward moral: mend the fissures wrought by outsourcing and bring workers back into the company family, and working-class communities will recover their animating purpose. But unfortunately for Case and Deaton, the fairytale is just that.

According to a 2018 CDC report, those who report job strain or long working hours are four times more likely than average to experience moderate to severe suicidal ideation. These factors, not the dissolution of the social fabric, explain the worsening mental toll of American work. At the same time that working hours have increased dramatically in the United States, the pace and intensity of work have also worsened. Almost half of workers without college degrees report that there aren’t “enough hours in the day to finish the job.” (For those with college degrees, the figure is 33.3 percent.) Meanwhile, workplace safety protections dissolved under the Obama and Trump administrations, and the rate of injuries due to violence in the workplace doubled in the 2010s. Nearly a quarter of working men without college degrees, 14.6 percent of men with college degrees, and about 18 percent of women regardless of educational status now report experiencing verbal or physical abuse on the job. During the pandemic, service jobs that once seemed safe have been transformed into psychologically taxing high-wire acts. Workers are not despairing because they aren’t invited to the holiday party. They are despairing because they are bullied, harassed, assaulted, worked to exhaustion, and saddled with debt as their wages stagnate. 

 

In deemphasizing the material facts of debt and exploitation in favor of a convenient story about the decline of the workplace community, the traditional family, and religion, Case and Deaton explicitly situate themselves in an intellectual tradition that long predates this decade’s white-working-class elegies — one that helped to usher in our present nightmare. Throughout Deaths of Despair, as well as in their promotional interviews, Case and Deaton lean heavily on the authority of the fin-de-siècle French sociologist Emile Durkheim to fill the gaps in their own argument. “There is no simple theory of suicide,” they concede at one point, but they hold up “Durkheim’s view,” a “milestone of sociology,” as the definitive account of the “social causes” that complement individual idiosyncrasies in leading to suicide. It’s a choice as revealing as it is appropriate. For more than a hundred years, Durkheim and his later epigones in the United States, from early management theorist Elton Mayo to sociologist Robert Putnam, have sounded the alarm about the decay of the social fabric and its disturbing psychic consequences. 

With the publication of his monograph Suicide in 1897, Durkheim hoped to provide empirical evidence for his theory that both the intensity of nineteenth-century class struggle and rising suicide rates were being caused by the decay of the institutions and belief systems that had once allowed people to embrace their positions in an unequal society — the whole ideological apparatus of feudalist Europe. Individuals had all sorts of subjective reasons for committing suicide, Durkheim allowed, but viewed statistically, suicide was more common in populations where robust social norms that once promoted psychic stability had deteriorated. Protestants rather than Catholics; men rather than women; single rather than married people; childless people rather than parents — it was the tragically individualized, those divorced from the comforting constraints of tradition and family, who were at highest risk. Durkheim even claimed that suicide was more common in peacetime than during war, since war provided societies with a unifying sense of collective purpose.

One of Durkheim’s first champions in the United States was the Harvard Business School professor Elton Mayo. A failed psychiatrist turned management theorist, Mayo enchanted the American business elite in the 1920s and 1930s with his account of the psychological problems fueling worker unrest. Mayo pressed the analogy between suicide and class struggle even more strongly than Durkheim had. Striking, unionization, absenteeism, anxiety, and alcohol abuse were all just different faces of the same pathology, Mayo argued: the unwitting destruction of workers’ traditional ways of life by industrial capitalism. (His legendary three-martini lunches in Harvard Square restaurants, presumably, did not count as alcohol abuse.) 

Mayo felt that it was imperative that business leaders attempt to reknit a “social fabric” within their companies. What he and his colleagues called “human relations” management (not to be confused with today’s human resources departments) emphasized the interpersonal skills of managerial leaders and the creation of new forms of community in the workplace. Workers could not be permitted to view their jobs as simply ways of earning a living. They had to be able to identify themselves with their work on a deep level — to feel that they were contributing something special and irreplaceable to society as a whole. 

Drawing on Mayo’s work, the management theorist Peter Drucker encouraged executives in several major American corporations, including “Generous Motors,” to create the postwar work environment that Case and Deaton look back upon with such nostalgia. Following Drucker’s advice, large corporations “decentralized” their divisional structure, ostensibly to help workers feel a greater sense of belonging, and created pension plans and private health insurance schemes to make them feel taken care of. They let workers organize blood drives and employee picnics and even, on occasion, invited them to holiday parties.

You wouldn’t know it from reading Case and Deaton, but none of this worked. Beginning in the late 1950s and intensifying throughout the 1960s and 1970s, many American workers took an increasingly militant stance against employers, even those that adopted strategies from the burgeoning field of “human relations.” Much of the energy of this rank-and-file movement came from Black workers who had been largely cast out of the imagined community of the postwar workplace, but white workers were also angry that their employers spun tales of labor-management harmony while violating labor law at an accelerating pace, refusing wage-and-hour improvements at the bargaining table, and speeding up assembly lines. The result was a spate of industrial actions like the widely publicized 1972 strike at GM’s Lordstown, Ohio plant, which lasted 22 days and cost the company $150 million.  

Management intellectuals concluded that the social fabric they had so carefully and generously tried to knit in the 1950s was once again falling apart, as it tended to do in the modern industrial era. Drucker responded by taking his earlier writing on decentralization to its logical conclusion, advocating the practice that came to be known as outsourcing. “Do what you do best and outsource the rest,” his slogan went. If dividing large corporations into smaller, more specialized units helped workers feel like their work mattered, why not actually convert units into separate businesses? In the slimmed-down post-outsourcing workplace, it would be easier for individual workers to understand their contributions within the firm’s larger mission. “As employees of a college, managers of student dining will never be anything but subordinates,” Drucker argued. But “in an independent catering company,” the same employees would feel a greater sense of “responsibility,” no longer just taking orders but actively seeking to exercise initiative at work.

Drucker also argued that to feel like true corporate citizens, workers should at minimum be required to pay into pension and healthcare plans, as opposed to receiving benefits as a corollary of employment — ask not what your company can do for you, but what you can do for your company. In fact, because work was so central to individual identity, Drucker recommended abolishing the institution of retirement entirely. “A second career,” he wrote, “is a great deal more satisfying — and fun — than the bottle, a torrid affair with a chit of a girl, the psychoanalyst’s couch, or any of the other customary attempts to mask one’s frustration.” While Drucker once thought corporate welfare policies would promote “plant community,” now he worried they were breeding an attitude of “entitlement” that was an obstacle to real commitment to work. The reforms that came into vogue in the 1980s and ’90s — outsourcing and the destruction of the internal corporate welfare state — are exactly the developments Case and Deaton now excoriate as symptoms of corporate heartlessness and social decay. But their earliest proponents framed them as devices for encouraging workers to feel that they had a home at work. There were other, baser motives at play in the late-twentieth-century restructuring of work, of course, but advocates propagandized on their behalf by fearmongering about the erosion of the social fabric.

Neoliberal policymakers also sought to revitalize the supposedly moribund institutions of work, family, and religion. They shared Drucker’s suspicion of “entitlements” as anti-social. When the parties came together to dismantle welfare in the 1990s, it was on the grounds that it was discouraging people from the morally enriching experience of work and incentivizing the social disaster of single parenting. (Case and Deaton cheer the Clinton welfare reforms in Deaths of Despair.) At the same time, the Clinton White House hit on the idea of lubricating credit markets to use household debt to expand access to housing, higher education, and healthcare without creating new government-funded “entitlements.” It was not just a phobia of government spending that fueled the rise of debt-based policymaking. It was also the conviction that what Reagan education secretary William Bennett called the “traditional role of parents” needed to be restored by any means necessary — including the expansion of intergenerational debt. (The family that goes into debt together stays together.) Under Reagan and Clinton and particularly under George W. Bush, religious organizations were also beneficiaries of the dismantling of the welfare state, receiving billions of dollars in federal grants that once might have gone to government programs. The concept of “faith-based initiatives” allowed policymakers to recast the privatization of social services as a mechanism for restoring the crucial place of religion in American daily life. 

The era’s bogeyman was captured in the title of the Harvard political scientist Robert Putnam’s influential 1995 essay “Bowling Alone,” later expanded into a bestselling book. Once, in the 1950s, a more civic-minded generation of Americans joined bowling leagues, the story went; now, in the decadent 1990s, a generation of aimless individuals went to the lanes by themselves. Putnam’s glowing blurb now adorns the back cover of Deaths of Despair — a lament over the world built when Putnam’s communitarianism was at the height of its influence.

 

Case and Deaton certainly hit all of the right Durkheimian notes. They’re particularly eager to resuscitate the idea that suicide and class conflict are expressions of the same underlying pathology. They view Donald Trump and Bernie Sanders as two avatars of a pathological dissatisfaction with the status quo that festers in white-working-class communities. It’s a refrain Elton Mayo would have recognized. For Case and Deaton, as for Mayo, symptoms of social fabric decay include not only suicide and substance abuse, but also “seeing capitalism as [the] enemy.” 

But while past policymakers and intellectuals went about the business of repairing the social fabric with deathly seriousness and programmatic vision, no matter the consequences, Case and Deaton seem almost afraid of making comparably ambitious recommendations. They don’t support a universal basic income, because they think working-class communities need more of the salvific power of work, not less. They don’t support taxes on the wealthy, because their statistics supposedly prove that inequality itself is not a problem. At one point they simply pronounce that “a rebirth of unions is unlikely.” Alas. They are in favor of “a modest increase in the minimum wage,” but mostly they are in favor of vague platitudes like “making capitalism stronger by extending markets, rather than by undermining them.”

This degree of political timidity seems endemic among today’s social-fabric alarmists, particularly those conservatives who want to position themselves against the amoralism of the Republican Party while also resisting the radicalism of the resurgent left. One of the most prominent representatives of this tendency in today’s media landscape, New York Times columnist David Brooks, has more or less given up on public policy. His new nonprofit, Weave: The Social Fabric Project, instead aspires to repair the fraying bonds of society by encouraging ordinary people to build community themselves. On its website you can glean helpful suggestions for becoming a Weaver, such as “Lend a Hand” and “Host a distanced BBQ.” Say what you want about ending welfare as we knew it, at least it was an ethos.

It is unsurprising that Brooks and others have reached this impasse. Their longstanding strategy has been to validate the sense that contemporary society is profoundly broken, but to insist that it is a return to work, family, and religion that the radicals are truly hungry for. That leaves them in a difficult spot today, when elite policymakers have for decades pursued a singularly destructive program of political-economic transformation in the name of precisely those sacrosanct values of work, family, and religion.

This Sisyphean struggle with the destruction of the social fabric underscores the inadequacy of the underlying conception of class at work here. As the French philosopher Louis Althusser once joked, it often seems like conservative intellectuals imagine classes as competing soccer teams. They exist independently of each other, come into contact occasionally on the field, and share a primary interest in ensuring that the rules of the game are fair and everyone comports themselves in a sportsmanlike manner. Like other popular writers on the “white working class,” Case and Deaton thoroughly inhabit the soccer team understanding of class. For them, the “working class” is a kind of affinity group or cultural condition, the team that just so happens to value manual work, tradition, and NASCAR over education, avant-garde art, and NPR. The problem, in their view, is that developments in the economy, as a force somehow external to class, have made it hard for members of the working-class team to live their lives the way they were accustomed to for generations.

Following Marx, the left has historically viewed class very differently: the working class is a structural position in the capitalist economy, the segment of the population whose members have no choice but to work for a wage, or to depend on someone who does. Workers and employers are not preexisting types of people who bump into one another every so often. There are no rules that could make the game of labor markets fair. No amount of sportsmanship could obviate the imperative for employers to extract as much work as possible from their employees for as little money as possible. And the work that is extracted is not some abstract cultural signifier but real labor wrested from laborers, often brutally so. Durkheimian interventions might help people make their peace with class relations in the short term. But the persistence of exploitation ensures that no peace can last forever. It is the force of this everyday violence that grinds hope into despair. 

 

As their subtitle suggests, what Case and Deaton want most is a future: a future for capitalism, a future for work, family, and religion, a future for a social order whose ability to reproduce itself now seems in jeopardy. And it is true that despair is one name for the absence of such a future, for the impossibility of going on like this. But we should not want to go on like this. Case and Deaton, like Durkheim, are correct to perceive a relationship between political radicalism and despair. But if they want us to dissolve the threat of radicalism by anesthetizing despair with work and family and church, we should instead seek an even more radical despair: a politicized despair, a despair that seeks not the destruction of ourselves but the destruction of everything in our world that has made life so intolerable for so many. 

We can be thankful that, unlike the AIDS activists of the 1980s and 1990s, we do not have to fight to cajole the biomedical establishment into pursuing effective treatments for today’s pandemic with sufficient vigor and focus. But Covid does not just kill by infecting bodies. It has also killed by saddling people with ever worsening piles of debt; by reinforcing the power of tyrannical bosses in workplaces through the intensification of precarity; by trapping those employees lucky enough to work at home in their apartments, where it is all too easy for work to swell to consume every waking hour. Despite all the ways the pandemic has disrupted life as we knew it, there is a deeper sense in which it represents not a departure from normal but the intensification of normality in all its cruelty. By pathologizing radical social movements as a symptom of social breakdown, Case and Deaton insist that only those ways of living and working together that promote the stability of capitalism are worth defending and promoting. But channeling despair into collective action can actually help fulfill the very real longing for community and belonging that, after more than a year of lockdowns, distance, and unfathomable loss, many people feel more acutely than ever. For those of us for whom despair is not merely a sociological question, building a new world in the ashes of the old might just be our only hope. 

Erik Baker is a doctoral candidate in the Department of the History of Science at Harvard University and a contributing editor at The Drift.

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