A number of research papers have drawn attention to the poor health performance of the USA since at least the late 1970s. Not only has life expectancy failed to keep up with other high income countries, but more recently it has actually deteriorated. By coining the term “deaths of despair” to refer to deaths from suicide, drugs and alcohol that have been a major component of the adverse trends in all-cause mortality, Case and Deaton have drawn American media and public attentionto this problem, disillusioning many people of the profoundly mistaken assumption that America has the best health in the world. That is an important achievement.

In 2017 there were 158,000 deaths from suicide, drugs and alcohol in the USA. For comparison, in the same year there were 40,000 deaths from traffic accidents and 19,500 from homicide. These deaths buck the tendency common to most other causes of death of being more prevalent among the African American population. They are, instead, most common among white, non-Hispanic men and women aged 45-64 years. Among them, Case and Deaton show a very sharp distinction between those with a university degree, among whom there has been little or no rise in ‘deaths of despair’, and those without, who show huge rises. That difference in death rates from these causes started to widen dramatically from the late 1990s. Although weread that thepay gap between these two educational groups widened from 40 to 80 per cent in the period 1980-2000, the divide is treated primarily as educational rather than a status divide powered by a bigger income gap. Although deaths are currently highest in middle age, successive cohorts have, age for age, higher mortality rates from these causes of death. So although deaths of despair are currently higher among the middle aged, younger generations seem on an even worse trajectory. If present trends continue, their future looks grim.

Another reason why the label ‘deaths of despair’ is welcome is that it implies the authors’ acceptance of the role of psychosocial causes. For two such distinguished economists, that is an important step because the psychosocial world has been largely foreign territory to most of their profession. But they themselves do not seem to be well grounded in it. For example, they show little recognition of the link between physical pain – such as back pain – and social pain, regarding the former as purely mechanical. They also seem unaware of the way in which chronic stress increases vulnerability to so many health problems that its effects amount almost to more rapid ageing. And with that goes a failure to make use of the rich research evidence linking psychosocial factors to health.

Case and Deaton argue that there has been a rise in psychosocial and physical pain among people whose lives have lost everything that once made them meaningful. They emphasise (and document) particularly the decline in marriage, religion, and worthwhile jobs.

Understanding the causes of despair and depression in populations is not the easiest task and the authors handicap themselves by an unwillingness to recognise the psychosocial effects of inequality. Whilst they note “the mechanisms that redistribute money upward, away from working people, and towards firms and their shareholders” and say “ …this process has eaten away at the foundations of working-class life … and has been central in causing deaths of despair” they also deny that there is a “simple causal arrow running from inequality to death” and add “We are not disturbed by inequality in and of itself, but are very concerned with inequality that comes through theft and rent-seeking.” The reader is left with a sense that the authors are conflicted about the effects of inequality and prefer not to dwell on it. Indeed, among the many graphs, there is not one showing the scale and trends in American inequality even though the rise in US inequality coincides with the rise in deaths of despair.

The most widespread, but extremely naïve, view of inequality is that it only matters if it creates absolute poverty. The truth, however, is that it increases the importance of class and status and the accompanying feelings of superiority and inferiority (Wilkinson and Pickett, Reference Wilkinson and Pickett2018). It has been shown that a consequence of living in more unequal societies, in which people at the top are regarded as almost supremely important and those at the bottom as almost worthless, is to increase ‘status anxieties’ – people’s worries about how they are seen and judged – across all income groups (Layte and Whelan, Reference Layte and Whelan2014). And with that goes a decline in confidence and an increase in people’s insecurity about their own self-worth. These processes are particularly important not only because a large proportion of the population feel they lack confidence, but also because income and status are so often seen as marks of personal worth.

The failure of the authors to recognise these consequences of inequality is surprising given that they recognise similar psychological issues round black-white status difference and see them as relevant to the fact that deaths of despair are so much greater among the whites than African Americans. When they say that “White workers perceive black progress as an unfair usurpation” which has led to a white loss of sense of racial privilege, the basic issue – of who is better or worse than whom – is exactly the same territory as makes inequality so powerful. And Case and Deaton quote opinion polls to the effect that “more than 50 per cent of white working-class Americans believe discrimination against whites has become as big a problem as discrimination against blacks and other minorities”.

At bottom it is about whether people feel valued or devalued. Whether that sense of being valued comes from a network of friends or from social status and income, research shows that these are among the most highly protective influences on health we know of. But instead of pointing in this direction, the book ends by naming the soaring costs (from 5 to 18 per cent of GDP between 1970-2018) of American medical care as the ‘leading villain’. For Case and Deaton the problem this creates has nothing to do with the quality of, or access to, health care; it is instead that because employers pay many people’s medical insurance, the burden of rising costs will have prevented employers increasing working class incomes faster. But if medical care costs have been the chief villain, then surely there should have been at least a mention of their accomplices: among the biggest 350 US companies the 40-fold pay differential between production workers and CEOs expanded over the period 1980-2005 to something like a 300-fold differential (Mishel and Sabadish, Reference Mishel and Sabadish2012).