Russel Sage Foundation

Announcement of a forthcoming 2026 issue of RSF: The Russell Sage Foundation
Journal of the Social Sciences

Anne Case
Princeton University

Andrew J. Cherlin
Johns Hopkins University

Angus Deaton
Princeton University

In 2014, economists Anne Case and Angus Deaton were at their summer home in Montana, when they became puzzled by the high suicide rate in that seemingly placid rural state.¹ They turned to national data on suicide, which showed, not only that suicide had long been high in Montana and other mountain states, but that rates were rising for middle-aged, non-Hispanic White (whom we will refer to as “White”) Americans not just in Montana but across the country. Intrigued, they examined detailed public health data on mortality to see what else was happening. Mortality rates, they found, were increasing among middle-aged White Americans with less than a bachelor’s degree (which we will refer to as a “college degree”), but declining among middle-aged Black and Hispanic Americans and more-educated White Americans. It was surprising to see a rise in mortality rates among any racial or ethnic group because a steady decline in mortality, and the resulting extension of life expectancy, has been one of the great achievements of advanced societies. It was all the more surprising to see that the rise was largely restricted to White Americans. Intrigued, Case and Deaton delved into the government statistics on causes of death to see what particular causes might be driving this increase. They found that deaths due to drug overdose, suicide, and alcohol-related liver disease and cirrhosis had increased among White American men and women aged 45 to 54, between 1999 and 2013, which they described in the Proceedings of the National Academy of Sciences (Case and Deaton 2015).²

To Case and Deaton, the increases in mortality from drug overdose, alcohol-related disease, and suicide seemed to be an indicator of mental distress among a population that had been left behind by changes in the American economy. A few weeks after the publication of the 2015 paper, Anne Case wrote an article for Quartz titled, “‘Deaths of despair’ are killing America’s White Working Class” (Case 2015). The alliterative phrase “deaths of despair” soon became the ubiquitous descriptor for the rising tide of mortality among White Americans who lacked a college degree. The study triggered a flood of articles in the scholarly and popular media that continues to this day. The 2015 Case and Deaton article has been cited over 3,000 times in the academic literature. In the New York Times alone, the phrase “deaths of despair” has appeared more than 150 times in news articles, opinion columns, and guest essays.

Of the three components, deaths from drug overdose is the largest, comprising half of all deaths of despair in 2023. Drug overdose mortality began to rise among White Americans without college degrees in the 1990s and rose steadily in the 2000s. Then, in the 2010s, it rose sharply for both White and Black Americans without college degrees. Although suicide is the smallest component of the three, it is the clearest form of self-destruction and is less affected by the changing availability of legal and illegal drugs. In the U.S., among those without a college degree, suicide rates have been on an upward trend since 2000, while rates among those with a college degree have been low and relatively flat. In contrast, rates have been falling in most other rich countries, taken together (Dattani et al. 2024). The third component, mortality from alcoholic liver disease and cirrhosis, began to rise rapidly after 2010 for Whites without college degrees, nearly doubling by 2021 despite the downward trend in the total consumption of alcohol in the US.³ Unlike suicide and much of drug overdose mortality, the majority of deaths from alcoholic liver disease reflect a long period, perhaps decades long, of heavy usage, although the increase in binge drinking has reduced the time lag between heavy drinking and death for many.

In a subsequent book-length treatment, Case and Deaton (2020) pointed to the cumulative effects of decades of industrial decline on successive cohorts and contended that American capitalism is not working well for people without college degrees. They argued that when decent-paying, often unionized work is in short supply, people who are unable to obtain these jobs experience a loss of purpose and dignity that can lead to self-destructive behaviors. In making this argument, the authors drew upon, in part, the writings of sociologist Andrew Cherlin, on the working-class family (Cherlin 2014). Cherlin argued that the psychological distress among the White working class stemmed from the comparisons that young adults were making between their standard of living and the standard of living of their parents when they were growing up – a comparison that often showed that the young adults were not doing as well as their parents and which left them unable to obtain dignified work (Cherlin 2016).

But mortality rates have evolved over time, and the metaphor of “despair” is not as useful as it was a decade ago. For Case and Deaton, “deaths of despair” was simply a label for the three causes, and they never proposed a clinical definition of “despair.” The overdose problem, however, is no longer simply about prescription opioids or even heroin usage, as it was in the early 2010s. It has also become a fentanyl problem, and it is not limited to White people. The huge increase among both Whites and Blacks in overdose deaths due to fentanyl since 2014 has more to do with the deadly power of this synthetic opioid than with feelings of despair among its users.

In addition, mortality rates are now rising among non-college-graduates, both Black and White, from a wide number of causes. Most importantly, progress against cardiovascular disease has slowed among both White and Black Americans, particularly for those without college degrees. Figure 1 displays age-adjusted trends in cardiovascular disease mortality from 2001 to 2023.

Among both White and Black Americans without college degrees, the downward trend stopped in the early 2010s, and worsened during the COVID-19 pandemic. The slowdown is less pronounced among White and Black people who have college degrees. Overall, differences in education are stronger predictors of the slowdown in progress against cardiovascular disease mortality than are racial differences. In fact, differences between Black and White Americans in mortality from all causes taken together narrowed until the arrival of COVID-19, while educational differences widened (Case and Deaton 2021). Nearly all of the major causes of death are now increasing more, or decreasing less, among people without college degrees (Case and Deaton 2023). Although cardiovascular disease is linked to smoking and obesity, which might be symptoms of disadvantage, its impact is broader than the original focus on deaths of despair suggests. And it is still not fully clear why this slowdown has occurred (Couillard et al. 2021).

Consequently, there is a need to go beyond the deaths of despair framework in order to fully understand the current situation. Case, Cherlin, and Deaton still maintain that the original focus on deaths of despair was useful. It pointed us toward the likely consequences of industrial decline. And it led to explanations of why the White working class turned to Donald Trump in the 2016, 2020, and 2024 elections – an understanding that is still relevant today. We now need to focus, however, on a broader set of issues that occur disproportionately among those with less than a college degree. This would encompass a more comprehensive analysis among all racial-ethnic groups.

This broader focus, however, should be guided by a central finding that has been consistent and unchallenged since the early Case and Deaton articles: the widening difference in mortality rates by educational level. This differential is shown in Figure 2.

The mortality gap has been well documented in the literature (Meara, Richards and Cutler 2008). What’s new is that, since 2010, adult life-expectancies for those with and without a four-year college degree have been going in opposite directions, as Figure 2 shows (Case and Deaton 2023). The college degree certificate appears to exempt its holders from increases in mortality from overdoses, suicide, alcohol-related disease, and cardiovascular disease, as well as a range of mental health problems. Using socioeconomic status, a composite indicator that is different from our focus (which is education), a National Academies of Sciences, Engineering, and Medicine committee (2021) found evidence of a substantial widening of mortality disparities among Whites, particularly women, since the 1990s. Studies conducted since this review have corroborated the finding that the educational differential has widened among both White women and White men; and all of them found some widening in the educational differential among Black women and men (Case and Deaton 2021, Case and Deaton 2023, Leive and Ruhm 2022, Novosad, Rafkin and Asher 2022, Sasson and Hayward 2019). Case and Deaton (2023) divided mortality into a complete set of ICD 10 (International Classification of Diseases, Tenth Revision) classifications, finding that for all major groupings of mortality, the educational divide has widened. This occurred for causes of death that were rising (like deaths of despair), for causes of death that were falling (like cancer), and for causes that fell and later rose (like cardiovascular diseases).

In sum, we can say with confidence that the differences in mortality rates that one would observe by comparing people using measures of education have increased among White men and women over the past few decades. These differences also increased among Black men and women with various levels of education as well, although the magnitude of the widening may be smaller and the reason behind the widening may reflect changes in the proportion of the Black population in degree categories. The rise in drug overdose deaths among people with less education has almost certainly been a major factor in the growing educational differential. Beyond drug overdose deaths, changes in major causes of death in the population at large, such as cardiovascular disease and cancer, have been the largest contributors.

What this widening of the educational differential signals about the lives of low- and moderately-educated Americans compared to college graduates remains a central question. In order to study it further, Case, Cherlin, and Deaton are in the process of editing an issue of RSF: The Russell Sage Foundation Journal of the Social Sciences on this topic. The editors commissioned a set of papers, preliminary versions of which were presented and discussed at a conference at The Russell Sage Foundation in March 2025. The papers are now being revised and will be subject to peer review. The issue, which will include an introductory article by the three editors, will be published in 2026.

¹ This account is drawn from Case and Deaton (2020).
² Deaths from alcohol, drugs and suicide were also rising among Native Americans aged 45-54. It is, however, difficult to estimate trends in cause-specific mortality rates for Native Americans because of the small population size and because of changes over time in whether individuals identify as Native American.
³ Authors’ calculations

References
Case, Anne. 2015, "“Deaths of Despair” Are Killing America’s White Working Class" Quartz. Retrieved April 26, 2024 (https://qz.com/583595/deaths-of-despair-are-killing-americas-white-worki...).
Case, Anne and Angus Deaton. 2015. "Rising Morbidity and Mortality in Midlife among White Non-Hispanic Americans in the 21st Century." Proceedings of the National Academy of Sciences 112(49):15078-83.
Case, Anne and Angus Deaton. 2020. Deaths of Despair and the Future of Capitalism. Princeton: Princeton University Press.
Case, Anne and Angus Deaton. 2021. "Life Expectancy in Adulthood Is Falling for Those without a BA Degree, but as Educational Gaps Have Widened, Racial Gaps Have Narrowed." Proceedings of the National Academy of Sciences 118(11):e2024777118.
Case, Anne and Angus Deaton. 2023. "Accounting for the Widening Mortality Gap between American Adults with an without a BA." Brookings Papers on EconomicActivity Fall.
Cherlin, Andrew J. 2014. Labor's Love Lost: The Rise and Fall of the Working-Class Family in America. New York: Russell Sage Foundation.
Cherlin, Andrew J. 2016. "The Downwardly Mobile for Trump." in The New York Times.
Couillard, Benjamin K, Christopher L Foote, Kavish Gandhi, Ellen Meara and Jonathan Skinner. 2021. "Rising Geographic Disparities in US Mortality." Journal of Economic Perspectives 35(4):123-46.
Dattani, Lucas, Guirao Lucas Rodés, Hannah Ritchie, Max Roser and Esteban Ortiz-Ospina. 2024, "Suicide": OurWorldinData.org. Retrieved January 22, 2025 (https://ourworldindata.org/suicide).
Leive, Adam A and Christopher J Ruhm. 2022. "Education Gradients in Mortality Trends by Gender and Race." Journal of Human Capital 16(1):47-72.
Meara, Ellen R, Seth Richards and David M Cutler. 2008. "The Gap Gets Bigger: Changes in Mortality and Life Expectancy, by Education, 1981–2000." Health Affairs 27(2):350-60.
National Academies of Sciences Engineering and Medicine. 2021, "High and Rising Mortality Rates among Working-Age Adults". Retrieved March 15, 2024 (https://nap.nationalacademies.org/catalog/25976/high-and-rising-mortalit...).
Novosad, Paul, Charlie Rafkin and Sam Asher. 2022. "Mortality Change among Less Educated Americans." American Economic Journal: Applied Economics 14(4):1-34.
Sasson, Isaac and Mark D Hayward. 2019. "Association between Educational Attainment and Causes of Death among White and Black US Adults, 2010-2017." Journal of the American Medical Association 322(8):756-63.