Russel Sage Foundation

CALL FOR ARTICLES

RSF: The Russell Sage Foundation Journal of the Social Sciences

Moving Beyond Deaths of Despair: Understanding Rising Mortality and Morbidity among Americans without College Degrees

Edited by
Anne Case, Princeton University
Andrew J. Cherlin, Johns Hopkins University
Angus Deaton, Princeton University

In articles published in 2015 and 2017, economists Anne Case and Angus Deaton, two of the co-editors of this issue of RSF: The Russell Sage Foundation Journal of the Social Sciences, reported that mortality rates were rising among middle-aged white Americans without four-year college degrees (Case & Deaton, 2015, 2017). Those papers and a subsequent book-length treatment (Case & Deaton, 2020) spurred research that, we believe, has deepened our understanding of the situation of these individuals. The authors pointed to the cumulative effects of decades of industrial decline on successive cohorts. 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 the other co-editor of this issue, 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 (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, suicide, drugs, and alcohol; 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. By 2021, as fentanyl flooded urban drug markets, two things had happened: First, the prevalence of heroin use had risen not just among white Americans but also among Black Americans (and to a lesser extent among Hispanic Americans) (Schuler, Schell, & Wong, 2021). Second, the rate of overdose deaths attributed to fentanyl had become larger among Blacks than among whites (U.S. Centers for Disease Control and Prevention, 2023). The huge increase 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. The causes of this slowdown are unclear, but they may not suggest the same type of distress as one would find in drug abuse, alcoholism, or suicide. In their more recent work, Case and Deaton have broadened their focus to accommodate these developments. They have noted that differences between Black and white individuals in all-cause mortality narrowed until the arrival of COVID-19, while educational differences widened (Case & Deaton, 2021). They have reported that nearly all of the major causes of death are now increasing, or decreasing less, among people without college degrees (Case & 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.

Consequently, there is a need to go beyond the deaths of despair label in order to fully understand the current situation. What we need going forward is a broadening of focus, in several respects, from the original articles. This would include a more comprehensive analysis among all racial-ethnic groups. Native Americans and Alaska Natives, for instance, are the group with the highest rates of self-reported prescription opioid abuse during most of the past 20 years (Schuler et al., 2021) and the highest rates of suicide deaths (U.S. Centers for Disease Control and Prevention, 2022) and alcohol-related deaths (Karaye, Malecki, & Yunusa, 2023). And although mortality rates among Hispanic Americans are lower than among white or Black Americans and fell until the arrival of COVID-19, sub-group differences within this diverse population are still of interest. Asian Americans have the lowest mortality but here again sub-group differences could be informative.

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. The mortality gap, and its widening over time, have been well documented in the literature (Meara, Richards, & Cutler, 2008). What is new now is that, since 2010, adult life-expectancies for those with and without a four-year college degree have been going in opposite directions, and that the college degree certificate appears to exempt its holders from increases in mortality from suicide, overdoses, alcoholism, and cardiovascular disease, as well as a range of mental health problems. In 2021 a committee formed by the National Academies of Sciences, Engineering, and Medicine issued a consensus report on mid-life mortality (National Academies of Sciences Engineering and Medicine, 2021). They concluded that a large number of studies “have convincingly documented a substantial widening of disparities in mortality by socioeconomic status” among working-age white adults and a “stable but persistent gap” among Black adults (pp. 4-5). Four studies too recent to be cited in the report all confirm the widening among both white and Black Americans (Case & Deaton, 2021; Leive & Ruhm, 2022; Novosad, Rafkin, & Asher, 2022; Sasson & Hayward, 2019). What this widening of the educational differential signals about the lives of low- and moderately-educated Americans is the central question that this issue of the journal will address.

We also need to better understand the broadening of the mortality problem to include deaths from cardiovascular disease and other major causes that were not emphasized in the initial writings about deaths of despair, including the sharp increase in mortality during the pandemic for those without a college degree. The scope of biomedical research on morbidity and mortality, of course, extends well beyond social science. Yet social scientists continue to make substantial contributions to the field. The Case and Deaton papers were situated in the social scientific study of mortality trends, and they have led to a number of papers from demographers and public health researchers who study mortality, many of which emphasize the slowdown in cardiovascular disease as a causal factor (e.g., Mehta, Abrams, & Myrskylä, 2020). But it is still not fully clear why this slowdown has occurred (Couillard, Foote, Gandhi, Meara, & Skinner, 2021).

CALL FOR ARTICLES

We invite scholars to submit proposals that address the questions of what explains the growing educational divide in physical and mental health and what this widening means for the lives of Americans without college degrees. We expect that many of the papers will directly address differences in mortality, including not only drug abuse, alcohol-related disease, and suicide but also major causes of death such as cardiovascular disease and cancer. But we also encourage papers that will encompass topics as diverse as the changing labor market; social class; gender, racial, ethnic perspectives; studies of family and personal life; spatial variation; political processes; and social policy.

We will not be interested, however, in papers that primarily continue the debate that has occurred over the past decade about the appropriateness of the deaths of despair framing. Rather, we wish to move forward by de-emphasizing that framing and focusing on important research questions for the next decade. We welcome evidence-based proposals from all social science disciplines and all methodological approaches. Below we offer a (non-exhaustive) list of the kinds of thematic questions that are well-suited for this issue.

Social Scientific Research on Widening Mortality Differentials

• Can we make further progress in understanding the educational differential in mortality risks? What can we learn about the slow-down in progress against cardiovascular disease, which is clearly a major factor in raising the risk of mortality? And why it is more severe among Americans without college degrees, even to the extent of reversal? In addition, what can be said about the evolution of other major sources of mortality? What can we learn from the experience in other countries? What, if any, are the long-term effects of COVID, which widened the gap between less and more educated, though it narrowed again post-COVID? How can we understand the surge in alcohol-induced deaths, which rose 43 percent between 2000 and 2018 (U.S. National Center for Health Statistics, 2020)? Is the drug abuse problem evolving in some areas beyond the heroin/fentanyl epidemic that has raised overdose rates so sharply since the mid-2010s?

Labor Market Processes

• What role has the continuing evolution of the labor market played in affecting rates of mortality, and how are further developments likely to be influential? Scholars have written about the consequences of the lack of opportunity in traditionally male-dominated occupations in the middle-third of the labor market as a result of deindustrialization and automation. Is this situation likely to change? Is there any evidence yet of the possible effects of artificial intelligence?
• What do we know about the consequences for health and mortality of precarious work? This would include independent contracting, which usually does not provide for health insurance or sick leave. It would also include working conditions that may impact health, such as jobs with uncertain and frequently changing hours of work. It could also include difficulty in finding full-time work and the resulting low income. The lack of mobility for less-educated workers—in part a consequence of living costs in prosperous areas and a reduction in the wage premium for less-educated workers there— may leave less-educated workers under the thumb of monopsonists (employers who can hold wages below the value of their employees).

Educational and Social Class Differentials

• Nearly all the recent literature on all-cause mortality differentials, including but not limited to deaths of despair, has found an educational dividing line, mostly at the level of the four-year college degree.  How can we explain the persistence of this finding? What does educational attainment do to people’s social and economic experiences?
• Is there evidence that other educational dividing lines (e.g., high school degree) are sometimes important? How is the dividing line being affected by the increase over time in the percentage of the population with four-year college degrees? Have college graduates been completely immune to the harmful trends or can we also see evidence of impacts on them?
• Scholars and commentators in this literature often use the term “working class” to describe the less-educated population. Is this term still useful? If so, what do we mean by it and how should we measure it? More generally, is the idea of social class useful in understanding educational differentials? And do we need to theorize class differently for white Americans than for nonwhite Americans?

Gender, Racial, and Ethnic Perspectives

• Much of the literature on drug abuse and feelings of distress due to the changing economy has been about men. Yet mortality has increased among non-college-graduate women too. And while rates have decreased for Black women, their overall mortality rates continue to exceed those of white women (albeit by smaller amounts over time). The increasing share of college degrees that are awarded to women is further changing gender roles. How can we better understand how women have experienced the events of the past few decades – the various stages of the drug abuse crisis, the changes in the labor market, the difficulty of finding suitable partners, and so forth?
• In the early (i.e., prescription opioid) stage of the drug abuse crisis, the greatest effects were seen among white Americans; but since the mid-2010s, drug abuse deaths have increased greatly among Black Americans, with timing synchronous to the introduction of fentanyl into the illegal drug market. Among Black Americans as a whole, life expectancy has declined since the mid-2010s.  This decline, however, appears to be confined to those without college degrees. The educational gap in life expectancy among Black Americans has widened. How can we better understand these developments and their implications for the lives of Black Americans? What role is played by differential access to health care and to differential treatment for pain management (Anderson, Green, & Payne, 2009).
• Native Americans show very high rates of drug overdose deaths, alcohol-related deaths, and suicides. Yet we know little about recent developments among them. Within the considerable limits of data on mortality for Native Americans, what can be said about their patterns? How are patterns of alcohol and drug abuse different from those of non-Native-Americans?
• All-cause mortality rates for Hispanic and Asian Americans have held steady and are lower than among white or Black Americans. The Hispanic advantage was almost eliminated in 2020 during the first year of COVID, but by 2023 the Hispanic advantage is almost back to where it was in 2018. Yet both groups are diverse and include sub-populations that vary greatly in socioeconomic status, geographical patterns of residence, immigration status, and other factors. Are there lessons to be learned from disaggregating the Hispanic and Asian American populations and examining the experiences of the sub-populations within each of them?

Family and Personal Life

• How can we better understand the relationship between the labor market and the family lives of Americans who do not have college degrees? Are the changes in the labor market for the non-college-degree population making it more difficult for them to establish enduring family and personal lives? And are these difficulties in family life contributing to behaviors that may raise mortality risks? Descriptively, the non-college-educated population is less likely to ever marry and more likely to divorce than are those with college degrees and more likely to have children outside of marriage. In place of stable partnerships, non-college-educated young adults often move quickly in and out of cohabiting relationships. Are working-class young adults developing weaker attachments to institutions such as family life, the labor market, and organized religion? Are there important racial and ethnic variations in how Americans relate to these institutions?
• Are we seeing a decline in social networks, community ties, and other forms of social capital among individuals without college degrees (Putnam, 2015)? Are these difficulties more prevalent among men than women? What are the implications for the well-being of children?

Spatial variation and Social Policy

• What is the importance of place of residence in understanding mortality differentials and trends? There is substantial geographic variation in mortality rates, both from self-harm such as drug and alcohol abuse and suicide, and from major causes such as cardiovascular disease. What do geographic differences look like today? Are there significant rural-urban or regional differences in mortality trends?
• Some studies suggest that life expectancy is greater in states that have implemented policies such as higher tobacco taxes and labor laws such as paid sick leave and paid family leave (Montez et al., 2020) Can we use spatial variation to evaluate the role of state policies with respect to health, as well as economic policies such as state minimum wages and cigarette taxes?

Political and Comparative Perspectives

• To what extent do current patterns of mortality reveal or reflect political processes? The early studies of deaths of despair suggested a relationship between mortality levels in an area and support for Donald Trump (as in the 2016 election). Some observers took this finding as suggesting a link between life dissatisfaction and the growth of Trump’s base. What are the political implications of the patterns of mortality that we now see with respect to factors such as political partisanship and participation?
• What can be learned from comparative perspectives? The deaths of despair phenomenon has been reported in other high-income countries such as the Canada (Khalid, 2019), United Kingdom (Walsh et al., 2021), and Spain (Piñeiro, Spijker, Trias-Llimós, Blanes Llorens, & Permanyer, 2023) as well as post-socialist Eastern Europe (King, Scheiring, & Nosrati, 2022). Can similarities and differences, both contemporary and historical, help us to understand the socioeconomic differences that we see in the United States?

ANTICIPATED TIMELINE

Prospective contributors should submit a CV and an abstract (up to two pages in length, single or double spaced) of their study along with up to two pages of supporting material (e.g., tables, figures, pictures, etc.) no later than 5 PM EST on September 4, 2024 to:

https://rsf.fluxx.io

NOTE that if you wish to submit an abstract and do not yet have an account with the Russell Sage Foundation, it can take up to 48 hours to get credentials, so please start your application at least two days before the deadline. All submissions must be original work that has not been previously published in part or in full. Only abstracts submitted to https://rsf.fluxx.io will be considered. Each paper will receive a $1,000 honorarium when the issue is published. All questions regarding this issue should be directed to Suzanne Nichols, Director of Publications, at journal@rsage.org. Do not email the editors of the issue. In September, Suzanne Nichols will notify all applicants if they have been accepted or not.

A conference will take place at the Russell Sage Foundation in New York City on March 27–28, 2025 with a group dinner on March 27, 2025. The selected contributors will gather for a two-day workshop to present draft papers, which are due a month prior to the conference on February 27, 2025, and receive feedback from the other contributors and editors. Travel costs, food, and lodging for one author per paper will be covered by the foundation. Papers will be circulated before the conference. After the conference, the authors will submit their revised drafts by 7/24/25. The papers will then be sent out to three additional scholars for formal peer review. Having received feedback from reviewers and the RSF board, authors will revise their papers by 10/7/25. The full and final issue will be published in fall 2026. Papers will be published open access on the RSF website as well as in several digital repositories, including JSTOR and UPCC/Muse.

References

Anderson, K. O., Green, C. R., & Payne, R. (2009). Racial and ethnic disparities in pain: causes and consequences of unequal care. The journal of pain, 10(12), 1187-1204.

Case, A., & Deaton, A. (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), 15078-15083.

Case, A., & Deaton, A. (2017). Mortality and morbidity in the 21st century. Brookings papers on economic activity, 2017, 397.

Case, A., & Deaton, A. (2020). Deaths of Despair and the Future of Capitalism. In. Princeton: Princeton University Press.

Case, A., & Deaton, A. (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, A., & Deaton, A. (2023). Accounting for the Widening Mortality Gap between American Adults with an without a BA. Brookings Papers on Economic Activity, Fall. Retrieved from https://www.brookings.edu/articles/accounting-for-the-widening-mortality-gap-between-american-adults-with-and-without-a-ba/

Cherlin, A. J. (2014). Labor's Love Lost: The Rise and Fall of the Working-Class Family in America. New York: Russell Sage Foundation.

Cherlin, A. J. (2016). Why Are White Death Rates Rising? The New York Times. February 22. Retrieved from https://www.nytimes.com/2016/02/22/opinion/why-are-white-death-rates-rising.html

Couillard, B. K., Foote, C. L., Gandhi, K., Meara, E., & Skinner, J. (2021). Rising geographic disparities in US mortality. Journal of Economic Perspectives, 35(4), 123-146.

Karaye, I., Malecki, N., & Yunusa, I. (2023). Racial and Ethnic Disparities in Alcohol-Attributed Deaths in the United States, 1999–2020. International Journal of Environmental Research and Public Health, 20, 5587.

Khalid, M. (2019). UNPACKING CANADIAN'DEATHS OF DESPAIR'. Canadian Issues, 43-48.

King, L., Scheiring, G., & Nosrati, E. (2022). Deaths of despair in comparative perspective. Annual Review of Sociology, 48, 299-317.

Leive, A. A., & Ruhm, C. J. (2022). Education gradients in mortality trends by gender and race. Journal of Human Capital, 16(1), 47-72.

Meara, E. R., Richards, S., & Cutler, D. M. (2008). The gap gets bigger: changes in mortality and life expectancy, by education, 1981–2000. Health Affairs, 27(2), 350-360.

Mehta, N. K., Abrams, L. R., & Myrskylä, M. (2020). US life expectancy stalls due to cardiovascular disease, not drug deaths. Proceedings of the National Academy of Sciences, 117(13), 6998-7000.

Montez, J. K., Beckfield, J., Cooney, J. K., Grumbach, J. M., Hayward, M. D., Koytak, H. Z., . . . Zajacova, A. (2020). US state policies, politics, and life expectancy. The Milbank Quarterly, 98(3), 668-699.

National Academies of Sciences Engineering and Medicine. (2021). High and Rising Mortality Rates Among Working-Age Adults. Retrieved from https://nap.nationalacademies.org/catalog/25976/high-and-rising-mortality-rates-among-working-age-adults

Novosad, P., Rafkin, C., & Asher, S. (2022). Mortality change among less educated Americans. American Economic Journal: Applied Economics, 14(4), 1-34.

Piñeiro, B., Spijker, J. J., Trias-Llimós, S., Blanes Llorens, A., & Permanyer, I. (2023). Trends in cause-specific mortality: deaths of despair in Spain, 1980–2019. Journal of Public Health, 45(4), 854-862.

Putnam, R. D. (2015). Our Kids: The American Dream in Crisis. New York: Simon and Schuster.

Sasson, I., & Hayward, M. D. (2019). Association between educational attainment and causes of death among white and black US adults, 2010-2017. Jama, 322(8), 756-763.

Schuler, M. S., Schell, T. L., & Wong, E. C. (2021). Racial/ethnic differences in prescription opioid misuse and heroin use among a national sample, 1999–2018. Drug and alcohol dependence, 221, 108588.

U.S. Centers for Disease Control and Prevention. (2022). Suicides Among American Indian or Alaska Native Persons — National Violent Death Reporting System, United States, 2015–2020. Morbidity and Mortality Weekly Report. 71 (37). Retrieved from https://www.cdc.gov/mmwr/volumes/71/wr/mm7137a1.htm#T1_down

U.S. Centers for Disease Control and Prevention. (2023). Estimates of Drug Overdose Deaths involving Fentanyl, Methamphetamine, Cocaine, Heroin, and Oxycodone: United States, 2021. Retrieved from https://stacks.cdc.gov/view/cdc/125504

U.S. National Center for Health Statistics. (2020). Rates of Alcohol-induced Deaths Among Adults Aged 25 and Over in Urban and Rural Areas: United States, 2000–2018. Data Brief. 383. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db383-H.pdf

Walsh, D., McCartney, G., Minton, J., Parkinson, J., Shipton, D., & Whyte, B. (2021). Deaths from ‘diseases of despair ’in Britain: comparing suicide, alcohol-related and drug-related mortality for birth cohorts in Scotland, England and Wales, and selected cities. J Epidemiol Community Health, 75(12), 1195-1201.