The diseases of despair are three classes of behavior-related medical conditions that increase in groups of people who experience
despair due to a sense that their long-term
social and economic prospects are bleak. The three disease types are
drug overdose
A drug overdose (overdose or OD) is the ingestion or application of a drug or other substance in quantities much greater than are recommended. (including
alcohol overdose
Alcohol intoxication, also known as alcohol poisoning, commonly described as drunkenness or inebriation, is the negative behavior and physical effects caused by a recent consumption of alcohol. In addition to the toxicity of ethanol, the main ...
),
suicide
Suicide is the act of intentionally causing one's own death. Mental disorders (including depression, bipolar disorder, schizophrenia, personality disorders, anxiety disorders), physical disorders (such as chronic fatigue syndrome), and s ...
, and
alcoholic liver disease
Alcoholic liver disease (ALD), also called alcohol-related liver disease (ARLD), is a term that encompasses the liver manifestations of alcohol overconsumption, including fatty liver, alcoholic hepatitis, and chronic hepatitis with liver fibrosis ...
.
Diseases of despair, and the resulting deaths of despair, are high in the
Appalachia
Appalachia () is a cultural region in the Eastern United States that stretches from the Southern Tier of New York State to northern Alabama and Georgia. While the Appalachian Mountains stretch from Belle Isle in Newfoundland and Labrador, Ca ...
region of the United States. The prevalence increased markedly during the first decades of the 21st century, especially among middle-aged and older
working class
The working class (or labouring class) comprises those engaged in manual-labour occupations or industrial work, who are remunerated via waged or salaried contracts. Working-class occupations (see also " Designation of workers by collar colou ...
White Americans starting in 2010, followed by an increase in mortality for Hispanic Americans in 2011 and African Americans in 2014. It gained media attention because of its connection to the
opioid epidemic
The opioid epidemic, also referred to as the opioid crisis, is the rapid increase in the overuse, misuse/abuse, and overdose deaths attributed either in part or in whole to the class of drugs opiates/opioids since the 1990s. It includes the sign ...
. For 2018, some 158,000 U.S. citizens died from these causes, compared to 65,000 in 1995. The economists
Anne Case
Anne Catherine Case, Lady Deaton, (born July 27, 1958) is an American economist who is currently the Alexander Stewart 1886 Professor of Economics and Public Affairs, Emeritus, at Princeton University.
Early life and career
She graduated from ...
and
Angus Deaton
Sir Angus Stewart Deaton (born 19 October 1945) is a British economist and academic. Deaton is currently a Senior Scholar and the Dwight D. Eisenhower Professor of Economics and International Affairs Emeritus at the Princeton School of Public ...
attribute this rising mortality to the flaws in contemporary
capitalism
Capitalism is an economic system based on the private ownership of the means of production and their operation for Profit (economics), profit. Central characteristics of capitalism include capital accumulation, competitive markets, pric ...
.
Deaths of despair have increased sharply during the
COVID-19 pandemic
The COVID-19 pandemic, also known as the coronavirus pandemic, is an ongoing global pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The novel virus was first identif ...
and associated
recession
In economics, a recession is a business cycle contraction when there is a general decline in economic activity. Recessions generally occur when there is a widespread drop in spending (an adverse demand shock). This may be triggered by various ...
, with a 10% to 60% increase above pre-pandemic levels. Life expectancy in the United States declined further to 76.4 years in 2021, with the main drivers being the COVID-19 pandemic along with deaths from drug overdoses, suicides and liver disease.
Definitions
The word despair derives from the Latin word ''desperare'', which means ''"down from hope"''. The concept of despair in any form can not only affect an individual person, but can also arise in and spread through social communities.
There are four basic types of despair. Cognitive despair denotes thoughts connected to defeat,
guilt
Guilt may refer to:
*Guilt (emotion), an emotion that occurs when a person feels that they have violated a moral standard
*Culpability, a legal term
*Guilt (law), a legal term
Music
*Guilt (album), ''Guilt'' (album), a 2009 album by Mims
*Guilt ( ...
, hopelessness and pessimism. It may make a person perceive other people's actions as hostile and discount the value of long-term outcomes. Emotional despair refers to feelings of sadness, irritability, loneliness and apathy and may partly impede the process of creating and nourishing interpersonal relationships. The term behavioural despair describes risky, reckless and self-destructive acts reflecting little to no consideration of the future (such as
self-harm
Self-harm is intentional behavior that is considered harmful to oneself. This is most commonly regarded as direct injury of one's own skin tissues usually without a suicidal intention. Other terms such as cutting, self-injury and self-mutilatio ...
, reckless driving, drug use, risky sexual behaviours and others). Lastly, biological despair relates to dysfunction or dysregulation of the body's stress reactive system and/or to hormonal instability.
Being under the influence of despair for an extended amount of time may lead to the development of one or more of the diseases of despair, such as suicidal thoughts or drug and alcohol abuse. If an individual has a disease of despair, there is an increased risk of death of despair, usually classified as a suicide, drug or alcohol overdose, or liver failure.
Risk factors
Unstable mental health, depression, suicidal thoughts and addiction to drugs and alcohol affect people of every age, every
ethnicity
An ethnic group or an ethnicity is a grouping of people who identify with each other on the basis of shared attributes that distinguish them from other groups. Those attributes can include common sets of traditions, ancestry, language, history, ...
, and every
demographic group
Demography () is the statistical study of populations, especially human beings.
Demographic analysis examines and measures the dimensions and dynamics of populations; it can cover whole societies or groups defined by criteria such as edu ...
in every country in the world. However, data show that in recent years these problems are on the rise, especially among the US
White non-Hispanic
Non-Hispanic whites or Non-Latino whites are Americans who are classified as "white", and are not of Hispanic (also known as "Latino") heritage. The United States Census Bureau defines ''white'' to include European Americans, Middle Eastern Amer ...
men and women in midlife. Since the beginning of the
millennium
A millennium (plural millennia or millenniums) is a period of one thousand years, sometimes called a kiloannum (ka), or kiloyear (ky). Normally, the word is used specifically for periods of a thousand years that begin at the starting point (ini ...
, this particular group of people is the single one in the world which experienced continual increase in
mortality
Mortality is the state of being mortal, or susceptible to death; the opposite of immortality.
Mortality may also refer to:
* Fish mortality, a parameter used in fisheries population dynamics to account for the loss of fish in a fish stock throug ...
and
morbidity
A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...
while US
Black non-Hispanics and US
Hispanic
The term ''Hispanic'' ( es, hispano) refers to people, Spanish culture, cultures, or countries related to Spain, the Spanish language, or Hispanidad.
The term commonly applies to countries with a cultural and historical link to Spain and to Vic ...
s, as well as all subgroups of populations in other rich countries (such as countries from the
EU,
Japan
Japan ( ja, 日本, or , and formally , ''Nihonkoku'') is an island country in East Asia. It is situated in the northwest Pacific Ocean, and is bordered on the west by the Sea of Japan, while extending from the Sea of Okhotsk in the north ...
,
Australia
Australia, officially the Commonwealth of Australia, is a Sovereign state, sovereign country comprising the mainland of the Australia (continent), Australian continent, the island of Tasmania, and numerous List of islands of Australia, sma ...
and others), show the exact opposite trend. Moreover, men and women having no more than high school education and those living in rural areas are more affected by this phenomenon than their college educated and in-urban-areas-living peers.
Recent trends in numbers
Mortality
Mortality is the state of being mortal, or susceptible to death; the opposite of immortality.
Mortality may also refer to:
* Fish mortality, a parameter used in fisheries population dynamics to account for the loss of fish in a fish stock throug ...
and
morbidity
A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...
rates in the United States have been decreasing for decades. Between 1970 and 2013, mortality rates fell by 44% and morbidity was on a decline even among the elderly. After 1998,
mortality rate
Mortality rate, or death rate, is a measure of the number of deaths (in general, or due to a specific cause) in a particular population, scaled to the size of that population, per unit of time. Mortality rate is typically expressed in units of de ...
s in other rich countries have been declining by 2% a year; midlife mortality fell by more than 200 per 100,000 for Black non-Hispanics and by more than 60 per 100,000 for Hispanics during the 1998-2013 period.
The infamous
AIDS
Human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency virus (HIV), a retrovirus. Following initial infection an individual m ...
epidemic was brought under control – in 2018, only 37,968 people received an
HIV
The human immunodeficiency viruses (HIV) are two species of ''Lentivirus'' (a subgroup of retrovirus) that infect humans. Over time, they cause acquired immunodeficiency syndrome (AIDS), a condition in which progressive failure of the immune ...
diagnosis in the
USA
The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territori ...
and its 6 dependent areas, which is an overall 7% decrease compared with the year 2014.
Cardiovascular disease
Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include stroke, h ...
and
cancer
Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal b ...
, the two biggest killers in middle age, are also on a decline,
even though the still growing problem with
obesity
Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's we ...
is not getting under control yet. Despite all of these satisfactory numbers, White non-Hispanic population exhibits an increase in premature deaths, especially in those caused by
suicide
Suicide is the act of intentionally causing one's own death. Mental disorders (including depression, bipolar disorder, schizophrenia, personality disorders, anxiety disorders), physical disorders (such as chronic fatigue syndrome), and s ...
,
drug overdose
A drug overdose (overdose or OD) is the ingestion or application of a drug or other substance in quantities much greater than are recommended. and
alcoholic liver disease
Alcoholic liver disease (ALD), also called alcohol-related liver disease (ARLD), is a term that encompasses the liver manifestations of alcohol overconsumption, including fatty liver, alcoholic hepatitis, and chronic hepatitis with liver fibrosis ...
.
There are two main factors driving this trend. Firstly, the data show the US
White non-Hispanic
Non-Hispanic whites or Non-Latino whites are Americans who are classified as "white", and are not of Hispanic (also known as "Latino") heritage. The United States Census Bureau defines ''white'' to include European Americans, Middle Eastern Amer ...
population significantly differs from populations in other countries. For example, in 2015, drug, alcohol and suicide mortality was more than two times higher among US White non-Hispanics in comparison to people from the United Kingdom, Sweden or Australia. In comparison to US
Black non-Hispanics, the mortality and morbidity rates are still lower; nevertheless the gap between these groups is narrowing quickly and, for example, for people aged 30–34 the difference between these two ethnicities has almost completely diminished. Also, white non-Hispanics aged 50–54 with no more than a high school diploma reached almost 1000 premature deaths per 100,000 in the year 2015, whereas the average for all White non-Hispanics regardless of their education was only around 500 deaths per 100,000. Therefore, the factor of education probably negatively correlates with the probability of developing a disease of despair (that means higher education correlates with lower probability of developing a disease of despair).
Secondly, the excess premature deaths are, as stated above, caused primarily by suicide, poisonings or drug overdoses and other causes connected especially to
alcoholism
Alcoholism is, broadly, any drinking of alcohol (drug), alcohol that results in significant Mental health, mental or physical health problems. Because there is disagreement on the definition of the word ''alcoholism'', it is not a recognize ...
such as chronic liver diseases. The proportion of these causes of death (in comparison to deaths caused by assaults, cancer, cardiovascular diseases, HIV and motor vehicle crashes) in population white non-Hispanic people aged 25–44 is increasing. It is also worth noting that the highest rates are to be discovered among people living in
rural area
In general, a rural area or a countryside is a geographic area that is located outside towns and cities. Typical rural areas have a low population density and small settlements. Agricultural areas and areas with forestry typically are descri ...
s. For example, during the years 1999–2015, the rate of deaths of despair increased twice as much as the rate of other causes of deaths in the population of
White non-Hispanics aged 30–44 living in rural areas. In total, death rates in rural subpopulations for ''all''
ethnicities
An ethnic group or an ethnicity is a grouping of people who identify with each other on the basis of shared attributes that distinguish them from other groups. Those attributes can include common sets of traditions, ancestry, language, history, ...
increased among those aged 25–64 years by 6%. As a result of these findings, it is possible to assume that living in rural areas is also connected to the diseases and deaths of despair.
COVID-19 pandemic
The
COVID-19 pandemic
The COVID-19 pandemic, also known as the coronavirus pandemic, is an ongoing global pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The novel virus was first identif ...
is the most severe global pandemic since the
1918 Spanish flu outbreak with lockdowns, social and economic disturbances and a sharp rise in unemployment.
Preliminary studies indicate an aggravation of depression, anxiety, drug overdoses, and suicidal ideation following the beginning of the COVID-19 pandemic. Though certain health aspects like stress can be concurrent with the crisis, other biopsychosocial risk factors such as job loss, housing precarity, and food insecurity can manifest over time. This range of social determinants, commonly experienced during an economic downturn, can induce and aggravate a sense of despair. Loneliness, which is associated with despair, was also aggravated by social isolation practices put in place during the COVID-19 pandemic, which may contribute to a rise in diseases of despair.
A preliminary review of 70 published studies conducted in 17 countries concerning the potential impacts of COVID-19 on deaths of despair indicates that women, ethnic minorities and younger age groups, may have suffered disproportionately more than other groups.
Drug overdoses
Preliminary indications in Canada and the United States demonstrate that the trajectory of drug overdose-related deaths was exacerbated.
In Canada, drug overdose-related deaths stabilized prior to the onset of COVID-19, but increased after the onset of COVID-19.
In the United States, drug overdose-related deaths increased prior to and accelerated after the onset of COVID-19.
Causes
The factors that seem to exacerbate diseases of despair are not fully known, but they are generally recognized as including a worsening of
economic inequality
There are wide varieties of economic inequality, most notably income inequality measured using the distribution of income (the amount of money people are paid) and wealth inequality measured using the distribution of wealth (the amount of we ...
and feeling of hopelessness about
personal financial success. This can take many forms and appear in different situations. For example, people feel inadequate and disadvantaged when products are marketed to them as being important, but these products repeatedly prove to be unaffordable for them. This increase in rates of mental distress and diseases of despair have been attributed to the flaws in contemporary capitalism and policies associated with the ideology of
neoliberalism
Neoliberalism (also neo-liberalism) is a term used to signify the late 20th century political reappearance of 19th-century ideas associated with free-market capitalism after it fell into decline following the Second World War. A prominent fa ...
, which seeks to release markets from all restrictions and reduce or eliminate government assistance programs.
The overall loss of employment in affected geographic regions, and stagnant wages and deteriorating working conditions along with the decline of
labor unions
A trade union (labor union in American English), often simply referred to as a union, is an organization of workers intent on "maintaining or improving the conditions of their employment", ch. I such as attaining better wages and benefits ( ...
and the
welfare state
A welfare state is a form of government in which the state (or a well-established network of social institutions) protects and promotes the economic and social well-being of its citizens, based upon the principles of equal opportunity, equitabl ...
, are widely hypothesized factors.
As such, some scholars have characterized deaths of despair as driven by
austerity
Austerity is a set of political-economic policies that aim to reduce government budget deficits through spending cuts, tax increases, or a combination of both. There are three primary types of austerity measures: higher taxes to fund spend ...
policies and
privatization
Privatization (also privatisation in British English) can mean several different things, most commonly referring to moving something from the public sector into the private sector. It is also sometimes used as a synonym for deregulation when ...
as "
social murder".
The changes in the labor market also affect social connections that might otherwise provide protection, as people at risk for this problem are less likely to get married, more likely to get divorced, and more likely to experience
social isolation
Social isolation is a state of complete or near-complete lack of contact between an individual and society. It differs from loneliness, which reflects temporary and involuntary lack of contact with other humans in the world. Social isolation c ...
.
However, some experts claim the
correlation
In statistics, correlation or dependence is any statistical relationship, whether causal or not, between two random variables or bivariate data. Although in the broadest sense, "correlation" may indicate any type of association, in statistics ...
between income and mortality/morbidity rate is only coincidental.
Anne Case
Anne Catherine Case, Lady Deaton, (born July 27, 1958) is an American economist who is currently the Alexander Stewart 1886 Professor of Economics and Public Affairs, Emeritus, at Princeton University.
Early life and career
She graduated from ...
and
Angus Deaton
Sir Angus Stewart Deaton (born 19 October 1945) is a British economist and academic. Deaton is currently a Senior Scholar and the Dwight D. Eisenhower Professor of Economics and International Affairs Emeritus at the Princeton School of Public ...
argue that "after 1999, blacks with a college education experienced even more severe percentage declines in income than did whites in the same education group. Yet black mortality rates have fallen steadily, at rates between 2 and 3 percent per year for all age groups." Many other examples from Europe also show that decreased incomes and/or increased unemployment ''do'' ''not,'' in general'','' correlate with increased
mortality rate
Mortality rate, or death rate, is a measure of the number of deaths (in general, or due to a specific cause) in a particular population, scaled to the size of that population, per unit of time. Mortality rate is typically expressed in units of de ...
s.
They argue that the ultimate cause is the sense that life is meaningless,
unsatisfying, or unfulfilling, rather than strictly the basic
economic security
Economic security or financial security is the condition of having stable income or other resources to support a standard of living now and in the foreseeable future. It includes:
* probable continued solvency
* predictability of the future cash fl ...
that makes these
higher order feelings more likely.
Recent data show that diseases of despair pose a complex threat to modern society and that they are not correlated only to the economic strength of an individual. Social connections, level of education, place of residence, medical condition, mental health, working opportunities, subjective perception of one's own future – all of these play a role in determining whether the individual will develop diseases of despair or not. Additionally, the younger generations are more and more influenced by social media and other modern technologies, which may have unexpected and unfavourable effects on their lives as well. For example, according to a study from 2016, the use of social media "was significantly associated with increased depression."
Contrasted with diseases of poverty
Diseases of despair differ from
diseases of poverty
Diseases of poverty (also known as poverty-related diseases) are diseases that are more prevalent in low-income populations. They include infectious diseases, as well as diseases related to malnutrition and poor health behaviour. Poverty is one o ...
because poverty itself is not the central factor. Groups of impoverished people with a sense that their lives or their children's lives will improve are not affected as much by diseases of despair. Instead, this affects people who have little reason to believe that the future will be better.
As a result, this problem is distributed unevenly, for example by affecting working-class people in the United States more than working-class people in Europe, even when the European economy was weaker.
It also affects White people more than racially disadvantaged groups, possibly because working-class White people are more likely to believe that they are not doing better than their parents did, while non-White people in similar economic situations are more likely to believe that they are better off than their parents.
[
]
Effects
Starting in 1998, a rise in deaths of despair has resulted in an unexpected increase in the number of middle-aged White Americans dying (the age-specific mortality rate
In actuarial science and demography, a life table (also called a mortality table or actuarial table) is a table which shows, for each age, what the probability is that a person of that age will die before their next birthday ("probability of deat ...
).[ By 2014, the increasing number of deaths of despair had resulted in a drop in overall ]life expectancy
Life expectancy is a statistical measure of the average time an organism is expected to live, based on the year of its birth, current age, and other demographic factors like sex. The most commonly used measure is life expectancy at birth ...
.[ Anne Case and Angus Deaton propose that the increase in mid-life mortality is the result of cumulative disadvantages that have occurred over decades, and that solving it will require patience and perseverance for many years, rather than a quick fix that produces immediate results.][ The number of deaths of despair in the United States has been estimated at 150,000 per year in 2017.
Even though the main cause of diseases of despair may not be purely economical, the consequences of this phenomenon are, in terms of money, expensive. According to a report from 2016, alcohol misuse, misuse of illegal drugs and non-prescribed medications, treatment of associated disorders and lost productivity cost the U.S. more than $400 billion every year. About 40 percent of those costs were paid by government, which implies a huge cost of alcohol and drug misuse to taxpayers. Another study claims even higher costs of around $1.5 trillion in economic loss, loss of productivity and societal harm.
]
Terminology
The phrase ''diseases of despair'' has been criticized for medicalizing problems that are primarily social and economic, and for underplaying the role of specific drugs, such as OxyContin
Oxycodone, sold under various brand names such as Roxicodone and OxyContin (which is the extended release form), is a strong, semi-synthetic opioid used medically for treatment of moderate to severe pain. It is highly addictive and a commonly ...
, in increasing deaths. While the disease model
''Medical model'' is the term coined by psychiatrist R. D. Laing in his ''The Politics of the Family and Other Essays'' (1971), for the "set of procedures in which all doctors are trained". It includes complaint, history, physical examinati ...
of addiction has a strong body of empirical support, there is weak evidence for biological markers of suicidal thoughts
Suicide is the act of intentionally causing one's own death. Mental disorders (including depression, bipolar disorder, schizophrenia, personality disorders, anxiety disorders), physical disorders (such as chronic fatigue syndrome), and s ...
and behaviors and no evidence that suicide fits a disease model. The use of the phrase ''diseases of despair'' to describe suicide in medical literature is more reflective of the medical model than suicidal thoughts and behaviors.
References
Further reading
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External links
{{external media
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, video1 = {{YouTube, 0FjQohkUKRE, Krystal and Saagar: New Study Shows Deaths Of Despair Hitting Poor Working Class Of ALL Races
Why Americans Are Dying From Despair
''The New Yorker
''The New Yorker'' is an American weekly magazine featuring journalism, commentary, criticism, essays, fiction, satire, cartoons, and poetry. Founded as a weekly in 1925, the magazine is published 47 times annually, with five of these issues ...
'', March 16, 2020.
'Deaths of Despair' and the Failure of Capitalism
'' Current Affairs'', April 28, 2021.
Death
Poverty
Public health
Social problems in medicine
Inequality