The Socio-Economics of Health and Dying
This essay examines the multidisciplinary debate around what has recently been referred to as an epidemic of ‘deaths of despair.’
Surviving and dying are life chances in the most profound sense. As Amartya Sen famously argued, our chances of survival are also a robust indicator of economic success and failure (Sen 1998). Today, the declining life expectancy in deindustrialized, rustbelt areas and the accompanying deepening of health inequalities in the U.S. signal the existential crisis of contemporary capitalism. Understanding the social and economic roots of this health crisis is paramount. Although socio-economics has remained peripheral in recent debates about health, the field has a lot to offer.
To demonstrate the potential of the socio-economic outlook, in this essay, I briefly examine the multidisciplinary debate around what has recently been referred to as an epidemic of ‘deaths of despair.’ I examine the wave of excess mortality that hit the postsocialist transition economies, and more recently, the United States, highlighting the fundamental difference between the economists’ perception of mortality crises of contemporary capitalism and the socio-economic alternative perspective on this issue. After showing why the socio-economic viewpoint should have a bigger presence in research and policy discussions, I conclude by describing the directions of potential policies informed by socio-economics.
Divergent disciplinary views on health
Despite the analytical importance of health, today, it is not a central topic in socio-economics. Following the popularity of institutional analysis in political science, sociology, and political economy, socio-economics has taken an institutionalist bent. As Amitai Etzioni noted, ‘an overwhelming majority of the topics listed in the Madison Declaration on the “Need for Socio-Economic Research and Theory” concern macro-elements’ (Etzioni 2003: 108). Consequently, compared to popular topics such as economic crises, varieties of capitalism, or labor market institutions, health is not a particularly prevalent topic in the Socio-Economic Review. The few articles that deal with health in the journal concentrate on health care institutions, with a few exceptions that look at individual health (Bourdieu and Reynaud 2005; Costa-Font and Gil 2006; Dwyer et al. 2016).
However, socio-economics can build on solid foundations to apply its view to health. The insight that abrupt socio-economic change can harm health goes back to the roots of social science. Durkheim (2002: 207) famously concluded that ‘whenever serious readjustments take place in the social order, whether or not due to a sudden growth or an unexpected catastrophe, men are more inclined to self-destruction.’ Engels (2009: 106) captured another way in which economic change can lead to mortality: ‘[W]hen society places hundreds of proletarians in such a position that they inevitably meet a too early and an unnatural death; when it deprives thousands of the necessaries of life, places them under conditions in which they cannot live, and yet permits these conditions to remain, its deed is murder.’
The notion of social deaths was also present at the birth of the Socio-Economic Review. The journal’s first article (Abell 2003) contemplated the possibility of a unified social science and used Durkheim’s analysis of suicide as an example of structuralist reasoning. Abell argued that economists follow rational choice theory and conceptualize the interaction between individuals as a matter of choice, whereas sociologists see interactions as structured by social factors, such as class, race, or gender. Consequently, economists want to ‘nudge’ health (Thaler and Sunstein 2009) by educating people about the negative consequences of harmful health behavior and optimizing the incentive structure through prices. Sociologists and social epidemiologists doubt that tinkering with the proximate causes of ill health will lead to long-term improvements. According to sociologists, the ‘fundamental causes’ of health influence people’s social contexts and shape the risk factors to which individuals are exposed (Phelan et al. 2010). Fixing health behavior without addressing the upstream fundamental causes leads to the reproduction of ill health and health inequality. Therefore, they propose policies, such as strengthening welfare arrangements and curtailing labor market precarity to reduce inequality and stress, thereby improving health (Wilkinson and Pickett 2020).
The mortality crisis in Eastern Europe
Several countries in postsocialist Eastern Europe were hit by an unprecedented mortality crisis in the 1990s, representing one of the most significant demographic shocks after the Second World War outside war or famine. Total excess mortality reached 3.26 million in 1990–1999 in Eastern Europe (UNICEF 2001: 47). This postsocialist mortality crisis — the topic of my Ph.D. thesis and several subsequent journal articles — is a unique opportunity for uncovering the social determinants of health and dying (Scheiring 2019).
Researchers agree that hazardous alcohol consumption was a crucial proximal cause of excess postsocialist deaths. Hazardous drinking increased strokes, infarctions, cirrhosis, and accidents. Social epidemiologists and sociologists also agree that the transition from state socialism to capitalism was a particularly stressful instance of institutional change, contributing to hazardous drinking as a negative stress-coping strategy (Perlman and Bobak 2009: 1818; Walberg et al. 1998).
A related study argued that mass privatization was a crucial economic policy factor driving excess deaths in Russia (Stuckler et al. 2009). However, economists quickly attacked this argument (Earle and Gehlbach 2010). In response, researchers launched the Privatization and Mortality project, using a quasi-experimental design. Based on surveys of a large number of individuals nested in a matched set of towns with and without mass privatization in Russia, they confirmed the association (Azarova et al. 2017). Complementary findings show that prolonged state ownership appears to have been health-protective compared to privatization in Hungary (Scheiring et al. 2018).
Among economists, however, the consensus view is that postsocialist workers died prematurely because they made wrong choices within the given structure of incentives. After Gorbachev’s unpopular anti-alcohol campaign in the 1980s, populist politicians allowed the price of alcohol to decline in the early 1990s, which led to excess drinking and excess deaths (Treisman 2010; Yakovlev 2018). Economists contend that ‘Russia’s transition to capitalism and democracy was not as lethal as commonly suggested’ (Bhattacharya et al. 2013: 232). Economists’ focus on individual choice and sociologists’ focus on social change as a source of stress could hardly be more different.
Deaths of despair in the U.S.
Mortality crises are not only seen in the transition economies but also in more established market economies like the U.S. Today, the world’s most powerful economy is experiencing an unprecedented epidemic of suicide-, alcohol-, and drug-related deaths, dubbed as ‘deaths of despair’ by Anne Case and Nobel-laurate economist Angus Deaton (Case and Deaton 2020). The life expectancy of middle-aged white Americans has been declining since the turn of the Millennium. As the two Princeton economists highlight, deaths of despair killed 158,000 Americans during 2017, equivalent to a packed Boeing 737 falling from the sky each day for a year (Case and Deaton 2020: 94).
As Case and Deaton argue, echoing sociologists, the social dislocation of the American working class is the most crucial background factor. The loss of stable industrial jobs has profoundly reshaped the fabric of communities and torn apart working-class culture. Three decades ago — as the first wave of mass plant closures wreaked havoc with inner-city communities — Black workers experienced a similar health crisis. New jobs in manufacturing and services tend to be more precarious. The towns that previously were the regional backbones of the blue-collar, working-class stability are today home to cascading social, economic, and health problems — homes of despair. This context is a fertile breeding ground for emotional and mental disorders that often translate into other health problems and addictions over time.
Despite offering a path-breaking inquiry into the deaths of despair epidemic, the disciplinary limitations of economics constrain Case and Deaton’s analysis. Instead of unpacking the complexities of the mechanism linking economic dislocation and mortality and drawing the necessary theoretical and policy conclusions, they stress the exceptionality of the American experience, missing the obvious parallels with other global experiences, including the postsocialist mortality crisis. They conclude their book with a rather underwhelming set of propositions concentrating on the need for better regulation of pharmaceuticals and ‘genuinely free and competitive markets’ (Case and Deaton 2020: 213). Their analysis starts from a sociologically informed view, but they switch back to a more reductionist view based on economics when it comes to policy prescriptions. They hope that people will make better health choices under the right set of incentives and given better regulation of drugs and alcohol.
However, changing one downstream behavioral factor does not eliminate the underlying factors associated with social class and economic dislocation contributing to the demand for drugs in the first place. For example, when the manufacturer Purdue Pharmaceutical finally decided to change the formula of OxyContin — a potent opioid pain killer — in response to its widespread abuse, OxyContin abusers switched to heroin and fentanyl. Deaths from heroin replaced deaths from prescription drugs, but the overall number of drug-related deaths of despair did not decline (Case and Deaton 2020: 115-20).
From socio-economic research to policy
The Covid-19 pandemic ushered in a horrible humanitarian crisis, once again revealing the power of fundamental causes in generating unequal health outcomes. Institutional and structural injustices disproportionately depress the life chances of non-Whites. In the U.S., adjusting for age differences across the groups, all populations of color experienced higher national death rates in 2020 than White Americans. Indigenous, Black, and Latino Americans were at least 2.7 times more likely to die than their White neighbors (Egbert and Liao 2020). Workers in precarious employment (e.g., fixed- and part-time workers, migrant workers, people without adequate sick pay), families without significant financial reserves, people living in crowded homes and dependent on public transportation to go to work—each of these groups has been more likely to suffer. The pandemic made it widely apparent that people’s survival chances fundamentally depend on health-protecting welfare institutions that can offset the adverse effect of economic factors. Despite these facts, some politicians and business leaders have failed to prioritize saving lives over saving the economy, continuing to promote economic growth over social welfare.
The postsocialist mortality crisis, the deaths of despair epidemic in the U.S., and the coronavirus are critical events that powerfully reveal the implications of the diverging disciplinary views. Economists focus on the direct behavioral factors and the availability of harmful substances, while proponents of the socio-economic paradigm emphasize that structural, upstream causes shape individual life chances. Despite its peripheral position in the public discussion, the socio-economic outlook has much to offer to the understanding of social and economic determinants of health and dying.
Increasing the voice of socio-economics in the debate about health inequality would also increase the chances of better policies – policies that, instead of nudging individuals, address the socio-economic root causes of ill health. Creating new institutions (e.g., global taxes) and strengthening existing ones (e.g., trade unions and crumbling welfare arrangements) are vital to equalizing life chances, reducing unequal access to resources, and eliminating precarity, thereby ending the existential crisis of contemporary capitalism.
Azarova, Aytalina, et al. (2017), ‘The effect of rapid privatisation on mortality in mono-industrial towns in post-Soviet Russia: a retrospective cohort study’, The Lancet Public Health, 2 (5), e231-e38. Bhattacharya, Jay, Gathmann, Christina, and Miller, Grant (2013), ‘The Gorbachev Anti-Alcohol Campaign and Russia’s Mortality Crisis’, American Economic Journal: Applied Economics, 5 (2), 232-60. Bourdieu, Jérôme and Reynaud, Bénédicte (2005), ‘Factory discipline, health and externalities in the reduction of working time in nineteenth century France’, Socio-Economic Review, 4 (1), 93-118. Case, Anne and Deaton, Angus (2020), Deaths of Despair and the Future of Capitalism (Princeton: Princeton University Press). Costa-Font, Joan and Gil, Joan (2006), ‘Revisiting the ‘Fat and Jolly’ hypothesis: socio-environmental determinants of obesity and depression in Spain’, Socio-Economic Review, 4 (3), 513-42. Durkheim, Émile (2002), Suicide: A study in sociology (London & New York: Routledge Classics). Dwyer, Rachel E., et al. (2016), ‘Mortgage worries: young adults and the U.S. housing crisis’, Socio-Economic Review, 14 (3), 483-505. Earle, John S. and Gehlbach, Scott (2010), ‘Did mass privatisation really increase post-communist mortality?’, The Lancet, 375 (9712), 372. Egbert, Andi and Liao, Kristine (2020), ‘The Color of Coronavirus: 2020 Year in Review’, December 21, 2020, APM Research Lab. URL: https://www.apmresearchlab.org/covid/deaths-2020-review Engels, Friedrich (2009), The Condition of the Working-Class in England (Oxford: Oxford University Press). Etzioni, Amitai (2003), ‘Toward a new socio-economic paradigm’, Socio-Economic Review, 1 (1), 105-18. Perlman, Francesca and Bobak, Martin (2009), ‘Assessing the Contribution of Unstable Employment to Mortality in Posttransition Russia: Prospective Individual-Level Analyses From the Russian Longitudinal Monitoring Survey’, American Journal of Public Health, 99 (10), 1818-25. Phelan, Jo C., Link, Bruce G., and Tehranifar, Parisa (2010), ‘Social Conditions as Fundamental Causes of Health Inequalities: Theory, Evidence, and Policy Implications’, Journal of Health and Social Behavior, 51 (1_suppl), S28-S40. Scheiring, Gábor (2019), ‘The Wounds of Post-Socialism: The Political Economy of Mortality and Survival in Deindustrialising Towns in Hungary’, (Cambridge: University of Cambridge, Ph.D. thesis). Scheiring, Gábor, et al. (2018), ‘The gendered effects of foreign investment and prolonged state ownership on mortality in Hungary: an indirect demographic, retrospective cohort study’, The Lancet Global Health, 6 (1), 95-102. Sen, Amartya (1998), ‘Mortality as an Indicator of Economic Success and Failure’, The Economic Journal,108 (446), 1-25. Stuckler, David, King, Lawrence, and McKee, Martin (2009), ‘Mass privatisation and the post-communist mortality crisis: a cross-national analysis’, The Lancet, 373 (9661), 399-407. Thaler, Richard H and Sunstein, Cass R (2009), Nudge: Improving decisions about health, wealth, and happiness (New Haven, CT: Yale University Press). Treisman, Daniel (2010), ‘Death and prices: The political economy of Russia’s alcohol crisis’, Economics of Transition, 18 (2), 281-331. UNICEF (2001), A Decade of Transition: Regional Monitoring Report 8 (Florence: UNICEF). Walberg, Peder, et al. (1998), ‘Economic change, crime, and mortality crisis in Russia: regional analysis’, BMJ, 317 (7154), 312-18. Wilkinson, Richard and Pickett, Kate (2020), The inner level: how more equal societies reduce stress, restore sanity and improve everyone’s well-being (New York: Penguin Books). Yakovlev, Evgeny (2018), ‘Demand for Alcohol Consumption in Russia and Its Implication for Mortality’, American Economic Journal: Applied Economics, 10 (1), 106-49.
Originally published on the SASE Blog, March 26, 2021 (Society for the Advancement of Socio-Economics)