Gary Seidman profiles Princeton’s Anne Case, who studies the intersection of health and economics
For decade after decade in the United States, children typically stayed healthier and lived longer than the generation that came before them. The country, it seemed to Anne Case, had been doing something right. By the late 1960s, advances in vaccines and antibiotics had helped extend the average American lifespan to nearly 70, about 50 percent longer than at the start of the century. By the 1980s, the introduction of antihypertensive drugs had reduced cardiovascular disease, among the leading causes of death in the United States. And through the postwar years, a steady drumbeat of government campaigns to quit smoking, improve workplace safety, regulate pollution, build safer highways, and expand medical access had prevented millions of premature deaths—remarkable feats of public policy.
But then, says Case, coauthor with Angus Deaton of the 2020 New York Times bestseller Deaths of Despair and the Future of Capitalism, something “important, awful, and unexpected” began to derail America’s century-long progress in reducing mortality. It involved a slew of factors: job displacements, substance abuse, fraying social ties, and ultimately, the failure of capitalism in recent decades to adequately care for working-class Americans. It was a situation that was tailor-made for Case’s approach to economics.
Empathetic upbringing
The umbrella over much of Case’s research is how poor people manage through difficult circumstances. “Growing up with parents who cared dearly about what happened to people less well off than themselves, that’s what led me to focus on how poorer people cope, how exactly they hold body and soul together,” she told F&D.
Case grew up in upstate New York in the 1960s and 70s and “had a ringside seat for watching deindustrialization.” Around her, shoe manufacturers and business machine factories were closing up shop and shedding workers. Local communities were feeling the pinch. The push for free trade and job offshoring was starting. “The high-water mark for blue-collar wages for men was 1972,” she points out. Labor unions were weakening, church attendance was waning, marriage rates were beginning to slide, and some of the traditional pillars that had long kept communities humming and thriving, she said, were disappearing. IBM, the pioneering computer maker, and an integral employer in Case’s local community, she remembers, was starting “to move on and move out.”
As a teenager, Case had become interested in social science and mathematics, “and I really wanted to do something for the common good.” She enrolled at the State University of New York in Albany, and after her first undergraduate economics course she was hooked. Econometrics became a passion. “I liked the fact that there was empirical work, and I very much liked statistics.” She pursued a master’s degree in public affairs from the Woodrow Wilson School at Princeton, and then, after a year working for the World Bank, returned to Princeton to earn her PhD in economics in 1988. Today, she is the university’s Alexander Stewart 1886 Professor of Economics and Public Affairs and the winner of many academic accolades. “I was captured by the life in academia. I love the combination of teaching and research and being able to take a step away and go to the field,” she said.
In the 1990s, she went to South Africa to witness firsthand the tragedy of AIDS and the damage that midlife mortality inflicted on the society and the economy. Some of that time she collaborated to study how early-life health influences later-life outcomes with her friend and fellow economist Christina Paxson, who is now the president of Brown University. She chronicled how disruptions to health impacted incomes. “People who are ill, or are in a lot of pain, or are having mental health problems are not going to be successful in the labor market,” she said. “I always thought that was really, really terrific work,” said Deaton, Case’s husband, frequent coauthor, and winner of the 2015 Nobel Prize in economics. And when Case returned to Princeton, she segued her research to look at how disruptions to incomes affected the health and well-being of workers in the United States.
Case has a unique “attention to detail and ability to make data understandable,” said Jonathan Skinner, a professor who studies health economics at Dartmouth College. She can “pull things out of data that maybe people hadn’t looked at before.”
Capitalism’s fatal flaws
What she and Deaton began to discover was that the well-being of Americans who did not have a college degree was deteriorating in all walks of life: economically, socially, emotionally, and medically. It was manifesting in how much pain they were physically experiencing (and self-reporting on US government surveys) and how many deaths were occurring as a result of drug overdoses, liver failure, and suicide. The life expectancy for adults without a college degree reached its peak around 2010 and has been falling ever since. By 2021, people without a bachelor’s degree were living “roughly eight and a half years less than people with college degrees,” Case and Deaton wrote in a New York Times essay last year. The country’s ever-transitioning economy had slowly beaten down the US working class over the past few decades, and they weren’t feeling good about it. It had eliminated many of their jobs, shrunk their paychecks, narrowed their employment opportunities, hollowed out their communities, taken a toll on their status in society, and led some to turn to unhealthy behaviors to cope.
Tim Besley, of the London School of Economics, said that Case and Deaton’s “initial work created quite a stir.” He remembers hearing a story that at a White House gathering, then-President Barack Obama cornered the two to talk about their findings.
What the Princeton duo later described in their 2020 book is a torrent of bad breaks that began to rain down on middle-aged, working-class, less-educated Americans over several decades. No race or gender was spared. But middle-aged white Americans who had not graduated from college did not fare particularly well, especially in regions where manufacturing and blue-collar jobs were once plentiful and rewarding. It was a familiar story for Case. It started with misfortune from economic shifts that had been slowly brewing for years, like the offshoring of US jobs to cheaper labor markets and the yawning disparity between the rich and the poor. And it generated resentment that leached into lifestyle behaviors. If it continued, it foretold a disturbing potential to accelerate social, economic, and educational polarization in the country.
The economy’s tilt was beneficial to some but deeply demoralizing for those it left behind. And this time around there was one big twist that Case and Deaton realized was making things exponentially worse. The overprescribing of painkillers such as OxyContin in the late 1990s, followed by the availability of cheaper heroin and then synthetic opioids such as fentanyl, led to an unusual spike in overdose deaths.
The drug epidemic arrived at a vulnerable moment in the United States, when the workforce was evolving, the Internet economy was dawning, and a lot of people were trying to find their balance. Case was poring over the government’s data and trying to connect the dots. “This work took on a life of its own, which was my life,” she said. “Once we started digging, it was just hard to stop.” “Sometimes I think Anne carries every piece of every number in the US statistical system in her head somewhere,” said Deaton.
“We found that the things that were rising were suicide, alcohol use, liver disease, and drug overdoses,” Case noted. “They’re all deaths by one’s own hand,” she said, and in the early 2000s those types of deaths began to pile up and have a profound impact on mortality rates in the country. “I thought they all signaled a certain amount of despair.”
Charles Fain Lehman, of the Manhattan Institute, is skeptical that all the dots connect so neatly. “I don’t necessarily think that the evidence supports the narrative that they were advancing,” he said. He believes that easy access to ever-stronger drugs on the street is more to blame for the rise in mortality than the economy-induced despair narrative that Case describes.
Other rich-world countries, Case points out, contended with many of the same challenges regarding globalization, automation, and the impact on their workforces. “But they did not unleash a drug that is basically heroin in pill form with an FDA label on it and give any doctor with a script pad the ability to prescribe this drug,” she said. “Congress just looked the other way.”
Unlike those other developed economies, the United States let “Purdue Pharma blanket the country with marketers who, with maps, targeted areas where people were in pain, where people had lost jobs, where people were less well educated, and they targeted those places.” Those pills had to land on fertile soil, she said.
Skills reconsidered
About two-thirds of the US working population does not have an undergraduate degree. It’s an important demographic to consider as the economy’s relentless modernization creates new jobs that overwhelmingly require increasingly digital and technical skills. The country, Case said, is more divided than ever by education levels, which has led to a pervasive and worrisome sense of injustice and inequality. “People without a BA don’t see hope for themselves. And perhaps as important, they don’t see hope for their children. They think that that they live in a system that’s rigged against them,” Case said. “It’s pretty understandable.”
She is encouraged by some of the efforts underway today to address the situation. One solution that is gaining traction is to prohibit discrimination based on educational attainment. During the past two years, according to the Brookings Institution, more than 20 states have expanded access to state government jobs by dropping requirements for an undergraduate degree. They are expanding hiring to workers who “gained their skills through community college, the military, partial college, certification programs, and, most commonly, on-the-job training.”
As an economist with a deep focus on how health issues affect income and how income disruptions affect health, Case believes that “capitalism needs to be put back on the rails,” particularly when it comes to access and affordability of health care.
Case’s journey from a young woman growing up in a region grappling with deindustrialization to a leading health and labor economist has been driven by profound compassion for those left behind by economic change. “I’ve been really moved by the number of people who have written to me personally,” she said. “They would tell stories about what has happened to them or to their sister or brother or father.”
Her work serves as a reminder of the importance of using economic analysis to improve the human condition, and it has ignited a national discussion about the challenges facing working-class Americans. Case’s work isn’t a “narrow empirical exercise,” said Besley, it’s “a piece of social science that joins everything together.” Ultimately it offers a stark and sobering assessment of the current state of US capitalism and the policies and investments that are needed to create a more equitable environment for workers, strengthen safety nets for those falling behind, and address the opioid epidemic.
GARY SEIDMAN is a Seattle-based journalist who has written for The Economist, The New York Times, Reuters, CNN and MSNBC.
Opinions expressed in articles and other materials are those of the authors; they do not necessarily reflect IMF policy.
