Dislocation and Deaths of Despair in Neoliberal America

This essay is a collaboration with Ryan Ward, who writes about politics, Marxism, and music at his Substack Free Market Moralism—subscribe to his newsletter here.

[Painting by April Burke]

Since the advent of neoliberalism in the US in the 1980s and with the acceleration of offshoring and factory closures and the rise of automation in the 1990s and 2000s, economic dislocation of precarious working communities and individuals has increased rapidly. Whole regions of the US that have historically housed industrial production have been hollowed out, leaving ghost towns, unemployment, and despair where once there were thriving communities.

These communities suffer a range of ill effects from the economic precarity introduced and amplified during these decades, including higher rates of early death. In fact, in recent years, a new category of death has been coined–deaths of despair.^[1] These are deaths that are due to suicide, drug and alcohol-related overdose, and alcohol-related liver disease. Those who suffer deaths of despair are disproportionately middle age, without a college education, and classified racially as white non-hispanic.^[2]

It’s one thing to say that economic dislocation leads to precarity and bad outcomes. It’s another thing entirely to say that dislocation plays a causal role in deaths of despair. The difficulty comes from the fact that economic dislocation lies upstream from a host of other ill effects, all of which increase the probability of disease, injury, or death. Thus, making causal claims about the relationship between the increased precarity caused by capitalism and deaths of despair difficult.

Dislocation and opioid overdose

Luckily, but also tragically, the US over the past couple of decades has provided a horrific natural experiment in deaths of despair. Specifically, the last few decades has seen the US battling an opioid overdose epidemic. In the period between 1999 and 2024, there have been almost one million opioid related deaths.^[3] Using this grisly tableau as a database, a number of recent studies have probed the relationship between dislocation that results from economic events and opioid overdose.

One measurable economic event is the decrease in industrial manufacturing that followed the market reforms and increased trade liberalization of the 1990s and 2000s. Employment in manufacturing has cratered in the last two decades. Wages have also decreased as jobs and production has been offshored. One of the areas to have been hardest hit is the midwest, particularly the so-called “rust belt.” A recent study by Kiang et al. (2019) showed that this area of the country also experienced the highest change in the rate of overdose deaths from 1999-2016.^[4]

While these data are suggestive, they are correlational in nature. Another recent study by Dean and Kimmel (2019) measured overdose deaths in counties that had lost manufacturing jobs as a result of free trade agreements vs. those that hadn’t for the period between 1999 and 2015.^[5] Overall they found that counties with more trade related job losses had higher overdose rates. Specifically, 1000 trade-related job losses produced a 2.7% increase in overdose deaths (this increases to 11.3% if fentanyl is in the local heroin supply). Importantly, these results cannot be accounted for by differences in population, per capita income, overall unemployment rates, opioid prescription patterns, population density, racial demographics, mass layoffs unrelated to trade liberalization, or individual characteristics of different states, as all of these variables were controlled for.

Another recent study by Venkataramani et al. (2020) assessed the difference between overdose deaths in counties that had or had not experienced the closure of an automotive assembly plant.^[6] Counties were matched on a number of characteristics. Interestingly, the authors analyzed data from five years before the plants closed (or an equivalent timeframe in control counties) to seven years afterwards. They found no difference in mortality rates for the pre-closure period. The difference in mortality increased significantly in counties with the closure of a plant. Most interestingly, the increase in overdose mortality was greatest for non-hispanic white men aged 18-34, followed by non-hispanic white men aged 35-65.

A similar result was found by Pierce and Schott (2020) when they studied mortality rates that occurred following the passage of a bill in 2000 that granted permanent normal trade relations with China, locking in lower tariffs on imported goods and exposing various regions to increased import competition.^[7] They found an increase in overdose deaths and deaths of despair that was largely driven by an increase in mortality of white working aged people. They concluded that the increase in overdose is due to economic disruption of the labor market produced by rapid changes in trade policy.

The results of these studies indicate that the dislocation that results from economic disruption caused by neoliberal market reforms leads directly to an increase in overdose deaths which are not attributable to factors unrelated to economic disruption.

Dislocation and the profit motive

While it is evident that a rise in deaths of despair in the US is caused by the neoliberal flight of manufacturing, it is not yet clear why this dislocation was a part of the neoliberal period in this first place. Why was manufacturing relocated when it was employable at home? Not only did entire communities depend on those jobs but also capitalist economies depend upon both an expanding workforce and a consumer base that can afford the products. How do we have the absurd situation in which people who are willing and able to work go unemployed while usable factories stand at a halt?

The primary motive of capitalists and capitalist society is the rate of profit—what Karl Marx described as the driving force of capitalist production. A capitalist is unlikely to replace workers with machines or foreign workers unless doing so increases the rate of profit. Critically, the economic crisis of the 1970s, which led to the neoliberal response, came amid a crisis of profitability that began in the mid-1960s, as shown in studies by Roberts (2016) and Basu et al. (2021).[8] This means that factories and workforces and the global arrangement of production that drove the post-war economic boom had reached a point of diminishing profitability.

Chronicling the neoliberal era as beginning with the crisis of profitability in the mid-60s and culminating around the peak of the dot.com revolution in the mid-90s, Roberts (2016) argues this boom-bust cycle occurred according to Marx’s theory of profitability,[9] a theory which explains how, over time, increased automation results in decreased profit rates, once a labor-replacing technical revolution becomes standardized in an economy and no longer gives the early adopters an advantage to undercut prices of competitors. Capital investment in foreign trade is one of several means which Marx identified as ways in which capitalists temporarily counteract falling profit rates.[10]

In the neoliberal case of offshoring, profit rates are boosted by taking capital produced here and employing it somewhere where workers have less legal protection and less union organization and therefore higher exploitability in the form of lower wages and less safety regulation protocols. Driving up unemployment domestically, offshoring also increases worker exploitability in the domestic economy.

From dislocation to solidarity

Given the working class’s dependency on wage work, a factory closure can affect the stability of the economy of entire communities for generations, and the neoliberal flight of manufacturing spanned entire regions. Short of a viable alternative or social safety net, a sudden burst in unemployment is more than enough to shift lives out of balance, leading to despair on a wide scale. Add to this the infusion of prescription opioids into these hurting communities (in some areas, the number of prescriptions was more than the number of adults) by unscrupulous pharmaceutical corporations and you have a perfect recipe for deaths of despair.

These are patterns of a system of production prioritizing short-term profit over all else. The rise in deaths of despair as a result of dislocation in the American industrial wastelands stands as a warning for the kinds of outcomes that can result from widespread economic dislocation. The solution going forward is not to avoid change and innovation but to adequately distribute the wealth produced. The ultimate solution is a society that grows and develops organically based on the needs of the producers rather than the needs of profit.

The immediate antidote to the dislocation of modern capitalism is solidarity. This is not just an abstract idea. In fact, studies of factors that are protective against overdose mortality have shown that community solidarity, or social capital, an index of strength of community relationships and trust, reciprocal cooperation and civic engagement, and a feeling of belonging is not only protective in and of itself, but also mediates the relation between economic factors and mortality.^[11] Similar results have been demonstrated recently regarding the relation between social capital and COVID-19 mortality.^[12] Such solidarity not only provides protections against the social effects of economic dislocation in the short term, but is a critical aspect of forging a class movement capable of replacing capitalism with a system that allows all to flourish.

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[1]. Rehder K, Lusk J, Chen JI. Deaths of Despair: Conceptual and Clinical Implications. Cogn Behav Pract. 2021 Feb;28(1):40-52. doi: 10.1016/j.cbpra.2019.10.002.

[2]. Anne Case and Angus Deaton (2020). Deaths of Despair and the Future of Capitalism. Princeton. NJ.

[3]. https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html

[4]. Kiang MV, Basu S, Chen J, Alexander MJ. Assessment of Changes in the Geographical Distribution of Opioid-Related Mortality Across the United States by Opioid Type, 1999-2016. JAMA Netw Open. 2019;2(2):e190040. doi:10.1001/jamanetworkopen.2019.0040

[5]. Dean A, Kimmel S. Free trade and opioid overdose death in the United States. SSM Popul Health. 2019 May 23;8:100409. doi:10.1016/j.ssmph.2019.100409.

[6]. Venkataramani AS, Bair EF, O’Brien RL, Tsai AC. Association Between Automotive Assembly Plant Closures and Opioid Overdose Mortality in the United States: A Difference-in-Differences Analysis. JAMA Intern Med. 2020;180(2):254–262. doi:10.1001/jamainternmed.2019.5686

[7]. Pierce, Justin R., and Peter K. Schott. 2020. “Trade Liberalization and Mortality: Evidence from US Counties.” American Economic Review: Insights 2 (1): 47–64. DOI: 10.1257/aeri.20180396

[8]. Roberts, M. (2016). The long depression: How it happened, why it happened, and what happens next. Haymarket Books, p. 60. Basu et al. (2021). “World Profit Rates, 1960–2019,” Working Paper. doi.org/10.7275/43yv-c721; Roberts, M. (2022) “A world rate of profit: important new evidence,” https://thenextrecession.wordpress.com/2022/01/22/a-world-rate-of-profit-important-new-evidence/

[9]. Roberts (2016), 60.

[10]. Marx, K. (1991). Capital: Vol. 3, trans. by David Fernbach. Penguin, 344-46; 364-5.

[11]. Zoorob, MJ., Salemi, JL. Bowling alone, dying together: The role of social capital in mitigating the drug overdose epidemic in the United States, Drug and Alcohol Dependence, 2017., https://doi.org/10.1016/j.drugalcdep.2016.12.011.

[12]. Fraser T, Aldrich DP, Page-Tan C. Bowling alone or distancing together? The role of social capital in excess death rates from COVID19. Soc Sci Med. 2021 doi: 10.1016/j.socscimed.2021.114241.