Anne Case
Anne Case is an American economist specializing in health economics and the intersection of socioeconomic factors with mortality and morbidity trends. She is the Alexander Stewart 1886 Professor of Economics and Public Affairs, Emeritus, at Princeton University, where her research has emphasized empirical patterns in health disparities across the life course.[1][2] Case's most influential contributions center on documenting the reversal of long-term declines in midlife mortality among white non-Hispanic Americans lacking college education, driven primarily by increases in suicide, drug overdoses, and alcohol-related deaths—a phenomenon she and collaborator Angus Deaton termed "deaths of despair."[2] This work, grounded in vital statistics and longitudinal data, revealed stark class-based divergences in health outcomes, with less-educated groups experiencing rising morbidity in pain, mental health issues, and self-reported poor health alongside these fatalities, challenging assumptions of inexorable progress in American life expectancy.[1] In their 2020 book Deaths of Despair and the Future of Capitalism, Case and Deaton extend this analysis to attribute the trends to structural economic shifts, including labor market erosion from trade and automation, wage stagnation, and failures in healthcare and social support systems disproportionately affecting working-class communities.[3] Her earlier studies examined how childhood socioeconomic status causally influences adult health and economic outcomes, using natural experiments like sibling comparisons to isolate effects from family environments and resources.[2] Case has received the Kenneth J. Arrow Prize in Health Economics for advancing understanding of health-wealth linkages, the Cozzarelli Prize from the Proceedings of the National Academy of Sciences for her midlife mortality research, and the American Economic Association's Distinguished Fellow award recognizing lifetime contributions to economic knowledge.[4][5] A fellow of the Econometric Society and member of the National Academy of Sciences, she has also served on the Committee on National Statistics, underscoring her role in shaping policy-relevant empirical inquiry.[2]Early life and education
Family background and upbringing
Anne Case grew up in Binghamton, an upstate New York town near the site of IBM's early operations, during the 1960s and 1970s.[6] She was the daughter of a civil engineer father and a teacher mother.[6] Her family resided in upstate New York, a region undergoing deindustrialization, where Case observed the decline of manufacturing jobs and population depopulation firsthand.[7][8] This environment exposed her to economic shifts affecting local industries, including shoe manufacturing, providing early insights into socioeconomic challenges that later informed her research.[7]Academic training and influences
Anne Case received her Bachelor of Arts degree from the State University of New York at Albany, where her initial exposure to economics through an undergraduate course ignited a strong interest in econometrics due to its empirical rigor.[7] She subsequently enrolled at Princeton University, earning a Master of Public Affairs from the Woodrow Wilson School of Public and International Affairs; during this period, Case worked in the World Bank's research department, an experience that solidified her commitment to pursuing a doctorate in economics to address applied policy questions.[9] Case completed her PhD in economics at Princeton University, with early training emphasizing labor economics, which shaped her subsequent focus on empirical analysis of socioeconomic factors.[5] Her academic influences stemmed from a teenage fascination with social sciences and mathematics aimed at advancing the common good, coupled with an appreciation for economics' capacity to trace causal pathways through data and theory without preconceived constraints.[7][10] This led to formative early research in development economics, including fieldwork in South Africa during the 1990s to study AIDS-related midlife mortality's societal and economic toll, highlighting health's interplay with economic outcomes.[7]Professional career
Early positions and research focus
Following receipt of her PhD in economics from Princeton University in 1988, Case served as an assistant professor of economics at Harvard University from 1988 to 1990.[11] She then held a similar position at the University of Chicago from 1990 to 1991.[11] In 1991, she returned to Princeton University as a faculty member in the economics department and Woodrow Wilson School of Public and International Affairs (now the Princeton School of Public and International Affairs).[11] These early academic roles established her as a labor economist, with initial appointments emphasizing empirical analysis in applied microeconomics.[5] Case's early research emphasized political economy and public finance, exploring how institutional rules shape political representation and policy outcomes.[5] In joint work with Timothy Besley, she investigated electoral accountability's effects on economic policy choices, using cross-country data to assess whether democratic incentives align fiscal decisions with voter preferences, as detailed in a 1993 NBER working paper analyzing public finance implications of political competition.[12] Another collaboration examined yardstick competition among local governments, where jurisdictions benchmark policies against neighbors to influence voter perceptions, evidenced by empirical patterns in U.S. state-level spending data from the early 1990s.[13] Her initial contributions also included econometric advancements, such as modeling spatial patterns in household demand, published in Econometrica in 1985, which addressed interdependence in consumer choices across regions using structural estimation techniques.[14] These works laid groundwork for later shifts toward health economics, though her pre-1990s focus remained on causal links between governance structures and resource allocation, prioritizing data-driven tests of institutional incentives over normative assumptions.[5] By the early 1990s, Case began integrating these themes with socioeconomic determinants of well-being, foreshadowing her sustained interest in income-health gradients.[11]Princeton University roles and emeritus status
Anne Case joined the Princeton University faculty in 1991, following a brief stint at Harvard University after earning her Ph.D. in economics from Princeton in 1988.[9] She was appointed to positions in both the Department of Economics and the Woodrow Wilson School of Public and International Affairs (now the Princeton School of Public and International Affairs).[9] During her tenure, Case served as the Alexander Stewart 1886 Professor of Economics and Public Affairs, a role that reflected her interdisciplinary focus on health, labor, and development economics.[1] In June 2017, after twenty-six years of full-time faculty service, Case transitioned to emeritus status as the Alexander Stewart 1886 Professor of Economics and Public Affairs, Emeritus.[15] This change allowed her to retain her academic title while stepping back from primary teaching and administrative duties.[9] Post-retirement, she has continued to engage with the university as a Lecturer with Rank of Professor, delivering courses and mentoring students on topics including health economics and mortality trends.[1] Her ongoing involvement underscores her sustained influence on Princeton's research programs, where she previously directed initiatives in economic policy and health-related studies.[16]Key research contributions
Health economics and social determinants
Case's research in health economics underscores the enduring influence of early-life socioeconomic conditions on health trajectories and economic productivity. Collaborating with Christina Paxson, she analyzed longitudinal data from British and American birth cohorts to show that childhood health investments yield substantial returns in adulthood, with healthier children achieving higher cognitive scores, better self-reported health, and increased earnings—effects persisting even after controlling for family background and later-life factors.[17] Her empirical work reveals that socioeconomic gradients in child health originate in infancy, driven by disparities in parental income, education, and behaviors such as smoking or breastfeeding, which exacerbate health inequalities from the outset.[18] Utilizing anthropometric measures like height as proxies for cumulative early nutrition and health shocks, Case and Paxson demonstrated that taller adults, indicative of better childhood conditions, exhibit superior cognitive function in later life and stronger labor market outcomes, including higher wages and employment rates—patterns attributable to prenatal and early postnatal environments rather than genetic endowments alone.[19][20] This approach highlights causal pathways from early deprivation to diminished human capital, challenging views that attribute adult disparities primarily to behavioral choices or access to healthcare in maturity. On social determinants, Case's studies in sub-Saharan Africa quantify how HIV/AIDS epidemics compromise health service delivery, leading to increased child morbidity and disrupted preventive care, while orphanhood—often resulting from parental deaths—correlates with poorer nutritional status, lower school enrollment, and heightened vulnerability to illness among affected children.[21] These findings, drawn from household surveys and epidemiological data, illustrate broader social disruptions as amplifiers of health inequities, with ripple effects on community-level outcomes like fertility and economic participation. In cross-country analyses, she emphasizes income growth's role in health advancements, positing that rising per capita GDP in developing nations has historically reduced infant mortality and improved life expectancy more potently than expanded medical infrastructure, reflecting underlying causal mechanisms in resource allocation and behavioral responses to prosperity.[22][23]Education, inequality, and life outcomes
Case's early research established a causal pathway from childhood health to educational attainment and subsequent life outcomes. Using height as a proxy for early-life health, she demonstrated that children with poorer health complete fewer years of schooling, experience worse adult health, and achieve lower socioeconomic status, with these effects persisting into later life.[24][25] This work highlighted how early health inequalities, often rooted in economic disadvantage, generate persistent gradients in education and adult well-being, independent of family background controls.[26] In later studies with Angus Deaton, Case quantified how educational disparities drive widening inequalities in mortality and life expectancy among American adults. From 1990 to 2018, the gap in expected years lived between ages 25 and 75 for those with versus without a bachelor's (BA) degree more than doubled, reaching 3.1 years by 2018; non-BA adults saw declines to 45.1 years post-2010, driven by stalled gains in cardiovascular mortality and rises in other causes, while BA holders reached 48.2 years.[27] Unlike in Western Europe, where mortality fell across all education levels, U.S. non-BA mortality rose, particularly after 2010, reflecting education's role as a stark divider of prosperity and survival.[28] These educational mortality gaps outpaced racial ones, with Black–White disparities in expected years lived narrowing by 70% over the same period; by 2018, Black BA holders outlived White non-BA individuals.[27] Case attributed much of the non-BA decline to "deaths of despair"—suicide (up 36% from 1999–2019 for ages 25–74), drug overdoses (up 73% from 2013–2019), and alcohol-related deaths (up 41%)—concentrated among those without college credentials amid labor market erosion and social disconnection.[29][28] Health-based selection partly explains attainment differences, as healthier children pursue more education, but Case's analysis shows excess mortality beyond selection, tied to post-education economic and psychic harms.[30]Deaths of despair research
Initial findings and epidemiological patterns
In a seminal 2015 analysis published in the Proceedings of the National Academy of Sciences, Anne Case and Angus Deaton identified a sharp reversal in the long-term decline of mortality rates among middle-aged white non-Hispanic Americans, with all-cause mortality for those aged 45–54 rising by 34 deaths per 100,000 between 1999 and 2013.[31] This increase contrasted with continued mortality reductions in other demographic groups, such as black non-Hispanics (down more than 200 per 100,000) and Hispanics (down more than 60 per 100,000 over the same period), as well as with trends in other high-income countries where midlife mortality continued to fall.[31] The rise accounted for nearly all of the net increase in all-cause mortality, with Case and Deaton estimating that adherence to pre-1999 trends would have prevented approximately 488,500 deaths over the 15-year span, including 7,000 in 2013 alone.[31] The primary drivers were deaths from three specific causes—suicide, drug and alcohol poisonings, and chronic liver diseases including cirrhosis—which exhibited consistent year-on-year increases during this interval.[31] For instance, poisoning mortality among those with a high school education or less escalated from 13.7 to 58.0 per 100,000, while cirrhosis mortality in the same group rose by 50%.[31] These "deaths of despair," as later termed by the authors, disproportionately affected individuals without a bachelor's degree, with the largest mortality surge (134 per 100,000) occurring among those with high school or less, compared to a decline of 57 per 100,000 among college graduates.[31] Both men and women experienced parallel increases, though absolute rates remained higher for men.[32] Epidemiologically, the patterns emerged nationally but showed uniform progression across U.S. census regions, with no offsetting declines in other causes like heart disease or cancer sufficient to mask the trend.[31] Accompanying morbidity indicators worsened concurrently, including a 6.7 percentage point drop in reports of excellent or very good health and a 4.3 percentage point rise in fair or poor self-assessed health among the affected cohort.[31] The trends originated in the late 1990s, initially concentrated in southwestern states before spreading nationwide by the mid-2010s, particularly amid the opioid epidemic's intensification.[32] This demographic specificity—middle-aged, less-educated white non-Hispanics—highlighted a distinct reversal from broader 20th-century gains in life expectancy, which had stalled and begun declining for this group by the early 2010s.[31]Theoretical framework and causal mechanisms
Case and Deaton frame deaths of despair as outcomes of cumulative disadvantage, a process whereby early-life setbacks in education, employment, and health compound over decades, disproportionately affecting those without a bachelor's degree and eroding resilience against self-destructive behaviors. This model posits that individuals entering adulthood without advanced credentials face initial labor market barriers, such as stagnant real wages and job displacement from globalization and automation, which hinder family formation, savings accumulation, and social mobility. Over time, these economic pressures foster chronic stress, physical pain from labor-intensive or unstable work, and social isolation, culminating in heightened vulnerability to addiction and suicide as maladaptive responses to unrelieved hardship.[33][34] At the core of their causal mechanisms is economic immiseration as the primary driver, where the erosion of stable, unionized manufacturing jobs—exacerbated by trade liberalization, including the "China shock" that displaced over 2 million workers between 1999 and 2011—stripped working-class communities of dignity and purpose, leading to despair manifested in substance abuse. Case and Deaton argue that this is amplified by family structure decline, with rising rates of single parenthood and divorce among less-educated cohorts correlating with poorer child outcomes and intergenerational transmission of disadvantage; for instance, children of non-college-educated parents are more likely to experience early health issues and educational shortfalls, perpetuating the cycle. Mental health deterioration follows, as economic insecurity correlates with increased reports of psychological distress and chronic pain, which in turn drive self-medication via alcohol and opioids.[3][35][36] The proliferation of prescription opioids, enabled by pharmaceutical industry practices and lax regulatory oversight in the late 1990s and 2000s, serves as a proximate mechanism, transitioning users from legal painkillers to illicit drugs like heroin and fentanyl after restrictions tightened around 2010, with overdose deaths surging from 4 per 100,000 in 1999 to over 20 per 100,000 by 2017 among middle-aged non-Hispanic whites without degrees. Alcoholic liver disease and suicide rates rose in tandem, reflecting a broader failure of social safety nets and community institutions to buffer against these shocks, as opposed to individual moral failings or genetic predispositions, which Case and Deaton downplay in favor of structural economic critiques. This framework contrasts with explanations emphasizing personal responsibility or cultural shifts alone, emphasizing instead how policy choices—such as asymmetric trade deals and healthcare monopolies—have widened the educational divide into a life-expectancy chasm.[37][35][3]Empirical evidence from data sources
Case and Deaton's analysis of deaths of despair draws on mortality statistics from the Centers for Disease Control and Prevention's (CDC) National Vital Statistics System (NVSS), which aggregates data from state vital registration systems based on death certificates coded using the International Classification of Diseases (ICD). These records enable calculation of age-adjusted death rates by cause, age, sex, race/ethnicity, and education, with underlying cause-of-death data available from compressed mortality files spanning 1981 onward. Supplementary measures of morbidity, such as self-reported health and pain, are sourced from surveys like the National Health Interview Survey (NHIS) and Behavioral Risk Factor Surveillance System (BRFSS), which track trends in chronic conditions and substance use. In their 2015 PNAS study, Case and Deaton reported that all-cause mortality for non-Hispanic white Americans aged 45–54 declined by about 2% annually prior to 1999 but reversed thereafter, with cumulative increases of 22 deaths per 100,000 for women and 34 per 100,000 for men from 1999 to 2013. This reversal contrasted with continued declines in other high-income countries and among U.S. Hispanic and Black populations in the same age group, where mortality fell by 1.8% and 2.1% per year, respectively, over the same period. The rise was concentrated in three "deaths of despair" categories—suicide, drug/alcohol poisonings, and alcohol-induced liver disease—with combined rates for these causes increasing from 30.0 to 62.0 per 100,000 among white men aged 45–54 and from 14.3 to 28.6 per 100,000 among women from 1999 to 2013. Drug poisonings, primarily opioid-related, accounted for the largest share, rising from 6.0 to 25.0 per 100,000 in men and 2.8 to 11.6 in women.[31] Subsequent extensions of the analysis, using NVSS data through 2017, confirmed the persistence of these trends, with deaths of despair rates for non-college-educated whites aged 45–54 reaching 78 per 100,000 by 2017, compared to stable or declining rates among college graduates in the same cohort. Education gradients sharpened over time: for adults without a bachelor's degree, mortality from these causes rose from 37 per 100,000 in 1992 to 70 per 100,000 in 2017, while rates for college graduates remained below 20 per 100,000. NVSS data also reveal geographic clustering, with higher rates in Rust Belt and Appalachian states, where opioid prescription rates correlated with poisoning deaths (e.g., age-adjusted drug overdose rates exceeded 30 per 100,000 in states like West Virginia by 2017).| Demographic Group (Ages 45–54) | Deaths of Despair Rate (per 100,000, 1999) | Deaths of Despair Rate (per 100,000, 2013) | Source |
|---|---|---|---|
| Non-Hispanic White Men | 30.0 | 62.0 | PNAS 2015[31] |
| Non-Hispanic White Women | 14.3 | 28.6 | PNAS 2015[31] |
| Non-College-Educated Whites (2017) | ~70 (extrapolated from trends) | N/A | Annual Reviews 2021 |