On a single weekend in June 2021, seven people died of drug overdoses in Rochester, New York. On that Saturday morning, three adults were found dead on a front porch on a quiet, residential street. Inside the house were six orphaned children. Lab tests showed that the lethal agent was heroin laced with xylazine, a powerful horse tranquilizer.
As we look forward to emerging from the COVID-19 pandemic, America remains in the grip of an epidemic of deaths from drug overdose, suicide, and alcohol poisoning. The epidemic began in the mid-1990s and is still escalating: The CDC estimates that 2020 saw ninety-three thousand drug overdose deaths, a 30 percent increase from 2019 and the highest total ever recorded. This epidemic was nearly two decades old before it was given a name—“deaths of despair”—and a face—principally white Americans without college degrees—in an influential 2015 paper by Princeton economists Anne Case and Angus Deaton, and in their 2020 book. Recent trends are severe: Deaths of despair caused drops in overall life expectancy in the United States for three consecutive years (from 2015 to 2017), the longest period of decline since World War I.
As Case and Deaton show, these deaths are not occurring in a vacuum. They are a response to “a long-term and slowly unfolding loss of a way of life,” hastened by sharp declines in wages, marriage rates, and community engagement among less-educated Americans. Though manufacturing job-losses and the opioid crisis are now widely recognized as drivers of deaths of despair, the role of social factors such as religious service attendance has been comparatively neglected in political and academic discussions. The Human Flourishing Program at Harvard University has worked to fill that gap, assembling a body of evidence that suggests that about 40 percent of the increase in suicides from 1996 to 2010 was attributable to declining religious participation.
On April 26, 1995, the FDA approved OxyContin, an ostensibly safe, “time-released” opioid, as a pain treatment. Case and Deaton describe it as “legalized heroin.” Its use peaked in 2012, when 8.13 prescriptions were written for every ten Americans. When the prescriptions ran out, many OxyContin addicts turned to the streets for cheaper and more potent opiates such as heroin and fentanyl. About six hundred thousand Americans died of opioid overdoses between 1999 and 2020.
Though the flood of opioids magnified the effect of American despair, the epidemic’s deepest causes are economic, social, and spiritual. Deaths of despair began to rise as American manufacturing employment entered a steep decline, from nearly eighteen million jobs in 1998 to roughly eleven million jobs in 2010. This shift was billed by its neoliberal boosters as the beginnings of “creative destruction,” a process in which lost manufacturing jobs would be replaced by opportunities in new and more profitable industries. Destruction arrived with a vengeance, but for many Americans across the Rust Belt, the “creative” upside never materialized.
In the same period, marriage rates fell overall, most steeply for those with a high school diploma or less. Community involvement likewise declined for this cohort: Weekly church attendance fell from its historically stable rate of about 44 percent in 2000, to 30 percent in 2020. In short, less-educated Americans on average have less purchasing power, marry and have sex less often, have fewer friends, invest less in their neighborhoods and towns, and worship less than their parents and grandparents did.
Case and Deaton regard the epidemic of deaths of despair as a symptom of our descent into an atomized state of nature. Their analysis stands in a sociological tradition pioneered by the French sociologist Émile Durkheim, who theorized that many suicides in his era were precipitated by rapid social and economic changes, which unraveled a previously tight cultural fabric. He described this coming apart as anomie, “normlessness,” the vertiginous sense of anxiety and disorientation that afflicts those left to navigate a world bereft of well-worn pathways or familiar landmarks.
Case and Deaton emphasize, however, that despair is the product not of poverty pure and simple, but of what poverty has wrought in American communities. “Declining wages are part of the story,” they write, “but we believe that it is impossible to explain despair through declining material advantage,” not least because the material conditions of less-educated whites in America are still far better than those endured by most of the world’s poor, who are not similarly overwhelmed by suicide and addiction. Rather, “we believe that much more important for despair is the decline of family, community, and religion.”
Yet declining religious participation receives relatively short shrift in Case and Deaton’s survey of the crisis. To address this omission, the Human Flourishing Program examined the effects of religious service attendance on tens of thousands of healthcare workers (whose demanding and stressful jobs give them a higher rate of suicide or addiction than the national average). After we controlled for income, baseline health, and other factors, we found that men and women who attended services at least once a week were 33 percent (men) and 68 percent (women) less likely to suffer deaths of despair than those who never attended.
Other large and well-designed studies show similar results. We have found that women who attend services weekly have rates of depression roughly 25 percent lower than nonattenders. Weekly attenders exhibit five to sixfold reductions in suicide compared with nonattenders. Perhaps most strikingly of all, people who attend services at least weekly are about 26 percent less likely to die of any particular cause than are those who attended less than weekly.
Job losses, declining marriage rates, and shrinking religious communities interact in complex ways to bring about deaths of despair. Low (or no) wages reduce men’s “marriageability” and so drive down marriage rates. Lower marriage rates cause church attendance to decline, which in turn has been shown to increase divorce rates. The result is an atomized society in which deep friendships and simple human warmth become luxury goods. One recent study found that loneliness may increase mortality risk over a fixed period of time by 26 percent, perhaps in part because communities afflicted by isolation and atomization are natural breeding grounds for self-destructive behaviors.
Religious communities are crucial sources of social connection, but perhaps equally important is their role in directly teaching that suicide or abusing drugs and alcohol is wrong. As social psychologist Jonathan Haidt has put it, “religions are moral exoskeletons.” They provide “a set of norms, relationships, and institutions” that protect individuals from their own worst instincts and from giving in to self-destructive temptations. Contrary to the popular view that teaching about the immorality of suicide or addiction only stigmatizes mental illness and discourages its sufferers from seeking help, our findings suggest that religiously prescribed moral norms are crucial in preventing people from harming themselves, whether through suicide or through substance abuse.
Durkheim never drew a connection between secularization and social disintegration. That was left to Friedrich Nietzsche, who, prior to Durkheim’s work on suicide and religion, articulated the link in his characteristically florid prose. “Where is God?” his madman cries in The Gay Science:
We have killed him—you and I. All of us are his murderers. But how did we do this? How could we drink up the sea? Who gave us the sponge to wipe away the entire horizon? What were we doing when we unchained this earth from its sun? . . . Are we not plunging continually? Backward, sideward, forward, in all directions? Is there still any up or down? Are we not straying, as through an infinite nothing?
The true social danger presented by anomie was not, as Durkheim worried, its effects on our disenchanted elites. Rather, as Nietzsche predicted, a world without a sun was apt to lose its life-giving atmosphere as well, becoming bereft of all deep convictions or lofty aspirations. “One must still have chaos in oneself to be able to give birth to a dancing star,” cries Nietzsche’s Zarathustra. “‘What is love? What is creation? What is longing? What is a star?’ thus asks the last man, and blinks”—or resumes scrolling on his smartphone.
With Purdue Pharma’s recent agreement to pay a $4.325 billion settlement over its role in the opioid epidemic, we might be reaching a turning point in the epidemic of deaths of despair. Doctors are increasingly aware of the risks opioids pose to their patients, with the result that opioid prescriptions in 2019 reached their lowest national rate in fourteen years. (“Lowest” is a relative assessment. In 2019, there were still 46.7 prescriptions for every one hundred Americans, roughly five times the rate in, for example, France.)
Nonetheless, despair is a social and, indeed, spiritual malaise. Drugs amplify its effects, but the fundamental problem, which no revision of prescription guidelines can address, is that many of the most vulnerable people in our society live with the gnawing fear that a flourishing life—one shaped by a happy marriage, a fulfilling job, deep friendships—is out of reach. Far too many seek refuge in drugs, alcohol, or suicide.
Thomas Aquinas described despair as “the most grievous of sins,” because it is “unhealable”—it refuses offers of healing. “Hope withdraws us from evils and induces us to seek for good things,” he observed, “so that when hope is given up, men rush headlong into sin, and are drawn away from good works.” Despair is so deadly and so hard to cure because it attacks not the organs that sustain life, as does heart disease or cancer, but the very will to live. We must find ways to learn anew that “those who hope in the Lord will renew their strength” (Isa. 40:31).
Religion usually figures in American public policy as a civil liberties issue. But it is also a matter of public health. Public health officials should explore efforts to encourage religious participation, particularly among the millions of believers who don’t attend services. To their warnings not to smoke or drink to excess, our leaders should add a positive admonition: If you want to flourish, go to church.
Brendan W. Case is the associate director for research at the Human Flourishing Program at Harvard’s Institute for Quantitative Social Science.