“Why are there so many mentally ill White homeless men on the streets of South LA?” This was the question posed on social media by the Black author Earl Ofari Hutchinson after encountering a half-dressed mentally disturbed White man standing in the middle of a busy street.
Hutchinson admitted that he did not expect the volume of replies and general traction the question would garner. This is because the democide of poor White Americans is a silent one; no hospitals are bombed or food stations fired upon like in Gaza as a horrified world watches on. The demolishing of the once-proud edifice of working-class White America is being achieved not in a spectacular explosion but a brick-by-brick deconstruction. The flotsam and jetsam of White mentally ill homeless men and women washing up on America’s streets is the result of decades of deliberate economic policies of de-industrialisation.1
The economic war against White America began over half a century ago. Around 1970, the economy that had sustained the White working class for a generation, and was the source of pride for many working men, was weaponised against them. The deliberate uprooting of American heavy industry through globalisation and automation—and the financialisation of the US economy—set real wages and job opportunities for workers without a university degree on their long, grinding decline.
The good jobs—those offering a sense of belonging, meaning, purpose and prospects for advancement—evaporated. What remained were precarious positions in the service economy, stripped of the dignity and security that had once defined working-class identity. The share and influence of labour, especially less-skilled labour, fell relative to the share and influence of capital. Workers who had once been able to support families on a single income now found themselves trapped in a cycle of declining attachment to employment, falling wages and diminishing prospects.
The social fabric of White America was unravelled alongside the economic one. Marriage rates declined sharply alongside rising rates of non-marital childbearing. Religious participation, which had long provided community and meaning, fell away. The tangle of pathology that the 1965 Moynihan Report had described among Black families half a century earlier began to echo among White families in the post-industrial heartlands.2
Unionisation—which had reached its peak in the 1950s—collapsed alongside the factories. Today, only 6.3 percent of private sector workers in the US are members of a union.3 Unions had done more than raise wages; they gave workers control over working conditions, a sense of collective (racial) purpose and political power both locally and nationally. They were the bridge between working-class communities and the Democratic Party. As the factories closed and the unions withered, that bridge crumbled.
The US healthcare system accelerated the devastation. America’s medical provision—more than twice as expensive as any other rich country—is financed in part through what is described as a head tax on wages.4 In 2020, employer-sponsored health plans cost an average of $21,342 per family, money that comes directly out of take-home pay.5 For low-skilled workers, these costs often make them unemployable, pricing them out of the very jobs that might offer a path back to stability.
The sense of collective identity that unions and factories had provided was replaced by isolation and fragmentation. Men who had once taken pride in their work found themselves unable to provide for their families and, consequently, unable to command respect in the communities that had once looked up to them.
Into this void stepped the pharmaceutical industry. The pain that accompanied this social and economic collapse created a baseline demand for opioids. Drug companies, seeing an opportunity, targeted communities that were already hurting: places where jobs had been lost, where pain was prevalent and where despair had become entrenched. The escalation of addiction that followed was not simply a demand-driven phenomenon; it was a supply-driven catastrophe in which the pharmaceutical industry and its political enablers flooded the country with largely unnecessary painkillers. As legal prescriptions were pulled back in the early 2010s, the epidemic mutated into an illegal street drug crisis—first heroin, then fentanyl, then deadly combinations. The term deaths of despair was coined to describe a White working-class extinction event via suicide, drug overdose and alcoholic liver disease.6
Concurrent with the targeting of White working-class America by the US state has been its abandonment by the Democratic Party. As the mainstream Democrats reoriented away from their traditional working-class and union base towards a coalition of minorities and educated professionals, less-educated workers moved to the right. This realignment continued through the 1990s and 2000s. By the time Donald Trump appeared on the political scene, millions of working-class voters had already abandoned the party of their parents.
The China shock, the loss of jobs following China’s admission into the World Trade Organisation, provided a clearly-demarcated exogenous change marked by rising political polarisation from 2000 to 2016. Moderate Democrats in Congress were replaced by right-wing Republicans, while the move to the left by progressives was not large enough to offset the shift.
Conservative media like Fox News amplified a narrative of government betrayal at the expense of ordinary White Americans. The distrust that working-class voters felt toward Washington was weaponised and deepened. The China shock led to political polarisation among both voters and donors, creating a feedback loop that favoured the right. Less-educated whites increasingly saw safety-net policies, the very policies that might have helped them, as favouring minorities at their expense. They voted for conservative candidates who opposed such programs, candidates whose wealthy backers also opposed the taxes necessary to pay for them. The desire for social solidarity gave way to resentment, and the political system that might have provided relief became a source of further injury.
The relationship between health and politics in the United States underwent a dramatic inversion. In the 1960s, healthier states—those with higher adult life expectancy—voted Republican. By the 2016 election, the correlation had reversed: the least-healthy states, those with the highest rates of deaths of despair and the lowest life expectancy, were the ones voting for Trump.7 As less-educated workers left the Democratic Party, the political economy of health became a politics of despair. The neoliberal policies that had inflicted economic hardship and worsened health did not generate a political demand for better safety nets and health provision, as one might expect in a well-functioning democratic state. Instead, the anger and disillusionment were channelled toward a political project that offered vibes-based cultural resentment and scapegoating rather than tangible material redress.
The evidence that the US state’s economic policies have disproportionately impacted middle-aged White Americans (non-Hispanic) is clear. Prior to 2000, mortality rates among White Americans aged 45-55 had been falling. Between 1978 and 1998, the mortality rate for US Whites declined by 2% a year on average, matching the rates of decline in other rich industrialised nations such as Canada, the UK, France and Germany.8 From about the year 2000, mortality rates for middle-aged Americans began to increase by half a percentage point per year while other rich nations maintained the 2% year-on-year declines.9
Between 1999 and 2013, all-cause mortality for Black Americans fell by more than 200 per 100,000 and for Hispanics by more than 60 per 100,000.10 In contrast, mortality for White Americans in midlife rose by 34 per 100,000. The much-touted narrowing of the Black-White mortality gap in the US has been largely driven by an increase in White mid-life deaths.
If the mortality declines had held constant at about 2% from the turn of the century, roughly 488,500 deaths of middle-aged White Americans could have been avoided, 54,000 in 2013 alone.11 This mortality phenomenon is restricted to White Americans in midlife. All-cause mortality for White Americans aged 55-59 and 65-74 declined by 0.5% and 2% respectively in the period 2000 to 2014.12
