Terminal Despair

December 15, 2023 | Zeki Tan MY ‘25

image description: desert horizon and sky

The phrase “deaths of despair” was coined  in a 2015 paper by Princeton University economists Anne Case and Angus Deaton to describe the unusual increase in mortality among middle-aged, non-Hispanic, white Americans starting in the 1990s. Deaths from suicide, chronic liver diseases (generally a consequence of alcoholism) and poisonings from drugs and alcohol accounted for most of this increase. Although mortality rates from these three “diseases of despair” increased across all education groups, they went up most sharply among middle-aged whites without a college degree. [1] 

Case and Deaton proposed that these deaths of despair were caused by the loss of economic opportunities for white, working-class individuals. Manufacturing jobs across the Rust Belt were outsourced to lower-income countries due to globalization and increased free trade throughout the 1980s and 1990s. Entire towns that depended on industries like automobile and steel production were devastated as companies moved their operations abroad. An entire generation of Baby Boomers, realizing that they would not do better in life than their parents, saw their expectations frustrated, and soon descended into hopelessness. Communities unraveled as social institutions like churches and families came under immense strain from economic strife. Overwhelmed and feeling excluded by a heartless economic system, many turned to opioids to alleviate their pain; reports that 20.8 million oxycodone and hydrocodone pills were shipped to a West Virginia town of 3,000 from 2008 to 2015 – that’s seven thousand pills for every single resident – grimly quantified these communities’ despair. [2] Political commentators attributed Donald Trump’s unexpected election win in 2016 to Rust Belt voters airing their economic and cultural grievances to an out-of-touch Washington elite.

Although this narrative is plausible and quite truthful, it is insufficient to fully understand the epidemic of despair ravaging rural and small-town America, much less contemplate possible treatments for it. Materialist causes of social phenomena can be helpful, but they are only proximate causes that point toward deeper problems. Philosopher Søren Kierkegaard, though certainly not the first to correlate despair with disease, described despair as “the sickness unto death.” [3] As I have come to understand it, despair is at its root a relational illness whose symptoms involve a breakdown of one’s relationships: the self to one’s self, the self to the eternal, and the self to one’s community.

Kierkegaard wrote that the self consists of a tension between one’s infinite nature, one that perceives and yearns for the transcendent; and a finite nature, one that recognizes mortality and the physical limits of the body. [4] To despair is to separate these two natures, instead of acknowledging the tension that must be navigated between the two extremes. This view of despair seems rather abstract, however. 

What does it mean for one’s infinite self to be separated from one’s finite self? 

To answer the first question I turn to the experience of children, who grow up with the hope of what we see in Tolkien’s eucatastrophe – that events, no matter how unfavorable they may be, invariably turn out in favor of the protagonist in the end. As a four-year-old, for example, I got into a fight with a classmate and was reprimanded by the principal. Yet, I could count on my parents to vouch for my character and spare me a class suspension. Despair is a loss of that childhood innocence: a realization that our parents won’t always be there to rescue us from the holes we dig for ourselves. Despair is also an infinite feeling of abandonment: a conviction that in a vast, amoral universe, no one who transcends our everyday reality will come to save us from ourselves. This tormenting reality of being alone is perhaps the “anxiety about some possibility in existence” that Kierkegaard believed everyone secretly carries with them. [5] Look to the laid-off coal miner in West Virginia: he witnesses the over-doses of neighbors and close friends, is told by a presidential candidate that she would put more of them out of a job, and has a sense of despondency and self-loathing for never being able to provide enough for his family. How can he not despair sensing the limitedness of what he alone, despite being a mortal human being with limited power and resources, could do to save his children and his community? [6]

What does it mean when one’s experience of the finite lacks elements of the infinite?

I’ll answer this by contrasting the “deaths of despair” in white, working-class communities with deaths of despair in another community: Native Americans on reservations. “Deaths of despair” on reservations have persisted for far longer than in white communities, and remain more prevalent. A 2023 paper published in The Lancet, an influential medical journal, uncovered some of these large disparities in mortality. In 2013, the death rate among midlife Native Americans from deaths of despair was 76 percent greater than non-Hispanic whites, a gap which increased to 103 percent by 2020. In that same year overdose deaths and alcoholic liver diseases among Native Americans were 34 percent and a whopping 432 percent greater than in white Americans. (Suicide death rates were about the same in both groups.) From 1999 to 2013, the time frame used in the Case and Deaton paper, the all-cause mortality rate increased by nine percent for white Americans but by twenty-nine percent for Native Americans. [7]

These findings should of course not be used to minimize or downplay the despair plaguing both communities. Yet, the all-encompassing term “deaths of despair” used by Case and Deaton overlooks the nuances of each group’s economic and social circumstances that led to those experiences of despair. Native Americans have been driven to near-extinction by centuries of white colonialism and genocide. They have been displaced from their homelands, slaughtered in mass killings, imprisoned in reservations and sterilized without informed consent. [8] The despair among many Native Americans is that in their powerlessness– lacking the ability to revive their culture, traditions and livelihoods–they lose hope that history will point toward some redemptive state of beauty and goodness. In contrast, working-class whites have prospered following the post-World War II economic boom and continue to enjoy vast material privileges– even as their communities are also harmed by changes in the economy. As Oscar Wilde wrote, “in this world there are only two tragedies. One is not getting what one wants, and the other is getting it.” [9] Thus, the tragedy of despair came about very differently in Native and white communities: for one the result of cruel deprivation and the other the result of worldly abundance. Nevertheless, as Kierkegaard observed, despair is a universal sign of the fallen condition of mankind as ubiquitous as sickness and death.

In which category do we find ourselves at Yale? 

Yale, the hallowed ivory tower walled off from the vicissitudes of the world, seems so far removed from both Rust Belt America and Native American reservations. I find, however, that despair abounds as much, if not more, among the Yale community. 

As a freshman, a common complaint I heard from my suitemates was that wait times for appointments at Yale’s Mental Health and Counseling services often extended up to three months. By Yale’s own admission, five thousand students availed of Mental Health and Counseling services in 2021, out of a student population of less than fifteen thousand. [10] This is not a statistic people ought to celebrate. Anger at Yale’s meager investments in mental health care, although understandable, should not distract from a broader question as to why so many students are seeking help in the first place. 

In my conversations with peers I believe that this is because Yale students experience simultaneously the two forms of despair Kierkegaard outlined. On the one hand, some, whether moved by the suffering they see in the world or their family’s own hardship, take it upon themselves to save those who are hurting. They pour all their efforts into their classes and extracurriculars on campus–burning themselves out before they have achieved their goal. On the other hand, there are those (myself included) who, because of impostor syndrome, experience a persistent sense of worthlessness and lack of purpose in spite of their impressive academic and professional achievements. Without grounding themselves in relation to the infinite, it becomes difficult to identify what their efforts are striving towards. (The fledgling activist movements I see on campus seem like an attempt to get around this problem, but that’s a topic for another time.) On top of that, a Yale administration that “want[s] nothing to do with you” when students are struggling, creates a culture in which despair is individualized and walled off from the community. [11]

We cannot occupy ourselves with work, however, to escape this reality. In attempting to cultivate an infinite self, essentially making us gods by taking on the burdens of the world, we find that our human constraints make this goal unattainable, and we are crushed very quickly. Conversely we cannot, in spite of our challenging circumstances, find ourselves so distant from aspirations toward goodness that we trap ourselves in despair, unable to believe in anything better. And we certainly cannot hide from despair and hurriedly cast out students who experience it.

With despair laid out as a universal and seemingly inescapable phenomenon, where might one find hope? 

Although despair is an inward, existential struggle, it is absurd to speak of it exclusively as a sickness of the individual. As author Wendell Berry said, community is “the smallest unit of health […] to speak of the health of an isolated individual is a contradiction in terms.” Health, according to Berry, means a sense of “wholeness [...] belonging to others and our place.” [12] Therefore, curing a 45-year-old in Appalachia of her despair means healing her community too – the rusting steel mills, the rotting warehouses, and the abandoned homes with their boarded-up windows and collapsing roofs. Solely promising the working classes more jobs and larger tax cuts, as Trump stated in his 2016 campaign, doesn’t quite heal. Understanding health as wholeness means adopting a “systems thinking” approach: mapping out the web of interactions between components of a social system instead of studying them independently of each other. “Systems thinking” uncovers previously unknown relationships between seemingly unrelated variables that play a role in deaths of despair. [13]

One interesting finding stated that attendance at religious services is an important factor in reducing the risk of deaths of despair. A 2020 paper published in JAMA, the Journal of the American Medical Association, used data from 110,000 healthcare workers that showed those who attended services at least once a week were much less likely to die of “deaths of despair” than those who attended infrequently or not at all. For women the mortality risk was reduced by 68%, whereas for men it was 33%. [14] Tyler VanderWeele, professor of epidemiology at Harvard University who co-authored the paper, proposed that the social relationships forged in religious communities provided emotional support to despairing individuals. [15] Non-religious forms of social support can most certainly create bonds of community that can ward off deaths of despair. Religious settings, nonetheless, provide a metaphysical framework for creating meaning and purpose in the midst of suffering that secular communities are ill-equipped to provide. Christianity, for example, offers a narrative of redemption from hopelessness that takes the form of a God who has experienced despair Himself. Was it not a cry of despair when the crucified Christ called out to His heavenly Father, “My God, my God, why have you forsaken me?” (Matthew 27:46, ESV) As Christ hung dying on the cross, separated from the hope of eternity with God Himself, he, as G.K. Chesterton wrote, “seemed for an instant to be an atheist.” [16] 

The phenomenon of “diseases of despair” demonstrates that the inward emotions we experience have visible effects–both in our physical health as well as the health of our communities. Despair poisons both the body and the heart, spilling over into our relationships with other people and with the divine. Tragically, today’s society fails to respond adequately to people’s despair. Instead, people are offered temporary relief from its symptoms through addictive painkillers or false promises from politicians and corporations that wealth accumulation is the highest good one should attain for. This will not do. Despair must be addressed as a fundamentally relational sickness. We retain a desire for the goods beyond this life, as finite humans who are separated from an infinite Creator. We are, as Kierkegaard writes, a synthesis of finitude and infinitude, and we need to approach each other on those terms. Navigating this tension between our two natures is difficult, and going it alone will likely sink us deeper in despair. When we do this in fellowship with others and with God, however, our despair is transformed. No longer is it the terminal sickness unto death, but instead one whose healing end is reconciliation and eternal joy with our Creator. 

Sources used:

[1] Anne Case and Angus Deaton. “Rising morbidity and mortality in midlife among white

non-Hispanic Americans in the 21st century.” November 2, 2015. https://www.pnas.org/doi/full/10.1073/pnas.1518393112 

[2] Laurel Wamsley. “Drug Distributors Shipped 20.8 Million Painkillers To West Virginia Town Of 3,000.” January 30, 2018. https://www.npr.org/sections/thetwo-way/2018/01/30/581930051/drug-distributors-shipped-20-8-million-painkillers-to-west-virginia-town-of-3-00#:~:text=Drug%20Distributors%20Shipped%2020.8%20Million,%3A%20The%20Two%2DWay%20%3A%20NPR&text=Press-,Drug%20Distributors%20Shipped%2020.8%20Million%20Painkillers%20To%20West%20Virginia%20Town,rate%20of%20drug%20overdose%20deaths. 

[3] Søren Kierkegaard. The Sickness Unto Death, p. 17. 1849. 

[4] Kierkegaard, p. 29. 

[5] Kierkegaard, p. 22. 

[6] Dan Merica. “Hillary Clinton apologizes for coal comments in West Virginia.” May 3, 2016. https://www.cnn.com/2016/05/02/politics/hillary-clinton-west-virginia-coal-comments/index.html 

[7] Joseph Friedman et al. “Deaths of despair and Indigenous data genocide.” January 26, 2023. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2822%2902404-7 

[8] Brianna Theobald. “A 1970 Law Led to the Mass Sterilization of Native American Women. That History Still Matters.” November 28, 2019. https://time.com/5737080/native-american-sterilization-history/ 

[9] Oscar Wilde. Lady Windermere’s Fan. 1892.

[10] Mallory Locklear. “Meeting student mental health needs at Yale.” November 17, 2022. https://news.yale.edu/2022/11/17/meeting-student-mental-health-needs-yale 

[11] William Wan. “What if Yale finds out?” November 11, 2022. https://www.washingtonpost.com/dc-md-va/2022/11/11/yale-suicides-mental-health-withdrawals/ 

[12] Wendell Berry. “Health is Membership.” October 17, 1994. https://scienceandsociety.duke.edu/wordpress/wp-content/uploads/Berry-Health-is-Membership.pdf 

[13] Seth D. Kaplan. “A Systems Approach to Social Disintegration.” Fall 2017. https://www.nationalaffairs.com/publications/detail/a-systems-approach-to-social-disintegration 

[14] Ying Chen, Sc.D., et al. "Religious Service Attendance and Deaths Related to Drugs, Alcohol, and Suicide Among US Health Care Professionals.” May 6, 2020. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2765488 

[15] Tyler J. VanderWeele, Ph.D. “Deaths of Despair and the Role of Religion.” May 11, 2020. https://www.psychologytoday.com/us/blog/human-flourishing/202005/deaths-despair-and-the-role-religion 

[16] Gilbert K. Chesterton. Orthodoxy. 1908.