Mercatus titled it Death and Politics.
Their new book, Deaths of Despair and the Future of Capitalism, includes both an actuarial analysis of disturbing patterns of mortality in the United States and a political statement calling for government action to overhaul pharmaceutical regulation, take control of the health care system, and shift the balance of power in the economy away from capital and toward labor. It seems evident to the authors that their political statement follows from their actuarial analysis, but the connection between the two struck this reader as tenuous.
If there were a Nobel Prize for scapegoating. . .
Excellent review.
One change. I think this paragraph is yours, not theirs. But the italics make it look as if it’s theirs:
But if the companies are to be blamed for providing warnings, one doubts that they would be exonerated had they failed to do so. And the authors go on to say that when prescription opioids were reformulated to be more resistant to abuse, “it is possible that the reformulation actually cost lives, if users switched to relatively unsafe street drugs.”
good catch, David
>Arnold writes: No one has pinned down the cause or causes, and it would be careless to imply that there is a clear and obvious solution.
This really does spell out a problem we face. A priori ‘political’ positions make it too easy to fit fuzzy pictures onto what you ‘expect’ to find, ‘expect’ being a euphemism for wishful thinking in this context
For clarity, reassembling Kling’s words into a single sentence: “No one has pinned down the cause or causes” of “the decline in the traditional working-class family.”
The opioid crisis is occurring in Charles Murray’s Fishtown from his book “Coming Apart”. As Kling points out, this phenomena is also about the ascent of women in our economic meritocracy which is both more complex than Case and Deaton’s focus on “a long-term and slowly unfolding loss of a way of life for the white, less-educated working class.”
Interestingly, Gallup reports that people in the USA have never been happier: https://news.gallup.com/poll/284285/new-high-americans-satisfied-personal-life.aspx
And the CDC recently reported that the drug overdose deaths declined in 2018 over 2017 and for the first time in 4 years in 2018 life expectancy increased.
So we have to look to non-economic explanations or we might be left wit the untenable notion that Trump is doing something right.
Speaking of “right”, the chronic inflammation in my right shoulder has significantly improved since Trump took office. Makes ya think.
The strange thing is how many of past drug epidemics simply burn itself out and I remember the 1980s of various cocaine and crack that both burn themselves out.
That said, here is what I wish:
1) Purdue knew exactly the dangers of their drugs and did very little to mitigate its dangers. I don’t like the cases against them but libertarians need to admit Purdue could have marketed these differently.
2) I wish the US schools would warn of the dangers of drugs that include Pharma drugs as well. These can be very dangerous and very little is said of this.
3) Doctors need to more honest with their patients. These can be dangerous.
Yes it is less perfect but it can mitigate a lot.
There was also this interesting historical event called The Opium Wars that never comes up even though the opioid crisis and the protests in Hong Kong are mentioned daily in the press. I think Hong Kong turned out OK eventually.
In terms of prevention, every discussion of opioids/opiates should emphasize the extreme constipation that occurs. Numbed bowels are more visceral than overdose/addiction statistics.
Case and Deaton write, “. . .we believe that opioids are still being wildly overprescribed for chronic pain.”
With all due respect, they are almost certainly full of shit. I have a friend in chronic pain who relies on opioids and the hoops she now has to go through … As I recall, before “the opioid crisis” was named, there was a fair amount of research that in many cases, opioids were underprescribed (and, of course, in others overprescribed). But as we all know, if you try to get rid of all Type I errors, you get a lot of Type II. The correct response is to try to prescribe what is right in each individual case, not just “crack down”.
yes++
But calling back to yesterday’s discussion of institutions, when I hear about Oxycontin in reference to the opioid crisis I think about how the design of incentive systems for the enterprise sales force can inadvertently bring down the corporation. There is a great deal of gaming going on but I’m not sure if Purdue was the perpetrator or the victim. Same holds prescribers, payers, patients, physicians. Anything with a “p”.
Based on what I’ve seen in prescription statistics, I find it not just improbable but laughable to say that opioids were under-perscribed or hard to get. Both in a general sense of overall prescription levels and the constant drone of new pill mills popping up.
There has been a concerted effort the last few years that has stemmed the tide of this nonsense compared to its peak.
I’m sure there are anecdotes abound of someone who finds these new controls difficult, but based on what I’ve seen of the system anyone who claims that things were fine or “fine enough” before is full of shit.
A “tense” moment, as in the past vs. present “tense” sense. Before the crisis, chronic pain and cancer pain were not well managed. Slow-release Oxycontin and fentanyl patches were a godsend for these cases. During the crisis there was an extreme overprescription of Oxycontin, and an interesting question is why fentanyl patch prescriptions did not keep pace with Oxycontin. After the crisis, people with chronic pain are assumed to be guilty of opioid abuse and must go through hoops to get relief.
I completely agree that “anyone who claims that things were fine or ‘fine enough’ before is full of shit.”
I was disagreeing with Case and Deaton that “. . .we believe that opioids are still being WILDLY overprescribed for chronic pain.” Simply not true.
What RAD said.
In discussions of opioids, sadly pain patients are often completely unconsidered. I think Scott Alexander is probably right that, at least nowadays, the pendulum has swung too far and people are too frivolously diagnosed with addiction, in part because the symptoms of chronic, untreated pain often overlap with symptoms of addiction.
And selfish as this sounds: the mere possibility of getting a kidney stone and being given Tylenol for it is enough to put me squarely against increased regulation of pain meds. And since the vast majority of ODs are illicit opioids (Case and Deaton overstate their case; many or maybe most cases where prescription opioids are ‘involved’ also involve illicit opioids; and when a person overdoses on heroin while also taking a prescription opioid, the heroin is probably what did them in), if cracking down on pharma companies leads even a fraction of people to go to the more dangerous illicit alternatives, it may reduce addiction while still increasing ODs.
There are two independent paths people take to opioid addiction. The first starts and ends with a supply chain involving various illicit drugs with injected opioid being the pinnacle of effect and a point of no return. Heroin serves this market and it’s urban/inner-city. Some may have come to the same place via prescription morphine (think Caravaggio during WWII in The English Patient) but this is rare outside war zones and palliative care.
The second path comes via prescription opioid pills/patches. The slow release formulas opened up the use cases beyond what could only previously be achieved with an IV drip. The effect of normal single dose opioids is too short lived to treat chronic pain. This is Case and Deaton’s Death of Despair story and it applies to a non-urban working class market. Many of these addicts end up using heroin but their path getting there is different.
Solving the second problem, now that is well established, requires balancing prevention and tratment; preventing new addictions and treating established addictions. The lesson learned is that using opioids for more than about three weeks to treat chronic pain results in addiction that requires a difficult withdrawal regiment when the medication is removed.
+1 RAD
Mark,
Prescriptions are lower than the peak, but above the level in 90s. So maybe we are finding an equilibrium.
From my perspective as someone who has dealt with prescription fraud, at the peak you could basically commit all the fraud you wanted in a brazen manner and totally get away with it. Nowadays you will often (but not always) get shut down and sometimes get prosecuted (but sometimes not).
Pill mills still open up with great frequency, but someone out there is trying to shut them down and catch the perp, which wasn’t being done as well during the peak. Still, it takes the government a long time to build a case/shutdown these places and if you “keep moving” you can stay ahead of the game. So the people who get caught generally have to screw up themselves.
Part of the change is simply that a lot of the fraudsters have moved on from opioids. Creams (sometimes pain related) and compounding are the big things (you can check out a John Oliver segment on compounding pharmacies).
Unlike opioids, the fraudulent claims are for prescriptions that will never be taken by an actual person. There was a lady that had enough boxes of creams fraudulently sent to her in her name to fill her apartment, and there was not question of her taking it. In many cases these Rx would actually kill someone that took them, but nobody takes them. The fraudsters can charge ungodly amounts for these, and they rarely get shut down. Or if they do its a really slow process and its easy to not get prosecuted and just start a new pharmacy. I actually saw a fraudulent pharmacy start a second pharmacy with the same name as the first but with “#2” at the end.
With opioids, there is a corpse. And if there is a corpse there is a family. And if there is a family there is a congressmen. And if there is a congressmen then someone in the government might actually do something.
If there is no corpse little gets done, even if the fraud if brazen and gigantic in cost. Well I won’t say nothing…but the response is wildly insufficient and nowhere near the effort and effectiveness being put into opioids.
So a lot of the people that would have been pushing opioids are still around, they just don’t bother filling real scripts that will be taken by real people.
As to illicit drugs and OD, I’m not really that concerned. OD rates are small in the grand scheme of things. It bothers me a lot more that people are addicted to these drugs on a mass scale. There is a class of libertarians that thinks being chronically addicted to debilitating and unhealthy drugs is OK, or at least its the price we have to pay to not have people OD off black market stuff. I don’t share that opinion. Life with addiction is no life at all, and we ought to work to prevent being addicted in the first place.
If there is no corpse little gets done, even if the fraud if brazen and gigantic in cost. Well I won’t say nothing…but the response is wildly insufficient
Totally off topic: I get several calls a day from scammers, even though I am on the government “do not call” list. There seem to be tens of millions with the same experience.
Scammers make their money when people respond so it seems that sting operations would quickly shut them down. But noooooo. As far as I can tell, nothing is tried, nothing is done.
+1 right back at ya asdf,
We agree on the underlying structure of the opioid crisis. Hopefully you can also understand, though not agree with, my position on Purdue. The fines and demonization are not helpful at this point; it seems more about virtue signalling and extraction. Now that I think of it, perhaps forcing an early expiration of their slow-release “contin” parents might have been a better positive-sum punishment.
Patents not Parents. Stinkin’ Autocorrect.
Roger,
We could end most frauds tomorrow if we had the will. These fraud pharmacies I speak of, they are all easy to spot in a database. If I had unilateral authority to arrest, sentence, and imprison the perps it could be done in a week.
And there wouldn’t be any errors, it’s very easy to tell the fraud pharmacies from regular ones. The fraud isn’t much covered up, its brazen. When a pharmacy is 99%+ obvious fraud scripts, you don’t have to worry about locking up the innocent.
There isn’t even a libertarian argument here as far as I’m concerned. Just laziness, corruption, and lack of incentive on the part of those that should enforce.
The difficulty in my mind is that multiple people at multiple levels have to decide to be brave and do the right thing all at once. If they do the right thing but another person in another stage of the chain doesn’t, their bravery is for naught, and might cost them. And they can’t really coordinate with the rest of the chain before the fact, so they respond to an incentive structure that says “its pointless anyway so don’t take personal risks.” Which only self reinforces the belief.
I believe the same state of affairs is true of much wrongdoing in our society. It would take a different cultural/social/government equilibrium to break out of.
asdf said:
Them words are red flags for me. Perhaps you are underestimating how foreign tabular data is to most people. As a case close to home, the trial of Adnan Said as presented in the Serial Podcast turned on a single ~twenty row table with call records and their related cell towers/antennas. They couldn’t do it in two trials with a young man’s life in the line and they couldn’t get their heads around it in the podcast nor could the massive public following of the podcast narrow in on the data. This horrified me.
“Them words are red flags for me.”
Then do the hard work of looking into it and making a decision. When I look at this data, I want to throw up. Only someone evil or incompetent could come to a different conclusion, and everyone involved admits this.
“As a case close to home, the trial of Adnan Said as presented in the Serial Podcast”
I never listened to this and don’t know much about the trial beyond what I looked up in the last five minutes.
My general impression, from personal experience with the Baltimore justice system, is that it’s so hard to convict even when surely guilty and if mistakes are made we are still leaning far too much towards acquittal.
My wife was on a trial where the perpetrator stabbed someone else in the abdomen over getting “dissed”. There were multiple witnesses (some of which “went missing” before the trial). Nonetheless, there was overwhelming evidence against him, of which all twelve jurors agreed.
However, one juror said that he shouldn’t be convicted because “he was on drugs” when it was done. And apparently crimes while on drugs aren’t real crimes. Also this particular juror had done drugs. And he also felt that prison only makes things work so people should never get sent to prison. He spent three days going through his self published autobiography and talking about the street people he had saved by taking into his house (he referred to them as “his children”, except the one that stole his laptop, who he has arrested and convicted).
After which the stabber with a rap sheet got released to no doubt stab again.
I suggest to anyone that can not to go anywhere near Woodlawn or send your kids to Woodlawn high school. This is the sort of thing happens when you go to a ghetto school (78% black, 58% FARM). I get that Asian immigrants that are poor when they move here look for a cheap place to live, but they should have done what it took to get out of that neighborhood and their daughter would be alive.
You can google “woodlawn high school violence”
and get a stream of video on youtube to get an idea of what’s typical there.
The Woodlawn area is also the set of schools they wanted to implement busing so that it would mix with the whiter Catonsville schools. The middle class people of Catonsville naturally resisted sending their kids to murder schools, for which the superintended of Baltimore county schools called them racist (he was later convicted and sent to prison for other crimes, like every other black Baltimore civil servant).
My own experiences going anywhere near Woodlawn have always been negative, and the kids that flood into the library next door are ill-behaved. For all the talk of privilege the best Baltimore County libraries with expensive children story time areas are all in ghetto places, even though they are paid for with white taxes from the I-83 corridor we are expected to drive down to these ghetto neighborhoods to use them. And of course my car got damaged in the parking lot while playing with my kid, which is nothin but chaos after school gets out.
The victims family seems to think this guy is guilty, and everything I know about the area says that anyone from there is trouble. A court of law convicted him despite defendants having huge institutional advantages. A jury of his peers thought the evidence was good enough. That’s good enough for me.
That is what I would have said too before learning about this case. Now I think the criminal law system is closer to Trial By Water where bleeding a person of their life savings is a substitute for boiling water. You might have an opinion about a defendants guilt but this case was a no-brainer not-guilty due to lack of evidence. All your Bayesian priors have to be supported by evidence.
I don’t know if he’s guilty or innocent. Doing so would require an immense investment of my time and probably yield some probabilistic answer.
I think it’s very hard to convict people. So if you manage it, it’s probably true that the person is guilty. True enough that I wouldn’t consider it worth my time to think otherwise, and true enough that I don’t necessarily think we ought to try these things over and over again forever.
This case, from my limited looking into it, just doesn’t strike me as something where I consider guilt implausible enough to want to overturn the state. Criminal element in ghetto criminal place kills on again off again girlfriend. Believable.
I don’t think it has much relevance to the case I’m talking about. Where I have an incredible wealth of information, I’m an expert in the area, and I consider the probability of guilt to be 100% with zero doubt to the contrary.
P.S. I’m not one of those let 100 men go free lest 1 guilty man be convicted kind of person. That seems highly inefficient and an injustice that makes the world a worse place. When I think of 12 Angry Men I think of that wacko in my wifes trial.
Rather, I think that we ought to consider the context and probabilities when weighing the considerations of (change convicted if innocent) vs (chance not convicted when guilty). Given the context of the situation, I don’t think overturning this dudes verdict is at the top of my list from what I know.
Maybe I would change my mind if I spent more time considering it, but its not worth my time. I also distrust many media sources on things like this based on past experience of their being untrustworthy.
1) did very little to mitigate its dangers
If that was all they did, I don’t think people would be as angry. They actively pushed this stuff in immoral ways.
“But non-compete clauses do not apply to the sort of blue-collar worker that Case and Deaton have identified as prone to deaths of despair.”
Right, though, a very minor quibble. About five years ago, as the labor market even for low-skill workers tightened up, there were a series of stories regarding ‘no-poaching’ and other non-compete-like clauses applying to fast food employees (fully 80% of them – that’s a lot of workers – and sometimes among other blue collar workers.
You might be surprised how often and where they turn up, as it’s become something of a ‘best-practice’ for lawyers for small business to recommend these to the owners, for new employees especially. Car dealerships are fond of it for their salesmen and mechanics.
Under pressure from the progressive press and a bunch of state attorneys generals, most fast food companies recently voluntarily agreed to stop enforcing the clauses, though they still often include them in the contracts.
Sharp book review!
Compare Scott Alexander’s blogpost (5 February 2020), “Suicide Hotspots of the World”:
https://slatestarcodex.com/2020/02/05/suicide-hotspots-of-the-world/
“Case and Deaton point out that the earnings gap has widened between those with and without a college degree, and they attribute the divergence in mortality trends to this divergence in economic prospects.”
According to the online America’s Health Rankings.org suicide mortality by state tables, for 2019, Louisiana has maintained a mid-range rate of 11.3 per 100,000 adolescents ages 15-19, from 2016 to 2019.
However, as Joanne Jacobs blogs today, Louisiana is increasing economic opportunity for its younger citizens by providing alternative pathways to remunerative employment:
” More than one in five Louisiana high school graduates now earns a career diploma, up from 2 percent in 2013, reports Will Sentell in The Advocate. The state’s goal is to raise that to 40 percent of graduates
‘Some new graduates with industry-based ‘Jump Start’ credentials ‘are landing jobs paying $40,000 or $50,000 per year or more,’ writes Sentell.
‘We have pushed students and families that ‘you have to go to college, you have to go to college,’” said Troy Borne, lead Jump Start teacher at the St. James Parish Career and Technical Center. ‘Because of that we have created a skills gap,’ he said. ‘Now the push is to create career and technical education to close that gap.’ … …
‘The state is launching Jump Start 2.0, which cuts the number of career pathways from 40 to 11 to ensure all are “aligned with high-need, high-wage jobs,’ reports Sentell.”
Will Louisiana’s teen suicide rate be affected by these reforms? Correlations in the next few years may suggest additional research would be worthwhile.
Similarly, program evaluations of the new PAYA apprenticeship programs ( https://www.newamerica.org/education-policy/press-releases/paya-grantee-announcement/ ) may lead to suggestive correlations.
Case and Deaton are obviously correct to dismiss diploma-ism as a protective factor, but can the diploma-ism chokepoint to opportunity be as readily dismissed as a causal factor?
I think Case and Deaton’s “Deaths of Despair” are technically “Middle-aged Deaths of Despair in Middle America”. Teenage suicide is a different story and it can be divided into youths in highly competitive communities (e.g. Japan) and broken communities (e.g. Inuit).
Pretend you don’t have a high school diploma and you are told that if you don’t, you won’t get a good job, and, man, what’s wrong with you? You might feel a little despair.
That is one thing people are told to motivate them to “stay in school.” For their own good, of course.
Perhaps the cause of deaths of despair is not so much capitalism as educationism, the marketing strategy of the school industry.
Something you don’t mention (I think) is that if education is mostly signaling, then more people getting more education will just deflate the value of the signal, not make anyone better off. If everyone went to college and then the top half got graduate degrees to distinguish themselves from those that just go to college, we end up in the exact same place, only wasting more resources on higher education.
In fact, there seems to be a general issue with most of their policy prescriptions. The merit of raising the min. wage, increasing union membership, tightening anti-trust law, etc. hinge on contentious assumptions independent of the opioid crisis. Like monopsonies being rampant across US labor markets. If we don’t buy that, then these policies may exacerbate unemployment and backfire, just as if we don’t buy the human capital theory of higher education, that policy proposal looks unhelpful at best..
I think this review might also have been a good time to mention Russ Roberts’ article and it’s general theme. The opioid crisis came on the tail of a long period of steadily increasingly generous entitlements (e.g. unemployment benefits, disability enrollment etc.), eligibility for Medicaid, and increasing household income of unemployed people. The actual ‘political economy’ trend was more likely going in the opposite direction of the one Case and Deaton are arguing. Conservatives often argue that growing dependency on the welfare state is more the problem, and though I think that story has its issues, it seems more consistent with the data the Case and Deaton story.
Over at PJM, Dennis Prager talks about the Question That Explains Almost Everything.
https://pjmedia.com/news-and-politics/the-question-that-explains-almost-everything/
“What gives your life meaning?” (He goes on to criticize the Left as to try to give their lives meaning thru Leftist politics – probably relevant to authors Case and Deaton.) The various answers to this question are most likely the reasons for drug problems.
For many men, what gives their live meaning is wife, kids, family; work; friends; hobbies. The things one loves. I claim the opioid / drug dependence problem is multi-caused, with the biggest fuel being the lack of self-respect, itself seen mostly in those without jobs.
As the US moves towards wanting more education signaling, a good counter policy would be to require 60% of new hires of Federal Employees to go to those without college degrees. Very few federal jobs actually need college, it’s mostly … just a signal.
The opioid crisis is, significantly, based on the confusion of signals.
Fed with hiring responsibilities here: I understand the good intention, but in terms of likely results, it’s a really terrible idea. I can go into detail if you like.
The ugly truth is that a “four year degree” without more isn’t even enough anymore for an employer to expect a new employee will walk in on day-1 ready to use skills one used to be able to assume would be among the certain capabilities of any “college graduate”.
There is no such thing as “just a signal”. It’s all about the margins for Type I and II errors.
Bad signals are unreliably noisy and too easy to fake.
Good signals are tolerably accurate, and cheap, easy, and safe to apply as first-pass, low-pass filters when one has to quickly reduce a set to a much smaller fraction.
The real tragedy of the “degree as signal” problem arises precisely because it’s a good signal. Indeed, the more debased it is as a currency, the better a signal it is, as the likelihood of something being unacceptable with a person who didn’t hop over a bar increases with how low it is.
And a lot of hiring is risk-averse, with focus on trying to avoid issues rather than being willing to take risks in order not to miss out on top talent.
Perhaps “self-worth” is a better metric than self-respect. What Charles Murray’s “Coming Apart” highlights is that a man’s “worth” is being ranked in a new marriage market where women now have the power of “voice and exit”. Handing out unearned jobs seems like a poor way to influence this market. A decrease in self-respect may have increased the rate of alcoholism and suicide but I think there are structural reasons that explain why opioids became a popular option for the self-medicated.
Most men are worth what they bring home in a paycheck.
Don’t get me wrong, they can also be good fathers and husbands. But at least at the lower levels that doesn’t seem to be enough to form the keep marriages. I doubt 70% of lower middle class men are completely worthless as fathers and husbands, and if by some chance they are that’s probably not intrinsic and a cultural failing that ought to be addressed.
The government sets a floor on what a household will earn, especially a household with children. And that floor is at or above what lower middle class men can reasonably expect to earn with their talents in the modern era. So the man’s earnings provide no marginal benefit, are in fact worthless to the household. So if people feel worthless, it’s because they are worthless, at least in our system as it is today.
But to make the man worth something again, you would have to withdraw the income floor from the household, thus making his earnings worthwhile.
But what if the man didn’t stick around? What would happen to the woman and her children? We aren’t going to let the kids suffer. And we aren’t going to “chain” a woman to a man.
Well, I don’t think my society is up for that at least, I’m a heartless bastard. The honest answer is the only way to make the man “worth” something is if his earnings really do put food on the table, and without them there would be no food. Not starving is pretty valuable!
You say “a UBI will solve it”. But a UBI isn’t enough for a single mother of two. As I’ve noted, a $10,000 UBI would be a vast decrease compared to the benefits she receives currently (perhaps four times that). More for those that can really use it to the fullest (copays on medicaid are basically non-existent).
So whose going to vote to decrease their benefits? Whose going to keep a stern face when it turns out that they can’t pay their kids medical bills. Even if you provide them a high deductible catastrophic plan, how does someone making $10,000 a year pay the high deductible.
The value of non high status men is that they can produce the goods necessary for the households survival. If the household can survive without them, then they aren’t valuable. Better to survive on ones own and chase after high status men or fulfill the whims of the moment. So the only way to restore the value of low status men is to make low status women dependent on them to survive. But women can vote and they are half the population, so it isn’t happening.
Perhaps this is unlikely to happen, but why can’t low status men create their own value? Isn’t that in part what unions, fraternal organizations, churches and gangs are for?
“How do you fight people who have nothing to lose? Give them something.”
Some men need to be family-men to have that “something to live for” the prospect of the future satisfactions of which motivate them to avoid choices that lead to these kinds of deaths.
But women choose, men are chosen. So, a woman’s subjective definition of a man’s ‘value’ to her is the cost-benefit utility analysis of hitching her wagon to the dude vs. staying single.
Now, one thing a man can bring to the table is enough additional stable income to make a significant bump in purchasing power and lifestyle.
Another thing is that, human nature being what it is, a status gap between the man and woman is an important ingredient in maintaining the attraction and stability of the relationship.
A man must also do his own cost-benefit utility analysis, to try and figure out that if he worked as hard as he could, what are the chances he could get and keep himself in the family situation he wants?
The trouble now – post-sexual-revolution, post-women-in-the-workplace, post-services-revolution, is that for a lot of guys, even if they bust their asses and do everything in their power to make themselves a catch, they can’t rise to “marriageable” in the eyes of the women they might have any hope to marry, because of the cost-benefit analysis mentioned above.
So the next best opportunity is to give up, check out of that life-script, and take the easier, if lonelier and more vice-centered path.
Case and Deaton didn’t title it, “Deaths of Despair and the Future of Patriarchy”. But when the dream of being a patriarch dies, so too will some of the dreamers.
Dark and lyrical. A sad but beautiful sentence.
In the modern day, one can choose between, on the one hand, joining and participating in a fraternal organization and, on the other, staying home with TV, the Internet, streaming, and gaming. For most people, the second is easier. It probably gives you “greater utility” in the short run. So fraternal organizations die out and new ones don’t get started.
Churches can help make men feel valuable but it really helps if you believe in the mission of the church, which many moderns don’t.
Fifty years ago, there was a lot of social pressure to join a church. Today, not so much. Decades ago, you would join even if you didn’t have a lot of religious feeling and you might become a valued member.
In my church group we have a few men that are like “sociable hikimori”. They come to the events, but they aren’t very attractive or sociable. Many have an advantage on the working class in terms of income (they are accountants and such).
Even though nearly all the “normal” men in my church group hooked up, those dudes remain single. As we all formed families the church group started to dissolve, though we still hang with each other when time and the kids allow.
I’m not sure any of them will ever get with someone. And most of these church groups don’t allow anyone over 40 (with good reason, its gets creepy and leads to incidents as I’ve seen).
Medical people talk about “diseases of civilization”. Cheap point-to-point transportation means people don’t walk. Desk jobs mean people don’t get much exercise. Cheap palatable food means people eat a lot. Put it all together and you get high blood pressure, diabetes, obesity, heart disease, etc.
To the extent that drug abuse, over-drinking, and suicide are diseases, and to the extent that they are caused by a lack of status/meaning/self-esteem, and to the extent that this lack is associated with the decline of “meaning-providing” organizations caused by more convenient/more pleasant (at least in the short run) alternatives, perhaps they are also “diseases of civilization”.
The terrible thing about “diseases of civilization” is that they are basically caused by people’s free choice.