In rich countries, death rates are supposed to decline. But in the past decade and a half, middle-aged white Americans have actually been dying faster. Princeton economists Anne Case and Angus Deaton first pointed out this disturbing trend in a 2015 study that highlighted three “diseases of despair”: drugs, drinking and suicide. On Thursday, the pair released a deeper analysis that clears up one of the biggest misconceptions about their earlier research. The problem of dying whites can’t only be blamed on rising rates of drug overdoses, suicides and chronic alcoholism, they say. More and more, middle-aged white Americans are dying for all kinds of reasons — and the underlying issue may have less to do with opioids and more to do with how society has left behind the working class. “Ultimately, we see our story as about the collapse of the white, high school educated, working class after its heyday in the 1970s, and the pathologies that accompany that decline,” they write. This is slightly different than what they said in their first paper, where they emphasized that the trend of rising white mortality was “largely accounted for by increasing death rates from drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis.” That’s technically correct — but by focusing only on the increase in death rates, Case and Deaton distracted from the larger picture. The alarming fact isn’t just that middle-aged whites are dying faster, but also that mortality rates have been dramatically declining in nearly every other rich country. The United States is getting left behind. In the last 15 years, a chasm opened up between middle aged whites in America and citizens of European countries like France, Germany and the United Kingdom. While white death rates in America rose slightly, death rates in those other countries continued to plummet. In comparison to what happened in Europe, the situation for American whites starts looks much more dire — and it’s a bigger problem than opioids or suicides can explain. It’s not just about what went wrong in America, but what stopped going right. Fifteen years ago, middle-aged whites in the United States were neck and neck with their German counterparts. Now, middle-aged white Americans are 45 percent more likely to die than middle-aged Germans. As this chart from the latest paper shows, the gap in mortality between white middle-aged Americans and middle-aged Germans is about 125 deaths per 100,000 people now. Every year, of 100,000 Germans between the ages of 45 and 54, about 285 die. In the United States, it’s more than 410. Out of those 125 additional American deaths, only about 40 might be explained by the spike in deadly drug use, drinking and suicides. And the rest? It’s hard to say. In their latest paper, Case and Deaton show that heart disease is part of the problem. While other countries have cut down heart disease deaths by over 40 percent in the past 15 years, heart disease remains a significant killer for white middle-aged Americans. The researchers describe a double whammy hitting white America: Around the same time that the three “diseases of despair” really took off, improvements in heart disease also slowed down. There’s still much left unexplained, but the latest data tell a larger — and more troubling — story. Most of the increase in white deaths is concentrated among those who never finished college. These are the same people who have been pummeled by the economy in recent decades. It’s gotten more difficult for them to find jobs, and what jobs they do come across nowadays don’t pay as well. Yet, it’s not entirely a matter of income either. Some of these same economic trends — driven by globalization and automation — afflicted countries like the U.K. and Germany. Besides, according to a Washington Post analysis of recent Census Bureau data, white American men without a college degree still earn 36 percent more than their black counterparts. But the death rate among less-educated black Americans has actually been decreasing. In recent years, the two groups have converged — they are dying at about the same rate — even though white Americans still earn more. So the theory comes back to despair. Case and Deaton believe that white Americans may be suffering from a lack of hope. The pain in their bodies might reflect a “spiritual” pain caused by “cumulative distress, and the failure of life to turn out as expected.” If they’re right, then the problem will be much harder to solve. Politicians can pass laws to keep opioids out of people’s hands or require insurers to cover mental health costs, but they can’t turn back the clock to 1955.