Diseases of Despair
By: Laura Jaramillo
While midlife mortality has improved among the college-educated in the United States , the opposite seems to be true for middle-aged white Americans, who, at most, may or may not have received a high-school diploma (Case and Deaton, 2017). Given that the US seems to be falling far behind other developed countries, many scientists and scholars in the field have sought to understand how this could be possible, especially since the US’s annual healthcare spending exceeds those very countries (America’s Health Ranking, 2016). One potential reason for this has been attributed to the increasing amount of “deaths of despair” (abbreviated DoD) (Case and Deaton, 2017), which refers to mortality or morbidity from suicides, substance use disorders, and alcohol-related diseases (George, Snyder, Van Scoy et al., 2021).
To better understand how the term “diseases of despair” emerged, we must take historical context into account. During the 1980s, U.S. life expectancy began to slow down in comparison to other high-income countries, especially as the income inequality gap began to widen (Woolf et al., 2019). Some economists have noticed an overall deterioration of people’s lives, without a college degree, beginning most notably after 1970 e (Gold, 2020). Current research seems to align with these opinions, indicating that an increase in midlife mortality is directly correlated to living in rural or poor areas with low levels of education (Gold, 2020). Although deaths of despair have increased in all parts of the country (Case and Deaton, 2017), the Appalachian region has experienced a more noticeable impact due to significant substance abuse (Woolf et al., 2019).
With regards to mortality caused by DoD, there are significant differences across both state and town lines. Some states, like New Jersey, have experienced a drug mortality growth of 20% whereas Utah has a growth of essentially zero, and Hawaii has negative growth (Etemadifar, 2021). Focusing more narrowly on the Appalachian region, there are higher mortality rates among economically distressed counties, and in some there is almost a 34% increase (Meit et al., 2017). When analyzing disparities by rurality, it varies based on the specific disease of despair. Overdose deaths were greater in metro counties while rates of suicide and alcohol-related disease were higher in more rural areas (Meit et al., 2017).
As mentioned above, while the increase in mortality rates isn’t restricted to the Appalachian region, they represent a large portion of the total deaths nationally. While the Appalachian region only consists for approximately 30% of the US population, the region is disproportionately responsible for 50% of deaths – these deaths are attributed to diseases of despair (Scutchfield, 2019). Looking more closely, research has shown how the opioid crisis is responsible for the majority of these deaths (Scutchfield, 2019). Additionally, it is clear that what occurs in Appalachia also has a significant impact on national trends. During the pandemic, research has shown deaths of despair have risen significantly; according to one paper, the increase varies between 10% to 60% (Fottrell, 2021). However, it is important to recognize that much more research still needs to be conducted in order to fully understand what the research indicates.
The Appalachian region extends over multiple states, and contains around 25.7 million people, the majority being white (80.8%) (Appalachian Regional Commision, n.d.). The average median household income is around $51,000, almost 20% lower than the national average of around $63,000 (Appalachian Regional Commision, n.d.). And looking at poverty rates, the Appalachian region suffers from a rate of 15.2% (Appalachian Regional Commission, n.d.), faring around 13% worse than the national poverty rate of 13.4% (Income, Poverty, and Health, 2021). As described above, DoD encompasses three factors, but opioids are one that has hit the area the strongest. In Appalachia, there are 84 opioid prescriptions per 100 residents, which is starkly higher than the national average of 58 opioid prescriptions per 100 residents in non-Appalachian counties (National Association of Counties & Appalachian Regional Commission, 2019) (Committee on Transportation & Infrastructure, 2017). Lastly, the death rate for opioid overdoses was 72% higher than that of non-Appalachian counties (Opioids in Appalachia, 2019).
From a broader perspective, economic deterioration due to generational poverty and a lack of well-paying jobs is one determinant that explains why people might be gravitating toward self-harm and drug abuse (Etemadifar, 2021). Another possible determinant could be social well-being; as reports of pain, poor health, and mental health increase, marriage rates have also fallen (Case and Deaton, 2017). Furthermore, some have argued that it appears that the counties with a lower socioeconomic status have suffered a more rapid increase in drug mortality (Etemadifar, 2021). Recent studies have found that socioeconomic status is a consistent predictor of health outcomes, probably because it affects both the economic and social wellbeing of individuals, having effects on lifestyle, habits, and relationships, among other things, – all aspects that impact health. These factors can unfortunately cause “adverse childhood events,” which can impact later aspects of adulthood. As exposure to ACEs increase, so do the chances of becoming involved in risky behavior. So, if marriage rates are falling, or parents are working non-stop to provide for the family or are, even, suffering from mental health issues, it can leave a child with an unstable and unsafe support system. Government policies and institutions also play a large role in the lives of citizens from providing employment opportunities and wages to facilitating more accessible and quality health care. Policies have focused on growing cities, which are usually urban areas, abandoning rural parts of America that are struggling most with “stagnant economies, unemployment, persistent poverty, depopulation and social isolation” (Woolf et al., 2019). Given the stresses that many individuals residing in Appalachia experience, it makes sense that DoD would be most prominent in the area; alcohol and drugs are a common coping strategy and can result in mental health issues. Sadly, cumulative disadvantage is an active mechanism in the area, and that, combined with being exposed to additional disadvantages so early on during the most formative and critical years, makes it much harder for upcoming generations to escape this cycle .
Looking at more specific examples of determinants in the Appalachian region, many of the jobs in this area revolve around coal mining which commonly results in workplace injuries and chronic pain; as a result, opioids are commonly prescribed from healthcare professionals to deal with such injuries (Metcalf, 2019). But to make matters worse, coal mining jobs have decreased significantly due to the recent closure of plants, leaving many unemployed (Thornton et al., 2010). Education wise, high school completion has improved with around 87% of the population graduating, but beyond that, only around 24% of the population has graduated from college (Appalachian Regional Commission). Moreover, internet access continues to be an issue; while it is something that was certainly useful pre-pandemic, during the pandemic, it was and continues to be a necessary and crucial component to ensuring the continuation of learning through virtual education for elementary, middle and high school (Fregni, 2020). Education is arguably one of the most important determinants of health; for every extra year of education, a person’s socioeconomic status exponentially increases, positively influencing one’s health. Lastly, the lack of healthcare providers has affected individuals’ access to it. Compared to the rest of the country, there are 12% fewer primary care physicians, 28% fewer specialty physicians, 26% fewer dentists, and 35% fewer mental health providers in the Appalachian region (Getting healthcare in the Appalachian Region, 2019); many hospitals in the rural parts of the region have closed (around 20% of rural hospital closures since 2010) (Meehan, 2019). As a result, individuals rely on each other much more for medical advice and even are forced to share prescription medications (Huttlinger, Schaller-Ayers et. al., 2004).
In order for implemented policies to be effective, they must target the root of the problem. As seen above, the loss of mining jobs, and/or a lack of education seem to be constant culprits found among those who suffer from one of the three DoD. Consequently, these constants lead to unemployment, income inequities, harmful health habits, and/or unfavorable living conditions which could explain why people might self-medicate, abuse substances, suffer from alcohol-related diseases, or sadly, commit suicide (Scutchfield, 2019). The issue will persist and worsen if we continue to resolve this issue symptomatically, by treating the symptoms only when they appear; for people to successfully help these communities, an upstream perspective is needed from everyone, including doctors, government employees, and, yes, even citizens themselves.
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