Despair as a Cause of Death: More Complex Than It First Appears

Recent analyses have documented the alarming fact that, in the United States, mortality declines have stalled or even reverted in some population groups over the past few years.^1–3 Studies have described increases in death rates among middle-aged Whites and especially among Whites with a high-school education or less, primarily attributable to drug overdoses, suicides, and alcohol-related liver disease.² Perhaps the most influential of these was a study by Case and Deaton² that received extensive press coverage. The study highlighted the health problems of middle-aged Whites (especially less-educated Whites) and fueled extensive discussion of the plight of poor Whites in today’s economy.

“SELF-DESTRUCTIVE HEALTH BEHAVIORS”

The article by Stein et al. (p. 1541) in this issue of AJPH adds to previous work by carefully documenting the evolution of death rates between 2000 and 2015 across subgroups defined by age, race/ethnicity, and urbanicity. A major contribution is the detailed description of changes for specific causes of death and the urban–rural comparisons. The authors report decreases in death rates in most demographic groups but increases among non-Hispanic Whites, largely in rural or small or medium metro counties, primarily attributable to suicide, accidental poisoning, and liver disease. In line with previous work, the authors suggest that these increases are the result of “self-destructive health behaviors and may be related to underlying social and economic factors in these communities” (p. 1541).

The overall four- to six-percent increase in premature deaths in Whites aged 25 to 64 years in small or medium metropolitan counties and rural areas is indeed striking. It is tempting to draw quick conclusions from these findings. An explanation that has achieved great resonance in the media is that less-educated Whites have been especially hard hit in recent economic times. Case and Deaton referred to the increased deaths linked to overdoses, suicides, and alcoholism in working class Whites as “deaths of despair.”^4(p27) Stein et al. explicitly adopt the same explanation in the title of their article. They note the “stress and hopelessness faced by this population as they enter the labor market are met with bleaker prospects and lower paying job opportunities relative to the prior generation” (p. 1545). Angus Deaton recently testified before the US Senate that “Heavy drinking, overeating, social isolation, drugs, and suicide are plausible outcomes of processes that have cumulatively undermined the meaning of life for White working-class people.”⁵

BLACK–WHITE DIFFERENCES

A striking pattern that is present in these data and often obscured by the emphasis on the increase in death rates in Whites (especially in ensuing press coverage) is that, despite increases in Whites and declines in Blacks, in 2015, the death rates in Whites remained substantially lower than in Blacks across all urbanicity categories. The relative rates for persons aged 25 to 64 years in Whites versus Backs, derived from Stein’s Table 2, are 0.60, 0.77, 0.69, and 0.72 for urban, small and medium metropolitan, suburban, and rural, respectively. Comparisons of absolute levels are even more striking: Black–White differences are 209, 87, 163, and 160 deaths per 100 000 for urban, small and medium metropolitan, suburban, and rural, respectively. These are very large differences when compared with an absolute increase over the 15-year period of 15 and 25 deaths per 100 000 for suburban and rural Whites aged 25 to 64 years.

PERSISTENT HEALTH INEQUITIES

The important reductions in death rates in Blacks are a welcome development, but rates still remain unacceptably high. We should guard against the unintended consequence that the focus on the increase in death rates in some Whites (significant as they are) detract attention from the persistent health inequities by race and social class, which are so large that they dwarf the size of what is a very troublesome increase in some Whites. The fact that the despair explanation has been so quickly adopted (with personal responsibility explanations being quickly discarded) to explain the mortality increase in Whites, despite persistent questioning of the relevance of factors like despair to Black–White differences, is itself telling. It raises interesting questions about how causal explanations emerge and what influences the speed with which they are adopted.

It is indeed likely that social and economic circumstances are major contributors to the increase observed in Whites as they are to the large differences in rates by race or social class. But questions remain. Despite the careful analyses by Stein et al., the extent to which this is a rural phenomenon may require additional investigation. Most of the US population lives in urban areas, and there is enormous heterogeneity in life expectancy within urban areas. Stein et al. observed increases in death rates in Whites living in small and medium metro areas, and even in larger urban and suburban areas in the youngest age group. In their most recent report, Case and Deaton also found that the increase in death rates is observed across both urban and rural areas.⁴ Moreover, as Stein et al. note, the data they have do not allow them to disentangle the impact of social class and place of residence.

OUTSTANDING QUESTIONS

Although in their original article Case and Deaton² did not report analyses by gender, and Stein et al. do not examine differences by gender either, other analyses have found that the increase in death rates in Whites is more pronounced in women than in men.^3,6 The presence of this type of gendered response could cast some doubt on the somewhat male-dominated labor market–related despair explanations. Previous research has shown that Whites are more likely to be prescribed opioids than are Blacks.⁷ Could this put them on a path to dependence and overdose regardless of whether they experience despair (although undoubtedly the experience of despair could enhance these effects)? Why is it that Blacks and Hispanics are somehow protected from the adverse health effects of the adverse economic trends creating despair in Whites? Have they not experienced similar adversity and frustrated expectations? Is frustrated expectation really the driving factor, and is it so differentially distributed by race that recent economic circumstances would cause increases in death rates in Whites but not in other groups?

UPSTREAM CAUSES

Most fundamentally, data like these challenge us to address the upstream causes. These may operate in different ways in different population groups. As Stein et al. suggest, poor Whites may indeed be experiencing the health consequences of seeing their expectations frustrated, and these frustrated expectations may be interacting with overprescriptions of opioids to fuel the increase in death rates. Likewise, many Blacks (and other groups) continue to experience adverse environments and economic circumstances resulting from history and racism that affect their health in profound ways, despite promising reductions in HIV, motor vehicle–related, and chronic disease deaths.

NEXT STEP

To the extent that the findings reported by Stein et al. motivate scientists, politicians, and the public to recognize that health is affected by much more than medical care, and that even behaviors are conditioned by social and economic context, their publication will have accomplished very much indeed. The next step is to determine what can be done, not only to reverse the worrisome increase in death rates among Whites, but also to eliminate the profound health inequities by race, social class, and geography that have characterized our society for so long.