Not all is well in the rural heartland. This is the underlying message of numerous research reports published this year, from respected institutions including the Centers for Disease Control and Prevention and the Brookings Institution. These reports indicate a sharp increase in premature death rates in rural areas from 1999 to 2015.

Recognizing the importance of this topic, the October 2017 issue of the American Journal of Public Health (AJPH) has a special focus on rural health. The issue contains sophisticated research papers and accompanying editorials documenting which rural Americans are most affected by the increase in premature death, as well as speculation on underlying causes.

All these papers point to one clear conclusion.

Rural whites with a high-school education or less have seen the highest increase in premature death rates in the last 15 years. This stands in contrast to falling premature death rates in urban whites, as well as falling premature death rates in minorities (though blacks still have the highest premature death rates overall, an important health disparity that I will explore in a future post).

These findings are fleshed out in detail in the flagship paper from the AJPH special issue by Dr. Elizabeth Stein and colleagues at the University of Wisconsin, ominously sub-titled “The Epidemic of Despair Among White Americans."

So what is happening? Evidence from these research papers suggests that an increase in self-destructive behaviors is the largest contributor to the rise in death rates in rural whites. These include a significant increase in suicide (especially in rural men) from 1999 to the present. They also include an increase in drug abuse and overdoses, especially common where there is a local opioid crisis. Furthermore, liver disease and cirrhosis (often due to long-term alcohol abuse) account for a large proportion of these excess deaths.

Why this self-destruction?

These statistics raise the question of why are so many less-educated white rural Americans engaging in self-destructive and risky behaviors that lead to premature death. Numerous explanations have been advanced.

Firstly, rural America has undergone a radical economic transition in the last 30 years. Family farms have decreased in number, and manufacturing jobs have been outsourced in a global economy. Indeed, rural areas were hit particularly hard by the 2008 recession, with a precipitous decline in manufacturing and manual labor. This led to high rates of unemployment and poverty among manual, rural and blue-collar workers, with the attendant hopelessness and despair.

Second, some research suggests rural residents are underserved vis-a-vis health and social services. There are fewer community and voluntary clinics, given sparse population density. This can mean costly travel to specialist (e.g. addictions) services. Likewise, the informal safety net provided by charitable organizations, such as homeless missions or free clinics, may be smaller in rural areas as they tend to congregate in urban centers, as explored in the video below.

Third, rural less-educated whites remain a stigmatized population, written off by some more highly educated people as irredeemable ‘rednecks,' 'hillbillies,' or ‘white trash.' This rhetoric became particularly intense after the election of Donald Trump. These attitudes may contribute to a lack of empathy among decision-making elites, possibly contributing to patchy health and charitable service provision. Such stigma may also be internalized by rural less educated whites, perhaps contributing to self-stigma, a known predictor of self-destructive behaviors.

I witnessed all of the above first-hand during a recently completed ethnographic study of people living in poverty in northern New England. Study participants often reported a sudden job loss, followed by unemployment and depletion of savings, leading to poverty and even homelessness. Many used drugs and alcohol to dull psychological and physical pain. While this study was local to northern New England, it is a familiar pattern repeated across America.

The authors of the research papers describing the rise in premature deaths among less educated rural whites must be commended for raising awareness of this important disparity. So far, this issue has been worsening under the radar of society, but now it is emerging into public discourse.

Hopefully, appropriate action will follow.

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