Many may recall this past spring when the media led a full-court press focusing on work published by Case and Deaton in PNAS in 2015 on the rising morbidity and mortality among white Americans. In short, Case and Deaton’s work highlighted what they characterize as “deaths of despair.” These deaths from suicide, poisoning and liver disease are speculated to be results of self-destructive health behaviors. Similarly, the article “The Epidemic of Despair Among White Americans: Trends in the Leading Causes of Premature Death, 1999-2015” published in the American Journal of Public Health (AJPH) analyzes the impact of county level urbanization on premature deaths by stratifying the study population into 48 subpopulations by geographic areas. This study found that of the 48 subpopulations, only nine experienced increased death rates when comparing periods from 1999 to 2001 and 2013 to 2015, and each of these nine subpopulations were largely outside large urban areas and white. This article also points out that though these geographic findings of premature death are important, black Americans still experience the highest absolute rates of premature deaths during the study periods.

In the same issue of the AJPH, F. Douglas Scutchfield and C. William Keck offer explanations and solutions. They focus on the role of education in premature death and how their findings from the Organisation for Economic Cooperation and Development (OECD), who have experienced financial strains, yet have chosen paths to fund efforts to retrain and support the jobless, are strikingly different than those from the U.S. Lastly they propose that solutions to this crisis “must start with political change—that may be the ultimate social determinant of health."

Ana Diez Roux offers another perspective pointing out that these self-destructive health behaviors occur in the context of social and economic factors. Roux offered a recent U.S. Senate testimony from Angus Deaton that points to “heavy drinking, overeating, social isolation, drugs and suicide” as part of the mechanisms which have “cumulatively undermined the meaning of life for white-working-class people.” However, she also urges us to not conclude that these behaviors are the result of recent economic times that have impacted the health of white but not black Americans. Roux also emphasizes that it is telling that although persistent health inequities exist and the absolute premature death rates among blacks dwarf that among whites, “the despair explanation has been so quickly adopted (with personal responsibility explanations being quickly discarded) to explain the mortality in whites, despite persistent questioning of the relevance of factors like despair to black-white differences.” Roux ends with a call to action 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.”

All in all, this series of articles provides thoughtful analysis and perspective on opportunities and solution as we strive for better health and healthcare equity for all Americans.

-Thomas K.M. Cudjoe, fellow in Geriatrics

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