December 11, 2019

Over the past couple of years, many of us have heard and read about so-called ‘deaths of despair’—the increasing mortality rates of middle aged white Americans (age 45-54) due to drugs, alcohol, and suicide.  One of the root causes of this trend, as proposed by the authors of a recent study featured by NPR, is a lack of steady, well-paying jobs for whites without college degrees, which in turn has caused pain, distress, and social dysfunction to build up over time, leading ultimately to people killing themselves “either quickly with a gun or slowly with drugs and alcohol.”

More recently, there were multiple news stories about a JAMA article published in late November of this year, entitled Life Expectancy and Mortality Rates in the United States, 1959-2017. This study showed us that the problem is even broader than ‘deaths of despair’, and it affects all races and ethnicities in our country.  U.S. life expectancy increased from 1959 and peaked in 2014, but has been decelerating for decades, plateaued in 2011, and for the past 3 years, life expectancy has decreased each year, in the country that spends more per capita for health care than any other country in the world, while it has continued to increase in every other developed country.  This decline in life expectancy is driven primarily by increased all-cause mortality in young and middle-aged adults (ages 25-64).  While all-cause mortality in midlife increased fairly recently, since 2010, cause-specific mortality such as drug overdoses and hypertensive diseases began increasing earlier, in the 1990s.

Of particular concern here in the Granite State is that between 2010 and 2017, New Hampshire had the largest relative increase in midlife mortality in the country, with a rate of 23.3%.  While the contribution to the overall number of increased deaths was relatively small due to our smaller population, nonetheless this is alarming and not an area in which we want to lead the nation.

The authors of the study discuss many potential root causes of this trend in decreased life expectancy, including fatal drug overdoses, suicide, and alcoholic liver disease, but also the long-term impacts of tobacco use and obesity, deficiencies in the health care system, psychological distress, and socioeconomic conditions and education level.  There were also differences noted between states that may be attributable to policy choices.

An accompanying JAMA editorial suggests that given the multiple possible root causes, we will in turn need a multidisciplinary solution to this crisis.  From the standpoint of health care, we can do a better job taking a comprehensive, population health approach to obesity, hypertension, and tobacco use, as well as continuing our part to combat the ‘deaths of despair’.  However, we can’t do this work alone, and will need partners from across the spectrum, from social services to education to state and federal legislators increasing funding for the social determinants of health and finding new ways to integrate social care into healthcare.  A National Academy of Sciences 2019 report outlines a framework and guidance for health sector leaders for moving forward:  Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health

While more research is needed on the root causes on this problem and the potential solutions, we know enough today to start building a broad coalition across sectors to start working to reverse these trends, in New Hampshire and across the country.

Please send comments or questions to John.Klunk@nhms.org.