Deaths of Despair

Deaths of despair increasing, but only in the USA

Mortality rates are rising in the United States, especially among poor, rural populations, and specifically among whites.  Life expectancy in other groups continues its historic rise, and this rising pattern is also found in 16 other countries with comparable economic levels.  This phenomenon has been dubbed “deaths of despair” because the reduction in life expectancy is driven by increasing rates of suicide, drug and alcohol overdose, and metabolic and cardiac causes related to obesity.

An interesting debate is now developing around the use of the term “despair”, with the National Academy of Sciences arguing that despair is not well-defined, and “not a clinical diagnosis”.  In response, a special communication paper published in JAMA online argues that “suicide and spiraling addictive behaviors do define despair” and asks “how can despair not be a clinical diagnosis?”

Humans evolved to live in social groups

Arguing from studies of hunter-gatherer tribes, the authors reason that humans evolved over thousands of years to support child-rearing in a multi-generational family group in which food gathering and production duties are shared and children’s needs for care are met by several caregivers, not just the two biological parents.  This social support, they argue, is essential for human life and health, and when, in the modern world, child-rearing becomes atomized and left to two, or, often, only one adult caregiver, the health of the family suffers.

In other industrialized countries although the modern world of work and single-family dwelling is not very different from that of the USA, similar rates of deaths of despair have not been found.  Mortality rates continue to decline and, while obesity is found across the modern world, it is not associated with markedly greater death rates.  Other industrialized countries provide much greater levels of social support including paid vacation and sick leave, subsidized schooling through higher education, subsidized child care and preschool, and adequate allowances for people who cannot earn their way.  The ”welfare state” provides a substitute for the close social and tribal groups that, historically, have been the organizing principle of human societies worldwide.

People can’t fight despair all alone

On the other hand, the individualization of need and the medicalization of problems like impulse control, dopamine-seeking leading to addiction, and overuse of alcohol, opiates, and rich foods leaves many without a viable path forward, leading to despair, ill-health, increasing violence, and early death. When people are left to fend for themselves, it is not surprising that they become overwhelmed and prey to the deaths of despair.

The authors point out that best practices in avoiding deaths of despair are readily observable in 16 nations with similar economic and technical levels to our own.  Why do we not treat increasing mortality rates as a crisis and call urgently for adoption of the practices of our neighbors?