Recent research documents surprising increases in death rates among economically disadvantaged, less educated, middle-aged whites. This pattern has literally puzzled demographers, but recent analysis points to “suffering” and “anxiety” among working-class whites. Researchers attribute this trend to drug overdoses, liver disease (from alcohol), and suicide as the main drivers to earlier mortality.

Recent federal data from all deaths recorded in the country in 2014 show life expectancy for whites dropped to 78.8 years that year, down from 78.9 in 2013. “This increase in death in this segment of the population was great enough to affect life expectancy at birth for the whole group – that is very unusual,” said Elizabeth Arias, the statistician at the National Center for Health Statistics who analyzed the data that specifically identifies whites from their mid-20s to their mid-50s. In contrast, life expectancy for Blacks and Hispanics increased by roughly one year.

Crumbling blue-collar labor market

Researchers and economists Anne Case and Angus Deaton, a husband and wife team at Princeton University who are among those analyzing this trend, call it “deaths by despair.” They say a lack of steady, well-paying jobs for whites without college degrees has caused pain and distress, and as a result, social dysfunction built up over time.

“Mortality rates have been going down forever,” Deaton told NPR. “There’s been a huge increase in life expectancy and reduction in mortality over 100 years or more. And then for all of this to suddenly go into reverse for whites ages 45 to 54 – we thought it must be wrong. We spent weeks checking out the numbers because we just couldn’t believe that this could have happened. Or that if it had, someone else must have already noticed. It seems like we were right and that no one else had picked it up.”

Deaton noted “proximate causes” include increases in suicide, prescription drug overdoses, and alcoholic liver disease. Case added that deaths of despair were a result of reduced labor force participation, reduced marriage rates, and increases in poor physical and mental health. “We are beginning to thread a story in that it’s possible the trend is consistent with the labor market collapsing for people with less than a college degree,” she told NPR. “In turn, those people are being less able to form stable marriages, and, in turn, that has effects on the kind of economic and social support people need in order to thrive.”

Another calculation Case made is, “In general, the longer you’re in the labor force, the more you earn in part because you understand your job better and you’re more efficient on your job. You’ve had on-the-job training, you belong to a union, and so your wages grow with age.” Case said this scenario happens less these days. Deaton equated deaths of despair to the decline of the white working class. “If you go back to the early ‘70s when you had the so-called blue-collar aristocrats, those jobs have slowly crumbled away. Many more men are finding themselves in a much more hostile labor market with lower wages, lower quality, and less permanent jobs,” he told NPR. “That makes it harder for them to get married. They don’t get to know their own kids. There’s a lot of social dysfunction building up over time. There’s a sense that these people have lost status and belonging. And these are classic preconditions for suicide.”

Deaths of despair in rural Missouri

Closer to home, the Missouri Foundation for Health (MFFH) funded a study of Missouri’s increasing death rates among middle-aged whites. The study involved a partnership between Center on Society and Health at Virginia Commonwealth University and Graduate School of Public Health at the University of Pittsburgh. The study focused on where and why this is happening in Missouri. Using the state’s vital statistics from 1995 to 2014, it provided a detailed comparison across Missouri’s 114 counties, along with the city of St. Louis.

Findings from this study concentrated on 79 of the 114 Missouri counties and concluded a rise in death rates among whites 25-59 years old. MFFH reported that the leading causes responsible for excess deaths in these counties were substance abuse (i.e. drugs, alcohol, and tobacco) and suicide. The Missouri study revealed an estimated 68% of these excess deaths were due to accidental drug overdoses, suicide, alcoholic liver disease, and chronic lower respiratory disease mainly because of tobacco use. MFFH reported that death rates from accidental drug overdoses in the 79 affected counties increased by 585% between 1995 and 2014 among middle-aged whites, 25-59 years. Between 2010 and 2014, more than 3,000 people died from overdoses.

Although suicide rates among Missourians increased by 28.8% from 2010-2020, the change from 2019-2020 was negative — down 0.7%. Unfortunately, data from 2021 and more detailed demographic data from 2020 is lacking, as the majority of data collection focused on COVID-19. 

Here is a breakdown by MFFH of the number of deaths caused by substance use, complications caused by substance use, and suicide in Missouri from 2010 to 2014:

  • Alcohol poisoning – 147
  • Suicide – 2,862
  • Chronic lung disease (smoking is the leading cause) – 1,500
  • Viral hepatitis (caused by injectable drugs) – 417
  • Liver cancer (common causes Hepatitis C and other viral hepatitis) – 561
  • Hypertensive heart disease – 615

Also noteworthy from MFFH’s findings is death rates from chronic liver disease, or alcoholic liver diseases, like cirrhosis, increased by 32% after 2000. Whites as young as 35-39 years and as old as 70-74 years were impacted.

Some rural Missouri counties hit the hardest

MFFH reported the 33 counties in Missouri where mortality increased by more than 50 deaths per 100,000 among whites 25-59 years were located in the south-central part of the state (Ozarks), the southeastern area (Bootheel), as well as southwestern and northwestern counties – with the Ozarks and Bootheel faring the worst. (Lafayette County was not a part of the 33 counties hardest hit.) Missouri counties with the highest mortality rates faced limited employment opportunities, low and stagnant wages, and extreme poverty, the study reveals.

MFFH proposed the following strategies to address rising mortality rates:

Strengthen Behavioral Health Services

  • Prevention, detection, and early treatment of drug and alcohol abuse—including the opioid epidemic.
  • Strategies for suicide prevention, including better access to treatment for depression and other risk factors for suicide. Address root causes by improving economic and social conditions for populations in need.
  • Policy action by the government and the private sector to improve job opportunities, increase wages, reduce poverty, and promote economic mobility.
  • Reforms and investments to improve the quality of education— from preschool through high school—and to improve the affordability of college, vocational training, and professional education.

Invest in Communities

  • Economic development by business, investors, and philanthropy, along with the promotion of new industry in marginalized and resource-poor rural counties.
  • Civic engagement and cross-sector partnerships to leverage and target resources and expand opportunities to break the cycle of poverty.
  • Cross-racial alliance building to understand and address common causes of health threats facing different racial and ethnic groups.

Prepare the Health Care System for Expanding Caseloads

  • Affordable health care and insurance coverage, and strategies to address shortages in clinicians and facilities.
  • Resources to address expanding caseloads among clinicians, practices, hospitals, emergency medical services for care at the scene, intensive care in the hospital, long-term care in rehabilitation facilities, and psychological counseling for mental illness and addiction.

Conduct Research on Underlying Causes

  • Establish the causal links responsible for rising death rates.
  • Research by social scientists and economists is also important to better understand the unique challenges facing young and middle-aged whites, the explanations for deteriorating health in this population while health improves in other racial and ethnic groups, and the economic and social conditions in impacted communities such as rural counties.