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White Americans are dying at higher rates from drugs, alcohol, and suicides. And the sharpest increases are happening in rural counties, often in regions with long-standing social and economic challenges.

The reasons behind these increases are unclear and complex. The opioid epidemic plays a role but is just one part of a larger public health crisis. Life expectancy in the US as a whole has fallen for the second year in a row, and the nation’s health relative to other countries has been declining for decades.

Some combination of factors in American life must explain why the rise in mortality is greatest among white, middle-aged adults and certain rural communities. Possibilities include the collapse of industries and the local economies they supported, greater social isolation, economic hardship, and distress among white workers over losing the security their parents’ generation once enjoyed. Also, over the past 30 years, income inequality and other social divides have widened, middle-class incomes have stagnated, and poverty rates have exceeded those of most rich countries. 

Recent legislation and regulations, however, may prolong or intensify the economic burden on the middle class and weaken access to health care and safety net programs. The consequences of these choices are dire—not only more deaths and illness, but also escalating health care costs, a sicker workforce, and a less competitive economy.

This article was originally published in The BMJ on February 7, 2018. Reprinted with permission.