According to the latest-available set of comparable data, North Carolina ranks 33rd in the nation in “deaths of despair” — that is, in the combined rates of suicides, fatal drug overdoses, and alcohol-induced deaths. In 2020 our age-adjusted rate was 55.5 deaths of despair per 100,000 residents, slightly higher than the national average of 54.8. From 2018 to 2020, our rate rose by 26%.
To say the crisis is more acute in states such as South Carolina (65.1) and Tennessee (79.2) is not to say North Carolinians shouldn’t be concerned. I also think there are steps policymakers can take to ameliorate the problem. Unfortunately, much of the commentary I’ve seen lately about deaths of despair is based on facile and politically charged analysis.
The reason I cited age-adjusted death rates in my opening paragraph is that some mortality indicators exhibit strong correlations with age. To respond effectively to a phenomenon such as rising deaths of despair, we need to understand its causes. Looking only a raw data can lead to misunderstandings.
For example, the two Princeton University scholars who helped coined the phrase “deaths of despair,” Anne Case and Angus Deaton, argue that the trend is primarily a reflection of rising inequality, inadequate social programs, and weak labor unions. Our free-enterprise system, they argue, once “lifted countless people out of poverty” but “is now destroying the lives of blue-collar America.”
A 2019 staff report from the Joint Economic Committee of the U.S. Congress threw cold water on their thesis. A careful examination of age-adjusted rates going back to the early 20th century reveals a “lack of correspondence” between economic indicators such as poverty or inequality and the death rates in question.
For one thing, age-adjusted rates of suicide and alcohol-induced deaths (such as cirrhosis of the liver) were about the same in 2017 as they were in 1975. They also declined from the mid-70s to around 2000, then went up again. These patterns don’t comport well with attempts to finger capitalism as the culprit. “It is very difficult,” the report notes, “to find such trends that improve over the 1970s and 1980s, then worsen after either 1990 or 2000.”
The trendline looks very different for drug-induced deaths. The rate rose consistently but rather gradually during the last four decades of the 20th century then shot up dramatically during the first two decades of the 21st century. What’s changed? Both the potency (and potential lethality) of illicit drugs and the widespread overuse of opioids.
In other words, if you’re looking for a public-policy lever to pull, you’re more likely to get results if you pull the one marked “discourage drug abuse” instead of the one marked “strengthen labor unions.”
More generally, North Carolina can do a better job of making it easier for residents to obtain high-quality treatment for mental illness and addictions. Government funding can and should play a role here, to be sure, though a recent John Locke Foundation study argues persuasively that loosening the state’s certificate-of-need laws would also enhance the number and geographical distribution of treatment options.
To the extent deaths of despair reflect a lack of social connection, however, I think private associations need to take the lead in remedying it. Consider a study published a couple of years ago in the Journal of the American Medical Association’s psychiatry edition. It found a strong association between death rates and church attendance. For women, regular attendance was associated with 68% lower rate of deaths by despair. For men, the difference was about 33%.
Naturally, we can’t just assume a causal relationship from the correlation. There was no experiment here in which the researchers identified depressed or lonely people and then randomly compelled some to go to church and others to stay home. But based on other empirical evidence for religion as a social determinant of health, I think it’s fair to conclude that faith-based institutions are integral to any realistic strategy for reducing deaths of despair.