White women have been dying prematurely at higher rates since the turn of this century, passing away in their 30s, 40s and 50s in a slow-motion crisis driven by decaying health in small-town America, according to an analysis of national health and mortality statistics by The Washington Post.
Among African Americans, Hispanics and even the oldest white Americans, death rates have continued to fall. But for white women in what should be the prime of their lives, death rates have spiked upward. In one of the hardest-hit groups — rural white women in their late 40s — the death rate has risen by 30 percent.
The Post’s analysis, which builds on academic research published last year, shows a clear divide in the health of urban and rural Americans, with the gap widening most dramatically among whites. The statistics reveal two Americas diverging, neither as healthy as it should be but one much sicker than the other.
In modern times, rising death rates are extremely rare and typically involve countries in upheaval, such as Russia immediately after the collapse of the Soviet Union. In affluent countries, people generally enjoy increasingly long lives, thanks to better cancer treatments; drugs that lower cholesterol and the risk of heart attacks; fewer fatal car accidents; and less violent crime.
But progress for middle-aged white Americans is lagging in many places — and has stopped entirely in smaller cities and towns and the vast open reaches of the country. The things that reduce the risk of death are now being overwhelmed by things that elevate it, including opioid abuse, heavy drinking, smoking and other self-destructive behaviors.
White men are also dying in midlife at unexpectedly high rates. But the most extreme changes in mortality have occurred among white women, who are far more likely than their grandmothers to be smokers, suffer from obesity or drink themselves to death.
White women still outlive white men and African Americans of both sexes. But for the generations of white women who have come of age since the 1960s, that health advantage appears to be evaporating.
This reversal may be fueling anger among white voters: The Post last month found a correlation between places with high white death rates and support for GOP presidential candidate Donald Trump.
Public health experts say the rising white death rate reflects a broader health crisis, one that has made the United States the least healthy affluent nation in the world over the past 20 years. The reason these early deaths are so conspicuous among white women, these experts say, is that in the past the members of this comparatively privileged group have been unlikely to die prematurely.
Laudy Aron, a researcher with the Urban Institute, said rising white death rates show that the United States’ slide in overall health is not being driven simply by poor health in historically impoverished communities.
“You can’t explain it away as, ‘It’s those people over there who are pulling us down,’ ” Aron said. “We’re all going down.”
For this article, The Post examined death records from the Centers for Disease Control and Prevention, breaking the information down geographically, county by county, by level of urbanization and by cause of death.
Big cities and their suburbs — metropolitan areas of more than 1 million people — looked strikingly different from the rest of the country. The Post divided these populations into urban and rural categories, with the rural population encompassing smaller cities as well as small towns and the most remote places.
The statistics show decaying health for all white women since 2000. The trend was most dramatic for women in the more rural areas. There, for every 100,000 women in their late 40s, 228 died at the turn of this century. Today, 296 are dying. And in rural areas, the uptick in mortality was noticeable even earlier, as far back as 1990. Since then, death rates for rural white women in midlife have risen by nearly 50 percent.
In the hardest-hit places — 21 counties arrayed across the South and Midwest — the death rate has doubled, or worse, since the turn of the century for white women in midlife.
In Victoria County, Tex., a rural area near the Gulf Coast, deaths among women 45 to 54 have climbed by 169 percent in that time period, the sharpest increase in that age group of any U.S. county. The death rate climbed from 216 per 100,000 people to 583.
Lisa Campbell, medical director for the Victoria County health department, said a third of adults in the county are obese, roughly in line with the national average. Also, 1 in 5 smokes — well above the national average — and people can still light up in restaurants and other public places.
Campbell said she has been struck by how many white women she knows who have some kind of cancer.
“It’s kind of weird, actually,” she said.
Researchers circled the dying-whites phenomenon for several years before clearly recognizing what they were seeing. In 2014, the increase in the death rate of relatively young white women was right there in the CDC’s massive annual report on American health, but it drew no comment in the introductory highlights. Readers had to scrutinize Table 23 on Page 109 to spot the trend.
Other reports were more explicit. A 2013 study at the University of Wisconsin looked at the geography of death and discovered that mortality for women of all races had risen in 43 percent of U.S. counties between 1992 and 2006. Men’s mortality had risen in only 3 percent of counties.
Also in 2013, a sweeping study, “Shorter Lives, Poorer Health,” from the National Research Council and the National Academies’ Institute of Medicine showed a broad “health disadvantage” among Americans, compared with people in other affluent countries.
Aron, the Urban Institute researcher who co-authored the study, wrote in January 2014 that “increases in mortality are especially pronounced among white women of reproductive age, not a group we generally think of as being disadvantaged.” Last year, she and two co-authors published a separate article highlighting the perplexing number of white women who are dying prematurely.
Then, in November, Case and her husband, Angus Deaton, another Princeton economics professor, published their paper in the Proceedings of the National Academy of Sciences. Deaton had recently won the Nobel Prize in economics, an honor that added media gloss to the dying-whites study. Suddenly, it was a national story.
Other researchers weighed in, debating aspects of the Case-Deaton statistical analysis. For example, their study played down differences in gender; Case and Deaton contend that the noticeably higher death rates for women were largely driven by smoking patterns.