So the deaths of despair
have generally been defined as self harm, which includes unintentional and intentional
drug overdose deaths, alcohol related deaths like
cirrhosis of the liver, and of course suicide. I'm Shannon Monnat, I'm Lerner Chair of
Public Health Promotion and associate professor of sociology in the Maxwell School of
Citizenship and Public Affairs at Syracuse University. My research is really interested in social disparities and health as well as geographic variation in a
variety of health outcomes. Most recently, I've been
interested in trying to understand the causes and
correlates of disparities from drug, alcohol,
and suicide mortalities and related diseases of despair. So one of the things that
I think distinguishes these types of diseases and deaths from some other types of mortality, for instance heart disease
or stroke or cancer, are that drug, alcohol,
and suicide mortality seem to have an underlying
link in terms of main drivers of them are
things like depression and anxiety and
frustration, and dislocation from social institutions which include things like not having a job, having a lot of family distress, and not being connected
to social institutions. Individual level data on these things are really hard to come
by, and so often times what we have to do is aggregate up to larger geographic levels, like the county level for instance, and when you do that,
what you're doing is using contextual indicators
of things like poverty and unemployment to try
to predict overall rates in these areas. And that of course is flawed, because we don't have
information on the individual person who died other than
their sex, their race, their age so we don't know about
their whole life course and the extent to which that influenced the way in which they died,
or influenced their first initiation of drug
misuse or alcohol misuse, or when the mental health
problems started to develop. One of the things that my
research really shows is that drug, alcohol, and suicide mortality are very geographically dispersed, range pretty substantially
across the country from really low rates
to really high rates. In general, the most salient
predictors of county level high rates of drug, alcohol,
and suicide mortality is not only current economic distress, the conditions that are present right now like poverty and
unemployment and disability, but more of a long-term
transition into economic distress. So places that were
once economically stable and even prosperous in the 1980s because of strong manufacturing, industry, because of unionization, those are the places that
have seen the most significant economic decline over the
past three decades or so. And that decline matters just as much as kind of chronic
long-term economic distress. So at the absolute level,
poor economies really matter, lack of opportunity really matters, but so does change, as sort of a shock into that labor market. The other thing is that the media often used the sentiment that
addiction doesn't discriminate. And of course that's true,
anyone can become addicted, but it's also true that drug
overdose mortality rates are much higher in some
geographic areas than others. And one of the problems
that can arise when we say addiction doesn't discriminate, is that it assumes that we should just distribute resources equally, and often times the places
that are dealing with it the largest consequences get
under-cut because of that. On election night when the
returns were coming in, what I noticed from the map
is that the places where Donald Trump was winning,
especially places where he wasn't predicted to win,
that map looked an awful lot like my drug overdose mortality map. And so I purchased some data
just for Michigan at the time, and ran a basic correlation
and noticed that counties where Trump
over-performed the most relative to how the previous
republican candidate did, those places had the highest drug, alcohol, and
suicide mortality rates. And then I purchased the
rest of the national data and expanded that from
there and found that he over-performed the
most in counties where drug, alcohol, and suicide
mortality rates were high but even more than that,
he performed the most in places that were distressed
upon all kinds of indicators. So not just mortality, but
also economic distress, family distress, places
for instance that have higher rates of divorce
were also more likely to be places where Trump over-performed. And places that have
a less social capital, so opportunities for building
social relationships, organizations that people
can be involved in. All of these factors were
partial explanatory indicators of why Trump over-performed
in the places that he did. I'm from upstate New York, when people think of New York, they often think of it as
a really liberal state. But the reality is, when
you go north of, say, Westchester County, if you
get out of the city at all, the level of conservative increases the further north that you go. So, I'm from a rural town,
a very conservative town, and a lot of people in
that town voted for Trump, and they were very enthusiastic about it. And one of the things
that they know is that they feel like the
Democratic party has really helped the poor people the most, and kind of forgotten working
class folks in small towns and these are people who are working, they're working in jobs like diners, they're mechanics, they're bus drivers, some of them are small
business owners who have seen the profits significantly decline because of increased regulation that might make sense for corporations but doesn't make as much financial sense for small businesses. What they're seeing is that
the best and the brightest leave the small town to go off to college and never come back, and that leaves a larger and larger concentration
after multiple generations of the people who are least
resource and most vulnerable and those people tend to not be working, and people in my town see
this and they get frustrated because it's a small
town, you know everybody. So if there's one grocery store to go to and you see somebody
using their SNAP benefits on food that you can't
afford to buy yourself, then that is a big frustration for people who live in my town. They're also increasingly saying that young people here don't wanna work. That there are jobs
available but they can't find people to take those jobs. And that frustrates people in my hometown that are working class, and feel like they're
just breaking their back to make ends meet, and
that so many resources appear to be going to the low
income people in that town. They're also seeing
increases in drug overdoses, and police officers are frustrated because they're spending a lot of their time having to revive people, and carry Narcan, and it limits their ability to it limits their ability
to call on other problems that arise because their time is so taken by these drug overdoses
and it's a resource that isn't available for
other kinds of responses. So ultimately, people in my town express a lot of frustration
with political elites, with academic elites, they watch
different news than I watch they read different things than I read, and the message that they're
getting from the sources that they're consuming media from are that America is in pretty dire straits, things don't look to be going very well and it's the Democrats' fault, and what we really need
is someone to come in here and just blow everything up. One of the big debates is
whether this is really about economic distress or racial resentment, and I don't think that those
are competing explanations. So in places that the economy declines, those places are really
vulnerable and ripe to internalizing messages
of racial resentment. And sociologists have
been talking about this for a long time, when
the economy is going well overt expressions of racism decline, and when the economy is doing poorly and it feels like it's a zero sum game and there's a limited number
of resources available, then racial resentment tends to increase. The other issue is that
we have to remember that Donald Trump lost the popular
vote by nearly 3 million votes so not only did Hillary
Clinton receive more votes than Trump, but Trump
actually under-performed relative to Mitt Romney. He received a lower percentage
of the vote share in 2016 compared to what Romney received in 2012. But because our system is
based on the electoral college what that means is that
some states matter more when it comes to the election outcome. And in this particular case, Pennsylvania, Wisconsin, and Michigan were the three game changers. Trump won those three states
by a combined 77,000 votes spread across three states. If we just break it down to
Pennsylvania for instance, he won Pennsylvania by 26,000 votes and over 60% of his victory share there of those 22,000 votes came from
one county, Luzerne County. Which is the home to Wilkes Barre. Now, Wilkes Barre is one of these places that has experienced
significant economic decline over the past 30 years. The income there, median
household income in Luzerne County is now lower than it was in 1980. A quarter of prime age men
and women are not working, they're either unemployed or out of the labor force altogether. And so when we start actually pin-pointing the regions where Trump won, where he wasn't predicted to win, these are the game changer
regions, the swing places, those are places that have experienced significant economic decline. Now that's not to say that
other parts of the country didn't have large concentrations of highly educated and affluent
people also voting for Trump, but we need to distinguish
between whether our question is who voted for Trump, versus
what was the difference maker for Trump winning this election? In the primaries, Hillary
Clinton won Southern states, won Western states,
she won the states that a Democrat likely would have won in the national election anyway. Sanders won the primary in
states in the industrial Midwest that then Trump ended up
winning in national election. So the question is then,
for Democrats going forward, is it more important
that your candidate win the so-called swing states,
versus the majority of states? Because right now the system is based on whoever gets the most delegates. But whoever gets the most delegates might end up being irrelevant
in the national election if increasingly our elections come down to a handful of states. A lot of people in the media,
and academics, and the public were surprised at the
outcome of this last election and there have been all
kinds of explanations of trying to understand
why, what happened. And underlying a lot of these explanations is that this was just an
all of a sudden thing, that, oh my gosh, our country
just changed overnight. What the heck went wrong? When the reality is that
the cues have been there for a long time. That since the 1980s the
overwhelming majority of places in this
country have not received any of the economic gain. Increasingly, more and
more income and wealth are filtering into the hands
of very, very smaller groups so that we have a massive
income and wealth inequality problem in this country, and
that didn't happen overnight. So while we have devalued
trade skills, we've devalued work in manufacturing,
and increased the value that we place on technology and finance, large swathes of this
country have been left behind it's been building for
the last three decades. And it's not just about the economics, it's not just about the paycheck. We used to be a nation of producers, we used to actually make things. And now the highest
paid jobs are people who click a button on a
keyboard and move money from one balance to another balance. And so increasingly, people in the US and even internationally, are feeling disconnected from their labor. They feel like their work is
devalued, underappreciated, is not meaningful, and
that meaning has influence for the rest of their lives. It affects mental health, physical health, it affects family relationships, and so all of this decline together, this kind of package or basket of decline, the chickens are finally
coming home to roost on this and people are reacting with
their voting behavior now. I've always been interested
in trying to understand social and geographic disparities in a wide-range of health outcomes. And I always said I wasn't
necessarily interested in what the health outcome was, I was just interested in the
things that lead to inequality. But then when I started
to try to understand what was going on with
substance misuse disparities, I started to see these
tight connections to this sense of enemy and aimlessness and anxiety and frustration, and that all made sense, given that the economy has been
declining in these places for a long time and so, I thought, what are the common binds here? And that's what really got
me fascinated and interested. When you see these problems
affecting rural areas drugs have always been an issue, but heroin kinda came
along and is now decimating small cities in rural
areas that just don't have the resources to combat it. And I think I just wanted
to try to understand why this is happening. So the majority of resources thus far have gone into trying to
increase access to treatment and Naloxone, Narcan
brand name which is the antidote to an opioid overdose. A tremendous amount of
resources have been spent on these things. And certainly, treatment is important and increasing access to
Narcan is important but we're not going to Narcan
our way out of this, because the problem is
bigger than opioids, it's bigger than drugs, the problem is a result of
long-term economic decline and social decline. Our relationships have disappeared. We have traded space and houses, which have continued to get bigger, for friendship, which
has continued to decline. We've given up connection for
stuff in the United States and so what that means is that in order to solve the opioid problem and all the connected problems with is we really have to get down to the core foundation of those problems and that has to do with
people feeling like there is no meaning in their life, and that things are worse off
than they were in the past.
