Deaths of Despair

Dear Friends, We hope this finds you all well. Deaths of Despair is an important and underappreciated topic in our modern society where most of us have abundance and are better off than our forefathers. I first got exposed to some of these problems as a medical student in central Pennsylvania at Penn State as I worked in indigent clinics in both inner-city Harrisburg and in the rural coal country in the northeast region of the state. Although this term is more recent, the epidemic is over twenty years old and continues to have societal wide impacts.

Professor Brendan Case, the associate director for research at the Human Flourishing Program at Harvard’s Institute for Quantitative Social Science states it well-

As we look forward to emerging from the COVID-19 pandemic, America remains in the grip of an epidemic of deaths from drug overdose, suicide, and alcohol poisoning. The epidemic began in the mid-1990s and is still escalating: The CDC estimates that 2020 saw 93,000 drug overdose deaths, a 30% increase from 2019 and the highest total ever recorded. Deaths of despair caused drops in overall life expectancy in the U.S. for the three consecutive years (from 2015 to 2017), the longest period of decline since World War I.

It was with this background that I read a great recent newsletter from one of my favorite health blogs led by one of America’s leading experts on deep health and lifestyle, Dan Pardi Ph.D.,  referencing this recent JAMA article:

Why Deaths of Despair Are Increasing in the US and Not Other Industrial Nations—Insights From Neuroscience and Anthropology

The blog post reads:

So, a thought-provoking article in JAMA Psychiatry came out this week that explored the recent increase in “deaths of despair” in the US, meaning deaths due to suicide and drug poisoning; deaths that generally occur when people feel that they have no path forward. This is obviously a complex phenomenon, but one of the explanations provided by the authors is that modern life tends to be simultaneously very predictable and very isolating.

This stands in stark contrast to the dynamic environment and the close interdependence that we observe in hunter-gatherer societies, and which mirrors the conditions of the world in which we evolved. Now, this loss of day-to-day stimulation (and danger) isn’t all bad. In fact, you could argue that much of our ability to specialize and make progress hinges on being able to work in quiet, safe conditions without a ton of distractions. But it also makes our daily lives less rewarding, and in turn might render us more vulnerable to the reliable dopamine surges offered by drugs and addictive behaviors.

That made me think about just how very different the modern industrialized world is, as well as the types of risks associated with it. Most of us are never confronted with mortal peril, the way that we might be if we lived in a more “natural” setting, accompanied by predators and other environmental threats. But that doesn’t mean that our lives are free of stress. Far from it!

…In fact, it’s worse in some respects, because instead of a short-lived stress response in the face of great danger, we are riddled with chronic stress. And, as Robert Sapolsky demonstrated in his iconic book, this kind of emotional stress can exact a physiological toll. As some of the studies below show, psychosocial stress can lead to increased risk of cancer and cardiovascular disease. It may even make you more likely to become infected with a virus, something that looms on all of our minds right now.

Professor Brendan Case with his research in the underappreciated field of Human Flourishing describes other important factors in his excellent recent article (see below) that may carry even more weight in our modern culture.

The Toll of Unbelief

Deaths are a response to “a long-term slowly unfolding loss of a way of life” hastened by sharp declines in wages, marriage rates, and community engagement among less-educated Americans.

Though manufacturing job-losses and the opioid crisis are now widely recognized as drivers of deaths of despair, the role of social factors such as religious attendance has been comparatively neglected in political and academic discussions.

Though the flood of opioids magnified the effect of American despair, the epidemic’s deepest causes are economic, social, and spiritual.

In short, less-educated Americans on average have less purchasing power, marry and have sex less often, have fewer friends, invest less in their neighborhoods and towns, and worship less than their parents and grandparents did.

He goes on to say that declining material advantages are not enough alone to explain the level of despair not least because the current material conditions of these groups are still far better than those endured by most of the world’s poor. Much more important for despair is the decline of family, community, and religion.

Yet declining religious participation receives relatively short thrift in academic centers, medical research, and in my experience is rarely thought of in most circles of cognitive elites and knowledge workers.

Professor Cases’ research center has assembled a body of evidence that suggests that the about 40 percent increase in suicides from 1996 to 2010 was attributable to declining religious participation.

He adds these important points-

Religious communities are crucial sources of social connection but perhaps equally important is their role in teaching that these behaviors (abusing drugs and alcohol, suicides, etc) are wrong. As social psychologist Jonathan Haidt has put it- religions are moral exoskeletons. They provide a set of norms, relationships, and institutions that protect individuals from their own worse instincts and from giving in to their own worst instincts.

Many experts believe with Purdue Pharma’s recent agreement to pay a $4 billion settlement over its role in the opioid epidemic things will get better but America’s opioid prescriptions are still 5x that of France and speaks to a deeper challenge. Professor Case describes despair as a social and spiritual malaise. Drugs may amplify its effects but the fundamental problem he believes that no prescription guidelines can address is “many of the most vulnerable people in our society live with the gnawing fear that a flourishing life– one shaped by a happy marriage, a fulfilling job, and deep friendships-is out of reach.”

Despair, Case goes on to describe, is so deadly because it attacks not the organs that sustain life but the very will to live. Thomas Aquinas described despair as, “the most grievous of sins because it is unhealable”- it refuses offers of healing.

I have started to see more despair and isolation in our patients during our prolonged societal response to COVID so this is far from just an economic problem. A report, “Projected Deaths of Despair During the Coronavirus Recession,” suggests as many as 75,000 Americans could die from “despair” due to unemployment, depression from isolation, and fear of the indefinite and uncertain nature of the pandemic.

We all would do well to think about how modernity affects our ability to handle despair and flourish. I’ll be sharing more information on flourishing and its role in optimal health in future articles. Acknowledging the understanding that our society is not only full of toxic food and air but also a toxic culture, is the first step to a path of improved health. Having a health care philosophy that embraces a traditional culture’s view of meaningful connections and the need to overcome agon or misery/pain, and seeks vitality and vigor through physical and metaphysical practices to have a Fit Soul and Fit Body should be the goal of all.

Yours in health-

Dr. Pappas and the Pappas Health team