The United States: From 1 Epidemic to Another

The present epicenter of the COVID-19 pandemic is already facing severe public health issues. Depression, suicides and opioids have been wreaking havoc in America’s heartland. There, thousands of men and women are dying from despair.

The United States has become the country most affected by the COVID-19 pandemic. As of April 21, more than 42,000 people have died. The inconsistency in the management of the crisis by a fanciful and incompetent president, the difficulties faced in accessing health care by the most disadvantaged, and the heavy price paid by the African American community are a few factors underlined in the influx of information that has infiltrated our confined lives over the past several weeks. But one central issue has been overlooked: The United States was already facing a major public health crisis with an abnormally high death rate for one part of the population. One epidemic is, therefore, following on the heels of the other, and their entanglement could have dramatic and lasting consequences for the world’s leading power.

During a trip to every state in the country after Donald Trump’s election in 2016, Mark Zuckerberg, founder of the social network Facebook, lost his ready smile. While Silicon Valley was funding research into eternal life through artificial intelligence, the plucky entrepreneur stumbled upon thousands of deaths. Far from the picture-perfect images that advertising presents, depression, suicide and opiates are wreaking havoc in the heart of America. There, many are dying, and well before the 80 years predicted by national life expectancy statistics. For a long time, this sad destiny was reserved for ethnic minorities, in particular for African Americans in large urban centers and for Native American populations in the West. Recently this has extended to white, middle-aged and poorly educated men and women, an additional indicator of the public health crisis taking place in the United States’ democratic society.

Since 2015, economist couple Anne Case and Angus Deaton have been raising the alarm with one simple fact: The mortality rate for poor men and women, aged 45 to 54 years, has been rising since the end of the 1990s, while declining overall across Western countries as a result of improved nutrition and medical advances. Case and Deaton provide a chilling explanation: At the heart of the world’s richest country, men and women are dying in the thousands from “despair” — to use their own term. In the context of growing inequalities, a fragmented labor market and the housing crisis affecting the most desperate, and drug and alcohol consumption, depression and suicide are leading to the silent deaths of the most vulnerable citizens.

From Montana to Louisiana, through West Virginia and Nebraska, a macabre funeral dance is unfolding. In these “counties of despair” where life expectancy was already lower, it continues to decline primarily because of the increased number of suicides. Traditionally, in the United States as elsewhere in the world, it is the youngest and the oldest who typically commit suicide. More recently, middle-aged men and women are taking the fatal step. The center of the country, the heartland, is particularly affected, especially in rural areas. With the help of firearms and drugs, an increasing number of citizens are definitively giving up on the American dream.

These counties of despair are also ravaged by another scourge that no one expected in rural areas: overdosing. For a long time, such deaths were associated with large urban centers, like New York or Los Angeles. Now, there are many in West Virginia and Kentucky. This dramatic reality stems from the massive and regular consumption of opioids. Initially, the pills were taken to cure small, ordinary ailments (lower back pain, passing anxiety and fatigue). Leading the antidepressant sector, the pharmaceutical industry marketed them as if it were selling popcorn. One of its first advertisements promised that patients would “get in the swing” with the help of Oxycodone, its bestselling medicine to treat minor pains. In the absence of “swing,” consumers entered a death spiral. The addiction led them to take hard drugs (cocaine and heroin). Once again, middle-aged men and women are the first casualties in this America, now under the influence of antidepressants.

Long ignored by health authorities, this crisis is drawing growing attention, despite the widespread understanding that there is no magic bullet to treat addiction and depression, especially when these conditions are fueled by economic and social inequalities. The wall that Trump promised to ward off drug dealers from Mexico, or the lawsuits against the big pharmaceutical groups, are exercises in chasing shadows. Only a “precision public health policy,” as it has been called by specialists, and better management of medical coverage as envisaged in Barack Obama’s time, will protect populations in the grips of despair.

Essentially, to understand what is presently playing out in the United States, the COVID-19 epidemic must be viewed against the backdrop of this first health crisis. For the time being, mortality figures point to differences in the social composition of the affected populations. The virus affects more urban and older populations, especially in the Northeast, so far sparing rural areas. Although the African American population has been less affected by opioids and especially suicides, it has been strongly affected by the virus. But in both cases, the poorest populations are the first to fall victim. Whether you die from COVID-19 or from despair, in the United States you die — first and foremost — according to your monthly income.

This succession of crises is only just beginning. It is indeed highly probable that the generalized deregulation of the economy and its social consequences will further fuel despair for part of the population. What will become of the millions of unemployed and those without social insurance in the coming weeks? In this still very macabre dance, the possible end of the spread of the coronavirus will leave plenty of room for the resurgence of the other crisis throughout the country. In his now somewhat forgotten 1976 essay, “The Final Fall,” demographer Emmanuel Todd predicted the collapse of the Soviet model by skillfully dissecting medical and social indicators in the Soviet Union. The state of public health in the United States today speaks volumes of the decay of its democracy. Before rushing to revive business as usual, Trump would do well to take a hard look at the sick body of the nation he leads. From one epidemic to another, the country displays, in ever sobering clarity, the frailties of its own system.