Sunday, July 10, 2016

St. Louis, Meet Flint. Part 1: Rural Mortality

I want to kick off a set of three blog posts that explore the causes of some of our most serious public health problems. Today I want to look at alarming trends in health in rural Michigan and ask what is happening to us? What I will do in the next two posts is ask whether rural Michigan is a victim of the same kind of forces that cause public health crises in other rural areas like Appalachia, but also in some urban areas, like Flint.

I’m going to show you three maps. The maps show the distribution of some serious health problems in the Midwest. What you will see is that rural central and northern Michigan is in trouble.  In fact we look like some of the sickest parts of North America. What you will also see is that even though the maps represent different public health problems, the distribution is the same in each case. This provides evidence about what those forces causing our public health crisis might be.

This map is from a well-known analysis of the distribution of heart disease deaths originally done by the CDC and reproduced many, many times.  First notice the legend. The disparity in heart disease deaths is enormous. The places with the highest rates of heart disease death (red) have rates eight times higher than those with the lowest (white)!  Then look at northern Michigan.  Excluding the prosperous communities around Grand Traverse and Charlevoix, northern Michigan tends to have high heart disease mortality rates.

I do not understand why, but Minnesota and Wisconsin, which I think of as being similar to us, fare much better.  But look at big cluster of mortality centered on Kentucky and West Virginia; our heart disease death rates are like theirs.

The next map is of the opioid overdose death rate, again from the CDC.  Opioids include prescription painkillers and illegal drugs like heroin.

Opioid overdoses have recently shot up in some rural areas, especially in Kentucky and West Virginia, and also in northern Michigan. Opioid use has been identified as a risk factor in the spread of HIV in rural areas.  Again, Minnesota and Wisconsin seem to be spared.  New York is spared also, because of policies ensuring access to drugs that aid in recovery from addiction.

The last map is of the gun suicide rate (sorry about the poor quality reproduction). It was made by the digital magazine Braid using CDC data. Suicides have increased sharply in some parts of rural North America. Again we see the same pattern, with northern Michigan, Kentucky and West Virginia having very high rates and other places being lower.  My conclusion:  Northern Michigan has something in common with coal country!

These problems—chronic disease, drug abuse and suicide—are part of a cluster of health problems befalling low-income, rural communities in some parts of North America that are so severe, they are actually causing measurable increases in the overall mortality rate.  For background on that look here and here.

And these unprecedented mortality rate increases are happening in low-income, rural parts of Michigan. You can see it at the local level. This line chart is for Montcalm County but you get the same results in many counties in Michigan.

The chart shows the heart disease death rate; the blue line is for Montcalm. For years heart disease death rates had been trending down locally just like everywhere else in North America due to reductions in smoking and improvements health care, but in the past few years the trend locally has reversed.

There are many factors that are contributing to rising mortality rates. Some of these factors, like stagnating rural economies, involve complex public policy and political issues. Other factors, like the pushing of opioids by pharmaceutical companies, are specific and narrow.  But low-income, rural communities seem especially vulnerable and are being hit harder than other areas. In my next two blog posts I want to explore why they are so vulnerable.

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